Comorbidity in Schizophrenia: Conceptual Issues and Clinical Management

Schizophrenia is a complex psychiatric disorder that affects cognitive, perceptual, and emotional functioning. The currently available evidence suggests heterogenous intertwining of biological and psychosocial etio-pathogeneses. Clinical and research interests in the comorbidity issues of schizophrenia were borne out of the real-world clinical challenges that patients often present with multiple coexisting psychopathologies as well as comorbid medical conditions. The recent DSM-5 shift toward a symptom dimensional-based perspective, the NIMH Research Domain Criteria (RDoC) initiative to examine biopsychosocial pathogeneses in mental illness, and the FDA's emphasis on real world-based clinical trial criterion all have promoted a shift in clinical research that has facilitated understanding and treatment of comorbidity in schizophrenia. This emerging conceptual shift as well as pharmacological developments that address the multidimensional pathogeneses in schizophrenia may pave the way for a better understanding and treatment.

DEVELOPING A NEW CARE PATHWAY FOR TRANSIENT ISCHEMIC ATTACK AT A COMMUNITY MEDICAL CENTER

Review the steps needed to research, develop and put into action a new outpatient urgent care pathway for selected transient ischemic attack patients.

Transcending Psychosis: The Complexity of Comorbidity in Schizophrenia

Schizophrenic illness encompasses diverse clinical phenomena and consists of unclear underlying pathogeneses. For the past century, the comorbidities in schizophrenia have drawn persistent interest and debate due to its high prevalence rate and a need for better management. However, its clinical and biological diversity continue to challenge both the practicing clinicians and researchers. Emerging clinical and research evidence in the past decade suggest a distinct biopsychosocial pathogenesis and unique clinical attributes in some comorbid disorders in patients with schizophrenia. In addition, current evidence also supports improved outcomes with specific assessment and treatment of these subgroup of schizophrenia. The recent changes in DSV-5 and shift in the NIMH focus towards the real world clinical practice and research provide increased impetus to explore the pathogeneses and treatment of schizophrenia with comorbid disorders.

Reevaluation of postoperative radiation dose in the management of human papillomavirus-positive oropharyngeal cancer

BACKGROUND

The purpose of this study was to compare outcomes of patients with p16-positive oropharyngeal squamous cell carcinoma (SCC) treated with postoperative intensity-modulated radiotherapy (IMRT) before and after an institutional dose reduction policy effective on February 2009.

METHODS

Between 1998 and 2013, 175 consecutive patients with p16-positive oropharyngeal SCC with extracapsular extension (ECE) and/or close or positive margins were treated postoperatively to 66 Gy (n = 109) or 60 Gy (n = 66) in 2 Gy/fx.

RESULTS

Between the 66 and 60 Gy groups, there was no difference in tumor classification (pT4 vs pT1-T3; p = .181) and nodal classification (pN2c-N3 vs pN0-N2b; p = .704), and American Joint Committee on Cancer (AJCC) group stage (IV vs I-III; p = .473). Median follow-up was 5.9 years overall (66 Gy: 7.4 years; 60 Gy: 4.0 years). There was no difference in locoregional recurrence-free survival (2-year: 98.1% vs 98.5%; p = .421).

CONCLUSION

This study suggests that treating p16-positive oropharyngeal SCC with ECE and/or close or positive margins with postoperative IMRT to 60 Gy may not compromise locoregional recurrence-free survival compared to 66 Gy. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Associations of obsessive-compulsive symptoms with clinical and neurocognitive features in schizophrenia according to stage of illness

This study aimed to investigate the association of obsessive-compulsive symptoms with clinical and neurocognitive features in patients with schizophrenia. This study enrolled 163 people with schizophrenia who were receiving risperidone monotherapy. Comorbid obsessive-compulsive symptoms were assessed using the Yale-Brown Obsessive-Compulsive Scale, and subjects with a score ≥ 10 constituted the obsessive-compulsive symptom group (n=30, 18.4%). The learning index was significantly higher in patients with obsessive-compulsive symptoms than in those without such symptoms after adjusting for age, stage (early and chronic), duration of illness, and CDSS score. However, there was no significant interaction between obsessive-compulsive symptoms and stage of illness. Scores on Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, and Beck Depression Inventory were significantly higher in the obsessive-compulsive symptom group. In addition, the Subjective Well-being under Neuroleptic Treatment score was significantly lower in the obsessive-compulsive symptom group. In conclusion, comorbid obsessive-compulsive symptoms in patients with schizophrenia were associated with a higher learning ability without a significant interaction with stage of illness. However, schizophrenia patients with obsessive-compulsive symptoms had more severe psychotic and depressive symptoms and poorer quality of life.

Abstract TP402: TIA Evaluation - Is Hospitalization Really Necessary?

Objective: A transient ischemic attack (TIA) is a major risk factor for a future disabling stroke. This risk can be lowered by the immediate evaluation of stroke risk factors and rapid intervention. TIA patients are generally admitted to the hospital for this evaluation, but this can take several days, and even then, their evaluation may be incomplete. We have started an outpatient open-access TIA rapid evaluation center at our medical center for comprehensive determination of stroke risk factors. We conducted a retrospective utilization and outcome review of all TIA patients hospitalized at our medical center over the last four years to help validate our new outpatient model.

Methods: We identified 398 patients admitted with either an admission or discharge diagnosis of TIA, reviewed their charts to calculate an ABCD2 score, for diagnostic testing and treatment, and then checked for readmissions within the subsequent 90 days for further TIAs or stroke.

Results: Only 5% of our patients admitted with TIA had recurrent cerebrovascular events within 90 days, none during their initial hospitalization. Despite a mean three-day length of stay, not all TIA patients underwent the complete diagnostic evaluation we are offering in our outpatient center. The ABCD2 score correlated with subsequent TIA and stroke, and in particular an ABCD2 score of 6-7 indicated a higher stroke risk.

Conclusion: Recent TIA patients, particularly those with an ABCD2 score of 0-5, can be safely and more expeditiously evaluated as outpatients.

Management of schizophrenia with obsessive-compulsive features

Although obsessive-compulsive symptoms (OCS) in schizophrenia have been conceptually controversial and clinically challenging, recent evidence suggests that schizophrenia with OCS may constitute a distinct schizophrenic subgroup. Recent epidemiological and clinical findings have shown that the subgroup obsessive-compulsive (OC) schizophrenia is associated with poor outcome and is more frequent than previously realized. Emerging biological evidence suggests that OCS in schizophrenia has more than one pathogenesis, with distinct mechanisms that may require different treatment interventions. Therefore, the management of OCS in patients with schizophrenia requires an individualized treatment approach based on the pathogenesis and clinical status of the patient. For example, the atypical antipsychotics that are potent serotonin antagonists sometimes induce de novo or exacerbate preexisting OCS, which resolves if the patient is switched to an antipsychotic with a different profile or if adjunctive treatment with serotonin reuptake inhibitors (SSRIs) is undergone. Regarding OC schizophrenia, SSRIs are often a necessary part of treatment, with knowledge of potential pharmacokinetic interactions with antipsychotic drugs essential. In this article, recent progress and current knowledge of OC schizophrenia is reviewed and treatment guidelines are offered for this complex and challenging subgroup of schizophrenic patients.

Schizophrenia and eating disorders

Schizophrenia requires diverse and individualized treatment approaches. Accurate identification and management of comorbid psychiatric syndromes determine outcome. Disturbances in eating and the distorted perception of body image are difficult to separate from other psychotic phenomena. Eating is a complicated integration of psychoneuroendocrinology. Despite the difficulties in defining the distinction between behaviors and cognitive perceptions that are and are not of diagnosable severity, there are patients with clearer coexistence of eating disorders and schizophrenia that carry on independent courses. This article presents clinical cases that portray a spectrum of eating pathology in patients with schizophrenia.

Amisulpride versus risperidone in the treatment of depression in patients with schizophrenia: a randomized, open-label, controlled trial

OBJECTIVE

To determine the effectiveness of amisulpride on depression in patients with schizophrenia, in comparison to risperidone.

METHOD

In this open-label, 12-week study, patients with stable schizophrenia and a comorbid major or minor depressive episode (DSM-IV) taking risperidone were randomized into a risperidone-continuation group (N = 45) or an amisulpride-switch group (N = 42). The main outcome measures were changes from baseline on the Calgary Depression Scale for Schizophrenia (CDSS) and the Beck Depression Inventory (BDI). Secondary efficacy measures included the Positive and Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning. Safety measures included treatment-emergent adverse events and extrapyramidal symptoms.

RESULTS

The mean dose at endpoint was 4.2 mg/day for risperidone and 458.3 mg/day for amisulpride. Improvements in the CDSS and BDI scores were significantly greater in the amisulpride-switch group than in the risperidone-continuation group at weeks 8 and 12, and at the endpoint. The amisulpride-switch group also showed a significantly greater reduction in the score for the PANSS depression/anxiety factor, and the total score from baseline to endpoint. No significant difference was observed between the two groups for treatment-emergent adverse events or change from baseline for extrapyramidal symptoms.

CONCLUSION

Switching from risperidone to amisulpride in patients with stable schizophrenia with comorbid depression improved depressive symptoms significantly compared to continuing with risperidone.

Diagnostic validity of assessment scales for depression in patients with schizophrenia

The aim of this study was to examine the diagnostic validity of four commonly used assessment scales for depression in schizophrenia. The study population consisted of 84 inpatients meeting the DSM-IV criteria for schizophrenia. Depression in the study subjects was defined by the DSM-IV criteria for major depressive episode. The Positive and Negative Syndrome Scale (PANSS) and the Simpson-Angus Rating Scale (SARS) were used to differentiate depression from the negative and extrapyramidal symptom-related depressive phenomena in schizophrenia. The following four depression scales were assessed for their diagnostic validity as measures of depressive disorder in schizophrenia: the Calgary Depression Scale for Schizophrenia (CDSS), the Beck Depression Inventory (BDI), the Hamilton Rating Scale for Depression (HAM-D), and the depression subscale of the PANSS (PANSS-D). Of 84 patients with schizophrenia, 32 were diagnosed as having comorbid depressive disorder. The areas under the Receiver Operating Characteristic (ROC) curves of the CDSS, HAM-D, PANSS-D, and BDI were 0.94, 0.89, 0.90, and 0.81, respectively. The area under the ROC curve of the CDSS was significantly greater than that of the BDI and tended to be more favorable than those for the HAM-D and the PANSS-D. Our study suggests that the CDSS may provide the best assessment for depression in patients with schizophrenia.

Schizophrenia with obsessive compulsive features

While the obsessive compulsive (OC) phenomena in schizophrenia have been described over the years, the condition has received increasing attention in recent years. The clinical and biological significance of OC symptoms in schizophrenia, however, still remain controversial. Although OC symptoms in schizophrenia were once thought to occur rarely and were associated with more benign clinical courses, recent studies have shown greater prevalence rate and poor outcome. In addition, the OC subgroup of schizophrenia responds poorly to the traditional antipsychotic treatments, but may respond positively to adjunctive anti-OCD regimen according to the emerging clinical evidence.(1) While further systematic studies are needed to explore the clinical neurobiological implications of OC phenomena in patients with schizophrenia, current evidence suggests that these patients require specific symptom assessment and individualized pharmacological and psychotherapeutic treatment interventions for optimal outcome.

Obsessive-compulsive and panic symptoms in patients with first-admission psychosis

OBJECTIVE

The occurrence, persistence and specificity of the association between comorbid obsessive-compulsive and panic symptoms and three psychotic disorders--schizophrenia/schizoaffective disorder, bipolar disorder with psychosis, and major depression with psychosis--were examined in a first-admission, epidemiologically defined group of patients with psychotic symptoms.

METHOD

The Structured Clinical Interview for DSM-III-R obsessive-compulsive and panic modules were administered at baseline and 24-month follow-up to patients with schizophrenia/schizoaffective disorder (N=225), bipolar disorder with psychosis (N=138), and major depression with psychosis (N=87) participating in the Suffolk County (N.Y.) Mental Health Project. The rates of subsyndromal symptoms and disorder criteria met were compared across the three psychosis groups. Recognition and treatment of anxiety symptoms at initial discharge and impact of the baseline presence of anxiety symptoms on 24-month clinical status were also examined.

RESULTS

Obsessive-compulsive and panic symptoms were present at baseline in 10%-20% of all three groups. There was no specific association between obsessive-compulsive symptoms and any specific psychosis diagnosis; however, women with major depression with psychosis had a significantly higher rate of panic symptoms than the other two groups, and schizophrenia/schizoaffective disorder patients with baseline panic symptoms were significantly more likely to exhibit positive symptoms of psychosis after 24 months.

CONCLUSIONS

The authors found no specific association between obsessive-compulsive symptoms and diagnosis early in the illness course, but the finding of an association between panic symptoms and psychotic depression among female patients and between baseline panic and positive psychotic symptoms in schizophrenia/schizoaffective disorder patients at 24 months suggests the need for further study.

MR findings of the spinal paraganglioma : report of three cases

Extraadrenal paragangliomas involving the spine is less common and usually takes the form of intradural compression of the cauda equina. The authors report three cases of spinal paragangliomas resulting in extradural spinal cord compression and their MR findings. The MR imaging revealed a well-demarcated extradural mass with low to intermediate signal intensity on T1-weighted images and intermediate to high signal intensity on T2-weighted images compared to paravertebral muscles. After Gd-DTPA administration, heterogeneous and intense enhancement was found. Multiple punctate and serpiginous structures of signal void due to high-velocity flow were noted around and within the tumors on all sequences. In one case, the signal void structures were well corresponded with feeding arteries on angiography. These may be the characteristic findings of the extraadrenal paraganglioma involving the spine.

Expressed sequence tags (ESTs) analysis of Acanthamoeba healyi

Randomly selected 435 clones from Acanthamoeba healyi cDNA library were sequenced and a total of 387 expressed sequence tags (ESTs) had been generated. Based on the results of BLAST search, 130 clones (34.4%) were identified as the genes encoding surface proteins, enzymes for DNA, energy production or other metabolism, kinases and phosphatases, protease, proteins for signal transduction, structural and cytoskeletal proteins, cell cycle related proteins, transcription factors, transcription and translational machineries, and transporter proteins. Most of the genes (88.5%) are newly identified in the genus Acanthamoeba. Although 15 clones matched the genes of Acanthamoeba located in the public databases, twelve clones were actin gene which was the most frequently expressed gene in this study. These ESTs of Acanthamoeba would give valuable information to study the organism as a model system for biological investigations such as cytoskeleton or cell movement, signal transduction, transcriptional and translational regulations. These results would also provide clues to elucidate factors for pathogenesis in human granulomatous amoebic encephalitis or keratitis by Acanthamoeba.

Clinical and neuropsychological profiles of obsessive-compulsive schizophrenia: a pilot study

This pilot study compared characteristics of obsessive-compulsive (OC) schizophrenic patients and a matched non-OC schizophrenic control group. The OC-schizophrenic group required more intensive clinical interventions and had a poorer clinical course, lower levels of functioning, and longer periods of hospitalization. They showed greater negative symptoms and more impaired executive functioning. These findings suggest OC-schizophrenic patients may have an atypical set of clinical and neuropsychiatric characteristics, perhaps constituting a subgroup within the schizophrenia spectrum. Pathophysiology and possible treatment implications require further study.

Effect of arachidonic acid metabolic inhibitors on hypoxia/reoxygenation-induced renal cell injury

The present study was undertaken to examine the role of arachidonic acid (AA) metabolites in hypoxia/reoxygenation (H/R)-induced renal cell injury in rabbit renal cortical slices using AA metabolic inhibitors. Inhibitors of cyclooxygenase (indomethacin and diclofenac sodium) and lipoxygenase pathways (nordihydroguaiaretic acid, caffeic acid, and eicosapentaenoic acid) reduced H/R-induced LDH release in a dose-dependent manner, whereas an inhibitor of cytochrome P-450 monooxygenase pathway ethoxyresorufin was not effective. AA increased LDH release in control slices, and the effect was not altered by indomethacin and nordihydroguaiaretic acid. The protective effect of indomethacin was not affected by addition of PGE2, a main product of cyclooxygenase pathway in the kidney. H2O2-induced LDH release was prevented by inhibitors of lipoxygenase but not by inhibitors of cyclooxygenase and cytochrome P-450 monooxygenase H/R-induced LDH release was not altered by iron chelators, phenanthroline and deferoxamine, and a potent antioxidant, N,N'-diphenyl-p-phenylenediamine, suggesting that the H/R-induced cell injury is not attributed to a generation of reactive oxygen species. Morphological studies showed that H/R-induced structural changes including cell necrosis were significantly prevented by indomethacin. These results suggest that inhibitors of cyclooxygenase and lipoxygenase pathways exert a direct protective effect against the H/R-induced cell injury in renal tubules. Whether these effects are mediated by alterations of AA metabolic pathways is not certain.

Phylogenetic relationships among Acanthamoeba spp. based on PCR-RFLP analyses of mitochondrial small subunit rRNA gene

We investigated the value of mitochondrial small subunit rRNA gene (mt SSU rDNA) PCR-RFLP as a taxonomic tool for Acanthamoeba isolates with close inter-relationships. Twenty-five isolates representing 20 species were included in the analysis. As in nuclear 18S rDNA analysis, two type strains (A. astronyxis and A. tubiashi) of morphological group 1 diverged earliest from the other strains, but the divergence between them was less than in 18S riboprinting. Acanthamoeba griffini of morphological group 2 branched between pathogenic (A. culbertsoni A-1 and A. healyi OC-3A) and nonpathogenic (A. palestinensis Reich, A. pustulosa GE-3a, A. royreba Oak Ridge, and A lenticulata PD2S) strains of morphological group 3. Among the remaining isolates of morphological group 2, the Chang strain had the identical mitochondrial riboprints as the type strain of A. hatchetti. AA2 and AA1, the type strains of A. divionensis and A. paradivionensis, respectively, had the identical riboprints as A. quina Vil3 and A. castellanii Ma. Although the branching orders of A. castellanii Neff, A. polyphaga P23, A. triangularis SH621, and A. lugdunensis L3a were different from those in 18S riboprinting analysis, the results obtained from this study generally coincided well with those from 18S riboprinting. Mitochondrial riboprinting may have an advantage over nuclear 18S rDNA riboprinting because the mt SSU rDNAs do not seem to have introns that are found in the 18S genes of Acanthamoeba and that distort phylogenetic analyses.

Generation and chromosome mapping of expressed sequence tags (ESTs) from a human infant thymus

In an effort to identify novel genes that are expressed differentially in an infant thymus, we constructed an oligo-d(T) primed cDNA library from a human infant thymus followed by single-run partial sequencing to generate expressed sequence tags (ESTs). Characterization of more than 1400 sequences enabled us to convert human thymus transcripts into 1223 useful ESTs. These ESTs consisted of 613 (50.1%) showing homology to known human genes, 51 (4.2%) matching to genes from other species, 289 (23.6%) matching ESTs of unknown functions, and 182 (14.9%) being novel transcripts. The expression profile of an infant thymus features a high number of genes related to cell division-DNA synthesis and gene-protein expression, indicating the active growth stage of an infant thymus. To identify the chromosomal localization of 43 thymus ESTs, PCR-based mapping was performed using a human-rodent somatic cell hybrid or radiation hybrid mapping panel. The results indicated that several novel genes were determined to be located in the vicinity of previously mapped disease loci; histidinemia loci, plasminogen Tochigi disease loci, Ehlers-Danlos syndrome, hypertriglyceridemia, thyroid resistance locus, ocular albinism, galactosemia, porphyria variegata, Charcot-Marie-tooth disease, FEOM (fibrosis of extraocular muscles), Prader-Willi syndrome.

Subgenus classification of Acanthamoeba by riboprinting

Subgenus classification of Acanthamoeba remains uncertain. Twenty-three reference strains of Acanthamoeba including 18 (neo)type-strains were subjected for classification at the subgenus level by riboprinting. PCR/RFLP analysis of 18S rRNA gene (rDNA). On the dendrogram reconstructed on the basis of riboprint analyses, two type-strains (A. astronyxis and A. tubiashi) of morphological group 1 diverged early from the other strains and were quite distinct from each other. Four type-strains of morphological group 3, A. culbertsoni, A. palestinensis, A. healyi were considered taxonomically valid, but A. pustulosa was regarded as an invalid synonym of A. palestinensis. Strains of morphological group 2 were classified into 6 subgroups. Among them, A. griffini which has an intron in its 18S rDNA was the most divergent from the remaining strains. Acanthamoeba castellanii Castellani, A. quina Vil3, A. lugdunensis L3a, A. polyphaga Jones, A. triangularis SH621, and A. castellanii Ma strains belonged to a subgroup, A. castellanii complex. However, A. quina and A. lugdunensis were regarded as synonyms of A. castellanii. The Chang strain could be regarded as A. hatchetti. Acanthamoeba mauritaniensis, A. divionensis, A. paradivionensis could be considered as synonyms of A. rhysodes. Neff strain was regarded as A. polyphaga rather than as A. castellanii. It is likely that riboprinting can be applied for rapid identification of Acanthamoeba isolated from the clinical specimens and environments.

[Bacterial endosymbiosis within the cytoplasm of Acanthamoeba lugdunensis isolated from a contact lens storage case]

Transmission electron microscopy of an Acanthamoeba isolate (KA/L5) from a contact lens case revealed bacterial endosymbionts within cytoplasm of the amoebae. The Acanthamoeba isolate belonged to the morphological group II. Based on the polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) of 18S ribosomal RNA coding DNA (rDNA), the isolate was identified as A. lugdunensis. Strain typing by isoenzyme analysis using isoelectric focusing (IEF) and mitochondrial (Mt) DNA RFLP revealed that the isolate was closely related with KA/L1, the most predominant type of isolates from contact lens storage cases, KA/E2, a clinical isolate, KA/W4, previously reported to host endosymbionts, and L3a strains of A. lugdunensis. The endosymbionts were similar to those of KA/W4 in aspects that they were randomly distributed in both trophozoites and cysts, and were rod-shaped bacteria measuring approximately 1.38 x 0.50 microns. But the number of endosymbionts per amoeba was significantly lower than that of KA/W4. They were neither limited by phagosomal membranes nor included in lacunaelike structure.

Close relatedness of Acanthamoeba pustulosa with Acanthamoeba palestinensis based on isoenzyme profiles and rDNA PCR-RFLP patterns

The taxonomic validity of morphological group III Acanthamoeba spp. is uncertain. In the present study, six type strains of group III Acanthamoeba spp., A. culbertsoni, A. healyi, A. pustulosa, A. palestinensis, A. royreba and A. lenticulata were subjected for the evaluation of their taxonomic validity by comparison of the isoenzyme patterns by isoelectic focusing on polyacrylamide gels, mitochondrial DNA (Mt DNA) restriction fragment length polymorphism (RFLP), and small subunit ribosomal DNA (ssu rDNA) PCR-RFLP patterns. The Mt DNA RFLP patterns were heterogeneous between the species. The type strains of A. palestinensis and A. pustulosa showed almost identical patterns of isoenzymes and rDNA PCR RFLP with an estimated sequence divergence of 2.6%. The other species showed heterogeneous patterns of isoenzymes and rDNA PCR-RFLP. It is likely that A. pustulosa is closely related with A. palestinensis and that the former may be regarded as a junior synonym of the latter.

Effect of high-velocity missile injury on plasma cortisol concentration in dogs

Plasma cortisol concentrations were measured in nine dogs after high-velocity missile injury induced by spherical steel bullets. All nine dogs sustained soft-tissue wounds in the thighs without damage to large vessels, femur, or nerves. When the dogs were considered as one group the mean plasma cortisol concentration increased promptly 10 min after injury (p less than 0.05) and reached its peak at 1 hour and then decreased. The mean concentration at 6 hours after injury was still higher than that before injury (p less than 0.05). Even though the severities of the injuries varied rather much there was a significant difference (p less than 0.01) between the plasma cortisol concentrations at 1 hour of the two groups into which the dogs were divided according to the severity of their injuries. The changes of the plasma cortisol concentrations may be parallel with the extent of the injuries and there was a positive correlation with the dimensions of the entrance wounds.

Misalignment characteristics of resonators formed by 90 degrees cone and mirror

The stability condition of a resonator formed by a 90 degrees cone and mirror has been derived using ray tracing techniques. The result showed that this type of resonator is relatively insensitive to mirror misalignment. From this basis, the mirror misalignment tolerance was studied experimentally. Output energy and transverse mode characteristics vs. misalignment were measured, and the results show that this type of resonator does possess certain advantages over the two-mirror resonator.