Descriptive analysis of unplanned readmission and reoperation rates after intradural spinal tumor resection

IntroductionSpinal cord tumors (SCT) are relatively uncommon and usually require surgical treatment. Readmission within 30 days after discharge is an important indicator of health care quality. The aim of this study was to investigate the rates and causes of unplanned readmissions and reoperations after SCT surgery.MethodsA retrospective analysis of patients’ charts at a single center from May 2007 to September 2015 was completed. Inclusion criteria: history of laminectomy with excision of neoplasm in the spinal cord. Exclusion criteria: (1) surgery outside the timeframe; (2) less than 19 years old; (3) non-neoplastic intramural pathologies; (4) previous resection at the same location; (5) metastatic lesions.ResultsWe found 131 patients that met criteria. Six patients (4.5%) were readmitted within 30 days and two within 90 days (1.5%). Four underwent reoperation: one for a cerebrospinal fluid leak, two for pseudomenigoceles, and one for repeat laminectomy. Resection of intramedullary tumors resulted in twice the risk of having one or more complications compared to extramedullary tumors (RR 2.0; 95% CI: 1.0–4.2; p = 0.057), and nearly four times the risk of having a neurological complication (RR 3.8; 95% CI 1.5–9.5; p = 0.005).ConclusionThis study analyzes readmission, reoperation and complication rates for the surgical care of SCT highlighting how SCT surgery is still involved with morbidity in experienced and specialized centers. This information is useful both for health care enhancement projects and for evidence-based patient counseling.     

Post-operative delirium is an independent predictor of 30-day hospital readmission after spine surgery in the elderly (≥65 years old): A study of 453 consecutive elderly spine surgery patients

In the last decade, costs of U.S. healthcare expenditures have been soaring, with billions of dollars spent on hospital readmissions. Identifying causes and risk factors can reduce soaring readmission rates and help lower healthcare costs. The aim of this is to determine if post-operative delirium in the elderly is an independent risk factor for 30-day hospital readmission after spine surgery. The medical records of 453 consecutive elderly (≥65 years old) patients undergoing spine surgery at Duke University Medical Center from 2008 to 2010 were reviewed. We identified 17 (3.75%) patients who experienced post-operative delirium according to DSM-V criteria. Patient demographics, comorbidities, and post-operative complication rates were collected for each patient. Elderly patients experiencing post-operative delirium had an increased length of hospital stay (10.47 days vs. 5.70 days, p = 0.009). Complication rates were similar between the cohorts with the post-operative delirium patients having increased UTI and superficial surgical site infections. In total, 12.14% of patients were re-admitted within 30-days of discharge, with post-operative delirium patients experiencing approximately a 4-fold increase in 30-day readmission rates (Delirium: 41.18% vs. No Delirium: 11.01%, p = 0.002). In a multivariate logistic regression analysis, post-operative delirium is an independent predictor of 30-day readmission after spine surgery in the elderly (p = 0.03). Elderly patients experiencing post-operative delirium after spine surgery is an independent risk factor for unplanned readmission within 30-days of discharge. Preventable measures and early awareness of post-operative delirium in the elderly may help reduce readmission rates.     

Discharge to a rehabilitation facility is associated with decreased 30-day readmission in elective spinal surgery

The aim of our study was to determine independent predictors of discharge disposition to rehabilitation or skilled care (SC) facilities and investigate whether discharge location is associated with unplanned readmission and/or reoperation rates. All elective spinal surgery patients in a national surgical registry were analyzed using between 2011 and 2012. Multivariable logistic regression analysis was used to assess for predictors of discharge to rehabilitation or SC facilities versus home as well as to determine whether discharge disposition was significantly associated with the 30-day unplanned readmission or reoperation. Of 34,023 elective spinal surgery patients, the distribution of discharge locations was as follows: 30,606 (90.0%) discharged home, 1674 (4.9%) discharged to rehabilitation, and 1743 (5.1%) discharged to SC. Patients discharged home were associated with the lowest complication rate relative to rehabilitation and SC facilities. Following multivariable regression analysis, there was a significant increase in the odds of discharge to rehabilitation associated with age, male gender, current smoking, ASA class three and four, history of diabetes, operative time, total hospital length of stay, preoperative neurologic morbidity and having at least one postoperative morbidity event. Moreover, there were 804 (4.06%) 30-day unplanned readmissions and 822 (2.45%) unplanned reoperations. After risk adjustment, discharge to rehabilitation was independently associated with decreased odds of 30-day unplanned readmission (OR = 0.41; p = 0.008) but not reoperation.     

Rate of readmission and mortality risks of schizophrenia patients who were discharged against medical advice

PurposeTo compare the readmission and the mortality rates of schizophrenia patients who were discharged against medical advice (AMA) and patients who were discharged by physician recommendation.MethodsThe records (1984–2005) of all consecutive admissions (n = 12,937) of schizophrenia patients (n = 8,052) were reviewed. Out of this group, 673 (8.3%) refused to remain in the hospital and signed a hospital form for discharge AMA. Their records were analyzed for rates of re-hospitalization and mortality at study closure. The records of AMA patients were compared to those of patients with regular discharge (n = 1345).ResultsAMA patients were younger at admission (P < 0.001), comprised more males (P < 0.01), more were single (P < 0.0001), and had a shorter duration of illness than the controls (P < 0.05). A total of 49.9% of AMA events occurred within the first 2 weeks of hospitalization. The readmission rate was significantly higher for AMA patients than for the controls (P < 0.001). The mortality rate as a result of suicide (P < 0.0001) and accidents (P < 0.05) was higher for AMA patients compared to controls.ConclusionThe schizophrenia patients discharged AMA have a higher readmission rate and a higher mortality rate due to suicide and accidents compared to non-AMA discharged patients. Patients with AMA discharge warrant special community surveillance to improve outcome.     

Effects of risperidone on glucose metabolism in Chinese patients with schizophrenia: A prospective study

BackgroundWhile most of the second generation antipsychotic agents are associated with abnormal glucose metabolism, previous studies have shown that risperidone has relatively little effect upon blood glucose levels. This study aimed to explore the effect of risperidone on the glucose-regulating mechanism of patients with schizophrenia by using the oral glucose tolerance test (OGTT), measuring insulin and C-peptide levels.MethodsThirty inpatients with schizophrenia taking risperidone were studied. All the patients were given a simplified OGTT at baseline and six weeks after treatment. Plasma glucose, insulin, and C-peptide concentrations were measured at fasting, then 1 and 2 h after OGTT respectively. Other data, including demographic characteristics and plasma drug concentrations, were also recorded.Results(1) There was no significant increase in the proportion of patients demonstrating abnormal plasma glucose levels compared with baseline (p = 1.000, McNemar test); (2) risperidone was associated with elevated insulin concentrations (p = 0.013), C-peptide levels (p = 0.020), insulin/glucose ratio (p = 0.020) and BMI (p < 0.01); (3) no sex differences in glucose-related measures were observed.ConclusionRisperidone treatment may be associated with alterations in glucose-regulating mechanisms in patients with schizophrenia.     

Effects of clozapine and olanzapine on cortical thickness in childhood-onset schizophrenia

BackgroundLittle is known about the effects of antipsychotic medications on gray matter (GM) in schizophrenia. Although clozapine remains the most effective antipsychotic medication in treatment-refractory cases, it is unknown whether it has a differential effect on GM development.MethodsIn an exploratory analysis, we used automated cortical thickness measurements and prospectively scanned childhood-onset schizophrenia (COS) patients who were maintained on one medication. Two atypical antipsychotic medications, clozapine (n = 12, 37 scans) and olanzapine (n = 12, 33 scans) were compared with respect to effects on cortical development, in contrast to GM trajectories of matched controls.ResultsThere were no significant differences in the trajectories of cortical thickness between the two treatment groups with the exception of a small circumscribed area in the right prefrontal cortex, where the olanzapine group showed thicker cortex. As expected, both groups showed thinner GM compared to matched controls.ConclusionsAlthough these analyses do not rule out effects of antipsychotic medications on GM development in schizophrenia, they show no differential effect between clozapine and olanzapine on GM trajectory.     

Improvements in metabolic abnormalities among overweight schizophrenia and bipolar disorder patients

PurposeAs weight-gain and metabolic abnormalities during treatment with psychotropic drugs are of great concern, we evaluated effects of psycho-education and medical monitoring on metabolic changes among severely mentally ill patients.Materials and methodsDuring repeated, systematic psycho-education about general health among 66 consecutive patients diagnosed with DSM-IV-TR schizophrenia (n = 33) or type-I bipolar disorder (n = 33), we evaluated (at intake 1, 2, 3, and 6 months) clinical psychiatric status, treatments and doses, recorded physiological parameters, and assessed attitudes about medication.ResultsAt intake, patients with schizophrenia vs bipolar disorder were receiving 3–7 times more psychotropic medication, with 14% higher initial body-mass index (BMI: 29.1 vs 25.6 kg/m2), 12 times more obesity, and significantly higher serum lipid concentrations. During 6-months follow-up, among bipolar disorder patients, polytherapy and serum lipid concentrations declined more than among schizophrenia patients (e.g., total cholesterol + triglycerides, by 3.21 vs 1.75%/month). BMI remained stable. Declining lipid levels were associated with older age, bipolar disorder, being unemployed, higher antipsychotic doses, and lower initial BPRS scores (all P ≤ 0.001).ConclusionsPsychotropic treatments were more complex, and metabolic measures more abnormal among bipolar disorder than schizophrenia patients. Intensive psycho-education, clinical monitoring, and encouragement of weight-control for six months were associated with improvements in metabolic measures (but not to BMI), and more realistic attitudes about medication.     

The interaction of subjective experience and attitudes towards specific antipsychotic-related adverse effects in schizophrenia patients

BackgroundDiscontinuation of antipsychotic drugs in schizophrenia patients is a major concern, since it results in relapse and re-hospitalizations. Non-adherence is strongly associated with negative-subjective response to antipsychotics, which is composed of the subjective experience of negative drug effects and attitude towards the treatment.ObjectiveTo investigate the elements of subjective experience and subjective attitude towards specific drug-related adverse effects, leading to a generally negative-subjective attitude towards antipsychotics.MethodsSchizophrenia inpatients (n = 84) were administered a questionnaire measuring attitude and experience on eight subscales: weight gain, sedation, sexual anhedonia, extra-pyramidal syndrome, affective flattening, excessive sleep, diminished sociability and metabolic syndrome. DAI-30 was used to measure attitude towards drugs, and PANSS to assess psychopathology.ResultsWeak correlation was found between subjective experience and attitude on most of the subscales. The only strong, albeit inverse, correlation between experience and attitude that was found was with regard to affective flattening, experienced by 37% of the sample, and it also predicted negative drug attitude as measured by the DAI-30, RR: 1.87 (95% CI: 1.06–3.3, df = 1, χ² = 4.525, P < 0.05).ConclusionNegative attitude towards most adverse drug effects did not correlate with personal experience. Drug-related affective flattening should be evaluated routinely, since experiencing it may predict negative attitude towards drugs, potentially leading to poor compliance and relapse.     

Early improvement as a predictor of remission and response in schizophrenia: Results from a naturalistic study

ObjectiveTo examine the predictive validity of early improvement in a naturalistic sample of inpatients and to identify the criterion that best defines early improvement.MethodsTwo hundred and forty-seven inpatients who fulfilled ICD-10 criteria for schizophrenia were assessed with the Positive And Negative Syndrome Scale (PANSS) at admission and at biweekly intervals until discharge from hospital. Remission was defined according to the recently proposed consensus criteria, response as a reduction of at least 40% in the PANNS total score from admission to discharge.ResultsReceiver operating characteristic (ROC) analyses showed that early improvement (reduction of the PANSS total score within the first 2 weeks of treatment) predicts remission (AUC = 0.659) and response (AUC = 0.737) at discharge. A 20% reduction in the PANSS total score within the first 2 weeks was the most accurate cut-off for the prediction of remission (total accuracy: 65%; sensitivity: 53%; specificity: 76%), and a 30% reduction the most accurate cut-off for the prediction of response (total accuracy: 76%; sensitivity: 47%; specificity: 90%).ConclusionThe findings of clinical drug trials that early improvement is a predictor of subsequent treatment response were replicated in a naturalistic sample. Further studies should examine whether patients without early improvement benefit from an early change of antipsychotic medication.     

Results of phase 3 of the CATIE schizophrenia trial

ObjectiveThe Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study examined the comparative effectiveness of antipsychotic treatments for individuals with chronic schizophrenia. Patients who had discontinued antipsychotic treatment in phases 1 and 2 were eligible for phase 3, in which they selected one of nine antipsychotic regimens with the help of their study doctor. We describe the characteristics of the patients who selected each treatment option and their outcomes.MethodTwo hundred and seventy patients entered phase 3. The open-label treatment options were monotherapy with oral aripiprazole, clozapine, olanzapine, perphenazine, quetiapine, risperidone, ziprasidone, long-acting injectable fluphenazine decanoate, or a combination of any two of these treatments.ResultsFew patients selected fluphenazine decanoate (n = 9) or perphenazine (n = 4). Similar numbers selected each of the other options (range 33–41). Of the seven common choices, those who selected clozapine and combination antipsychotic treatment were the most symptomatic, and those who selected aripiprazole and ziprasidone had the highest body mass index. Symptoms improved for all groups, although the improvements were modest for the groups starting with relatively mild levels of symptoms. Side effect profiles of the medications varied considerably but medication discontinuations due to intolerability were rare (7% overall).ConclusionsPatients and their doctors made treatment selections based on clinical factors, including severity of symptoms, response to prior treatments, and physical health status. Fluphenazine decanoate was rarely used among those with evidence of treatment non-adherence and clozapine was underutilized for those with poor previous response. Combination antipsychotic treatment warrants further study.     

Eurofit test battery in patients with schizophrenia or schizoaffective disorder: Reliability and clinical correlates

ObjectiveTo investigate the reproducibility of the Eurofit physical fitness test battery in patients with schizophrenia or schizoaffective disorder. Secondary aims were to assess clinical and demographic characteristics that correlate with the performance on the Eurofit and evaluation of the feasibility of the test.MethodsFifty patients with schizophrenia or schizoaffective disorder (mean age of 32.9 ± 9.5 years) with a mean body mass index (BMI) of 26.1 ± 6.0 kg/m² performed two Eurofit tests administered within 3 days.ResultsAll Eurofit items showed good reproducibility with intraclass correlation coefficients ranging from 0.72 for flamingo balance to 0.98 for standing broad jump test. All participants could perform five of the seven test items without problems. The whole body balance and abdominal muscle endurance test could be executed by 74 and 90%, respectively. Significant correlations were found with age, BMI, waist circumference, dose of antipsychotic medication and extrapyramidal, negative and cognitive symptoms.ConclusionsThe Eurofit test showed good reproducibility and can be recommended for evaluating physical fitness parameters in patients with schizophrenia or schizoaffective disorder. Physical fitness measures were related to both physical and mental health parameters.     

Maternal schizophrenia and pregnancy outcome: Does the use of antipsychotics make a difference?

ObjectiveThis study compared the risk of adverse pregnancy outcome—including preterm births, low birth weight (LBW), large-gestational-age (LGA), and small-gestational-age (SGA)—among mothers with schizophrenia receiving typical, atypical, and no antipsychotics during pregnancy. They were all compared with control subjects.MethodsWe used population-based data from the Taiwan National Health Insurance Research Database and birth certificate registry covering the years 2001 to 2003. In total, 696 mothers with schizophrenia and 3480 matched unaffected mothers were included for analysis. After adjusting for characteristics of mother, father, and infants, multivariate logistic regression analyses were performed to examine the risk of LBW, preterm gestation, SGA, and LGA, comparing mothers with schizophrenia and unaffected mothers.ResultsAfter adjusting for potential confounders, the odds of LBW and SGA for unaffected mothers respectively were 0.72 (95% CI = 0.50–0.88) and 0.81 (95% CI = 0.64–0.92) times those of mothers with schizophrenia who had not receiving antipsychotics during pregnancy. There was no significant difference in the risk of LBW, preterm births, LGA, and SGA babies compared to mothers with schizophrenia receiving atypical antipsychotics during pregnancy and those not receiving antipsychotics. However, mothers with schizophrenia receiving typical antipsychotics during pregnancy had higher odds of preterm birth (OR = 2.46, 95% CI = 1.50–4.11) compared to those not receiving antipsychotics.ConclusionsThe data suggest that the risks for LBW and SGA among mothers with schizophrenia are not affected by antipsychotic use. Women who receive treatment with typical antipsychotics during pregnancy are at slightly higher risk of preterm birth.     

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.     

A controlled family study of cannabis users with and without psychosis

BackgroundCannabis is one of the most highly abused illicit drugs in the world. Several studies suggest a link between adolescent cannabis use and schizophrenia. An understanding of this link would have significant implications for legalization of cannabis and its medicinal value. The present study aims to determine whether familial morbid risk for schizophrenia is the crucial factor that underlies the association of adolescent cannabis use with the development of schizophrenia.MethodsConsecutively obtained probands were recruited into four samples: sample 1: 87 non-psychotic controls with no drug use; sample 2: 84 non-psychotic controls with cannabis use; sample 3: 32 patients with a schizophrenia spectrum psychosis with no drug use; sample 4: 76 patients with schizophrenia spectrum psychosis with cannabis use. All cannabis using subjects used this drug during adolescence, and no other substance, with the exception of alcohol. Structured interviews of probands and family informants were used to obtain diagnostic information about probands and all their known relatives.ResultsThere was an increased morbid risk for schizophrenia in relatives of the cannabis using and non-using patient samples compared with their respective non-psychotic control samples (p = .002, p < .001 respectively). There was no significant difference in morbid risk for schizophrenia between relatives of the patients who use or do not use cannabis (p = .43).ConclusionsThe results of the current study suggest that having an increased familial morbid risk for schizophrenia may be the underlying basis for schizophrenia in cannabis users and not cannabis use by itself.     

Real-world effectiveness of antipsychotic monotherapy vs. polypharmacy in schizophrenia: To switch or to combine? A nationwide study in Hungary

BackgroundLeading guidelines recommend antipsychotic (AP) monotherapy for schizophrenia, nonetheless the combination of antipsychotics (polypharmacy) is common practice worldwide. We conducted a nationwide population-based study to investigate the comparative effectiveness of monotherapy versus polypharmacy in schizophrenia and other psychotic disorders.MethodsData was collected from the Hungarian National Health Insurance Fund's database and a non-interventional retrospective–prospective parallel arm study was designed with a monotherapy arm (MA, switch to a new antipsychotic after > 60 days of monotherapy, N = 5480) and a polypharmacy arm with two APs (PA, addition of a second antipsychotic after > 60 days of monotherapy, N = 7901). The analyses focused on therapy changers, who started a new monotherapy or added a new AP to the existing one. Polypharmacy combinations with more than two APs were not investigated. Fourteen APs were investigated representing the majority of marketed antipsychotics of Hungary in the period of 1/2007–12/2009. The principal endpoint was the time to all-cause treatment discontinuation during a one-year observation period. Kaplan–Meier survival analysis and Cox proportional hazards model were applied with propensity score adjustment.ResultsThe principal outcome measure time to all-cause discontinuation indicated superiority for monotherapy over polypharmacy for the majority of (oral and depot) second generation APs (SGAs). For first generation APs (FGAs), oral formulations did not show a difference between monotherapy and polypharmacy, while depot formulations exhibited polypharmacy advantage. For the four most frequently used oral SGAs, the median times to all-cause discontinuation for monotherapy and polypharmacy, respectively, were 192 and 100 days for aripiprazole; 222 and 86 days for olanzapine; 176 and 91 days for quetiapine; and 157 and 93 days for risperidone. For mortality and hospitalization, a significant overall advantage of polypharmacy was detected.ConclusionsOur study provides evidence for the superiority of monotherapy over polypharmacy for SGAs in terms of all-cause treatment discontinuation in schizophrenia. Polypharmacy, however, was associated with a lower likelihood of mortality and hospitalizations. The finding that MA is superior to PA for long-term sustained treatment whereas polypharmacy has advantage in mortality and psychiatric hospitalizations suggests that combination treatments may be more efficacious during exacerbation of psychotic symptoms.     

Type-2 diabetes mellitus in schizophrenia: Increased prevalence and major risk factor of excess mortality in a naturalistic 7-year follow-up

ObjectivePhysical co-morbidity including type 2 diabetes mellitus is more prevalent in patients with schizophrenia compared to the general population. However, there is little consistent evidence that co-morbidity with diabetes mellitus and/or other diseases leads to excess mortality in schizophrenia. Thus, we investigated whether co-morbidity with diabetes and other somatic diseases is increased in schizophrenics, and if these are equally or more relevant predictors of mortality in schizophrenia than in age- and gender-matched hospitalised controls.MethodsDuring 2000–2007, 679 patients with schizophrenia were admitted to University Hospital Birmingham NHS Trust. Co-morbidities were compared with 88,778 age- and gender group-matched hospital controls. Predictors of mortality were identified using forward Cox regression models.ResultsThe prevalence of type 2 diabetes mellitus was increased in schizophrenia compared to hospitalised controls (11.3% versus 6.3%). The initial prevalence of type 2 diabetes mellitus was significantly higher in the 100 later deceased schizophrenic patients (24.0%) than in those 579 surviving over 7 years (9.2%). Predictors of mortality in schizophrenia were found to be age (relative risk [RR] = 1.1/year), type 2 diabetes mellitus (RR = 2.2), pneumonia (RR = 2.7), heart failure (RR = 2.9) and chronic renal failure (RR = 3.2). The impact of diabetes mellitus on mortality was significantly higher in schizophrenia than in hospital controls (RR = 2.2 versus RR = 1.1). In agreement, deceased schizophrenics had significantly suffered more diabetes mellitus than deceased controls (24.0 versus 10.5%). The relative risks of mortality for other disorders and their prevalence in later deceased subjects did not significantly differ between schizophrenia and controls.ConclusionSchizophrenics have more and additionally suffer more from diabetes: co-morbidity with diabetes mellitus is increased in schizophrenia in comparison with hospital controls; type 2 diabetes mellitus causes significant excess mortality in schizophrenia. Thus, monitoring for and prevention of type 2 diabetes mellitus is of utmost relevance in hospitalised patients with schizophrenia.     

Les facteurs liés aux actes d’homicide chez les patients tunisiens atteints de schizophrénie

IntroductionEvaluation of variables correlated to homicide is a fundamental issue for developing preventive and therapeutic strategies to deal with such criminal behavior.ObjectivesThe objectives of this study were to assess the characteristics of homicide in Tunisian patients suffering from schizophrenia and to determine the correlated socio-demographic, clinical and therapeutic variables.MethodsThe study included two groups of male patients with a DSM-IV diagnosis of schizophrenia who attended the “Razi” university psychiatric hospital of Tunis. The first group was composed of 36 patients hospitalized for homicide in the forensic unit between the first of January 2000 and the 30th of May 2012. The second group included 50 patients without any criminal record. Demographic, clinical and therapeutic variables were analyzed and compared between the two groups.ResultsNo differences were found between the two groups regarding the different socio-demographic variables. Significant differences were found with respect to a duration of untreated psychosis equal to or more than one year (p = 0.048), shorter duration of psychiatric care (p = 0.002), lower number of hospitalizations (p = 0.026), antecedent of forced hospitalization (p < 0.001), low degree of insight (p = 0.001), poor medication compliance (p < 0.001) and higher antipsychotic doses (p = 0.001).DiscussionDemographic variables as suggested by other studies are less valuable predictors of homicide in patients with schizophrenia.ConclusionInterventions for reducing such behavior should focus on clinical variables and integrate an early diagnosis of the disease and improvement of insight as well as medication compliance.     

Establishing remission and good clinical functioning in schizophrenia: Predictors of best outcome with long-term risperidone long-acting injectable treatment

ObjectiveTo measure symptomatic and functional remission in patients treated with risperidone long-acting injectable (RLAI).MethodsStable patients with psychotic disorders requiring medication change were switched to open-label RLAI in the switch to risperidone microspheres (StoRMi) trial. In this post-hoc analysis of the trial extension, follow-up was ≤18 months. Symptomatic remission was based on improvement in positive and negative syndrome scale (PANSS) scores and global remission (best outcome) was based on symptomatic remission, functional level, and mental-health quality of life. Predictive factors were evaluated.ResultsAmong 529 patients from seven European countries, mean participation duration was 358.7 ± 232.4 days, with 18 months completed by 39.9% of patients. Symptomatic remission lasting ≥6 months occurred at some point during treatment in 33% of patients; predictors included comorbid disease, country, baseline symptom severity, baseline functioning, type of antipsychotic before switching, and duration of untreated psychosis. Best outcome occurred in 21% of patients; predictors included baseline symptom severity, baseline functioning, country, schizophrenia type, and early positive treatment course.ConclusionsOne in three patients with stable schizophrenia switching to RLAI experienced symptomatic remission, with combined symptomatic, functional, and quality-of-life remission in one in five patients. Symptomatic remission was predicted by better baseline symptom severity and country of origin, with a significantly greater likelihood of remission occurring among patients in Estonia/Slovenia compared with Portugal. Relapse was predicted by higher mode doses of RLAI, additional use of psychoactive medications, male gender, and country of origin, with relapse occurring most frequently in France and least frequently in Portugal. RLAI dose, additional use of psychoactive medications, and country of origin predicted best outcome, with best outcome occurring most frequently in Estonia/Slovenia and least frequently in Portugal.     

Arrêt et réduction du tabac chez le patient souffrant de schizophrénie

ObjectivesThis systematic review of the literature looked at data on pharmacological and non-pharmacological strategies of smoking cessation and reduction of consumption in patients with schizophrenia.MethodThe research was conducted on Medline for the period 1980–2018. We included randomized controlled trials, including preliminary studies of stable schizophrenic patients with no other severe psychiatric disorder and no other substance use than tobacco, treated with antipsychotic medications. Individual or group smoking cessation programs with or without pharmacological treatment, including a validation of abstinence, were included.ResultsPharmacotherapies for nicotine dependence—nicotine replacement therapy (n = 3), bupropion (n = 6), varenicline (n = 8), association of medications (n = 4)—were used in 23 studies combined with behavioral support. Compared to the placebo, bupropion and varenicline at the end of treatment were found to be the most effective pharmacotherapies to stop or reduce smoking and control craving. All the medications were well tolerated and did not lead to aggravation of psychosis or changes in symptoms. Non-pharmacological interventions: behavioral and cognitive therapies (n = 5) combined with pharmacological treatment facilitated the management of smoking risk situations and improved adherence to antipsychotics; other psychosocial interventions (n = 7) allowed the development of social skills; contigency management strategies with financial reinforcement can be used (n = 4); the practice of physical activity and the use of an electronic cigarette allowed reduction of tobacco consumption. The results of transcranial electromagnetic stimulation studies (n = 6) were discordant. Atypical antipsychotics appear to be associated with a better success of attempts to stop smoking.ConclusionSmoking cessation strategies for patients with schizophrenia appear to be effective and should combine (1) smoking cessation medications with sufficient duration, (2) diversified psychosocial approaches and (3) physical activity practice.