Poor Premorbid Functioning Research Articles

Clinical epidemiology and outcomes of emergency department-acute kidney injury: A systematic review

BackgroundOver half of all community-acquired acute kidney injury (CA-AKI) initially presented to emergency department (ED), but emergency department acute kidney injury (ED-AKI) is poorly characterised, poorly understood with no systematic review, often under-recognized and under-managed. ObjectiveTo review the incidence, risk factors, and outcomes of ED-AKI, and risk factors of post-ED-AKI mortality globally. MethodsWe included published prospective or retrospective observational studies, controlled trials, and systematic reviews reporting AKI in adult ED attendees within 24 h of ED admission. Iatrogenic causes of AKI from medical interventions were excluded. We used PubMed to identify articles from 1996 to August 14, 2021, and adopted the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies to assess risk of bias. We used a Forest plot to present pooled ED-AKI incidence rates and I2 statistics. Other parameters were summarized narratively. ResultsUsing 24 h from ED admission as the definition for ED-AKI we identified six articles from 2005 to 2018 in high-income settings and one article with a 48-h timeframe. The pooled incidence of ED-AKI was 20 per 1000 adult ED attendances. Risk factors for ED-AKI included increasing age, nursing home residence, previous hospital admission within 30 days, discharge diagnosis of diabetes, obstructive uropathy, sepsis, gastrointestinal medical conditions, high serum creatinine, bilirubin, C-reactive protein, white blood cell, alanine aminotransferase, low serum sodium or albumin on admission, poor premorbid renal function, antibiotic use, active malignancy, lung disease, hyperlipidaemia, and infection. Crude, all-cause 24-h mortality rate was 4.56 % and the one-year mortality rate was 35.04 %. Increasing age and comorbidities including cardiovascular disease and malignancy were associated with higher mortality rates. ConclusionThe review reveals a paucity of relevant literature which calls for further research, increased vigilance, red flag identification, and standardized management protocols for ED-AKI.

Long-term diagnostic stability, predictors of diagnostic change, and time until diagnostic change of first-episode psychosis: a 21-year follow-up study.

Although diagnostic instability in first-episode psychosis (FEP) is of major concern, little is known about its determinants. This very long-term follow-up study aimed to examine the diagnostic stability of FEP diagnoses, the baseline predictors of diagnostic change and the timing of diagnostic change. This was a longitudinal and naturalistic study of 243 subjects with FEP who were assessed at baseline and reassessed after a mean follow-up of 21 years. The diagnostic stability of DSM-5 psychotic disorders was examined using prospective and retrospective consistencies, logistic regression was used to establish the predictors of diagnostic change, and survival analysis was used to compare time to diagnostic change across diagnostic categories. The overall diagnostic stability was 47.7%. Schizophrenia and bipolar disorder were the most stable diagnoses, with other categories having low stability. Predictors of diagnostic change to schizophrenia included a family history of schizophrenia, obstetric complications, developmental delay, poor premorbid functioning in several domains, long duration of untreated continuous psychosis, spontaneous dyskinesia, lack of psychosocial stressors, longer duration of index admission, and poor early treatment response. Most of these variables also predicted diagnostic change to bipolar disorder but in the opposite direction and with lesser effect sizes. There were no significant differences between specific diagnoses regarding time to diagnostic change. At 10-year follow-up, around 80% of the diagnoses had changed. FEP diagnoses other than schizophrenia or bipolar disorder should be considered as provisional. Considering baseline predictors of diagnostic change may help to enhance diagnostic accuracy and guide therapeutic interventions.

The impact of early factors on persistent negative symptoms in youth at clinical high risk for psychosis.

Persistent negative symptoms (PNS) are described as continuing moderate negative symptoms. More severe negative symptoms have been associated with poor premorbid functioning in both chronic schizophrenia and first episode psychosis patients. Furthermore, youth at clinical high risk (CHR) for developing psychosis may also present with negative symptoms and poor premorbid functioning. The aim of this current study was to: (1) define the relationship between PNS and premorbid functioning, life events, trauma and bullying, previous cannabis use, and resource utilization, and (2) to examine what explanatory variables best predicted PNS. CHR participants (N = 709) were recruited from the North American Prodrome Longitudinal Study (NAPLS 2). Participants were divided into two groups: those with PNS (n = 67) versus those without PNS (n = 673). A K-means cluster analysis was conducted to distinguish patterns of premorbid functioning across the different developmental stages. The relationships between premorbid adjustment and other variables were examined using independent samples t-tests or chi square for categorical variables. There was significantly more males in the PNS group. Participants with PNS had significantly lower levels of premorbid adjustment in childhood, early adolescence, and late adolescence, compared to CHR participants without PNS. There were no differences between the groups in terms of trauma, bullying, and resource utilization. The non-PNS group had more cannabis use and more desirable and non-desirable life events. In terms of better understanding relationships between early factors and PNS, a prominent factor associated with PNS was premorbid functioning, in particular poor premorbid functioning in later adolescence.

Bullying in clinical high risk for psychosis participants from the NAPLS-3 cohort.

Bullying is associated with a heightened risk for poor outcomes, including psychosis. This study aimed to replicate previous findings on bullying prevalence in clinical high-risk (CHR) individuals, to assess the longitudinal course of clinical and functional variables between bullied and non-bullied CHR and the association of bullying with premorbid functioning, clinical outcome, transition to psychosis and risk of violence. The sample consisted of 691 CHR participants and 96 healthy controls. Participants reported whether they had experienced bullying and how long it had lasted. Assessments included DSM-5 diagnoses, attenuated psychotic symptoms, negative symptoms, social and role functioning, depression, stress, premorbid functioning, and risk of violence. The bullied and non-bullied CHR groups were compared at baseline and further longitudinally on clinical and functioning variables and transition to psychosis. Bullying was more prevalent among CHR individuals than healthy controls. Bullied CHR had a higher prevalence of PTSD and more severe depression and stress at baseline than non-bullied CHR. There was no impact of bullying on clinical and functional variables over time. Bullying was not related to final clinical status or transition to psychosis. However, bullied participants had poorer premorbid functioning and a greater risk of violence. While bullying may not impact the likelihood of CHR individuals to transition to psychosis, it may be a risk factor for development of the at-risk state and may be related to a greater risk of violence. Future studies should consider bullying perpetration among CHR individuals.

Negative Symptoms and Functioning in Youth at Risk of Psychosis: A Systematic Review and Meta-analysis.

After participating in this activity, learners should be better able to:• Evaluate the relationship between negative symptoms and functioning in youth at clinical high risk for psychosis. Youth at CHR for psychosis often demonstrate significant negative symptoms and poor functioning, though the magnitude and direction of the relationship between the two remains unknown. The objective of this systematic review is to summarize the relationship between negative symptoms and functioning in CHR samples. Electronic databases CINAHL, EBM, Embase, MEDLINE, and PsycINFO were searched from inception. Studies were selected if they included any study that reported a relationship between negative symptoms and functioning in youth at clinical high risk (CHR). The correlation coefficient r was converted to Cohen's d, and all random-effects meta-analyses were performed using the transformed values. Forty-one studies met the inclusion criteria, including a total of 4574 individuals at CHR for psychosis. Negative symptom total scores were significantly associated with poorer global functioning (d, -1.40; 95% CI, -1.82 to -0.98; I = 79.4%; p < .001 [9 studies, n = 782]), social functioning (d, -1.10; 95% CI, -1.27 to -0.93; I = 10.40%; p < .001 [12 studies, n = 811]), and role functioning (d, -0.96; 95% CI, -1.17 to -0.76; I = 41.1%; p < .001 [9 studies, n = 881]). In addition, negative symptoms were consistently associated with poor premorbid functioning. When examining negative symptom domains, avolition, anhedonia, and blunted affect were each significantly and independently associated with poorer social functioning and role functioning. In terms of prediction models, negative symptoms contributed to the prediction of lower functioning across multiple studies. This meta-analysis demonstrates a strong relationship between negative symptoms and functioning in youth at clinical high risk for psychosis.

S120. CANDIDATE FACTORS MAINTAINING SOCIAL ANXIETY IN PSYCHOTIC EXPERIENCES: A SYSTEMATIC REVIEW

BackgroundSocial anxiety disorder (SAD) is common in people experiencing psychosis, with a pooled prevalence rate of 21% (16%-26%). It is evidenced that the factors maintaining SAD in psychosis is inconclusive, and more work is needed to understand the causal and maintenance mechanisms in order to develop more targeted therapies. So far, no previous systematic review has investigated factors that maintain SAD in psychosis. An integrated analysis of key factors from the literature combined with existing therapeutic knowledge (e.g. Cognitive Behavioural Therapy) could positively impact clinical practice. We therefore aimed to identify candidate factors maintaining SAD in psychosis, along with the factors related social anxiety in those with psychotic experiences.MethodsMEDLINE, Embase, CENTRAL and PsycINFO databases were searched on 31 October 2018. Which search terms used for Population were ((psychosis) or (psychotic) or (schizophreni*) or (schizoaffective) or (delusion*) or (paranoi*) or (clinical high risk*) or (ultra high risk*) or (attenuated) or (at risk mental state*) or (recent onset) or (first episode psycho*) or (early psycho*)), and for Outcome were ((social anxi*) or (social phob*)). According to included studies are highly heterogeneous data, then we planned a narrative synthesis. The methodological quality and risk of bias of included studies were assessed using the Mixed Methods Appraisal Tool (MMAT) - Version 2011.ResultsOf 43 out of 3982 studied were eligible for narrative synthesis. The studies included cross-sectional (33 studies), prospective (7 studies), randomised controlled trials (1 studies), a non-randomised clinical trial (1 study) and a qualitative study (1 study). Total participants were 11,825; the majority were drawn from the general population (N=8680), followed by psychosis samples (N=2512) and those at high risk of psychosis (N=633). General quality of the literature (41 studies) were determined as good to high quality.Regarding the objective, the psychological factors that may play a role in the maintenance of SAD in psychosis were identified. The major factors were cognitive factors; here are stigma, low self-esteem, shame, low social rank, negative thoughts, hopelessness and post-event processing, respectively. Metacognitive factors were found in different factors: mentalization, theory of mind, metacognition and reasoning bias. Few studies examined safety behaviours factor. Other maintenance factors were adult attachment, empathy, intolerance of uncertainty and coping style.We also identified the factors related social anxiety in psychotic context. There were poorer quality of life (QoL), poorer daily functioning with poorer premorbid functioning, poorer well-being, poorer family functions, more traumatic events, personality problems, more anomalous experiences, impaired executive function, suicidality, subclinical paranoia, persecutory threat and anhedonia.DiscussionThe results of this review have raised three main factors: cognitive, metacognitive and behavioural factors. A high number of candidate cognitive factors were identified, and stigma is the most commonly maintenance factors. Poor QoL and daily function were common impairments associated with social anxiety. The evidence of metacognitive and behavioural factors is limited and needed more research attention. Due to lack of research examining factors across cultures in social anxiety and psychosis, future research required empirical evidence for cross-cultural aspects. Limitations are the major studies were cross-sectional, which is far less conclusive of causation; and the heterogeneous data which prevented us from applying meta-analysis.

Factors influencing decisions to admit or refuse patients entry to a South African tertiary intensive care unit.

When critically ill patients with life-threatening conditions need urgent, expensive, life-sustaining care, admission and triage decision-making may be extremely challenging as critical care practitioners strive to balance these high-stakes, high-stress, time-sensitive decisions against a limited resource. The factors affecting the decision to admit or refuse a patient entry to an intensive care unit (ICU) have not been described in the South African (SA) context. To identify and describe the factors that influence ICU triage decision-making for patients referred to a regional/tertiary facility for intensive care. A retrospective review of recorded data from January 2014 to December 2017 was conducted for all referrals to the 12-bed, intensivist-led, closed general ICU at King Edward VIII Hospital, an 800-bed tertiary public facility in KwaZulu-Natal Province, SA. Data were extracted to identify factors associated with the decision to admit or refuse patients referred to the unit. Significant factors on univariate analysis were then included in a multivariable analysis using binary logistic regression to identify significant independent factors. A total of 4 469 referrals were received over the 48-month period studied. Of these, 507 (11.3%) were withdrawn before a final decision of acceptance or refusal and 94 (2.1%) had an unknown outcome, leaving 3 868 referrals where an acceptance/refusal decision was made as our study cohort. Of these, 38.7% were refused admission. The commonest reason for refusal (57.0%) was assessment of the patient as 'too sick' by the admitting specialist. Multivariable analysis identified age, referring discipline as medicine, poor or unknown premorbid functioning, and comorbidities of HIV, malignancy and cardiac failure as significant factors for refusal of admission to the ICU. Referrals were significantly more likely to be accepted from private institutions, and if the comorbidity was asthma or psychiatric disease. A better understanding of factors affecting ICU admission/refusal decisions will allow for a more effective and appropriate referral process and more rational utilisation of scarce ICU resources. Further prospective studies are necessary to elucidate fully the impact of various other factors.

Development of a Moderated Online Intervention to Treat Social Anxiety in First-Episode Psychosis.

Background: It is well established that social anxiety disorder (SAD) is a significant clinical problem for individuals with a psychotic disorder. Comorbid social anxiety in individuals with psychosis has been associated with poorer premorbid functioning, increased depression, and a reduced quality of life. Cognitive behavior therapy (CBT) is recommended for people with psychosis as a first-line psychological treatment; however, its focus and evaluation primarily revolves around reducing psychotic symptoms and not necessarily targeting comorbid social anxiety symptoms. We developed a novel online social cognitive behavioral intervention (entitled EMBRACE) specifically designed to treat social anxiety symptoms in first episode psychosis (FEP). Methods: The key clinical and engagement features of the intervention were established through integrating evidence-based material derived from 1) CBT-based treatment models for SAD, 2) relevant literature findings related to psychosis and its clinical correlates (e.g., shame, social rank, and its relationship with social anxiety and paranoia), 3) feedback from youth focus groups in order to inform a user-centered intervention design, and 4) a highly multidisciplinary collaborative development approach to design therapy comics. Results: A detailed description of the final version of the 12-week online social intervention to treat social anxiety in FEP is presented. Conclusion: The EMBRACE intervention was designed to provide young people with the necessary skills and confidence to overcome social anxiety within a supportive, safe online space. By design, it allows young people the opportunity to practice their newly learnt skills to connect with others and in doing so, learn to embrace their true authentic selves.

Clinical indicators of treatment-resistant psychosis.

Around 30% of individuals with schizophrenia remain symptomatic and significantly impaired despite antipsychotic treatment and are considered to be treatment resistant. Clinicians are currently unable to predict which patients are at higher risk of treatment resistance. To determine whether genetic liability for schizophrenia and/or clinical characteristics measurable at illness onset can prospectively indicate a higher risk of treatment-resistant psychosis (TRP). In 1070 individuals with schizophrenia or related psychotic disorders, schizophrenia polygenic risk scores (PRS) and large copy number variations (CNVs) were assessed for enrichment in TRP. Regression and machine-learning approaches were used to investigate the association of phenotypes related to demographics, family history, premorbid factors and illness onset with TRP. Younger age at onset (odds ratio 0.94, P = 7.79 × 10-13) and poor premorbid social adjustment (odds ratio 1.64, P = 2.41 × 10-4) increased risk of TRP in univariate regression analyses. These factors remained associated in multivariate regression analyses, which also found lower premorbid IQ (odds ratio 0.98, P = 7.76 × 10-3), younger father's age at birth (odds ratio 0.97, P = 0.015) and cannabis use (odds ratio 1.60, P = 0.025) increased the risk of TRP. Machine-learning approaches found age at onset to be the most important predictor and also identified premorbid IQ and poor social adjustment as predictors of TRP, mirroring findings from regression analyses. Genetic liability for schizophrenia was not associated with TRP. People with an earlier age at onset of psychosis and poor premorbid functioning are more likely to be treatment resistant. The genetic architecture of susceptibility to schizophrenia may be distinct from that of treatment outcomes.

Cortical abnormalities in youth at clinical high-risk for psychosis: Findings from the NAPLS2 cohort.

In a recent machine learning study classifying “brain age” based on cross-sectional neuroanatomical data, clinical high-risk (CHR) individuals were observed to show deviation from the normal neuromaturational pattern, which in turn was predictive of greater risk of conversion to psychosis and a pattern of stably poor functional outcome. These effects were unique to cases who were between 12 and 17 years of age when their prodromal and psychotic symptoms began, suggesting that neuroanatomical deviance observable at the point of ascertainment of a CHR syndrome marks risk for an early onset form of psychosis. In the present study, we sought to clarify the pattern of neuroanatomical deviance linked to this “early onset” form of psychosis and whether this deviance is associated with poorer premorbid functioning. T1 MRI scans from 378 CHR individuals and 190 healthy controls (HC) from the North American Prodrome Longitudinal Study (NAPLS2) were analyzed. Widespread smaller cortical volume was observed among CHR individuals compared with HC at baseline evaluation, particularly among the younger group (i.e., those who were 12 to 17 years of age). Moreover, the younger CHR individuals who converted or presented worsened clinical symptoms at follow-up (within 2 years) exhibited smaller surface area in rostral anterior cingulate, lateral and medial prefrontal regions, and parahippocampal gyrus relative to the younger CHR individuals who remitted or presented a stable pattern of prodromal symptoms at follow-up. In turn, poorer premorbid functioning in childhood was associated with smaller surface area in medial orbitofrontal, lateral frontal, rostral anterior cingulate, precuneus, and temporal regions. Together with our prior report, these results are consistent with the view that neuroanatomical deviance manifesting in early adolescence marks vulnerability to a form of psychosis presenting with poor premorbid adjustment, an earlier age of onset (generally prior to the age of 18 years), and poor long-term outcome.

Intact illusory contour formation but equivalently impaired visual shape completion in first- and later-episode schizophrenia.

Visual shape completion is a fundamental process that constructs contours and shapes on the basis of the geometric relations between spatially separated edge elements. People with schizophrenia are impaired at distinguishing visually completed shapes, but when does the impairment emerge and how does it evolve with illness duration? The question bears on the debate as to whether cognition declines after illness onset. To address the issue, we tested healthy controls (n = 48), first-episode psychosis patients (n = 23), and chronic schizophrenia patients (n = 49) on a classic psychophysical task in which subjects discriminated the relative orientations of four sectored circles that either formed or did not form visually completed shapes (illusory and fragmented conditions, respectively). Visual shape completion was quantified as the extent to which performance in the illusory condition exceeded that of the fragmented. Half of the trials incorporated wire edge elements, which augment contour salience and improve shape completion. Each patient group exhibited large visual shape completion deficits that could not be explained by differences in age, motivation, or orientation tuning. Patients responded normally to changes in illusory contour salience, indicating that they were forming but not adequately employing such contours for discriminating shapes. Shape completion deficits were most apparent for patients with cognitive disorganization, poor premorbid early adolescent functioning, and normal orientation discrimination. Visual shape completion deficits emerge maximally by the first psychotic episode and arise from higher-level disturbances that are related to premorbid functioning and disorganization. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

F125. POOR OUTCOME SCHIZOPHRENIA (KRAEPELINIAN SUB-TYPE): SOCIAL COGNITIVE AND NEURODEVELOPMENTAL MARKERS

BackgroundPoor outcome schizophrenia represents a public health challenge and it asks questions about neurodevelopmental mechanisms by its own. The kraepelinian schizophrenia sub-type, defined by Keefe’s criteria (1987), refers to a very poor prognosis sub-group (severe dysfunction in self-care) on the basis of the longitudinal course of the illness. Studies on kraepelinian sub-group show differences with good outcome patients regarding pre-morbid functioning, negative and disorganized symptoms, impaired performance on specific social cognitive and motor deficits (visual-motor processing, abstraction/flexibility, fine motor dexterity) (Albus and al., 1996; Bralet and al., 2006). Neurological soft signs (NSS) refer to subtle neurological abnormalities comprising deficits in sensory integration, motor coordination and sequencing of complex motor acts. Previous studies showed that NSS scores are correlated to schizophrenia, specifically among patients with poor premorbid functioning and with severe negative and disorganization symptoms. NSS could be a neurodevelopmental marker interesting to detect patients with a risk of poor prognosis. Deficits in theory of mind is correlated with disorganization and poor prognosis. The aim of our study was to explore the association between NSS, Theory of Mind and kraepelinian sub-type in order to understand better the etiopathogenic mechanisms underlying the kraepelinian sub-type.MethodsIn 2016, we recruited 2 samples of 25 schizophrenic patients, kraepelinians and no-kraepelinians, matched on sex, ages (+/- 5 years) and duration of illness (+/- 5 years) from the psychiatric departments in Picardie area (France), according to DSM-IV-TR criteria and using Keefe’s criteria. Several socio-demographical, pharmacological, clinical, cognitive and NNS (with the 3 subscores, sensory integration, motor integration and motor coordination) (Krebs and al., 2000) were collected for each patient. To compare the 2 sub-groups we used bi-variate analysis and multivariate regression analysis (p< 0,05)ResultsResults showed a worse significant NSS score among kraepelinian patients: total score, sensory integration, motor integration, motor coordination, p< 0,0001; there was no link with treatment (equ mg/day chlorpromazine). As well kraepelinians show worse significantly performance at the eye gaze test p<0,001. Multivariate analysis showed that kraepelinian sub-type is more explained significantly by eyes-test, motor integration and disorganization dimensionDiscussionPoor prognosis schizophrenia refers to specific and complex neurodevelopmental mechanisms which could be markers of a poor outcome. We must confirm these results in a larger prospective cohort from UHR and first episode assessing some specific neurodevelopmental markers using NSS and cognitive assessment. As well some specific biological markers and genes implicating in neurodevelopment and glutamatergic system could be studied in these patients. Focusing on these specific markers could contribute to define innovating combinating therapeutic strategies (pharmacological, cognitive remediation and social skills) to avoid poor prognosis.

T233. DEFINING TREATMENT RESPONSE AND RESISTANCE IN FIRST EPISODE SCHIZOPHRENIA

BackgroundAlthough a substantial proportion of individuals with schizophrenia fail to respond to first-line dopaminergic blocking medications and are Treatment Resistant (TR), identifying these subjects prospectively remains challenging. Though clinically defined only after multiple treatment trials, TR is suspected to reflect a stable neurobiological phenomenon that can be identified even at the first episode of schizophrenia (FES). Establishing clear expectations for symptom improvement following antipsychotic initiation would facilitate development of objective thresholds for determining lack of efficacy. The Treatment Response and Resistance in Psychosis (TRIPP; Howes et al, 2017) working group has recently published consensus guidelines which define lack of response as a <20% improvement in psychotic symptoms. However, given that most patients with FES respond robustly to antipsychotics (Robinson et al, 1999), FES specific criteria for prospective identification of TR are warranted. We examined two symptom improvement thresholds across positive and negative symptom domains at 6 months in FES to investigate poor response (PR) as a proxy measure of early TR. We then examined the baseline/early clinical features that best prospectively predicted PR+ status. Given the estimated prevalence of TR is approximately 33%, we hypothesized that a comparable number (ie, 1/3rd) of individuals with FES would meet PR criteria using less a 50% response threshold, rather than a more stringent 20% threshold for determining symptomatic response. Furthermore, we hypothesized that very early lack of response would be associated with PR at 6 months.MethodsData from a longitudinal naturalistic cohort study of patients treated at the Prevention and Early Intervention Program for Psychosis (PEPP) in London, Ontario, Canada collected between 2002 and 2007 were used for this analysis. Only individuals meeting criteria for a primary psychotic disorder that were medication compliant were included. Positive and negative symptoms of psychosis were assessed using the SAPS (Andreasen, 1983) and SANS (Andreasen, 1984) at baseline, and at months 1, 2, 3, and 6. Treatment was administered in a naturalistic setting and followed clinical guidelines for the treatment of FES.ResultsApplying a 20% and 50% symptom improvement threshold for defining PR resulted in 2.2% and 14% rates for positive symptom PR, 33% and 60.9% rates of negative symptom PR, and 12% and 37.0% rates of total symptom PR at 6 months. Logistic regression analyses demonstrated that poor premorbid functioning, having a longer duration of untreated illness, and limited overall treatment response at months one and two were significantly associated with being PR+ (<50% improvement in total symptoms) at 6 months.DiscussionThis is the first study to our knowledge to investigate the symptom response thresholds suggested by TRIPP in FES. Our results suggest that including negative symptoms (either alone, with a 20% criteria for improvement, or in addition to positive symptoms, with a 50% improvement threshold) is necessary to identify the expected proportion of TR subjects prospectively in a FES sample. We propose that failing to achieve at least a 50% improvement in total symptoms, or at least 20% change in negative symptom severity by 6 months may be an early clinical indicator of eventual TR. On an optimistic note, we speculate that it may be possible to determine clozapine-eligibility as early as 6 months by using this approach. However, further studies are warranted to investigate the utility of this symptom threshold criteria in larger samples of patients with FES.

T123. PERSISTENT NEGATIVE SYMPTOMS IN FIRST EPISODE PSYCHOSIS: PREVALENCE, PREDICTORS AND PROGNOSIS

BackgroundNegative symptoms are a core component of schizophrenia. These symptoms have been shown to impact on a range of outcomes, and often are resistant to pharmacological and psychosocial interventions treatment. The goal of this study was to investigate the prevalence, baseline predictors and long-term impact of persistent negative symptoms (PNS) within a large representative cohort of people with first episode psychosis.MethodsThe study had prospective design. Patients recruited into the OPUS trial (1998–2000) with a first time diagnosis within the schizophrenia spectrum (F20-28) were included. People were classified with persistent negative symptoms, if they experienced enduring negative symptoms that were not secondary to psychotic symptoms, depression or due to medication side effects. Clinical data collected at baseline, 1 year, 2 years and 10 years was used to identify predictors of PNS and long-term outcomes.ResultsFull clinical data was available on 369 people. A total of 90 people (24%) displayed PNS, two years after diagnosis. Significant univariable predictors of PNS at baseline were low functioning, male sex, cannabis use, poor pre-morbid social functioning and high levels of negative symptoms. People that displayed PNS had significantly lower functioning and higher levels of psychopathology at 10 year follow-up. A total 3% of people with PNS were recovered at 10 year follow-up compared to rate of 20% recovered without PNS (OR 7.42, p<0.01).DiscussionA significant proportion of the cohort displayed persistent negative symptoms and these symptoms significantly impacted on long-term outcomes. Researchers and clinicians need to continue to develop effective interventions that can ameliorate these symptoms and potentially impact on illness prognosis within schizophrenia.

Self-reported visual perceptual abnormalities predict schizophrenia, poor premorbid functioning, and more severe positive symptoms: New Insights from the Bonn Scale

Background & Methods. Past studies using the Bonn Scale for Assessment of Basic Symptoms have shown that self-reported visual perceptual abnormalities (VPAs) predict which individuals convert to schizophrenia (Klosterkötter et al., 2001). To further consider the clinical value of VPAs and the Bonn Scale, we employed the instrument to assess lifetime occurrence of VPAs within 22 chronic schizophrenia/schizoaffective disorder patients and 21 first episode psychosis patients, and probed for potential relationships with illness duration, diagnosis, age of onset, symptom severity, and premorbid functioning. Corrections for multiple comparisons were implemented with the False Discovery Rate controlling procedure (Benjamini & Hochberg, 1995). Results. VPA frequency was similar between the chronic and first episode groups, and was uncorrelated with illness duration (ps>.45). Subjects with schizophrenia/schizoaffective diagnoses (SZ/SA; n=31) endorsed more VPAs compared to those with other less severe psychotic disorders (n=12; p=.04; d=0.79). Specifically, the SZ/SA group more frequently reported double/reversed vision and abnormal perception of color, faces, body parts, and object movement (ps< .05; ds>.65). Increased overall VPAs predicted more hallucinations, delusions, and bizarre behavior (ps< .001; rs>.57) but not negative, disorganized, excited, or depressed symptoms (rs< .34; ps>.05). Increased VPAs correlated with earlier age of onset, worse sociability and ability to adapt in school, and lower ability to function well during childhood and early adolescence (ps< .05; rs>.39). Conclusion. VPAs, as assessed with 17 simple yes/no questions from the Bonn Scale, are strongly linked to positive symptoms, premorbid functioning, and a schizophrenia/schizoaffective disorder diagnosis. Surprisingly, the full gamut of abnormal visual perceptual experiences will have already been experienced by the time a person reaches the first psychotic episode. These results underscore the relevance of VPAs and the Bonn Scale for understanding schizophrenia; they also highlight the need for vision researchers to document and explain the visual perceptual changes that accompany the disorder. Meeting abstract presented at VSS 2017

Management of hypoxaemic respiratory failure in a Respiratory High‐dependency Unit

There are limited data on outcomes of hypoxaemic respiratory failure (HRF), especially in non-intensive care unit (ICU) settings. To assess outcomes in HRF (without multi-system disease and not requiring early intubation) of patients directly admitted to a Respiratory High-dependency Unit (R-HDU). This is a retrospective cohort study of HRF compared to hypercapnic respiratory failure (HCRF) in a R-HDU (2007-2011). Patient characteristics (age, gender, pre-morbid status, diagnoses) and outcomes (non-invasive ventilation (NIV) use, survival, ICU admission) were assessed. There were 1207 R-HDU admissions in 2007-2011, 205 (17%) with HRF and 495 (41%) with HCRF. The proportion with HRF increased from 12.2% in 2007 to 20.1% in 2011 (P < 0.05). HRF patients were younger, more often male and had better pre-morbid performance. Compared to HCRF, HRF was more frequently associated with lung consolidation (61% vs 15%, P < 0.001), interstitial lung disease (12% vs 1%, P < 0.001) and pulmonary hypertension (7% vs 0%, P < 0.001) and less frequently with chronic obstructive pulmonary disease (24% vs 65%, P < 0.001) and obstructive sleep apnoea (8% vs 26%, P < 0.001). Fewer patients with HRF were treated with NIV (28% vs 87%, P < 0.001), but NIV was discontinued early more often (28% vs 7%, P < 0.001). A total of 18% with HRF was transferred to ICU compared to 6% with HCRF (P = 0.06). More patients with HRF died (19.5% vs 12.3%, P = 0.02). Interstitial lung disease, consolidation, shock, malignancy and poorer pre-morbid function were associated with increased mortality. Initial R-HDU management is an effective option in selected HRF to reduce ICU demand, although mortality and clinical deterioration despite NIV are more common than in HCRF.

Characterization of different subtypes of schizophrenia: Premorbid functioning, neurophysiological differences, functional outcomes

Introduction Although not included in current diagnostic systems, deficit versus non-deficit and resistant versus non-resistant schizophrenia subtypes look more promising than traditional schizophrenia subtypes in terms of stability across time, clinical utility and interest for research. Aims To critically analyze evidence supporting the validity of two schizophrenia subtypes: Deficit Schizophrenia (DS) and Treatment Resistant Schizophrenia (TRS). Methods Empirical data supporting the validity of DS and TRS subtypes will be critically reviewed. Results DS, in comparison with non-deficit schizophrenia, is characterized by poorer premorbid functioning, more insidious onset, lower prevalence of dysphoria, hostility, suicidal ideation, depressive symptoms and substance abuse, different neurobiological abnormalities, and poorer response to treatment. The diagnosis of DS shows high reliability and stability across time. However, research based on this approach has proven difficult, especially in first-episode schizophrenia, and findings have not been as homogeneous as expected. TRS patients, as compared to non-TRS ones, show persisting psychotic symptoms, greater severity of negative symptoms, more severe cognitive dysfunctions, poorer premorbid functioning, longer duration of untreated psychosis, more frequent co-morbidity with personality disorders, earlier illness onset and poorer social functioning. Conclusions Future research should consider a) refining diagnostic criteria for DS and identifying valid DS endophenotypes; b) dissecting TRS based on psychopathological characteristics (e.g. presence of primary and persistent negative symptoms or persistently severe positive symptoms), and underlying neurobiological mechanisms (e.g. dopamine synthesis capacity and glutamatergic transmission).

Predictors of favourable outcome in young people with a first episode psychosis without antipsychotic medication

IntroductionData from the literature suggests that some first episode psychosis (FEP) patients may recover without antipsychotic medication. There is however no reliable way to identify them. In a previous paper we found, in a cohort of 584 FEP patients, that those consistently refusing medication had poorer pre-morbid functioning, less insight, higher rate of substance use and poorer outcome. However, some medication refusers, had a favourable outcome. The study aim was to identify predictors of good short term outcome despite non-exposure to medication. MethodsThe Early Psychosis Prevention and Intervention Centre (EPPIC) admitted 786 FEP patients between 1998 and 2000. Data were collected from patients' files using a standardized questionnaire. Data on medication adherence was available in 584 patients. Among the 17.9% of patients who consistently refused medication over the entire treatment phase we compared patients who had a favourable symptomatic and functional outcome with those who did not. ResultsAmong patients who consistently refused medication, 41% achieved symptomatic remission and 33% reached functional recovery. Predictors of symptomatic remission were a better premorbid functioning level, higher education and employment status at baseline. Predictors of functional recovery were a shorter duration of the prodrome phase, less severe psychopathology at baseline and lower cannabis use. ConclusionsDespite limitations mainly linked to the fact that non-exposure to antipsychotic medication was based on patient's treatment refusal, this study identified some characteristics which may contribute to the identification of a sub-group of FEP patients who may have good short term outcome without antipsychotic treatment.

Multidisciplinary Comprehensive Care for Early Recommencement of Oral Intake in Older Adults With Severe Pneumonia.

HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE INSTRUCTIONS 1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must: 1. Read the article, "Multidisciplinary Comprehensive Care for Early Recommencement of Oral Intake in Older Adults With Severe Pneumonia" found on pages 21-29, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until September 30, 2019. CONTACT HOURS This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. ACTIVITY OBJECTIVES 1. Describe the effect of multidisciplinary comprehensive care (MDCC) on oral intake in older adults with severe pneumonia at the time of discharge. 2. Explore the impact of MDCC on the length of stay for hospitalized older adults with severe pneumonia. DISCLOSURE STATEMENT Neither the planners nor the authors have any conflicts of interest to disclose. The current study was designed to assess the effect of multidisciplinary comprehensive care (MDCC) on (a) oral intake at discharge and (b) hospital stay duration in older adult patients with severe pneumonia. Participants were divided into two groups: receiving and not receiving MDCC. MDCC comprises regular assessment of swallowing ability, aspiration risk management, improvement of oral hygiene, serving of nutritious texture-modified foods, and encouragement of early mobilization. The MDCC group (164 women, 206 men; mean age = 82.7, SD = 8.4 years) had severe pneumonia as well as high proportions of poor premorbid physical function and consciousness disturbance compared to the non-MDCC group (45 women, 56 men; mean age = 81.1, SD = 8.6 years). Nevertheless, MDCC was an independent determinant of hospital stay duration and oral intake (Functional Oral Intake Scale score ≥4) at discharge with Cox regression analysis (hazard ratio = 1.42, 95% confidence interval [1.09, 1.85]). MDCC may promote early oral intake and hospital discharge in older adults with severe pneumonia. [Journal of Gerontological Nursing, 42(10), 21-29.].

Durée de psychose non traitée : état des lieux et analyse critique

IntroductionPrognosis of schizophrenia has not significantly improved despite extensive research. There is often a relatively long delay between onset of symptoms and treatment initiation. Lately, duration of untreated psychosis (DUP), the time between the onset of psychosis and initiation of treatment, has been one of the most studied variables in patients presenting for a first psychotic episode in order to evaluate the impact of early intervention on the prognosis of schizophrenia. In the literature, a variety of criteria have been used to define both transition to psychosis and initiation of treatment. Furthermore, the dating of both of these variables is usually retrospective, further complicating the measurement of DUP. MethodsWe conducted a comprehensive review about DUP using Pubmed and Google Scholar databases up to January 2015 using the following keywords “schizophrenia”, “duration of untreated psychosis”, “duration of untreated illness” and “early intervention”. Papers were included if they were published in French or English. ResultsThe mean DUP was found to be 2 years but it can vary according to multiple factors such as denial of illness by the patient and family, withdrawal and isolation from friends and relatives, diagnostic errors, paranoid views of the mental health treatment systems, or negative symptoms. Long DUP may also be a correlate of poor premorbid functioning or of an insidiously unfolding psychosis. Considerable discrepancies exist in the way that DUP is estimated in different studies. Although the clinical interview remains the most common way of measuring DUP, so far there is no evidence for favoring one method over another. Regardless of measurement method, a longer DUP is found to be associated with poorer outcome in schizophrenia in both the short and long-term across a number of domains: symptoms severity, remission rates, the risk of relapse, global functioning and quality of life. Its role in functional outcome appears to be mediated largely by negative symptoms, for which there is still no effective treatment. A recent meta-analysis has shown that shorter DUP is associated with less severe negative symptoms at short and long-term follow-up, especially when DUP is shorter than 9 months. The mechanism of the relationship between DUP and outcome is still undefined. A hypothesis is that the shorter the DUP, the more likely the intervention is being applied during the period in which neurobiological deficit processes in schizophrenia are most active. DiscussionA study of the duration of untreated illness (DUI), which is defined as the DUP and the prodromal phase, seems necessary because results of studies evaluating the effect of early detection and intervention in individuals with clinical high risk for psychosis are promising. A number of interventions such as omega 3 fatty acids and integrated psychosocial interventions seem to delay transition in the at-risk population. However, replication studies are lacking, and a great proportion of at high-risk individuals will spontaneously remit or develop diseases other than chronic psychosis, making us question the advantages and disadvantages of a treatment. Taking into consideration the high prevalence of comorbidities in individuals referred for clinical high-risk state and their effect on the individual's functioning, future interventions in the field need to address not only the preventative efficacy on psychosis transition but also their effectiveness in improving the functioning of this population and their effect on the outcome of schizophrenia when transition to psychosis has occurred. ConclusionDespite the huge advances in the field of schizophrenia, many questions remain unanswered and huge efforts are still necessary to understand the pathophysiology of this illness in order to improve its outcome.