Affective dimensions as a diagnostic tool for bipolar disorder in first psychotic episodes

ObjectiveTo examine the predictive diagnostic value of affective symptomatology in a first-episode psychosis (FEP) sample with 5 years’ follow-up.MethodAffective dimensions (depressive, manic, activation, dysphoric) were measured at baseline and 5 years in 112 FEP patients based on a factor structure analysis using the Young Mania Rating Scale and Hamilton Depression Rating Scale. Patients were classified as having a diagnosis of bipolar disorder at baseline (BDi), bipolar disorder at 5 years (BDf), or “other psychosis”. The ability of affective dimensions to discriminate between these diagnostic groups and to predict a bipolar disorder diagnosis was analysed.ResultsManic dimension score was higher in BDi vs. BDf, and both groups had higher manic and activation scores vs. “other psychosis”. Activation dimension predicted a bipolar diagnosis at 5 years (odds ratio = 1.383; 95% confidence interval, 1.205–1.587; P = 0.000), and showed high levels of sensitivity (86.2%), specificity (71.7%), positive (57.8%) and negative predictive value (90.5%). Absence of the manic dimension and presence of the depressive dimension were both significant predictors of an early misdiagnosis.ConclusionThe activation dimension is a diagnostic predictor for bipolar disorder in FEP. The manic dimension contributes to a bipolar diagnosis and its absence can lead to early misdiagnosis.     

Duration of untreated psychosis predicts functional and clinical outcome in children and adolescents with first-episode psychosis: A 2-year longitudinal study

Longer duration of untreated psychosis (DUP) in adult patients with first-episode psychosis (FEP) has been associated with poor clinical and social outcomes. We aimed to estimate the influence of DUP on outcome at 2-year follow-up in subjects with an early-onset (less than 18 years of age) FEP of less than 6 months' duration. A total of 80 subjects (31.3% females, mean age 16.0 ± 1.8 years) were enrolled in the study. The influence of DUP on outcome was estimated using multiple regression models (two linear models for influence of DUP on the C-GAF at 2 years and C-GAF change through the follow-up period, and a logistic model for influence of DUP on 41 PANSS remission at 2 years in schizophrenia patients (n = 47)). Mean DUP was 65.3 ± 54.7 days. Median DUP was 49.5 days. For the whole sample (n = 80), DUP was the only variable significantly related to C-GAF score at 2-year follow-up (Beta = − 0.13, p < 0.01), while DUP and premorbid adjustment (Beta = − 0.01, p < 0.01; and Beta = − 0.09, p = 0.04, respectively) were the only variables significantly related to C-GAF change. In schizophrenia patients, DUP predicted both C-GAF score at 2 years and C-GAF change, while in patients with affective psychosis (n = 22), DUP was unrelated to outcome. Lower baseline C-GAF score (OR = 0.91, p < 0.01) and shorter DUP (OR = 0.98, p = < 0.01) were the only variables that significantly predicted clinical remission in schizophrenia patients. In conclusion, longer DUP was associated with lower C-GAF at 2 years, less increase in C-GAF, and lower rates of clinical remission in early-onset FEP. Our findings support the importance of early detection programs, which help shorten DUP.     

Do psychosis prodrome onset negative symptoms predict first presentation negative symptoms?

BackgroundNegative symptoms have been previously reported during the psychosis prodrome, however our understanding of their relationship with treatment-phase negative symptoms remains unclear.ObjectivesWe report the prevalence of psychosis prodrome onset negative symptoms (PONS) and ascertain whether these predict negative symptoms at first presentation for treatment.MethodsPresence of expressivity or experiential negative symptom domains was established at first presentation for treatment using the Scale for Assessment of Negative Symptoms (SANS) in 373 individuals with a first episode psychosis. PONS were established using the Beiser Scale. The relationship between PONS and negative symptoms at first presentation was ascertained and regression analyses determined the relationship independent of confounding.ResultsPONS prevalence was 50.3% in the schizophrenia spectrum group (n = 155) and 31.2% in the non-schizophrenia spectrum group (n = 218). In the schizophrenia spectrum group, PONS had a significant unadjusted (χ² = 10.41, P < 0.001) and adjusted (OR = 2.40, 95% CI = 1.11–5.22, P = 0.027) association with first presentation experiential symptoms, however this relationship was not evident in the non-schizophrenia spectrum group. PONS did not predict expressivity symptoms in either diagnostic group.ConclusionPONS are common in schizophrenia spectrum diagnoses, and predict experiential symptoms at first presentation. Further prospective research is needed to examine whether negative symptoms commence during the psychosis prodrome.     

Cortisol awakening response in patients with psychosis: Systematic review and meta-analysis

The cortisol awakening response (CAR), defined as the increase in cortisol release in response to waking up, shows associations with social and environmental risk factors of schizophrenia and has been studied as a potential biomarker in schizophrenia. We report a systematic review and meta-analysis of 11 studies and 879 participants focusing on the CAR of patients with schizophrenia, first-episode psychosis, and at-risk mental states. Random-effects meta-analysis showed that CAR is attenuated in patients with psychosis compared to healthy controls (g = ⿿0.426, 95% CI ⿿0.585 to ⿿0.267, p < 0.001, 11 between-group comparisons, n = 879). Subgroup analysis showed flattened CAR in patients with schizophrenia (g = ⿿0.556, 95% CI ⿿1.069 to ⿿0.044, p < 0.05, 2 between-group comparisons, n = 114) and first-episode psychosis (g = ⿿0.544, 95% CI ⿿0.731 to ⿿0.358, p < 0.001, 6 between-group comparisons, n = 505), but not in individuals with at-risk mental states. These distinctive alterations of hypothalamic-pituitary-adrenal axis function may have important implications for CAR as a marker for transition risk. However, the lack of objective verification of sampling adherence in these studies may limit the interpretation of the results.     

Comparing cognitive functioning in schizophrenia and autism using WAIS-III

The main goal of this study was to investigate differences and similarities in general cognitive functioning between adults with schizophrenia and autism, because this has not been systematically investigated. We used a cross-sectional design to compare adults with schizophrenia (n = 27), with autism (n = 114) and a healthy control group (n = 30). Schizophrenia diagnoses were based on the Structured Clinical Interview for the DSM-IV Axis I (SCID-I) and behavioral symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Autism was diagnosed with a DSM-IV questionnaire for autism spectrum disorders and the Autistic Diagnostic Interview, revised version. The Wechsler Adult Intelligence Scale, third version (WAIS-III) was used to assess cognitive functions. All participants were between 18 and 65 years of age and had a minimum full scale intelligence of 80. Results showed that patients with schizophrenia scored significantly lower on processing speed than patients with autism and the healthy control group. Differences on other index scales were not found. In participants with schizophrenia a correlation was found between processing speed impairment and negative symptoms. Diagnosis could be predicted correctly with WAIS-III profile in 70.4% of the cases with schizophrenia compared to 56.7% of the healthy control group and 22.8% of the autism group.     

Reduced folic acid,vitamin B12 and docosahexaenoic acid and increased homocysteine and cortisol in never-medicated schizophrenia patients: Implications for altered one-carbon metabolism

Abnormal one-carbon metabolism has long been suggested as one of the mechanisms for neuropathology and psychopathology of schizophrenia. Variable levels of components of one-carbon metabolism (folic acid and vitamin B₁₂) and consequent altered levels of homocysteine and phospholipid docosahexaenoic acid (DHA) have been independently reported, mostly in medicated patients. This study examined the simultaneous levels of these key components of one-carbon metabolism and its consequences in unique, medication-naïve first-episode psychotic patients (FEP, n = 31) and healthy controls (HC, n = 48) matched for confounds such as race, diet and lifestyle to reduce the variability. Significantly lower levels of folate and vitamin B₁₂ in plasma and folate in red blood cells were observed in FEP compared to HC. These reductions paralleled the significant increase in plasma homocysteine and cortisol levels. Significantly reduced levels of membrane DHA were also observed in FEP compared to HC. This study, using a unique cohort, provided a broader mechanism (disturbed folic acid–vitamin B₁₂–DHA balance) of altered one-carbon metabolism and one of its key consequential components, an increased homocysteine level that together with cortisol, can contribute to the neuropathology of psychosis. These data may have important implications for the amelioration of psychopathology in schizophrenia.     

Verbal fluency as a possible predictor for psychosis

BackgroundNeurocognitive abnormalities are prevalent in both first episode schizophrenia patients and in ultra high risk (UHR) patients.AimTo compare verbal fluency performance at baseline in UHR in patients that did and did not make the transition to psychosis.MethodBaseline verbal fluency performance in UHR-patients (n = 47) was compared to match first episode patients (n = 69) and normal controls (n = 42).ResultsVerbal fluency (semantic category) scores in UHR-patients did not differ significantly from the score in first episode schizophrenia patients. Both the UHR group (p < 0.003) and the patient group (p < 0.0001) performed significantly worse than controls. Compared to the non-transition group, the transition group performed worse on verbal fluency, semantic category (p < 0.006) at baseline.ConclusionsVerbal fluency (semantic category) is disturbed in UHR-patients that make the transition to psychosis and could contribute to an improved prediction of transition to psychosis in UHR-patients.     

Increased risk of psychosis in patients with hearing impairment: Review and meta-analyses

Several studies suggest hearing impairment as a risk factor for psychosis. Hearing impairment is highly prevalent and potentially reversible, as it can be easily diagnosed and sometimes improved. Insight in the association between hearing impairment and psychosis can therefore contribute to prevention of psychosis. This paper provides meta-analyses of all epidemiologic evidence on the association between hearing impairment and psychosis and summarizes mechanisms that potentially underlie this relationship.Meta-analyses showed an increased risk of hearing impairment on all psychosis outcomes, such as hallucinations (OR 1.40(95%CI 1.18–1.65; n = 227,005)), delusions (OR 1.55(95%CI 1.36–1.78; n = 250,470)), psychotic symptoms (OR 2.23(95%CI 1.83–2.72; n = 229,647) and delirium (OR 2.67(95%CI 2.05–3.48; n = 12,432). Early exposure to hearing impairment elevated the risk of later development of schizophrenia (OR 3.15(95%CI 1.25–7.95; n = 50,490)).Potential mechanisms underlying this association include loneliness, diminished theory of mind, disturbances of source monitoring and top-down processing and deafferentiation. Early assessment and treatment of hearing impairment in patients with (high risk of) psychosis may be essential in psychosis treatment and prevention.     

Predictors of short – and long-term clinical outcome in schizophrenic psychosis – the Northern Finland 1966 Birth Cohort study

ObjectiveSince the outcome in schizophrenia is heterogeneous and often poor, identification of specific predictors of outcome would be useful in clinical practice.MethodsSubjects with schizophrenic psychoses (n = 103) included in the Northern Finland 1966 Birth Cohort (n = 12,058), representing the general population, were followed-up for an average of 16.4 years. Predictor and outcome data were collected from the nationwide Finnish Hospital Discharge Register, hospital records and interviews.ResultsInsidious onset of illness predicted a rehospitalization due to psychosis in the 2 years after the initial discharge. Being single, having an early onset, insidious onset, suicidal ideations upon the first admission, a rehospitalization and a high number of treatment days due to psychosis in the early stages of the illness all predicted a poorer clinical outcome in the longer term, after a minimum follow-up of 10 years.ConclusionsThis population-based study indicates that clinical and sociodemographic factors around the onset of illness have significance for the long-term outcome in schizophrenia. These prognostic factors should be taken into account in clinical practice.     

Rémission symptomatique et sa relation avec le fonctionnement social chez des patients tunisiens suivis pour schizophrénie

IntroductionThe concept of symptomatic and functional remission represents an important challenge in the care of the mentally ill, particularly in patients with schizophrenia. Operational criteria for symptomatic remission in schizophrenia have been proposed by Andreasen et al. (2005). Over the last decade, these criteria have been widely validated; however few studies have been conducted outside developed countries. Moreover, the association of symptomatic remission with functional outcome has not yet been established in developing countries including Tunisia, as there may be variability in the social and familial environment.ObjectivesTo determine the frequency and associated factors of symptomatic remission in a sample of Tunisian out-patients with schizophrenia and to explore the relationship between symptomatic remission and some indicators of social functioning.MethodsA cross-sectional study was carried-out on 115 out-patients with schizophrenia (87 males, 28 females, mean age = 37.56 ± 10.2 years) in the psychiatry department of the university hospital in Monastir (Tunisia). Nearly all of the patients (98.26%) had been hospitalized at least once in a psychiatric unit. The last hospitalization dated back to 39 months on average (range = 6 months to 16 years). Symptomatic remission was assessed by the eight core items of the positive and negative syndrome scale (PANSS). These are the items P1 “Delusions”; P3 “Hallucinatory behavior” and G9 “Unusual thought content” for the positive dimension, the items P2 “Conceptual disorganization” and G5 “Mannerism and disorders of posture” for the disorganization dimension and the items N1 “Blunted affect”, N4 “Social withdrawal” and N6 “Lack of spontaneity and flow of conversation” for the negative dimension. A score of mild or less on all eight-core symptoms constitutes symptomatic remission. This symptom level should have been maintained for six months. The social functioning was assessed by the Social and Occupational Functioning Assessment Scale (SOFAS) and the Social Autonomy Scale (SAS) exploring personal care, management of daily life, resource management, the relationship with the outside and the emotional life and relationships social. A multivariate analysis using a binary logistic regression was conducted with as a dependent variable “symptomatic remission” and as explanatory variables the associated variables with symptomatic remission in bivariate analysis with age and gender.ResultsThe symptomatic remission was observed in 50.4% of patients. The items corresponding to positive dimension (P1, P3 and G9) and the item P2 “conceptual disorganization” had a better predictive value of symptomatic remission. After multivariate analysis, the associated factors of symptomatic remission were the acute of onset (P = 0.026), the low score of negative symptoms during the last hospitalization (P = 0.017) and the episodic course (P < 0.0001). However, age or gender of the patients, educational or socioeconomic level, psychiatric family history, age of onset, duration of untreated psychosis, number and duration of previous hospitalizations, antipsychotic treatment dosage were not associated with symptomatic remission in our sample. The mean score of the SOFAS was 48.47 ± 14.44, and the mean score of the SAS was 56.6 ± 16.84. A significant association was shown between the SOFAS score and the symptomatic remission (P < 0.0001) and between the SAS score and the symptomatic remission (P < 0.0001). Moreover, a significant association was found between symptomatic remission and occupational activity (P = 0.03).ConclusionThe frequency of symptomatic remission according the PANSS criteria in our sample is above the average of the reported rates in literature (30 to 60%). This can be explained by the frequency of symptomatic remission in outpatient versus inpatients, or in relation to the notion of a more favorable course of schizophrenia in developing countries, although this notion is controversial. Remitter patients had significantly an acute onset of disorders, a low score of negative symptoms during the last hospitalization and an episodic course. They also showed a significant trend for better social functioning. In fact, a significant association was shown in our sample between symptomatic remission and social functioning. These results suggest that the concept of remission has important implications for the treatment of patients with schizophrenia.     

Psychoses in epilepsy: A comparison of postictal and interictal psychoses

We retrospectively analyzed data of patients with epilepsy (n = 1434) evaluated with prolonged EEG monitoring in order to estimate the prevalence of postictal psychosis (PP) and interictal psychosis (IP), to investigate a potential association of psychosis subtype with epilepsy type, and to assess differences between PP and IP. The overall prevalence of psychosis was 5.9% (N = 85); prevalence of PP (N = 53) and IP (N = 32) was 3.7% and 2.2%, respectively. Of patients with psychosis, 97.6% had localization-related epilepsy (LRE). Prevalence of psychosis was highest (9.3%) in patients with temporal lobe epilepsy (TLE). When comparing PP with IP groups on demographic, clinical, and psychopathological variables, patients with IP were younger at occurrence of first psychosis (P = 0.048), had a shorter interval between epilepsy onset and first psychosis (P = 0.002), and more frequently exhibited schizophreniform traits (conceptual disorganization: P = 0.008; negative symptoms: P = 0.017) than those with PP. Postictal psychosis was significantly associated with a temporal seizure onset on ictal EEG (P = 0.000) and a higher incidence of violent behavior during psychosis (P = 0.047). To conclude, our results support the presumption of a preponderance of LRE in patients with psychosis and that of a specific association of TLE with psychosis, in particular with PP. Given the significant differences between groups, PP and IP may represent distinct clinical entities potentially with a different neurobiological background.     

The validity of self-rated psychotic symptoms in depressed inpatients

BackgroundSelf-ratings of psychotic experiences might be biased by depressive symptoms.MethodData from a large naturalistic multicentre trial on depressed inpatients (n = 488) who were assessed on a biweekly basis until discharge were analyzed. Self-rated psychotic symptoms as assessed with the 90-Item Symptom Checklist (SCL-90) were correlated with the SCL-90 total score, the SCL-90 depression score, the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale 21 item (HAMD-21) total score, the Montgomery Åsberg Depression Rating Scale (MADRS) total score and the clinician-rated paranoid-hallucinatory score of the Association for Methodology and Documentation in Psychiatry (AMDP) scale.ResultsAt discharge the SCL-90 psychosis score correlated highest with the SCL-90 depression score (0.78, P < 0.001) and with the BDI total score (0.64, P < 0.001). Moderate correlations were found for the MADRS (0.34, P < 0.001), HAMD (0.37, P < 0.001) and AMDP depression score (0.33, P < 0.001). Only a weak correlation was found between the SCL-90 psychosis score and the AMDP paranoid-hallucinatory syndrome score (0.15, P < 0.001). Linear regression showed that change in self-rated psychotic symptoms over the treatment course was best explained by a change in the SCL-90 depression score (P < 0.001). The change in clinician-rated AMDP paranoid-hallucinatory score had lesser influence (P = 0.02).ConclusionsIn depressed patients self-rated psychotic symptoms correlate poorly with clinician-rated psychotic symptoms. Caution is warranted when interpreting results from epidemiological surveys using self-rated psychotic symptom questionnaires as indicators of psychotic symptoms. Depressive symptoms which are highly prevalent in the general population might influence such self-ratings.     

At the boundary of the self: The insular cortex in patients with childhood-onset schizophrenia,their healthy siblings,and normal volunteers

The insular cortex (insula), whose normal function involves delineating the boundary between self and non-self stimuli, has been implicated in the pathophysiology of the positive symptoms of schizophrenia, including hallucinations and delusions. Childhood-onset schizophrenia (COS), that includes the onset of psychosis before age 13, is a severe and continuous form of the illness which shows profound and global progressive cortical brain abnormalities during adolescence which merge in the adult pattern with age. Using prospectively acquired anatomic brain magnetic resonance imaging (MRI) scans, a matched sample of COS patients, their nonpsychotic full siblings and healthy volunteers, we measured insular volume using the FreeSurfer automated software. COS patients (n = 98; 234 scans) had significantly lower right (p = 0.003), left (p < 0.001), and total (p < 0.001) insular volumes than healthy volunteers (n = 100; 248 scans). Right insular volume negatively correlated with positive symptoms as measured by the Scale for the Assessment of Positive Symptoms (SAPS) (p = 0.02), while both left (p = 0.01) and right (p = 0.006) insula volumes were positively correlated with overall functioning, as measured by the Children's Global Assessment Scale (CGAS) scores. COS siblings (n = 71; 153 scans), on the other hand, did not differ significantly from normal volunteers suggesting that the insular deficits are more related to the illness state than a familial endophenotype. These results also highlight the salience of the insula in positive symptoms of schizophrenia perhaps resulting from the inability to discriminate between self from the non-self in COS. Further work to connect insular deficits to other neurocircuitries is warranted.     

Suicide attempt in first-episode psychosis: A 7.4 year follow-up study

BackgroundIndividuals with first-episode psychosis demonstrate high rates of suicide attempt (SA).Aims1) To examine the prevalence of, and risk factors for, SA in a first-episode psychosis (FEP) cohort over a 7.4 year follow-up period. 2) To investigate differences between single versus multiple suicide attempters.MethodsThis study reports baseline and follow-up data from a naturalistic, prospective follow-up of 413 FEP patients treated at a specialist early psychosis centre. Assessments were conducted at treatment entry, initial symptom remission or stabilization, and long term follow-up. Binary logistic regression models were used to assess unadjusted and adjusted associations between early illness and sociodemographic characteristics and two outcome measures: any SA during follow-up; and multiple SAs.ResultsFollow-up data were available for 282 participants. Sixty-one (21.6%) made a suicide attempt over the follow-up period, including 12 successful suicides. The following baseline risk factors increased the risk of any SA: history of self-harm (OR = 4.27; p < 0.001), suicidal tendencies (OR = 2.30; p = 0.022), being depressed for > 50% of the initial psychotic episode (OR = 2.49; p = 0.045), and hopelessness (OR = 2.03; p = 0.030). History of problem alcohol use increased the risk of multiple SAs (OR = 4.43; 95% CI (1.05–18.7); p = 0.043).DiscussionThe prevalence of suicide attempt in this study exceeds reports from short-term FEP studies but is comparable to longer term follow-up studies, indicating that risk remains elevated for at least 7 years following commencement of treatment. The key predictor of future suicide attempt was previous self-harm, indicating that interventions for self-harm are required.     

Transition to first episode psychosis in ultra high risk populations: Does baseline functioning hold the key?

BackgroundBaseline functioning has been found to be a strong predictor of transition to psychosis in ultra high risk populations. However, the time course of functioning may enhance prediction. We investigated whether there were different patterns of functioning over time and whether particular temporal patterns were related to baseline characteristics and psychosis outcome.MethodFunctional data was assessed at baseline and after 3 to 6 year follow-up in an ultra high risk sample (n = 158; 92 female, mean age = 19.28 (SD = 3.33), range = 14–29). Using the median score of the GAF and the QLS scale, a ‘High’ and ‘Low’ group (comprising of subjects functioning above or below median at both baseline and follow-up) and a ‘Deterioration’ group and ‘Improving’ group were created.ResultsChi-square analyses showed that the Low and Deteriorating functioning groups were the most likely to develop first-episode psychosis (FEP). Importantly, UHR individuals with deteriorating functioning were at higher risk of transition than those whose functioning was low at baseline but improved over time (GAF: X² = 5.10, df = 1, p = .02; QLS: X² = 9.13, df = 1, p = .003). Binary logistic regression analyses showed that a decline in functioning was more strongly associated with FEP (GAF: p = < .0001; QLS: p < .0001) than the level of baseline functioning (GAF: p = .005; QLS: p = .09). The deteriorating group could not be distinguished from the High group in terms of baseline symptomatology.DiscussionWith the addition of the ‘low functioning’ criterion to the UHR criteria, we may miss out on some true positive cases. Limiting our attention to baseline poor functioning may therefore distort the picture in terms of risk for psychosis.     

TCF4 gene polymorphism and cognitive performance in patients with first episode psychosis

BackgroundSingle nucleotide polymorphisms in TCF4 gene have been consistently associated with schizophrenia in genome wide association studies, including the C allele of rs9960767. However, its exact role in modulating the schizophrenia phenotype is not known.AimsTo comprehensively investigate the relationship between rs9960767 risk allele (C) of TCF4 and cognitive performance in patients with first episode psychosis (FEP).Methods173 patients with FEP received a comprehensive neurocognitive evaluation and were genotyped for rs9960767. Carriers of the risk allele (CA/CC) were compared to non-carriers (AA) using Multivariate Analysis of Covariance MANCOVA. Ethnicity, negative symptoms and substance abuse were included as covariates.ResultsCarriers of the risk allele had a statistically significant lower performance in the cognitive domain of Reasoning/Problem-Solving compared to non-carriers (F_1,172 = 4.4, p = .038). There were no significant genotype effects on the other cognitive domains or general cognition. This effect on the Reasoning/Problem-Solving domain remained significant even when controlling for IQ (F_1,172 = 4.3, p = .039).Conclusionsrs9960767 (C) of TCF4 appears to be associated with neurocognitive deficits in the Reasoning/Problem-Solving cognitive domain, in patients with FEP. A confirmation of this finding in a larger sample and including other TCF4 polymorphisms will be needed to gain further validity of this result.     

Sleep quality and cognitive impairments in remitted patients with schizophrenia in Nigeria

BackgroundDespite the ubiquity of sleep disturbance in schizophrenia, it has generally been overlooked as a potential contributor to cognitive impairments. The main aim of this study was to find out if impaired sleep quality contributes to cognitive impairments in patients with a diagnosis of schizophrenia who are in remission.MethodsThe study was conducted at the University College Hospital, Ibadan and State Hospital, Ibadan, Nigeria. The Pittsburgh Sleep Quality Index (PSQI) and Screen for Cognitive Impairment in Psychiatry (SCIP) were applied in this cross-sectional study, to all consecutive and consenting remitted outpatients with schizophrenia (N = 130). Other instruments such as Hamilton Depression Rating Scale (HDRS), the Positive and Negative Syndrome Scale (PANSS), sociodemographic and clinical measures were also applied.ResultsThere were 130 participants made up of 69 females (53.1%) and 61males(46.9%). The mean age of the participants was 38.5 ± 9.1 years. The prevalence of poor sleep quality in remitted patients with schizophrenia was 56.9%. Sleep quality was significantly negatively correlated with Verbal Learning Test-Immediate (VLT-I) (r(128) = -.18, P = .044) and Verbal Learning Test-Delayed (VLT-D) (r(128) = -.18, P = .037). The variables that independently predicted cognitive functioning were the VLT-I, odds ratio (OR) 0.66; 95% confidence interval ((CI) 0.49-0.88) and education (OR) 0.61;(CI) 0.40- 0.92).ConclusionPoor subjective sleep quality measured by the PSQI is linked to cognitive impairment in remitted patients with schizophrenia. We suggest that sleep quality in remitted patients with a diagnosis of schizophrenia should receive better attention by physicians.     

Aneurysmal acute subdural hemorrhage: Prognostic factors associated with treatment

Acute subdural hematoma is an uncommon presentation of aneurysmal hemorrhage that has been identified as a poor prognostic sign. Current series are small, have short follow-up, or were collected over a long period during which treatment evolved. To evaluate prognostic factors, we analyzed a large modern series of aneurysmal subdural hematoma (aSDH) with long-term follow-up. A prospectively maintained database was queried for patients presenting with aSDH from 2001–2013. Thirty patients met the study criteria. Statistical analysis was performed with unpaired t-test or Fisher’s exact test. Aneurysm treatment involved open clipping (n = 18), endosaccular coiling (n = 8), both (n = 1), or no treatment (n = 3). Good Glasgow Outcome Scale score at discharge was present in 20% and increased to 40% at 6–12 months postoperatively. Good clinical presentation was associated with good final outcome in 75%, whereas poor clinical presentation correlated with good outcome in 30%. Good outcome correlated with younger age (p = 0.04), smaller aneurysm (p = 0.04), and lower Hunt-Hess score (HH) at intervention (p = 0.04). Favorable outcome did not correlate with sex, race, presence of subarachnoid or intraparenchymal hemorrhage, size or laterality of hemorrhage, midline shift, aneurysm treatment modality, or HH at admission (p > 0.15). There was no difference between good and poor outcomes in terms of time to treatment or hematoma evacuation. Poor clinical presentation may be exaggerated by mass effect of hematoma; aggressive treatment is not futile. Presenting neurological status, age, and aneurysm size are predictors of outcome, while laterality and size of hematoma and extent of midline shift are not, suggesting that clinical status is more important than radiographic findings.     

Évaluation de l’autonomie sociale et de ses facteurs associés chez des patients tunisiens suivis pour schizophrénie

IntroductionSocial autonomy concerns specific areas that people with chronic psychiatric disorders, such as schizophrenia, face daily when they live in the community. The degree of social autonomy is one of the principal determinants of success of the therapeutic project for patients suffering from schizophrenia. However, the domains of social autonomy would depend on the socio-cultural context and the familial and professional environment of the country.ObjectivesThe objectives of this study were to evaluate the social autonomy level and to research its associated factors in a sample of Tunisian out-patients with schizophrenia.MethodsIt was a cross-sectional study of 115 out-patients (mean age: 37.6 ± 10.2 years, 75.7% male), followed for schizophrenia according DSM-IV diagnostic criteria and treated with long-term antipsychotics, mainly first generation (81%), with a mean daily dosage of 1130 ± 875 mg in chlorpromazine equivalent. Data were collected during interviews with patients and their family members and supplemented by the review of medical records. Degree of social Autonomy was assessed by the Leguay's 17-items Social Autonomy Scale (EAS), exploring five dimensions: personal care, management of daily life, resource management, relationship with outside and affective and social relations. Global functioning level was assessed by the Global Assessment of Functioning (GAF) scale.ResultsThe total EAS score ranged from 14 to 90 with a mean score of 56.6 ± 16.8. Higher sub-scores indicating a poor social autonomy concerned the dimensions of “relationship with the outside world”, “resource management” and “management of daily life”. A negative correlation was found between the EAS total score and the GAF score (r = −0.78, P < 0.0001). Thus, the lower GAF score suggesting impaired global functioning was associated to the higher EAS score in favor of altered social autonomy. Altered social autonomy was associated with low school level (P = 0.02), lack of regular professional activity (P = 0.001), disorganized subtype (P = 0.002), negative symptoms at the last hospitalization (P = 0.03), continuous course (P < 0.0001) and daily dosage of antipsychotic medication (P = 0.02). However, age or gender of the patients, psychiatric family history, age of onset, duration of untreated psychosis, number and duration of previous hospitalizations, antipsychotic treatment generation were not associated with social autonomy in our sample.ConclusionsDespite therapeutic advances in recent decades, the social autonomy of our patients with schizophrenia remains precarious. Several socioeconomic and clinical factors seem to be involved. Further interventions will be needed to enable our patients to function more actively and autonomously in society.     

Intravenous alteplase for Chinese patients with stroke and borderline eligibility

Lack of efficacy and safety data among Chinese patients with stroke have contributed to the slow development of stroke thrombolysis as standard-of-care for these patients. We examined a retrospective cohort of 57 patients who received intravenous alteplase for acute ischemic stroke to identify predictors of outcome, including age, stroke severity, onset-to-treatment time, and early ischemic changes on brain CT scan. Overall, the mean National Institute of Health Stroke Scale (NIHSS) score was 15.7 and the mean onset-to-treatment time was 142 minutes. Twenty-nine (51%) patients had a favorable outcome with modified Rankin Scale (mRS) score of ?2 at three months. Ten (17.5%) patients were deceased at three months. Four (7%) patients developed symptomatic intracranial hemorrhage (sICH). For patients aged >80 years (n = 18), five (28%) achieved favorable outcome, six (33%) were deceased at three months and three (17%) had sICH. Prognosis was worst for patients with NIHSS score >25 (n = 5); one (20%) was dependent (mRS 4) and the other four (80%) were deceased. Multivariate analysis found that the Alberta Stroke Program Early CT Score (ASPECTS) was associated with favorable outcome (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1–3.0), and mortality (OR 0.5, 95% CI 0.3–0.9). Our findings showed advanced age and severe stroke were associated with less favorable outcome in Chinese patients receiving intravenous alteplase, ASPECTS can be used reliably to identify patients at risk of poor outcomes. Further studies are warranted.