Progressive brain changes in schizophrenia related to antipsychotic treatment? A meta-analysis of longitudinal MRI studies

Context

Antipsychotic treatment is the first-line treatment option for schizophrenia. Individual studies suggested they can significantly affect brain structure and account for progressive brain changes observed during the illness.

Objectives

To quantitatively examine the effect of antipsychotics as compared to illness related factors on progressive brain changes in schizophrenia.

Data sources

Electronic databases were searched until April 2012. All magnetic resonance imaging studies reporting progressive brain changes in schizophrenia subjects and antipsychotic exposure were retrieved.

Study selection

30 longitudinal MRI studies with antipsychotic administration in schizophrenia patients met the inclusion criteria.

Data extraction

Brain volumes before and after antipsychotic exposure, duration of illness, severity of psychotic symptoms as well as demographic, clinical, and methodological variables were extracted from each publication, or obtained directly from its authors.

Data synthesis

The overall sample was of 1046 schizophrenia patients and 780 controls for a median duration of follow-up of 72.4 weeks. At baseline, patients showed significant whole brain volume reductions and enlarged lateral ventricle (LV) volumes compared to controls. No baseline volumetric abnormalities were detected in the gray matter volumes (GMV), white matter volumes, cerebrospinal fluid and caudate nucleus. Longitudinally, there were progressive GMV decreases and LV enlargements in patients but not in controls. The GMV decreases were inversely correlated with cumulative exposure to antipsychotic treatments, while no effects were observed for duration of illness or illness severity.

Conclusions

Schizophrenia is characterized by progressive gray matter volume decreases and lateral ventricular volume increases. Some of these neuroanatomical alterations may be associated with antipsychotic treatment.     

Is the Prevalence of Metabolic Syndrome and Metabolic Abnormalities Increased in Early Schizophrenia? A Comparative Meta-Analysis of First Episode,Untreated and Treated Patients

We aimed to discover whether metabolic complications of schizophrenia (SZ) are present in first episode (FE) and unmedicated (UM) patients, in comparison with patients established on antipsychotic medication (AP).

Method:

A systematic search, critical appraisal, and meta-analysis were conducted of studies to December 2011 using Medline, PsycINFO, Embase and experts. Twenty-six studies examined FE SZ patients (n = 2548) and 19 included UM SZ patients (n = 1325). For comparison we identified 78 publications involving 24 892 medicated patients who had chronic SZ already established on AP.

Results:

In UM, the overall rate of metabolic syndrome (MetS) was 9.8% using any standardized criteria. Diabetes was found in only 2.1% and hyperglycaemia (>100mg/dl) in 6.4%. In FE, the overall MetS rate was 9.9%, diabetes was found in only 1.2%, and hyperglycaemia in 8.7%. In UM and FE, the rates of overweight were 26.6%, 22%; hypertriglyceridemia 16.9%, 19.6%; low HDL 20.4%, 21.9%; high blood pressure 24.3%, 30.4%; smoking 40.2%, 46.8%, respectively. In both groups all metabolic components and risk factors were significantly less common in early SZ than in those already established on AP. Waist size, blood pressure and smoking were significantly lower in UM compared with FE.

Conclusion:

There is a significantly lower cardiovascular risk in early SZ than in chronic SZ. Both diabetes and pre-diabetes appear uncommon in the early stages, especially in UM. However, smoking does appear to be elevated early after diagnosis. Clinicians should focus on preventing initial cardiometabolic risk because subsequent reduction in this risk is more difficult to achieve, either through behavioral or pharmacologic interventions.Key words: cardiovascular risk, diabetes, lipids, glucose, waist, obesity     

Experience and outcomes of stepping stones triple P for families of children with autism

This study investigated the experience and perceived outcomes of a behavioural family intervention, standard stepping stones triple P (SSTP), for parents of children with autism. An indepth, prospective, mixed-methods, multiple case-study design was employed. Parent participants and SSTP practitioners took part. Participation in SSTP was consistently associated with improved parental self-efficacy, and was also associated with improved parental psychological well-being and decreased perceived need for behavioural services for some families. Three key themes emerged from the qualitative interview data, reflecting changes attributed to participation in SSTP: (1) changes in the “attribution of cause” of misbehaviour, (2) “Who's the boss?” reflecting a change to parents feeling more in charge of their child's behaviour, daily routines and choices, and (3) “Rewarding is rewarding!” reflecting appreciation of a positive approach to behaviour management. Practitioners discussed their impressions of appropriate participants, timing, structure, and session preferences for SSTP, and implications related to the professional qualifications of practitioners delivering SSTP. Clinical implications for the use of SSTP with families of children with autism are discussed.     

Single‐Center Experience With HeartMate II Left Ventricular Assist Device Explantation

In patients with continuous flow left ventricular assist devices (CF‐LVADs) myocardial recovery is uncommon. Given the heterogeneity of the population implanted and low incidence of recovery, the discovery of native left ventricular (LV) recovery and criteria for explantation of CF‐LVAD system is not clearly determined. We sought to analyze the characteristics of the patients who underwent CF‐LVAD explantation at our institution. Prospectively collected data on patients supported with CF‐LVADs were reviewed retrospectively. Patients who underwent CF‐LVAD explants were identified and their characteristics were analyzed with a focus on patient presentation and determinants of explantability. From November 2006 to June 2014, 223 patients (181 male, 42 female) underwent implantation of HeartMate II LVAD. Seven female (16.7%) and one male (0.6%) patients were explanted (P < 0.001). Mean age was 43 ± 9 years and etiology for cardiomyopathy was ischemic in three (37.5%) patients, nonischemic in four (50%) patients, and mixed in the one (12.5%) male patient of the cohort. Five (62.5%) patients presented acutely with significant hemolysis, and were found to have LV improvement as well as reduced, absent, or reversed diastolic flow velocities on echocardiography. Overall, mean lactate dehydrogenase level before explantation was 1709 ± 1168 U/L compared to the mean baseline level of 601 ± 316 U/L (P = 0.048). Mean LV ejection fraction (LVEF) improved from 17 ± 7% preimplant to 56 ± 11% pre‐explantation (P < 0.001). Median number of days on CF‐LVAD support was 870 (interquartile range, 209–975) while mean duration of follow‐up after the CF‐LVAD explantation was 276 ± 240 days. Mean LVEF dropped from 46 ± 19% postexplantation to 34 ± 10% during the most recent follow‐up (P = 0.015). At our institution, patients who underwent LVAD explants were predominantly women with nonischemic cardiomyopathy. Clinical evidence of hemolysis and echocardiographic evidence of reduced or absent diastolic flow velocities were common findings in these patients. Over time, patient's native LV function declined in the absence of LVAD (after LVAD explantation). Significant challenges remain in predicting LV recovery and identifying those individuals who have recovered myocardial function significant enough to be explanted.     

Work related injuries in Qatar: a framework for prevention and control

Work related injuries (WRIs) are a growing public health concern that remains under-recognized, inadequately addressed and largely unmeasured in low and middle-income countries (LMIC’s). However, even in high-income countries, such as those in Gulf Cooperating Council (GCC) like Qatar, there are challenges in assuring the health and safety of its labor population. Countries in the GCC have been rapidly developing as a result of the economic boom from the petrochemical industry during the early seventies. Economic prosperity has propelled the migration of workers from less developed countries to make up for the human resource deficiency to develop its infrastructure, service and hospitality industries. Although these countries have gradually made huge gains in health, economy and human development index, including improvements in life expectancy, education, and standard of living, there remains a high incidence of work-related injuries especially in jobs in the construction and petrochemical sector. Currently, there is scarcity of literature on work-related injuries, especially empirical studies documenting the burden, characteristics and risk factors of work injuries and the work injured population, which includes large numbers of migrant workers in many GCC countries. This paper will focus on the current understanding of WRIs in those countries and identify the gaps in current approaches to workplace injury prevention, outlining current status of WRI prevention efforts in Qatar, and propose a framework of concerted action by multi-sectoral engagement.