Large Multicenter Sample Research Articles

Selective disrupted gray matter volume covariance of amygdala subregions in schizophrenia.

Although extensive structural and functional abnormalities have been reported in schizophrenia, the gray matter volume (GMV) covariance of the amygdala remain unknown. The amygdala contains several subregions with different connection patterns and functions, but it is unclear whether the GMV covariance of these subregions are selectively affected in schizophrenia. To address this issue, we compared the GMV covariance of each amygdala subregion between 807 schizophrenia patients and 845 healthy controls from 11 centers. The amygdala was segmented into nine subregions using FreeSurfer (v7.1.1), including the lateral (La), basal (Ba), accessory-basal (AB), anterior-amygdaloid-area (AAA), central (Ce), medial (Me), cortical (Co), corticoamygdaloid-transition (CAT), and paralaminar (PL) nucleus. We developed an operational combat harmonization model for 11 centers, subsequently employing a voxel-wise general linear model to investigate the differences in GMV covariance between schizophrenia patients and healthy controls across these subregions and the entire brain, while adjusting for age, sex and TIV. Our findings revealed that five amygdala subregions of schizophrenia patients, including bilateral AAA, CAT, and right Ba, demonstrated significantly increased GMV covariance with the hippocampus, striatum, orbitofrontal cortex, and so on (permutation test, P< 0.05, corrected). These findings could be replicated in most centers. Rigorous correlation analysis failed to identify relationships between the altered GMV covariance with positive and negative symptom scale, duration of illness, and antipsychotic medication measure. Our research is the first to discover selectively impaired GMV covariance patterns of amygdala subregion in a large multicenter sample size of patients with schizophrenia.

Real-World Experience and Outcomes With Percutaneous Coronary Intervention for Protected Versus Unprotected Left Main Coronary Artery Disease: Insights from the Veteran Affairs Clinical Assessment Reporting and Tracking Program

Practice patterns and outcomes of protected left main (PLM) and unprotected left main (ULM) percutaneous coronary intervention (PCI) are not well defined in contemporary US clinical practice. Data collected from all Veteran Affairs (VA) catheterization laboratories participating in the Clinical Assessment Reporting and Tracking Program between 2009 and 2019. The analysis included 4,351 patients undergoing left main PCI, of which 1,306 pairs of PLM and ULM PCI were included in a propensity matched cohort. Selected temporal trends were also assessed. The primary outcome was MACE outcomes at 1-year, which was defined as a composite of all-cause mortality, rehospitalization for myocardial infarction (MI), rehospitalization for stroke or urgent revascularization. ULM PCI patients in comparison to PLM PCI were older (71.5 vs 69.2; P < 0.001), more clinically complex and more likely to present with ACS. In the propensity matched cohort, radial access was used more often for ULM PCI (21% [273] vs. 14% [185], P < 0.001), and ULM PCI was more likely to involve the LM bifurcation (22% vs 14%; P = 0.003) and require mechanical circulatory support (10% [134] vs 1% [17]; P <0.001). One-year MACE occurred more frequently with ULM PCI compared to PLM PCI (22% [289] vs. 16% [215]; P = < 0.001) and all-cause mortality was also higher (16% [213] vs. 10% [125]; P = < 0.001). In the matched cohort there was a low incidence of rehospitalization for MI (4% [48] ULM vs. 4% [48] PLM; P = 1.000) or revascularization (7% [94] ULM vs. 6% [84] PLM; P = 0.485). In this real-world experience patients undergoing PLM PCI had better one-year outcomes than those undergoing ULM PCI, but in both groups there was a high rate of mortality and MACE at one-year despite a relatively low rate of MI or revascularization.•What is known?○In contemporary practice, the use of percutaneous coronary intervention (PCI) for left main coronary artery disease has increased.○Clinical trials have demonstrated that left main PCI can be performed safely, but observational studies have shown that patients who undergo left main PCI are older and with more co-morbid conditions than trial populations.•What the study adds?○In a large multi-center sample from the United States Department of Veterans Affairs, there has been increasing use of left main PCI in patients who have not undergone prior coronary artery bypass graft surgery (CABG).○Compared to patients with prior CABG who underwent left main PCI, those who underwent left main PCI without prior CABG had a higher rate of major adverse cardiovascular events and all cause death at 12 months.○While there was an overall low rate of rehospitalization for myocardial infarction or revascularization, there was a higher 12-month incidence of major adverse cardiovascular events in this real-world population compared to clinical trial populations.

IMPACT OF OUTDOOR TEMPERATURE ON BLOOD PRESSURE PHENOTYPES: A LARGE MULTICENTER HOME BLOOD PRESSURE MONITORING STUDY

Objective: Blood pressure (BP) increases in colder seasons, but the impact of outdoor temperature on BP phenotypes derived from office BP (OBP) and home BP monitoring (HBPM) is not is not completely established due to the scarcity of data. This study evaluated the relationship of outdoor temperature with normotension (NT), white-coat hypertension (WCH), masked hypertension (MH) and sustained hypertension (SH) in a large multicenter Brazilian sample. Design and method: This cross-sectional study evaluated 57,606 individuals [39% men, mean age = 57.4±15.6 years, OBP = 131.4±19.8/83.9±11.8 mmHg, HBPM = 125.0±15.8/79.4±9.6 mmHg, 51% using antihypertensive medications (AH)] from 13 cities/metropolitan regions of the 5 Brazilian regions (North, Northeast, Central-West, Southeast and South) who underwent OBP and HBPM measurements from 2018 to 2022. Data on daily outdoor mean temperature (OMT), wind velocity and atmospheric pressure, and outdoor monthly humidity were collected from meteorological stations located in the studied cities. BP phenotypes were defined as: NT (OBP&lt;140/90mmHg and HBPM&lt;135/85mmHg), WCH (OBP &gt; = 140/90mmHg and HBPM&lt;135/85mmHg), MH (OBP&lt;140/90mmHg and HBPM&gt; = 135/85mmHg) and SH (OBP&gt; = 140/90mmHg and HBPM&gt; = 135/85mmHg). All regression analyses were adjusted for age, sex, BMI, calendar time, region, AH use and city altitude, wind velocity, atmospheric pressure and humidity. Results: Adjusted linear regression analysis showed a direct relationship of OMT with the difference in systolic OBP minus systolic HBPM (beta = 0.153±0.025; p&lt;0.001) and the difference in diastolic OBP minus diastolic HBPM (beta = 0.066±0.015; p&lt;0.001). Adjusted logistic regression analysis showed that each 1oC OMT increase was associated with a higher risk of WCH (OR [95%CI] = 1.011 [1.001–1.021]; p = 0.025) and NT (OR [95%CI] = 1.059 [1.051–1.066; p&lt;0.001], and lower risk of MH (OR [95%CI] = 0.965 [0.950–0.975]; p&lt;0.001) and SH (OR [95%CI] = 0.945 [0.937–0.952]; p&lt;0.001). Conclusions: Higher OMT is associated with greater difference in OBP levels relative to HBPM levels and is related to greater risk of WCH and NT and lower risk of MH and SH. These findings suggest that outdoor temperature should be considered in the evaluation and management of hypertension and BP phenotypes.

Early Surgical Management of Infants with Robin Sequence in a Large Multi-center Sample

OBJECTIVE: Studies of infants with Robin sequence (RS), the triad of micrognathia, glossoptosis and upper airway obstruction, are limited by the rarity of the condition and heterogeneity of the sample that results from phenotypic and diagnostic variability. Most knowledge of this condition is sourced from small, single-institution samples and is inherently biased. The purpose of this study is to characterize early surgical management of infants with RS in a large multi-institution sample. METHODS: This is a cross-sectional study initiated as part of the Children’s Hospital Neonatal Consortium (CHNC) micrognathia working group and includes infants with micrognathia admitted to CHNC centers from 2010-2020. Data was abstracted from the Children’s Hospital Neonatal Database (CHND), which captures clinical information for infants admitted to neonatal intensive care units at each of the 34 CHNC centers. Predictor variables included demographic data, birth characteristics, cleft and syndrome status, and operative details. Outcome variables included length of stay, death, feeding and respiratory support at hospital discharge, and need for secondary airway operations. Trends in surgical management between centers and over time were also evaluated. A p-value<0.05 was considered statistically significant for all analyses. RESULTS: Of the 248,010 patients included in CHND during the study period, 3256 (1.3%) had a diagnosis of micrognathia and 1294 (39.7%) of these had an operation to correct upper airway obstruction during infancy. For those that had an operation, mean age and weight at operation were 34.9±33.6 days and 3515.4±712.8 grams, respectively. A syndromic diagnosis was made in 152 (1.2%) prior to hospital discharge, with Stickler (n=71, 46.7%) and Treacher Collins Syndromes (n=28, 18.4%) most common. Operations included: mandibular distraction osteogenesis (MDO), n=856 (66%); tracheostomy, n=331 (26%); and tongue-lip adhesion (TLA), n=107 (8%). Analysis revealed several notable associations: Compared to MDO and TLA, initial tracheostomy was performed more commonly for male (51.0% vs 58.0%, p=0.03) infants without a cleft palate (35.3% vs 63.1%, p<0.001), and/or with Treacher Collins syndrome (0.4% vs 7.3%, p<0.001). Length-of-stay was shorter for MDO compared to TLA (57.9 +/- 40 vs. 69.0 +/- 40 days, p=0.007), and shorter for TLA compared to tracheostomy (69.0 +/- 40.0 vs. 110.4 +/- 71.0 days, p<0.001). Exclusive oral feeding was achieved by NICU discharge more frequently after MDO than TLA (35.4% vs 15.0%, p<0.001) and least commonly after tracheostomy (3.6%). The rate of gastrostomy tube placement was highest after tracheostomy (76.4%) and was and lowest after MDO (TLA=54.7%, MDO=28.5%, p<0.001). Infants that had MDO were less likely to require a second airway operation than those with TLA (3.5% vs 17.8%, p<0.001). Mortality was low for all operations (0.5%). CONCLUSION: In this cohort, the largest dataset of infants with RS ever reported, MDO was associated with shorter hospital stay, improved oral feeding, and lower rates for gastrostomy tube placement and secondary airway operations compared to TLA and tracheostomy. Prospective multi-center studies are necessary to further support these conclusions.

Gender differences in psychosocial function and self-reported health status in late-diagnosed autistic adults: results from the FACE-ASD national cohort.

While adult outcome in autism spectrum disorder (ASD) is generally measured using socially valued roles, it could also be understood in terms of aspects related to health status - an approach that could inform on potential gender differences. We investigated gender differences in two aspects of outcome related to health-status, i.e. general functioning and self-perceived health status, and co-occurring health conditions in a large multi-center sample of autistic adults. Three hundred and eighty-three participants were consecutively recruited from the FondaMental Advanced Centers of Expertise for ASD cohort (a French network of seven expert centers) between 2013 and 2020. Evaluation included a medical interview, standardized scales for autism diagnosis, clinical and functional outcomes, self-perceived health status and verbal ability. Psychosocial function was measured using the Global Assessment of Functioning scale. While autistic women in this study were more likely than men to have socially valued roles, female gender was associated with poorer physical and mental health (e.g. a 7-fold risk for having three or more co-occurring physical health conditions) and a poorer self-perceived health status. Psychosocial function was negatively associated with depression and impairment in social communication. Half of the sample had multiple co-occurring health conditions but more than 70% reported that their visit at the Expert Center was their first contact with mental health services. To improve objective and subjective aspects of health outcome, gender differences and a wide range of co-occurring health conditions should be taken into account when designing healthcare provision for autistic adults.

Latency to treatment seeking in patients with obsessive-compulsive disorder: Results from a large multicenter clinical sample

This study aimed to identify the factors associated with a delay in treatment-seeking among patients with obsessive-compulsive disorder (OCD), a disabling neuropsychiatric disorder. To achieve this purpose, we conducted a cross-sectional study examining latency to treatment (LTT) and its associated correlates in 863 patients with OCD. We defined LTT as the time lag between the awareness of discomfort and/or impairment caused by symptoms and the beginning of OCD-specific treatment. To determine the socio-demographic and clinical characteristics associated with LTT, we built an interval-censored survival model to simultaneously assess the relationship between all variables, representing the best fit to our data format. The results of our study showed that approximately one-third of OCD patients sought treatment within two years of symptom awareness, one-third between two and nine years, and one-third after ten or more years. Median LTT was 4.0 years (mean = 7.96, SD = 9.54). Longer LTT was associated with older age, early onset of OCD symptoms, presence of contamination/cleaning symptoms and full-time employment. Shorter LTT was associated with the presence of aggression symptoms and comorbidity with hypochondriasis. The results of our study confirm the understanding that LTT in OCD is influenced by several interdependent variables – some of which are modifiable. Strategies for reducing LTT should focus on older patients, who work in a full-time job, and on individuals with early onset of OCD and contamination/cleaning symptoms.

Behavioral coping phenotypes and associated psychosocial outcomes of pregnant and postpartum women during the COVID-19 pandemic

The impact of COVID-19-related stress on perinatal women is of heightened public health concern given the established intergenerational impact of maternal stress-exposure on infants and fetuses. There is urgent need to characterize the coping styles associated with adverse psychosocial outcomes in perinatal women during the COVID-19 pandemic to help mitigate the potential for lasting sequelae on both mothers and infants. This study uses a data-driven approach to identify the patterns of behavioral coping strategies that associate with maternal psychosocial distress during the COVID-19 pandemic in a large multicenter sample of pregnant women (N = 2876) and postpartum women (N = 1536). Data was collected from 9 states across the United States from March to October 2020. Women reported behaviors they were engaging in to manage pandemic-related stress, symptoms of depression, anxiety and global psychological distress, as well as changes in energy levels, sleep quality and stress levels. Using latent profile analysis, we identified four behavioral phenotypes of coping strategies. Critically, phenotypes with high levels of passive coping strategies (increased screen time, social media, and intake of comfort foods) were associated with elevated symptoms of depression, anxiety, and global psychological distress, as well as worsening stress and energy levels, relative to other coping phenotypes. In contrast, phenotypes with high levels of active coping strategies (social support, and self-care) were associated with greater resiliency relative to other phenotypes. The identification of these widespread coping phenotypes reveals novel behavioral patterns associated with risk and resiliency to pandemic-related stress in perinatal women. These findings may contribute to early identification of women at risk for poor long-term outcomes and indicate malleable targets for interventions aimed at mitigating lasting sequelae on women and children during the COVID-19 pandemic.

Cadaveric Classification of the Genicular Arteries, with Implications for the Interventional Radiologist

PurposeTo document and assess the genicular arterial variation in a large multicenter cadaveric sample and to generate an anatomical classification with implications for genicular artery embolization (GAE). Materials and MethodsA total of 212 dissected donor body lower limbs from 3 medical school institutions were included. The descending genicular artery (DGA), superior lateral genicular artery, superior medial genicular artery, middle genicular artery, inferior lateral genicular artery, inferior medial genicular artery, and anterior tibial recurrent artery were identified for gross anatomical appearance, location of origin, diameter of vessels, and variation in branching patterns. ResultsA total of 198 DGAs, 204 popliteal-origin genicular arteries, and 183 anterior tibial recurrent arteries were adequately preserved and reviewed. Three types (A: 26%, B: 71%, and C: 5%) of DGA branching patterns were proposed along with 6 types (I: 28%, II: 22%, III: 15%, IV: 15%, V: 10%, and VI: 6%) of popliteal-origin genicular artery branching variants. Right versus left comparisons did not reveal clinically significant differences in the vessel distance (P = .30 to .82). ConclusionsDespite the large number of possible anatomical variations of the genicular arteries, 6 main patterns corresponded to >96% of the cases. The description and classification of the genicular arterial anatomy may provide useful information to the interventional radiologist and add to the technical nuances of GAE.

Long-term care utilization within older adults with schizophrenia: Associated factors in a multicenter study

ObjectiveData are scarce regarding the clinical factors associated with utilization of long-term care facilities among older adults with schizophrenia. In this multicenter study, we sought to examine potential clinical differences between older adults with schizophrenia who are living in a long-term care facility and their community-dwelling counterparts. MethodWe used data from the French Cohort of individuals with Schizophrenia Aged 55-years or more (CSA) study, a large multicenter sample of older adults with schizophrenia (N = 353). ResultsThe prevalence of long-term care utilization was 35.1% of older patients with schizophrenia. Living in a long term care facility was significantly and independently associated with higher level of depression (Adjusted odds ratio (AOR) [95%CI]=1.97 [1.06–3.64]), lower cognitive (AOR [95%CI]=0.94 [0.88–0.99]) and global functioning (AOR [95%CI]=0.97 [0.95–0.99]), greater lifetime number of hospitalizations in a psychiatric department (AOR [95%CI]=2.30 [1.18–4.50]), not having consulted a general practitioner in the past year (AOR [95%CI]=0.28 [0.0.14–0.56]), urbanicity (AOR [95%CI]=2.81 [1.37–5.80]), and older age (AOR [95%CI]=1.08 [1.03–1.13]). DiscussionOlder patients with schizophrenia who live in long-term care facilities appear to belong to a distinct group, marked by a more severe course of illness with higher level of depression and more severe cognitive deficits than older patients with schizophrenia living in other settings. Our study highlights the need of early assessment and management of depression and cognitive deficits in this population and the importance of monitoring closely this vulnerable population.

Prevalence of masked hypertension evaluated by home blood pressure monitoring in a large sample of patients with office blood pressure

Patients with masked hypertension have a higher incidence of target organ damage, including increased left ventricular mass and carotid atherosclerosis and cardiovascular events when compared with normotensive patients. The adverse cardiovascular risks are even greater in patients already taking antihypertensive medication. To identify the prevalence and clinical characteristics of masked hypertension in a large multicenter Brazilian sample that underwent office and home blood pressure monitoring. This was an observational cross-sectional analytical study based on secondary data from the teleMRPA online platform, which included 32 cities from 15 states in the five regions of Brazil. The database included 3704 outpatient participants with office blood pressure <140/90 mmHg who performed home blood pressure monitoring for diagnostic investigation (diagnosis group; n = 1819) or treatment (treatment group; n = 1885) of hypertension in 2018. The prevalence of masked hypertension was 18.0% in the whole studied population and 15.4% and 20.4% in the diagnostic and treatment group, respectively. Masked hypertension was more frequently detected in patients with office blood pressure classified as high normal [systolic blood pressure (SBP) = 130-139 mmHg or diastolic blood pressure (DBP) = 85-89 mmHg], followed by those classified as normal (SBP = 120-129 mmHg or DBP = 80-84 mmHg) and optimal (SBP < 120 mmHg and DBP < 80 mmHg), with respective prevalence of 28.3, 13.4 and 4.4% in the diagnostic group and 30.8, 18.8 and 7.1% in the treatment group. Masked hypertension has a significant prevalence among individuals with office blood pressure <140/90 mmHg, which is greater with patients with high normal office blood pressure and even higher in patients already using antihypertensive medication.

Textbook Outcome as a measure of surgical quality assessment and prognosis in gastric neuroendocrine carcinoma: A large multicenter sample analysis.

ObjectiveQuality assurance is crucial for oncological surgical treatment assessment. For rare diseases, single-quality indicators are not enough. We aim to develop a comprehensive and reproducible measurement, called the “Textbook Outcome” (TO), to assess the quality of surgical treatment and prognosis of gastric neuroendocrine carcinoma (G-NEC) patients.MethodsData from patients with primary diagnosed G-NEC included in 24 high-volume Chinese hospitals from October 2005 to September 2018 were analyzed. TO included receiving a curative resection, ≥15 lymph nodes examined, no severe postoperative complications, hospital stay ≤21 d, and no hospital readmission ≤30 d after discharge. Hospital variation in TO was analyzed using a case mix-adjusted funnel plot. Prognostic factors of survival and risk factors for non-Textbook Outcome (non-TO) were analyzed using Cox and logistic models, respectively.ResultsTO was achieved in 56.6% of 860 G-NEC patients. TO patients had better overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RFS) than non-TO patients (P<0.05). Moreover, TO patients accounted for 60.3% of patients without recurrence. Multivariate Cox analysis revealed non-TO as an independent risk factor for OS, DFS, and RFS of G-NEC patients (P<0.05). Increasing TO rates were associated with improved OS for G-NEC patients, but not hospital volume. Multivariate logistic regression revealed that non-lower tumors, open surgery, and >200 mL blood loss were independent risk factors for non-TO patients (P<0.05).ConclusionsTO is strongly associated with multicenter surgical quality and prognosis for G-NEC patients. Factors predicting non-TO are identified, which may help guide strategies to optimize G-NEC outcomes.

Impact of cortical and subcortical atrophy in the diagnosis and prognosis of bvFTD: A multicenter longitudinal study

AbstractBackgroundThe behavioral variant of frontotemporal dementia (bvFTD) presents with variable patterns of cortical and subcortical atrophy on Magnetic Resonance Imaging (MRI). We aimed to assess the clinical utility of two reproducible measurements of cerebral atrophy (Harper's visual atrophy scale [HVAS], and the Magnetic Resonance Parkinsonism Index [MRPI]) in a large multicenter sample of bvFTD with longitudinal follow‐up.MethodsWe included 466 participants from three centers: 241 bvFTD (according to the International bvFTD Criteria Consortium), and 225 healthy controls (HC). Clinical deterioration was assessed with Mini‐Mental State Examination (MMSE) and the Clinical Deterioration Scale Sum‐of‐boxes (CDR‐sb). bvFTD participants were considered to have an increased certainty of underlying Frontotemporal Lobar Degeneration (+FTLD) when: (i) FTLD was confirmed at autopsy (n=72); (ii) a secondary FTLD‐related phenotype was identified during follow‐up (n=47) or (iii) a FTLD‐related mutation was found (n=49). Six raters blinded to clinical data were first asked to dichotomize participants according to the presence of "a clear pattern of atrophy suggestive of probable bvFTD", and then applied the HVAS (ICC(2,k)=.86 to .96). The MRPI was calculated with a fully automated algorithm.ResultsMean age of bvFTD participants was 63.3 ± 10, 68% were male (MMSE=23 ± 7 and CDR‐sb=6.7 ± 3.5). Blinded raters had 52% sensitivity and 97% specificity for the identification of bvFTD participants (AUC=.74, p=.001). All HVAS measures with the exception of posterior atrophy discriminated between bvFTD and HC (AUC=.77 to .83, p&lt;.001). The composite bvFTD score (average score of orbitofrontal, anterior cingulate, anterior temporal, medial temporal lobe and frontal insula regions) showed the best diagnostic accuracy for the differentiation of bvFTD from HC (AUC=.91, p&lt;.001 in +FTLD). This composite score also differentiated between bvFTD participants that were not considered to have a clear pattern of atrophy suggestive of probable bvFTD (blinded raters) and HC (p&lt;.001). We hypothesized that HVAS and MRPI scores may be independent predictors of clinical deterioration and survival in bvFTD (definitive results pending).ConclusionThe combination of HVAS and MRPI may provide valuable diagnostic and prognostic information in the behavioral syndromes verifying bvFTD criteria. These measures represent reliable, reproducible and affordable imaging biomarkers.

183P Textbook outcome as a measure of surgical quality assessment and prognosis in gastric neuroendocrine carcinoma: A large multicenter sample analysis

183P Textbook outcome as a measure of surgical quality assessment and prognosis in gastric neuroendocrine carcinoma: A large multicenter sample analysis

What is the Real Rate of Radial Nerve Injury After Humeral Nonunion Surgery?

To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample. Consecutive retrospective cohort review. Eighteen academic orthopedic trauma centers. Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery. Humeral shaft nonunion repair and assessment of postoperative radial nerve function. Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery. Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved. In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A comprehensive model of predictors of quality of life in older adults with schizophrenia: results from the CSA study

Numerous factors are known to influence quality of life of adults with schizophrenia. However, little is known regarding the potential predictors of quality of life in the increasing population of older adults with schizophrenia. The main objective of the present study was to propose a comprehensive model of quality of life in this specific population. Data were derived from the Cohort of individuals with Schizophrenia Aged 55years or more (CSA) study, a large (N = 353) multicenter sample of older adults with schizophrenia or schizoaffective disorder recruited from French community mental-health teams. We used structural equation modeling to simultaneously examine the effects of six broad groups of clinical factors previously identified as potential predictors of quality of life in this population, including (1) severity of general psychopathology, (2) severity of depression, (3) severity of cognitive impairment, (4) psychotropic medications, (5) general medical conditions and (6) sociodemographic characteristics. General psychopathology symptoms, and in particular negative and depressive symptoms, cognitive impairment, reduced overall functioning and low education were significantly and independently associated with diminished quality of life (all p < 0.05). Greater number of medical conditions and greater number of antipsychotics were also independently and negatively associated with quality of life, although these associations did not reach statistical significance in sensitivity analyses, possibly due to limited statistical power. Several domains are implicated in quality of life among older adults with schizophrenia. Interventions targeting these factors may help improve importantly quality of life of this vulnerable population.

Effects of depression and cognitive impairment on quality of life in older adults with schizophrenia spectrum disorder: Results from a multicenter study

BackgroundLittle is known about the respective effects of depression and cognitive impairment on quality of life among older adults with schizophrenia spectrum disorder. MethodsWe used data from the Cohort of individuals with Schizophrenia Aged 55-years or more (CSA) study, a large multicenter sample of older adults with schizophrenia or schizoaffective disorder (N = 353). Quality of life (QoL), depression and cognitive impairment were assessed using the Quality of Life Scale (QLS), the Center of Epidemiologic Studies Depression scale and the Mini-Mental State Examination, respectively. We used structural equation modeling to examine the shared and specific effects of depression and cognitive impairment on QoL, while adjusting for sociodemographic characteristics, general medical conditions, psychotropic medications and the duration of the disorder. ResultsDepression and cognitive impairment were positively associated (r = 0.24, p < 0.01) and both independently and negatively impacted on QoL (standardized β = −0.41 and β = −0.32, both p < 0.01) and on each QLS quality-of-life domains, except for depression on instrumental role and cognitive impairment on interpersonal relations in the sensitivity analyses excluding respondents with any missing data. Effects of depression and cognitive impairment on QoL were not due to specific depressive symptoms or specific cognitive domains, but rather mediated through two broad dimensions representing the shared effects across all depressive symptoms and all cognitive deficits, respectively. LimitationsBecause of the cross-sectional design of this study, measures of association do not imply causal associations. ConclusionsMechanisms underlying these two broad dimensions should be considered as important potential targets to improve quality of life of this vulnerable population.

Psychiatric symptoms and quality of life in older adults with schizophrenia spectrum disorder: results from a multicenter study

The severity of psychopathology has a strong negative impact on quality of life (QoL) among older adults with schizophrenia spectrum disorder. However, because these subjects generally experience multiple psychiatric symptoms, it remains unclear whether decreased QoL in this population is due to specific symptoms (e.g., hallucinations), specific dimensions of psychopathology (e.g., negative symptoms), a general psychopathology dimension representing the shared effect across all psychiatric symptoms, or a combination of these explanations. Data were derived from the Cohort of individuals with Schizophrenia Aged 55years or more (CSA) study, a large (N = 353) multicenter sample of older adults with schizophrenia spectrum disorder recruited from French public-sector psychiatric departments. We used structural equation modeling to examine the shared and specific effects of psychiatric symptoms on QoL, while adjusting for sociodemographic characteristics, general medical conditions, global cognitive functioning and psychotropic medications. Psychiatric symptoms and QoL were assessed face-to-face by psychiatrists using the Brief Psychiatric Rating Scale (BPRS) and the Quality of Life Scale (QLS). Among older adults with schizophrenia spectrum disorder, effects of psychiatric symptoms on QoL were exerted mostly through a general psychopathology dimension (β = - 0.43, p < 0.01). Negative symptom dimension had an additional negative effect on QoL beyond the effect of that factor (β = - 0.28, p < 0.01). Because psychiatric symptoms affect QoL mainly through two dimensions of psychopathology, i.e., a general psychopathology dimension and a negative symptom dimension, mechanisms underlying those dimensions should be considered as promising targets for therapeutic interventions to substantially improve quality of life of this vulnerable population.

Abstract P354: Work-Family Conflict and Ideal Cardiovascular Health Score in ELSA-Brasil Baseline Assessment

Introduction: Perceived stress (including work-related stress) is associated with cardiovascular health. We studied the association between work-family conflict and AHA’s ideal cardiovascular health (ICH) score at the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline. Hypothesis: Individuals with more frequent work-family conflict have worse ICH scores. Methods: We analyzed data from 11,351 active workers, aged 35-74 years. ICH scores were calculated based on the four lifestyle (diet, physical activity, smoking and body-mass index) and three health (blood pressure, fasting plasma glucose and total cholesterol) metrics proposed by the AHA. Work-family conflict was assessed as time and strain-based work interference with family; family interference with work and lack of time for personal care and leisure. We used quasi-Poisson regression models to analyze the association between work-family conflict and ICH scores, with positive relative predicted score differences (rPSD) indicating higher predicted ICH scores. Results: Subjects with frequent lack of time for personal care and leisure had lower global (rPSD: -2.9%; p=0.01) and lifestyle (rPSD: -8.2%; p&lt;0.01) ICH scores but higher health ones (rPSD: +4.8%; p=0.02). After stratifying by sex, the negative association between lack of time for personal care and leisure and global ICH scores remained significant only in women. In addition, women had a negative association between lifestyle ICH scores and both frequent strain-based work interference with family (rPSD: -5.1%; p&lt;0.01) and family interference with work (rPSD: -8.6%; p&lt;0.01). Conclusions: We found significant associations between work-family conflict and ICH scores in this large multicenter sample. Associations between work-family conflict and ICH score (especially lifestyle metrics) were more intense in women.

Illness and drug modifiable factors associated with violent behavior in homeless people with severe mental illness: results from the French Housing First (FHF) program

ObjectiveThe aim of this study was to investigate the factors associated with violent behavior in a large multicenter sample of Homeless Schizophrenia (SZ) and Bipolar Disorder (BD) (HSB) subjects. MethodsThis multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. Violent behavior was defined by at least one episode of verbal or physical violence in the last 6 months. ResultsOverall, 675 HSB patients, mean aged 38 years and 82.5% men were included, 458 SZ (68.4%) and 212 BD (31.6%). During the 6 months before evaluation, 213 (34.3%) committed at least one physical or verbal violence. In multivariate analysis, violence has been associated with younger age (aOR = 0.96[0.94–0.99], p = .001), number of nights in the street (aOR = 1.01[1.01–1.01]), BD diagnosis (aOR = 1.63[1.01–2.65], p = .04), higher current illness severity (CGI score) (aOR = 1.32[1.07–1.64], p = .01), higher rates of current manic episode (aOR = 2.24[1.32–3.81], p = .002), current alcohol use disorder (aOR = 2.05 [1.33–3.15], p = .001), antisocial personality disorder (aOR = 2.51[1.55–4.07], p < .001) and with antidepressant consumption (aOR = 2.01[1.01–4.04], p = .04). No specific antipsychotic or mood stabilizer has been associated with decreased rates of violent behavior, however clozapine, lithium and carbamazepine remained poorly prescribed. ConclusionIn case of violent behavior in HSB subjects, clinicians should focus in priority on the treatment of mania, antidepressant iatrogenic effect and alcohol use disorder by pharmacological and non-pharmacological treatments. Clozapine, lithium and carbamazepine should be chosen as the treatments of reference in this population but may be hard to manage in some cases.The current clinical trial number is NCT01570712.

Prescription of potentially inappropriate psychotropic drugs in homeless people with schizophrenia and bipolar disorders. Results from the French Housing First (FHF) program

BackgroundGuidelines have been edited for the treatment of schizophrenia (SZ) and bipolar disorders (BD). Background regimen is currently recommended for both illnesses (antipsychotic drug for SZ and mood stabilizer for BD). The recommendations are less clear for major depression in these disorders. Long-term anxiolytic and hypnotic prescriptions may have potential side effects and should be withdrawn as soon as possible. ObjectiveThe aim of this study was to investigate the prevalence and associated factors of Potentially Inappropriate Psychotropic drugs (PIP) in a large multicenter sample of Homeless Schizophrenia (SZ) and Bipolar Disorder (BD) (HSB) patients. MethodsThis multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. PIP was defined by at least one item among: (i) absence of background regimen (antipsychotic for SZ or mood stabilizer for BD), (ii) absence of antidepressant for major depressive disorder and (iii) daily long-term anxiolytic or (iv) hypnotic prescription. ResultsOverall, 703 HSB patients, mean aged 38 years and 82.9% men were included, 487 SZ (69.3%) and 216 BD (30.7%). 619 (88.4%) of the patients reported at least one PIP. 386 (54.9%) patients had an inappropriate background regimen prescription (209(43.4%) of SZ had no antipsychotic prescription and 177(81.9%) of BD no mood stabilizer), 336 (48%) had an inappropriate antidepressant prescription (with no significant difference between SZ and BD), 326 (46.4%) had an inappropriate prescription of anxiolytics and 107 (15.2%) had an inappropriate prescription of hypnotics. 388(55%) of the subjects were diagnosed with major depression but only 52(13%) of them were administered antidepressants. In multivariate analysis, PIP was associated with bipolar disorder diagnosis (aOR = 4.67 [1.84–11.89], p = 0.001), current major depressive disorder (aOR = 27.72 [9.53–80.69], p < 0.0001), lower rate of willingness to ask for help (aOR = 0.98[0.96–0.99], p = 0.001). Potentially inappropriate background regimen prescription was associated with bipolar disorder diagnosis (aOR = 6.35 [3.89–10.36], p < 0.0001), lower willingness to ask for help (aOR = 0.99[0.98–0.99], p = 0.01) and lack of lifetime history of psychiatric care (aOR = 0.30[0.12–0.78], p = 0.01). Inappropriate antidepressant prescription was associated with antisocial personality disorder (aOR = 1.58 [1.01–2.48], p = 0.04) and current substance use disorder (aOR = 2.18[1.48–3.20], p < 0.0001). ConclusionThe present findings suggest that almost 9 on 10 HSB subjects may receive a PIP including inappropriate prescriptions or absence of appropriate prescription. Bipolar disorder and/or major depression should be targeted in priority and treated with mood stabilizers and/or antidepressants in this population, while anxiolytics and hypnotics should be withdrawn as much as possible. Major depression should be particularly explored in subjects with comorbid antisocial personality disorder and substance use disorder. The psychiatric care has been associated with better appropriate psychotropic prescriptions and should be reinforced in this population.