Time Of First Episode Research Articles

Addressing cognitive health in coordinated specialty care for early psychosis: Real-world perspectives.

Addressing cognitive health during the early phase of psychosis has the potential to enhance recovery outcomes, yet methods to assess and treat cognitive problems are not a systematic part of Coordinated Specialty Care (CSC) in the United States. We sought to understand how CSC providers perceive cognitive health and gauge the acceptability and appropriateness of cognitive interventions to inform the development and implementation of a cognitive health toolkit for OnTrackNY, a CSC program. Electronic surveys were sent to clinicians from 22 OnTrackNY teams. One unstructured and 10 structured questions assessed knowledge and beliefs about cognition, current cognitive health practices, the likelihood of adopting new practices, perceived facilitators, and barriers to assessing and treating cognitive health. Fifty-three clinicians responded. Clinicians identified a range of terms associated with cognitive impairment with specific neurocognitive deficits cited most frequently. The majority perceived the evidence for cognitive impairment at the time of first episode to be moderate to strong, that specific interventions for cognition are warranted, and that there is a significant link between cognition and community functioning. While current practices vary, 88% indicated a high likelihood of integrating tools to address cognitive problems if provided. Compensatory approaches to aid cognitive functioning were viewed most favourably. Results suggest that addressing cognitive health is acceptable and appropriate for OnTrackNY but there is a need for systematic training to integrate empirically supported interventions with existing recovery-oriented practices. Piloting a cognitive health toolkit will inform the potential uptake of assessment and treatment practices more broadly.

Cognitive Impairment in Schizophrenia: Current Perspective

Impairments in a variety of cognitive functions are found in patients with schizophrenia. These impairments affect a wide array of different cognitive abilities and are often of moderate to severe degree. Cognitive impairments appear to present across lifespan, detectable at the time of first episode of illness, probably predate the illness and manifest a generally stable course over time.Though cognitive impairment does not form a part of diagnostic criteria, it has been included in DSM-V and proposed to be included in ICD-11 as a schizophrenia course specifier. This review attempts to provide a broad overview of the domains, onset, severity and course of cognitive impairments in schizophrenia, with a focus on functional relevance and treatment possibilities. There is strong evidence for a relationship between cognitive impairment and vocational and functional impairment in individuals with schizophrenia.

Occupational exposures and sick leave during pregnancy: results from a Danish cohort study.

This study aimed to investigate associations between work postures, lifting at work, shift work, work hours, and job strain and the risk of sick leave during pregnancy from 10-29 completed pregnancy weeks in a large cohort of Danish pregnant women. Data from 51 874 pregnancies in the Danish National Birth Cohort collected between 1996-2002 were linked to the Danish Register for Evaluation of Marginalization. Exposure information was based on telephone interviews. Hazard ratios (HR) with 95% confidence intervals (95% CI) were calculated by Cox regression analysis, using time of first episode of sick leave as the primary outcome. We found statistically significant associations between all the predictors and risk of sick leave; for non-sitting work postures (HRrange 1.55-2.79), cumulative lifting HRtrend 1.29, 95% CI 1.26-1.31, shift work (HRevening 1.90, 95% CI 1.73-2.09, HRnight 1.52, 95% CI 1.15-2.01), monthly night shifts HRtrend 1.12, 95% CI 1.11-1.14, increasing weekly work hours HRtrend 0.93, 95% CI 0.91-0.95 and high job strain HR 1.52, 95% CI 1.42-1.63. Some exposures influenced HR in either a positive or negative time-dependent way. Our results support previous findings and suggest that initiatives to prevent sick leave during pregnancy could be based on work conditions. Preventive measures may have important implications for pregnant women and workplaces.

Prognosis and Predictors of Rebleeding After Bronchial Artery Embolization in Patients with Active or Inactive Pulmonary Tuberculosis.

The aim of this study was to characterize the prognosis and identify factors that contribute to rebleeding after bronchial artery embolization (BAE) in patients with active or inactive pulmonary tuberculosis (PTB). Following a retrospective review, 190 patients had hemoptysis requiring BAE due to PTB in one hospital between 2006 and 2013. The median age at the time of diagnosis of PTB was 37 years and 54 years at the time of first episode of hemoptysis. Among 47 patients (24.7 %) who experienced rebleeding after BAE during the median follow-up period of 13.9 months [interquartile range (IQR) 2.3-36.0 months], bleeding recurred in 12 patients (6.3 %) within 1 month and in 15 patients (7.9 %) after 1 year. The median non-recurrence time was 8.6 months (IQR 1.2-27.6 months). Independent predictors of rebleeding after BAE were tuberculous-destroyed lung [hazard ratio (HR) 3.0; 95 % confidence interval (CI) 1.5-6.2; p = 0.003], the use of anticoagulant agents and/or antiplatelet agents (HR 2.6; 95 % CI 1.1-5.8; p = 0.022), underlying chronic liver disease (HR 2.7; 95 % CI 1.1-4-6.9; p = 0.033), elevated pre-BAE C-reactive protein (CRP) (mg/dL) (HR 2.4; 95 % CI 1.0-5.5; p = 0.048), and the existence of fungal ball (HR 2.1; 95 % CI 1.0-4.3; p = 0.050). The risk of rebleeding after BAE in active or inactive PTB was high, particularly in patients with tuberculous-destroyed lung, chronic liver disease, the use of anticoagulant agents and/or antiplatelet agents, elevated pre-BAE CRP, and the existence of fungal ball.

Predictors of sickness absence in pregnancy: a Danish cohort study.

The aim of this cohort study was to investigate associations between parity, pre-pregnancy body mass index (BMI), assisted reproductive therapy (ART), time to pregnancy (TTP), and engagement in physical exercise and the risk of sickness absence in pregnancy from 10-29 completed pregnancy weeks. Data from 51 874 pregnancies in the Danish National Birth Cohort collected from 1996 until 2002 were linked to the Danish Register for Evaluation of Marginalization. Exposure information was based on questionnaires. Hazard ratios (HR) with 95% confidence intervals (95% CI) were calculated by Cox regression, using time of first episode of sickness absence as the primary outcome. Multiparity 1.26 (95% CI 1.10-1.45), overweight 1.13 (95% CI 1.08-1.18), obesity 1.23 (95% CI 1.15-1.31), ART 1.10 (95% CI 1.01-1.20), and TTP >12 months 1.06 (95% CI 0.99-1.13) were associated with higher HR of sickness absence. Physical exercise of >120 minutes per week was associated with lower HR 0.84 (95% CI 0.75-0.95). Risk for sickness absence was higher among women who were multiparous, overweight, obese, received ART, and had prolonged TTP, and lower among women engaged in leisure-time physical exercise. Few studies have investigated these associations, and the results should be confirmed in other studies of pregnant women.

Clinical and prognostic relevance of albumin dimers in patients with cirrhosis: A novel identified structural alteration of the molecule

partly improved its performance, but this result requires further confirmation. Aim: To assess the reliability of MELD-Na scores to predict mortality and to identify other independent prognostic factors in patientswithHCV-relatedcirrhosis after thefirst episodeofdecompensation. Patients and methods: The study design is a multicenter prospective cohort that enrolled all consecutive patientswithHCVrelated cirrhosis at the time of first episode of decompensation (Bruno, 2013). In time-to-event analyses, the considered events of interest were death or OLT. Hepatocellular carcinoma (HCC) was considered as a competing event. A direct comparison of a model that includes only MELD-Na score as a covariate and a model that included decompensation characteristic was carried out, as well. To evaluate the incremental predictive information of new disease definition we used the likelihood ratio test (LRT). Results: Two hundreds and two subjects were included in this analysis. Approximately two thirds of patients were men and the mean agewas 60.9 years. The distribution of CTP classeswas: 19.4% inclassA,61.0% inclassB, and19.6% inclassC.Cumulative incidence of failure was 18.2% and 27.9% at 12 and at 18 months, respectively. Median MELD-Na of 13 was considered as reference in the computation of the hazard ratios. Multivariate analysis is shown in Table 1. The 18-months risks of failure predicted by model considering only MELD-Na (Model 1) and by model including also Hb and Age (Model 2) were compared between patients with and without eventa. The continuous net reclassification improvement (NRI) index was 42.6%. Conclusions: In the clinical setting of HCV-related cirrhosis, MELD-Na calculation, with the inclusion of Hb value and age at the time of first decompensation, enhances the value of mortality prediction, thus enabling a better patient allocation for OLT.

Premier épisode psychotique, troubles cognitifs et remédiation

Cognitive difficulties are a core feature of schizophrenia. They are frequent, severe, and clearly associated with functional disabilities. They have been explored during different phases of the disease, but what we know essentially concerns the chronic period in middle-age patients. In this article we will specifically focus on cognition at the time of first episode. First episode is a key life period, occurring while social demands are increasing and more complex on the one hand, and while there are important changes in structural and functional cerebral anatomy on the other hand. Exploring cognitive difficulties at the time of first episode offers the opportunity to better know their time course, to avoid interpretative difficulties due to the chronicity of the disease and its treatments, and to develop early therapeutics in order to improve outcome. Cognitive difficulties are clearly present at the time of first episode; their nature and severity appear similar to those observed in more chronic patients. Therefore, they cannot be entirely explained by treatments, hospitalizations or chronicity, and appear more as an intrinsic feature of the disease. The course of their trajectory through the progression of the disease remains uncertain; while they are already present during childhood or adolescence in some subjects who will later declare schizophrenia, they seem to worsen during the period of early prodroms, that is years before psychotic symptoms emerge. Whether they aggravate again during the first episode process is still a matter of debate. While longer DUP is associated with a poor outcome, this does not seem to hold true for cognitive impairments. Cannabis or tobacco use are neither associated with worse cognitive abilities in first-episode patients; a reverse relationship even sometimes exists. Cognitive impairment appears as largely independent from other clinical dimensions, acknowledging its own physiopathology and requiring specific evaluation and treatment. Several cognitive batteries can be used in clinical practice to explore cognitive abilities in first-episode patients; this is a necessary step before treating. While current pharmacological treatments display little or no efficacy for treating cognitive impairments, new medications offer some hope for the future. Still, efforts especially concern cognitive remediation for the moment. Several programs can be used in patients following their first episode, and some studies suggest that deficits in cognition are more amenable to remediation during earlier phases of the illness especially when cognitive remediation is associated with psychosocial rehabilitation, including school or work support. In the future, exploring and treating cognitive difficulties in first episode patients appear as a matter of collaborative work between psychiatrists and cognitive psychologists and between health and social services.

Cognitive Remediation for Psychotic and Affective Disorders

Cognitive impairment has long been recognized as a symptom of schizophrenia, affective, and psychotic disorders. Until relatively recently, most research has focused on the severity, type, and course of impairment. As is reviewed in this series by Dr Alice M Saperstein and Dr Matthew M Kurtz,1 we have learned that cognitive deficits are evident in most people with schizophrenia and schizoaffective disorders, evident even in the prodromal phase but seem to worsen around the time of first episode, and stable for many years, even as positive symptoms, such as hallucinations and delusions, wax and wane. Dr Christopher R Bowie, Ms Maya Gupta, and Ms Katherine Holshausen2 report in this series that cognitive symptoms in the affective disorders appear to be more state related, though more than 60% of people with bipolar disorder (BD) continue to manifest cognitive dysfunction, even when clinically stable. Most studies comparing people with schizophrenia to nonpsychiatric samples find that cognitive test scores are on average 1.3 to 2.0 standard deviations below the mean, which means that 91% to 98% of the general population score higher. These deficits put patients at a considerable disadvantage when seeking employment and more generally facing the challenges of independent, productive living. Repeatedly, the research indicates that cognitive deficits are associated with functional outcome. It is for this reason that there is tremendous interest in finding ways to treat cognitive dysfunction.In this In Review are 2 papers that provide an overview of the behavioural approaches that have been developed to address cognitive dysfunction in the psychotic and affective disorders. Dr Saperstein and Dr Kurtz1 focus on cognitive remediation (CR) for schizophrenia, while Dr Bowie and colleagues2 address how CR is being used to treat people with psychotic and nonpsychotic affective disorders. We learn from these 2 papers that the field of psychology is at a crossroads. No longer is there debate about whether people with schizophrenia can learn, or if cognitive skills are malleable. The research overwhelmingly supports the efficacy of CR for schizophrenia and schizoaffective disorder-when it is done in the context of a psychiatric rehabilitation model. The evidence base for using CR for people with nonpsychotic affective disorders is relatively smaller; nevertheless, CR for mood disorders is emerging as an effective nonpharmacological treatment option for improving cognitive performance in people with major depressive disorder and BD. Further, CR impacts not only cognition but also, as intended, it helps to improve psychosocial functioning and reduce disability.Having established that cognitive deficits do respond to behavioural interventions, researchers are now tackling how to enhance the ability of CR to improve cognition, how to promote the transfer of cognitive gains to real-world functioning, and develop personalized treatments that are easily disseminated with fidelity. A tension has emerged as these issues are addressed. While there is tremendous enthusiasm for harnessing emerging knowledge about neuroplasticity to engineer more effective and efficient computer-based treatments, there is, simultaneously, a groundswell of support for integrating humanistic psychiatric rehabilitation principles into CR approaches to enhance functional outcomes. At their most extreme, these tensions emerge as camps.1 One side, fuelled by the technology industry, advocates a medical model approach that uses US Food and Drug Administration-approved computer devices that dose cognitive exercises like medications. The other side, fuelled by person-centred advocacy, emphasizes psychotherapeutic approaches to address the many factors (for example, beliefs, motivation, and emotions) that promote transfer of learning to real-world behaviours.The first large multisite study of CR in schizophrenia4 chose the model of dosed, device-based computer exercises to test the effectiveness of CR, and the results failed to replicate the promising findings from a single-site trial of device-based CR. …

MAPPING RELIABILITY OF MULTICENTER MRI: CORTICAL THICKNESS AND VOXEL-BASED MORPHOMETRY

bilaterally in the insular cortices, and in the superior frontal gyrus and left caudate relative to the healthy group. No significant differences were detected between the first-episode and either the chronic psychosis or healthy control groups. Grey matter deficits did not appear to be related to the severity of positive, negative, general or total illness symptoms, the age of illness onset or medication exposure. Discussion: Grey matter deficits observed later in illness course may not be present to the same extent at the time of first episode of psychosis. However, this would warrant further investigation using small volume correction applied to examine regions strongly implicated in the pathophysiology of schizophrenia including frontal cortical regions. Our findings are in line with those of the previous literature in identifying reduced grey matter in schizophrenia in frontal and temporal cortical regions.

Demographic, etiological and clinical features of liver cirrhosis at the onset of the first episode of clinical decompensation: Preliminary results of the “A.I.S.F.-EPASCO” Study

Background and aim. The occurrence of decompensation in patients with liver cirrhosis marks a crucial “cut-off” point in the natural course of the disease which deeply modifies both clinical management and follow-up strategies. In addition, it leads to great efforts in terms of economical and human resources. Aim of this study was to prospectively assess the clinical, etiological and demographic features and to identify, in every-day clinical practice, the predictors of early mortality of patients with liver cirrhosis at the time of first episode of decompensation during a 3 to 5 years follow-up period (A.I.S.F.-EPASCO Study).

Cerebrovascular disorders in childhood: etiology, clinical presentation, and neuroimaging findings in a case series study

To describe the main etiologies, neurological manifestations and neuro-imaging findings among children with sequelae of cerebrovascular disorders. Case series study of children whose diagnosis was stroke sequelae. Variables studied were age at the time of first episode, number of episodes, etiology, motor deficits, epilepsy, and effected vascular territory. Twenty three patients were studied. Average age at first episode was 6.91 (+/-2.08) years. Fourteen patients were female. The number of stroke events per patient ranged from one to five. The most frequent etiologies were heart disease and sickle cell anemia. The most frequent neurological deficit was right hemiparesis. Nine patients experienced seizures. The left middle cerebral artery was the most affected vascular area. Our findings are similar to those described in the literature. Despite a careful investigation, some causes of stroke remain unidentified.