Predictors of favourable outcome in first-episode patients who refuse medication: results from the FEPOS study

There are suggestions that some first-episode psychosis (FEP) patients can have favourable outcome without antipsychotic medication. However, there is very limited data regarding patients' characteristics on which the decision to propose medication free treatment could be based. FEPOS is a fi le-based study of an epidemiological sample of 704 FEP patients treated at EPPIC, Melbourne, between 1998 and 2000. Among the 661 patients where data was available, 108 consistently refused medication during the entire duration of their treatment at EPPIC. In this paper we compared, within this sub-group, patients who had a favourable outcome with those who did not. Patients were aged between 15 and 29 years (M = 21.9, SD = 3.40) and the majority were male (70.4%, n = 76). Symptomatic remission data was available on 105 patients; of these patients 41.0% (n = 41) had achieved remission. Functional remission data was available on 100 patients; of these patients 33.0% (n = 33) had achieved functional remission. Combined remission was evident in 23.0% (n = 23) of patients. Three factors were associated with symptomatic remission: better premorbid functioning (based on GAF, OR = 1.07, p = 0.006), higher number of years of education (OR = 1.43, p = 0.020), and being employed or studying at service entry (OR = 2.59, p = 0.034). Three factors were associated with functional remission: shorter duration of prodrome (OR = 0.50, p = 0.043), severity of psychopathology (CGI-S, OR = 0.51, p = 0.024), and vocational status at service entry (OR = 4.29, p = 0.003). While various aspects of pre-morbid functioning seem to correlate with the possibility of a favourable outcome in FEP patients who refuse medication, various limitations need to be taken into account in this study.

How Reliable Is Ki-67 Immunohistochemistry in Grade 2 Breast Carcinomas? A QA Study of the Swiss Working Group of Breast- and Gynecopathologists.

Adjuvant chemotherapy decisions in breast cancer are increasingly based on the pathologist's assessment of tumor proliferation. The Swiss Working Group of Gyneco- and Breast Pathologists has surveyed inter- and intraobserver consistency of Ki-67-based proliferative fraction in breast carcinomas. METHODS: Five pathologists evaluated MIB-1-labeling index (LI) in ten breast carcinomas (G1, G2, G3) by counting and eyeballing. In the same way, 15 pathologists all over Switzerland then assessed MIB-1-LI on three G2 carcinomas, in self-selected or pre-defined areas of the tumors, comparing centrally immunostained slides with slides immunostained in the different laboratoires. To study intra-observer variability, the same tumors were re-examined 4 months later. RESULTS: The Kappa values for the first series of ten carcinomas of various degrees of differentiation showed good to very good agreement for MIB-1-LI (Kappa 0.56-0.72). However, we found very high inter-observer variabilities (Kappa 0.04-0.14) in the read-outs of the G2 carcinomas. It was not possible to explain the inconsistencies exclusively by any of the following factors: (i) pathologists' divergent definitions of what counts as a positive nucleus (ii) the mode of assessment (counting vs. eyeballing), (iii) immunostaining technique, and (iv) the selection of the tumor area in which to count. Despite intensive confrontation of all participating pathologists with the problem, inter-observer agreement did not improve when the same slides were re-examined 4 months later (Kappa 0.01-0.04) and intra-observer agreement was likewise poor (Kappa 0.00-0.35). CONCLUSION: Assessment of mid-range Ki-67-LI suffers from high inter- and intra-observer variability. Oncologists should be aware of this caveat when using Ki-67-LI as a basis for treatment decisions in moderately differentiated breast carcinomas.

Integral cohomology of finite postnikov towers

Depuis le séminaire H. Cartan de 1954-55, il est bien connu que l'on peut trouver des éléments de torsion arbitrairement grande dans l'homologie entière des espaces d'Eilenberg-MacLane K(G,n) où G est un groupe abélien non trivial et n>1. L'objectif majeur de ce travail est d'étendre ce résultat à des H-espaces possédant plus d'un groupe d'homotopie non trivial. Dans le but de contrôler précisément le résultat de H. Cartan, on commence par étudier la dualité entre l'homologie et la cohomologie des espaces d'Eilenberg-MacLane 2-locaux de type fini. On parvient ainsi à raffiner quelques résultats qui découlent des calculs de H. Cartan. Le résultat principal de ce travail peut être formulé comme suit. Soit X un H-espace ne possédant que deux groupes d'homotopie non triviaux, tous deux finis et de 2-torsion. Alors X n'admet pas d'exposant pour son groupe gradué d'homologie entière réduite. On construit une large classe d'espaces pour laquelle ce résultat n'est qu'une conséquence d'une caractéristique topologique, à savoir l'existence d'un rétract faible X K(G,n) pour un certain groupe abélien G et n>1. On généralise également notre résultat principal à des espaces plus compliqués en utilisant la suite spectrale d'Eilenberg-Moore ainsi que des méthodes analytiques faisant apparaître les nombres de Betti et leur comportement asymptotique. Finalement, on conjecture que les espaces qui ne possédent qu'un nombre fini de groupes d'homotopie non triviaux n'admettent pas d'exposant homologique. Ce travail contient par ailleurs la présentation de la « machine d'Eilenberg-MacLane », un programme C++ conçu pour calculer explicitement les groupes d'homologie entière des espaces d'Eilenberg-MacLane. <br/><br/>By the work of H. Cartan, it is well known that one can find elements of arbitrarilly high torsion in the integral (co)homology groups of an Eilenberg-MacLane space K(G,n), where G is a non-trivial abelian group and n>1. The main goal of this work is to extend this result to H-spaces having more than one non-trivial homotopy groups. In order to have an accurate hold on H. Cartan's result, we start by studying the duality between homology and cohomology of 2-local Eilenberg-MacLane spaces of finite type. This leads us to some improvements of H. Cartan's methods in this particular case. Our main result can be stated as follows. Let X be an H-space with two non-vanishing finite 2-torsion homotopy groups. Then X does not admit any exponent for its reduced integral graded (co)homology group. We construct a wide class of examples for which this result is a simple consequence of a topological feature, namely the existence of a weak retract X K(G,n) for some abelian group G and n>1. We also generalize our main result to more complicated stable two stage Postnikov systems, using the Eilenberg-Moore spectral sequence and analytic methods involving Betti numbers and their asymptotic behaviour. Finally, we investigate some guesses on the non-existence of homology exponents for finite Postnikov towers. We conjecture that Postnikov pieces do not admit any (co)homology exponent. This work also includes the presentation of the "Eilenberg-MacLane machine", a C++ program designed to compute explicitely all integral homology groups of Eilenberg-MacLane spaces. <br/><br/>Il est toujours difficile pour un mathématicien de parler de son travail. La difficulté réside dans le fait que les objets qu'il étudie sont abstraits. On rencontre assez rarement un espace vectoriel, une catégorie abélienne ou une transformée de Laplace au coin de la rue ! Cependant, même si les objets mathématiques sont difficiles à cerner pour un non-mathématicien, les méthodes pour les étudier sont essentiellement les mêmes que celles utilisées dans les autres disciplines scientifiques. On décortique les objets complexes en composantes plus simples à étudier. On dresse la liste des propriétés des objets mathématiques, puis on les classe en formant des familles d'objets partageant un caractère commun. On cherche des façons différentes, mais équivalentes, de formuler un problème. Etc. Mon travail concerne le domaine mathématique de la topologie algébrique. Le but ultime de cette discipline est de parvenir à classifier tous les espaces topologiques en faisant usage de l'algèbre. Cette activité est comparable à celle d'un ornithologue (topologue) qui étudierait les oiseaux (les espaces topologiques) par exemple à l'aide de jumelles (l'algèbre). S'il voit un oiseau de petite taille, arboricole, chanteur et bâtisseur de nids, pourvu de pattes à quatre doigts, dont trois en avant et un, muni d'une forte griffe, en arrière, alors il en déduira à coup sûr que c'est un passereau. Il lui restera encore à déterminer si c'est un moineau, un merle ou un rossignol. Considérons ci-dessous quelques exemples d'espaces topologiques: a) un cube creux, b) une sphère et c) un tore creux (c.-à-d. une chambre à air). a) b) c) Si toute personne normalement constituée perçoit ici trois figures différentes, le topologue, lui, n'en voit que deux ! De son point de vue, le cube et la sphère ne sont pas différents puisque ils sont homéomorphes: on peut transformer l'un en l'autre de façon continue (il suffirait de souffler dans le cube pour obtenir la sphère). Par contre, la sphère et le tore ne sont pas homéomorphes: triturez la sphère de toutes les façons (sans la déchirer), jamais vous n'obtiendrez le tore. Il existe un infinité d'espaces topologiques et, contrairement à ce que l'on serait naïvement tenté de croire, déterminer si deux d'entre eux sont homéomorphes est très difficile en général. Pour essayer de résoudre ce problème, les topologues ont eu l'idée de faire intervenir l'algèbre dans leurs raisonnements. Ce fut la naissance de la théorie de l'homotopie. Il s'agit, suivant une recette bien particulière, d'associer à tout espace topologique une infinité de ce que les algébristes appellent des groupes. Les groupes ainsi obtenus sont appelés groupes d'homotopie de l'espace topologique. Les mathématiciens ont commencé par montrer que deux espaces topologiques qui sont homéomorphes (par exemple le cube et la sphère) ont les même groupes d'homotopie. On parle alors d'invariants (les groupes d'homotopie sont bien invariants relativement à des espaces topologiques qui sont homéomorphes). Par conséquent, deux espaces topologiques qui n'ont pas les mêmes groupes d'homotopie ne peuvent en aucun cas être homéomorphes. C'est là un excellent moyen de classer les espaces topologiques (pensez à l'ornithologue qui observe les pattes des oiseaux pour déterminer s'il a affaire à un passereau ou non). Mon travail porte sur les espaces topologiques qui n'ont qu'un nombre fini de groupes d'homotopie non nuls. De tels espaces sont appelés des tours de Postnikov finies. On y étudie leurs groupes de cohomologie entière, une autre famille d'invariants, à l'instar des groupes d'homotopie. On mesure d'une certaine manière la taille d'un groupe de cohomologie à l'aide de la notion d'exposant; ainsi, un groupe de cohomologie possédant un exposant est relativement petit. L'un des résultats principaux de ce travail porte sur une étude de la taille des groupes de cohomologie des tours de Postnikov finies. Il s'agit du théorème suivant: un H-espace topologique 1-connexe 2-local et de type fini qui ne possède qu'un ou deux groupes d'homotopie non nuls n'a pas d'exposant pour son groupe gradué de cohomologie entière réduite. S'il fallait interpréter qualitativement ce résultat, on pourrait dire que plus un espace est petit du point de vue de la cohomologie (c.-à-d. s'il possède un exposant cohomologique), plus il est intéressant du point de vue de l'homotopie (c.-à-d. il aura plus de deux groupes d'homotopie non nuls). Il ressort de mon travail que de tels espaces sont très intéressants dans le sens où ils peuvent avoir une infinité de groupes d'homotopie non nuls. Jean-Pierre Serre, médaillé Fields en 1954, a montré que toutes les sphères de dimension >1 ont une infinité de groupes d'homotopie non nuls. Des espaces avec un exposant cohomologique aux sphères, il n'y a qu'un pas à franchir...

Communicating geomorphology: global challenges for the twenty-first century

The British Society for Geomorphology (BSG), established as the British Geomorphological Research Group (BGRG) in 1960, is considering how best to represent geomorphology and geomorphologists in the light of recent changes in the nature of communication. These changes provide the BSG and other academic societies with challenges and opportunities. Seven drivers of communication change are outlined: the changing position of geomorphology in higher education, the nature of academic interaction, the means of communication available, a transformation in the nature of geomorphological research, changes in funding support, the government role in resource allocation, and developments in quantifying international research impact. Challenges arising from changing communications are identified as occurring beyond the `academy', in the nature of publication within the `academy', and associated with meetings of the `academy'. Although national societies now have to contemplate significantly different purposes to provide for their members than in the twentieth century, there are opportunities available that cannot be fulfilled by international organizations alone. Copyright (c) 2013 John Wiley & Sons, Ltd.

Indications for cardiovascular magnetic resonance in children with congenital and acquired heart disease: an expert consensus paper of the Imaging Working Group of the AEPC and the Cardiovascular Magnetic Resonance Section of the EACVI.

This article provides expert opinion on the use of cardiovascular magnetic resonance (CMR) in young patients with congenital heart disease (CHD) and in specific clinical situations. As peculiar challenges apply to imaging children, paediatric aspects are repeatedly discussed. The first section of the paper addresses settings and techniques, including the basic sequences used in paediatric CMR, safety, and sedation. In the second section, the indication, application, and clinical relevance of CMR in the most frequent CHD are discussed in detail. In the current era of multimodality imaging, the strengths of CMR are compared with other imaging modalities. At the end of each chapter, a brief summary with expert consensus key points is provided. The recommendations provided are strongly clinically oriented. The paper addresses not only imagers performing CMR, but also clinical cardiologists who want to know which information can be obtained by CMR and how to integrate it in clinical decision-making.

The swiss transplant cohort study: lessons from the first 6 years.

Prospective cohort studies significantly contribute to answering specific research questions in a defined population. Since 2008, the Swiss Transplant Cohort Study (STCS) systematically enrolled >95 % of all transplant recipients in Switzerland, collecting predefined data at determined time points. Designed as an open cohort, the STCS has included >3900 patients to date, with a median follow-up of 2.96 years (IQR 1.44-4.73). This review highlights some relevant findings in the field of transplant-associated infections gained by the STCS so far. Three key general aspects have crystallized: (i) Well-run cohort studies are a powerful tool to conduct genetic studies, which are crucially dependent on a meticulously described phenotype. (ii) Long-term real-life observations are adding a distinct layer of information that cannot be obtained during randomized studies. (iii) The systemic collection of data, close interdisciplinary collaboration, and continuous analysis of some key outcome data such as infectious diseases endpoints can improve patient care.

First Reported Successful Femoral Valve-in-Valve Transcatheter Aortic Valve Replacement Using the Edwards Sapien 3 Valve.

OBJECTIVES: Management of degenerated aortic valve bioprosthesis classically requires redo surgery, but transcatheter aortic valve-in-valve implantation is becoming a valid alternative in selected cases. In the case of a degenerated Mitroflow bioprosthesis, TAVR is associated with an additional challenge due to a specific risk of coronary occlusion. We aimed to assess the safety and feasibility of transfemoral valve-in-valve implantation of the new Edwards Sapien 3 (Edwards Lifesciences) in a degenerated Mitroflow bioprosthesis (Sorin Group, Inc). METHODS: We report here the safety and feasibility of transfemoral valve-in-valve implantation of a 23 mm Edwards Sapien 3 in a degenerated 25 mm Mitroflow valve and describe the specific assessment of the risk of coronary obstruction using a multi-imaging modality. RESULTS: The final result showed an absence of aortic regurgitation and a mean transvalvular gradient of 14 mm Hg. The patient had no major adverse cardiovascular events at 30-day follow-up. CONCLUSION: Transcatheter valve-in-valve implantation of an Edwards Sapien 3 in a degenerated Mitroflow is feasible and safe, considering a careful assessment of the risk of coronary obstruction with Mitroflow bioprosthesis due to leaflets mounted externally to the stent.

Indications for cardiovascular magnetic resonance in children with congenital and acquired heart disease: an expert consensus paper of the Imaging Working Group of the AEPC and the Cardiovascular Magnetic Resonance Section of the EACVI.

This article provides expert opinion on the use of cardiovascular magnetic resonance (CMR) in young patients with congenital heart disease (CHD) and in specific clinical situations. As peculiar challenges apply to imaging children, paediatric aspects are repeatedly discussed. The first section of the paper addresses settings and techniques, including the basic sequences used in paediatric CMR, safety, and sedation. In the second section, the indication, application, and clinical relevance of CMR in the most frequent CHD are discussed in detail. In the current era of multimodality imaging, the strengths of CMR are compared with other imaging modalities. At the end of each chapter, a brief summary with expert consensus key points is provided. The recommendations provided are strongly clinically oriented. The paper addresses not only imagers performing CMR, but also clinical cardiologists who want to know which information can be obtained by CMR and how to integrate it in clinical decision-making.

Olanzapine or chlorpromazine plus lithium in first episode psychotic mania: An 8-week randomised controlled trial.

BACKGROUND: Treatment strategies for mental disorders may vary according to illness stage. However no data currently exist to guide treatment in first episode psychotic mania. The aim of this study was to compare the safety and efficacy profile of chlorpromazine and olanzapine, as add-on to lithium, in patients with a first episode of psychotic mania, expecting better safety profile and adherence to olanzapine but similar efficacy for both treatments. METHODS: Data from 83 patients were collected in an 8-week randomised controlled trial on clinical variables, side effects, vital signs, and weight. Analyses of treatment differences over time were based on intent-to-treat principles. Kaplan-Meier estimated survival curves were used to analyse time-to-event data and mixed effects models repeated measures analysis of variance were used to determine treatment group differences over time on safety and efficacy measures. RESULTS: Ethics committee approval to delay informed consent procedure until recovery from the acute episode allowed the inclusion of 83 patients highly representative of those treated in the public sector. Contrary to our hypotheses, safety profile of both medications was similar. A signal for higher rate (P=.032) and earlier occurrence (P=.043) of mania remission was observed in the olanzapine group which did not survive correction for multiple comparisons. CONCLUSIONS: Olanzapine and chlorpromazine have a similar safety profile in a uniquely representative cohort of patients with first episode psychotic mania. The possibility for a greater impact of olanzapine on manic symptoms leading to earlier remission of the episode needs exploration in a large sample.

Pregnancy outcome after TNF-α inhibitor therapy during the first trimester: a prospective multicentre cohort study.

AIMS: TNF-α inhibitors are considered relatively safe in pregnancy but experience is still limited. The aim of this study was to evaluate the risk of major birth defects, spontaneous abortion, preterm birth and reduced birth weight after first trimester exposure to TNF-α inhibitors. METHODS: Pregnancy outcomes of women on adalimumab, infliximab, etanercept, certolizumab pegol or golimumab were evaluated in a prospective observational cohort study and compared with outcomes of a non-exposed random sample. The samples were drawn from pregnancies identified by institutes collaborating in the European Network of Teratology Information Services. RESULTS: In total, 495 exposed and 1532 comparison pregnancies were contributed from nine countries. The risk of major birth defects was increased in the exposed (5.0%) compared with the non-exposed group (1.5%; adjusted odds ratio (ORadj ) 2.2, 95% CI 1.0, 4.8). The risk of preterm birth was increased (17.6%; ORadj 1.69, 95% CI 1.1, 2.5), but not the risk of spontaneous abortion (16.2%; adjusted hazard ratio [HRadj ] 1.06, 95% CI 0.7, 1.7). Birth weights adjusted for gestational age and sex were significantly lower in the exposed group compared to the non-exposed cohort (P = 0.02). As a diseased comparison group was not possible to ascertain, the influence of disease and treatment on birth weight and preterm birth could not be differentiated. CONCLUSIONS: TNF-α inhibitors may carry a risk of adverse pregnancy outcome of moderate clinical relevance. Considering the impact of insufficiently controlled autoimmune disease on the mother and the unborn child, TNF-α inhibitors may nevertheless be a treatment option in women with severe disease refractory to established immunomodulatory drugs.

Clinical Application of Prognostic Gene Expression Signature in Fusion Gene-Negative Rhabdomyosarcoma: A Report from the Children's Oncology Group.

PURPOSE: Pediatric rhabdomyosarcoma (RMS) has two common histologic subtypes: embryonal (ERMS) and alveolar (ARMS). PAX-FOXO1 fusion gene status is a more reliable prognostic marker than alveolar histology, whereas fusion gene-negative (FN) ARMS patients are clinically similar to ERMS patients. A five-gene expression signature (MG5) previously identified two diverse risk groups within the fusion gene-negative RMS (FN-RMS) patients, but this has not been independently validated. The goal of this study was to test whether expression of the MG5 metagene, measured using a technical platform that can be applied to routine pathology material, would correlate with outcome in a new cohort of patients with FN-RMS. EXPERIMENTAL DESIGN: Cases were taken from the Children's Oncology Group (COG) D9803 study of children with intermediate-risk RMS, and gene expression profiling for the MG5 genes was performed using the nCounter assay. The MG5 score was correlated with clinical and pathologic characteristics as well as overall and event-free survival. RESULTS: MG5 standardized score showed no significant association with any of the available clinicopathologic variables. The MG5 signature score showed a significant correlation with overall (N = 57; HR, 7.3; 95% CI, 1.9-27.0; P = 0.003) and failure-free survival (N = 57; HR, 6.1; 95% CI, 1.9-19.7; P = 0.002). CONCLUSIONS: This represents the first, validated molecular prognostic signature for children with FN-RMS who otherwise have intermediate-risk disease. The capacity to measure the expression of a small number of genes in routine pathology material and apply a simple mathematical formula to calculate the MG5 metagene score provides a clear path toward better risk stratification in future prospective clinical trials. Clin Cancer Res; 21(20); 4733-9. ©2015 AACR.

Dix ans de revue de la littérature en médecine interne générale--un premier bilan [Ten years of literature review in general internal medicine--a first assessment].

A group of family physicians in an outpatient clinic in Switzerland prospectively followed scientific literature for ten years. What to remember among the numerous articles retrieved and which paper really changed our practice? If many readings are quickly forgotten, some of them marked our minds and changed our habits. This article is a summary of our efforts to keep the essential tools in clinical practice.

A single-blind, randomised controlled trial on the effects of lithium and quetiapine monotherapy on the trajectory of cognitive functioning in first episode mania: A 12-month follow-up study.

BACKGROUND: Cognitive deficits have been reported during the early stages of bipolar disorder; however, the role of medication on such deficits remains unclear. The aim of this study was to compare the effects of lithium and quetiapine monotherapy on cognitive performance in people following first episode mania. METHODS: The design was a single-blind, randomised controlled trial on a cohort of 61 participants following first episode mania. Participants received either lithium or quetiapine monotherapy as maintenance treatment over a 12-month follow-up period. The groups were compared on performance outcomes using an extensive cognitive assessment battery conducted at baseline, month 3 and month 12 follow-up time-points. RESULTS: There was a significant interaction between group and time in phonemic fluency at the 3-month and 12-month endpoints, reflecting greater improvements in performance in lithium-treated participants relative to quetiapine-treated participants. After controlling for multiple comparisons, there were no other significant interactions between group and time for other measures of cognition. CONCLUSION: Although the effects of lithium and quetiapine treatment were similar for most cognitive domains, the findings imply that early initiation of lithium treatment may benefit the trajectory of cognition, specifically verbal fluency in young people with bipolar disorder. Given that cognition is a major symptomatic domain of bipolar disorder and has substantive effects on general functioning, the ability to influence the trajectory of cognitive change is of considerable clinical importance.