The role of the medical emergency team in end-of-life care : a multicenter, prospective, observational study

<b>Objective:</b> To investigate the role of medical emergency teams in end-of-life care planning.<br /><br /><b>Design:</b> One month prospective audit of medical emergency team calls.<br /><br /><b>Setting:</b> Seven university-affiliated hospitals in Australia, Canada, and Sweden.<br /><br /><b>Patients:</b> Five hundred eighteen patients who received a medical emergency team call over 1 month.<br /><br /><b>Interventions:</b> None.<br /><br /><b>Measurements and Main Results:</b> There were 652 medical emergency team calls in 518 patients, with multiple calls in 99 (19.1%) patients. There were 161 (31.1%) patients with limitations of medical therapy during the study period. The limitation of medical therapy was instituted in 105 (20.3%) and 56 (10.8%) patients before and after the medical emergency team call, respectively. In 78 patients who died with a limitation of medical therapy in place, the last medical emergency team review was on the day of death in 29.5% of patients, and within 2 days in another 28.2%. Compared with patients who did not have a limitation of medical therapy, those with a limitation of medical therapy were older (80 vs. 66 yrs; p &lt; .001), less likely to be male (44.1% vs. 55.7%; p .014), more likely to be medical admissions (70.8% vs. 51.3%; p &lt; .001), and less likely to be admitted from home (74.5% vs. 92.2%, p &lt; .001). In addition, those with a limitation of medical therapy were less likely to be discharged home (22.4% vs. 63.6%; p &lt; .001) and more likely to die in hospital (48.4% vs. 12.3%; p &lt; .001). There was a trend for increased likelihood of calls associated with limitations of medical therapy to occur out of hours (51.0% vs. 43.8%, p .089).<br /><br /><b>Conclusions:</b> Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals, and to confirm our findings in other organizations.<br />

A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit

Objective: To compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients. Design: Randomized, controlled trial. Setting: General intensive care unit (24 beds) in an Australian metropolitan teaching hospital. Patients: Adult, mechanically ventilated patients (n = 312). Interventions: Patients were randomly assigned to receive sedation directed by formal guidelines (protocol group, n = 153) or usual local clinical practice (control, n = 159). Measurements and Main Results: The median (95% confidence interval) duration of ventilation was 79 hrs (56-93 hrs) for patients in the protocol group compared with 58 hrs (44-78 hrs) for patients who received control care (p = .20). Lengths of stay (median [range]) in the intensive care unit (94 [2-1106] hrs vs. 88 (14-962) hrs, p = .58) and hospital (13 [1-113] days vs. 13 (1-365) days, p = .97) were similar, as were the proportions of subjects receiving a tracheostomy (17% vs. 15%, p = .64) or undergoing unplanned self-extubation (1.3% vs. 0.6%, p = .61). Death in the intensive care unit occurred in 32 (21%) patients in the protocol group and 32 (20%) control subjects (p = .89), with a similar overall proportion of deaths in hospital (25% vs. 22%, p = .51). A Cox proportional hazards model, after adjustment for age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic category, and doses of commonly used drugs, estimated that protocol sedation management was associated with a 22% decrease (95% confidence interval 40% decrease to 2% increase, p = .07) in the occurrence of successful weaning from mechanical ventilation. Conclusions: This randomized trial provided no evidence of a substantial reduction in the duration of mechanical ventilation or length of stay, in either the intensive care unit or the hospital, with the use of protocol-directed sedation compared with usual local management. Qualified high-intensity nurse staffing and routine Australian intensive care unit nursing responsibility for many aspects of ventilatory practice may explain the contrast between these findings and some recent North American studies. (C) 2008 Lippincott Williams &amp; Wilkins, Inc. <br />

Outcomes and costs of primary care surveillance and intervention for overweight or obese children : the LEAP 2 randomised controlled trial

<b>Objective</b> To determine whether ascertainment of childhood obesity by surveillance followed by structured secondary prevention in primary care improved outcomes in overweight or mildly obese children. <br /><br /><b>Design</b> Randomised controlled trial nested within a baseline cross sectional survey of body mass index (BMI). Randomisation and outcomes measurement, but not participants, were blinded to group assignment. <br /><br /><b>Setting</b> 45 family practices (66 general practitioners) in Melbourne, Australia. <br /><br /><b>Participants</b> 3958 children visiting their general practitioner in May 2005-July 2006 were surveyed for BMI. Of these, 258 children aged 5 years 0 months up to their 10th birthday who were overweight or obese by International Obesity Taskforce criteria were randomised to intervention (n=139) or control (n=119) groups. Children who were very obese (UK BMI z score 3.0) were excluded. <br /><br /><b>Intervention</b> Four standard consultations over 12 weeks targeting change in nutrition, physical activity, and sedentary behaviour, supported by purpose designed family materials. <br /><br /><b>Main outcomes measures</b> Primary measure was BMI at 6 and 12 months after randomisation. Secondary measures were mean activity count/min by 7-day accelerometry, nutrition score from 4-day abbreviated food frequency diary, and child health related quality of life. Differences were adjusted for socioeconomic status, age, sex, and baseline BMI. <br /><br /><b>Results </b>Of 781 eligible children, 258 (33%) entered the trial; attrition was 3.1% at 6 months and 6.2% at 12 months. Adjusted mean differences (intervention &ndash; control) at 6 and 12 months were, for BMI, &ndash;0.12 (95% CI &ndash;0.40 to 0.15, P=0.4) and &ndash;0.11 (&ndash;0.45 to 0.22, P=0.5); for physical activity in counts/min, 24 (&ndash;4 to 52, P=0.09) and 11 (&ndash;26 to 49, P=0.6); and, for nutrition score, 0.2 (&ndash;0.03 to 0.4, P=0.1) and 0.1 (&ndash;0.1 to 0.4, P=0.2). There was no evidence of harm to the child. Costs to the healthcare system were significantly higher in the intervention arm. <br /><br /><b>Conclusions</b> Primary care screening followed by brief counselling did not improve BMI, physical activity, or nutrition in overweight or mildly obese 5-10 year olds, and it would be very costly if universally implemented. These findings are at odds with national policies in countries including the US, UK, and Australia.<br />

Amylase and glucosidase enzyme inhibitory activity of ginger (Zingiber officinale Roscoe) an in vitro study

The prevalence of type 2 diabetes has reached to an epidemic proportion in Sri Lanka. The need for achieving better control of blood glucose level has been evident in diabetes management. However it is not easy to achieve this goal in a large proportion of patients. This is partly due to limitations of currently available pharmacological agents which stimulate research on novel anti-diabetic agents with different mechanisms. Digestive enzymes have been targeted as potential avenues for modulation of blood glucose concentration through inhibition of the enzymatic breakdown of complex carbohydrates to meal derived glucose absorption. Acarbose is a widely used oral anti-diabetic drug which inhibits the &alpha;-glucosidase, enzyme responsible for breaking down of disaccharides and polysaccharides into glucose. Many herbal extracts have been found to posses similar inhibitory effects. Ginger (Zingiber officinale Roscoe) has developed a reputation in treatment of several diseases. In vitro enzymic inhibitory effect of ginger was investigated in this study. Enzymes &alpha; -amylase and &alpha; -glucosidase treated with either Acarbose or ginger extract were allowed to react with cooked rice and percentages of glucose content were measured. The glucosidase and amylase activities on the rice were inhibited by addition of ginger cause significant reduction in glucose percentages (36.86&plusmn; 1.05 to 26.87&plusmn; 2.17, P&lt;0.05 and 49.04&plusmn;0.65 to 35.35&plusmn;2.22, P&lt;0.05) which showed comparable results with Acarbose on glucosidase activity (36.86&plusmn; 1.05 to, 27.8&plusmn;1.32 P&lt;0.05). Results of the study indicates ginger as a potential plant based amylase and glucosidase inhibitor in carbohydrate digestion but usage in glycaemic control in human has to be investigated further.<br />

Cholesterol-lowering effects of plant sterol esters and non-esterified stanols in margarine, butter and low-fat foods

<b>Objectives:</b> To determine the efficacy on plasma cholesterol-lowering of plant sterol esters or non-esterified stanols eaten within low-fat foods as well as margarine.<br /><b>Design:</b> Randomised, controlled, single-blind study with sterol esters and non-esterified plant stanols provided in breakfast cereal, bread and spreads. Study 1 comprised 12 weeks during which sterol esters (2.4 g) and stanol (2.4 g) -containing foods were eaten during 4 week test periods of cross-over design following a 4 week control food period. In Study 2, in a random order cross-over design, a 50% dairy fat spread with or without 2.4 g sterol esters daily was tested.<br /><b>Subjects: </b>Hypercholesterolaemic subjects; 22 in study 1 and 15 in study 2.<br />Main outcome measures: Plasma lipids, plasma sterols, plasma carotenoids and tocopherols.<br /><b>Results: </b>Study 1&frac34;median LDL cholesterol was reduced by the sterol esters (-13.6%; P&lt;0.001 by ANOVA on ranks; P&lt;0.05 by pairwise comparison) and by stanols (-8.3%; P=0.003, ANOVA and &lt;0.05 pairwise comparison). With sterol esters plasma plant sterol levels rose (35% for sitosterol, 51% for campesterol; P&lt;0.001); plasma lathosterol rose 20% (P=0.03), indicating compensatory increased cholesterol synthesis. With stanols, plasma sitosterol fell 22% (P=0.004), indicating less cholesterol absorption. None of the four carotenoids measured in plasma changed significantly. In study 2, median LDL cholesterol rose 6.5% with dairy spread and fell 12.2% with the sitosterol ester fortified spread (P=0.03 ANOVA and &lt;5% pairwise comparison).<br /><b>Conclusion: </b>1. Plant sterol esters and non-esterified stanols, two-thirds of which were incorporated into low-fat foods, contributed effectively to LDL cholesterol lowering, extending the range of potential foods. 2. The LDL cholesterol-raising effect of butter fat could be countered by including sterol esters. 3. Plasma carotenoids and tocopherols were not reduced in this study.<br />

Dietary omega-3 fatty acids and depression in a community sample

To evaluate the association between omega-3 polyunsaturated essential fatty acids and depression, data regarding prevalence rates of self-reported depression and median daily dietary intakes of these fatty acids were obtained from an age-stratified, population-based sample of women (n = 755; 23-97 year) in the Barwon Statistical Division of south-eastern Australia. A self-report questionnaire based on Diagnostic and Statistical Manual-IV criteria was utilised to determine 12-month prevalence rates of depression in this sample, and data from biennial food frequency questionnaires examining seafood and fish oil consumption over a 6-year period were examined. Differences in median dietary intakes of omega-3 fatty acids between the depressed and nondepressed cohorts were analysed and results were adjusted for age, weight and smoking status. No significant differences in median intakes were identified between the two groups of women (median, interquartile range; depressed = 0.09g/day, 0.04-0.18 versus nondepressed = 0.11 g/day, 0.05-0.22, p = 0.3), although overall average intakes of omega-3 fatty acids were lower than recommended and rates of depression within this sample higher than expected, based on previous data. Further research that takes into account ratios of omega-6 to omega-3 polyunsaturated essential fatty acids, as well as other dietary sources of omega-3 fatty acids, is warranted.

Identifying co-regulating microrna groups

<b>Background:</b> Current miRNA target prediction tools have the common problem that their false positive rate is high. This renders identification of co-regulating groups of miRNAs and target genes unreliable. In this study, we describe a procedure to identify highly probable co-regulating miRNAs and the corresponding co-regulated gene groups. Our procedure involves a sequence of statistical tests: (1) identify genes that are highly probable miRNA targets; (2) determine for each such gene, the minimum number of miRNAs that co-regulate it with high probability; (3) find, for each such gene, the combination of the determined minimum size of miRNAs that co-regulate it with the lowest p-value; and (4) discover for each such combination of miRNAs, the group of genes that are co-regulated by these miRNAs with the lowest p-value computed based on GO term annotations of the genes. <br /><b>Results:</b> Our method identifies 4, 3 and 2-term miRNA groups that co-regulate gene groups of size at least 3 in human. Our result suggests some interesting hypothesis on the functional role of several miRNAs through a &quot;guilt by association&quot; reasoning. For example, miR-130, miR-19 and miR-101 are known neurodegenerative diseases associated miRNAs. Our 3-term miRNA table shows that miR-130/19/101 form a co-regulating group of rank 22 (p-value =1.16 &times; 10^-2). Since miR-144 is co-regulating with miR-130, miR-19 and miR-101 of rank 4 (p-value = 1.16 &times; 10^-2) in our 4-term miRNA table, this suggests hsa-miR-144 may be neurodegenerative diseases related miRNA. <b>Conclusions: </b>This work identifies highly probable co-regulating miRNAs, which are refined from the prediction by computational tools using (1) signal-to-noise ratio to get high accurate regulating miRNAs for every gene, and (2) Gene Ontology to obtain functional related co-regulating miRNA groups. Our result has partly been supported by biological experiments. Based on prediction by TargetScanS, we found highly probable target gene groups in the Supplementary Information. This result might help biologists to find small set of miRNAs for genes of interest rather than huge amount of miRNA set.

Reliability and validity of psychosocial and environmental correlates measures of physical activity and screen-based behaviors among Chinese children in Hong Kong

<b>Background : </b>Insufficient participation in physical activity and excessive screen time have been observed among Chinese children. The role of social and environmental factors in shaping physical activity and sedentary behaviors among Chinese children is under-investigated. The purpose of the present study was to assess the reliability and validity of a questionnaire to measure child- and parent-reported psychosocial and environmental correlates of physical activity and screen-based behaviors among Chinese children in Hong Kong. <br /><b><br />Methods : </b>A total of 303 schoolchildren aged 9-14 years and their parents volunteered to participate in this study and 160 of them completed the questionnaire twice within an interval of 10 days. Intraclass correlation coefficients (ICCs), kappa statistics, and percent agreement were performed to evaluate test-retest reliability of the continuous and categorical variables, respectively. Exploratory factor analyses (EFAs) were conducted to assess convergent validity of the emergent scales. Cronbach's alpha and ICCs were performed to assess internal and test-retest reliability of the emergent scales. Criterion validity was assessed by correlating psychosocial and environmental measures with self-reported physical activity and screen-based behaviors, measured by a validated questionnaire. <br /><b><br />Results :</b> Reliability statistics for both child- and parent-reported continuous variables showed acceptable consistency for all of the ICC values greater than 0.70. Kappa statistics showed fair to perfect test-retest reliability for the categorical items. Adequate internal consistency and test-retest reliability were observed in most of the emergent scales. Criterion validity assessed by correlating psychosocial and environmental measures with child-reported physical activity found associations with physical activity in the self-efficacy scale (r = 0.25, P &lt; 0.05), the peer support for physical activity scale (r = 0.25, P &lt; 0.05) and home physical activity environmental (r = 0.14, P &lt; 0.05). Children's screen-based behaviors were associated with the family support for physical activity scale (r = -0.22, P &lt; 0.05) and parental role modeling of TV (r = 0.12, P = 0.053). <br /><b><br />Conclusions : </b>The findings provide psychometric support for using this questionnaire for examining psychosocial and environmental correlates of physical activity and screen-based behaviors among Chinese children in Hong Kong. Further research is needed to develop more robust measures based on the current questionnaire, especially for peer influence on physical activity and parental rules on screen-based behaviors. <br />

Risk factors for recurrent Mycobacterium ulcerans disease after exclusive surgical treatment in an Australian cohort

Objective: To describe risk factors for recurrence after exclusive surgical treatment of Mycobacterium ulcerans infection. Design, setting and participants: Prospective observational cohort study of all M. ulcerans cases managed with surgery alone at Barwon Health, a tertiary referral hospital, from 1 January 1998 to 31 December 2011. A random-effects Poisson regression model was used to assess rates and associations of treatment failure. Main outcome measures: Rates of treatment failure and rate ratios (RRs) for factors associated with treatment failure. Results: Of 192 patients with M. ulcerans infection, 50 (26%) had exclusive surgical treatment. Median age was 65.0 years (interquartile range [IQR], 45.5-77.7 years), and median duration of symptoms was 46 days (IQR, 26-90 days). There were 20 recurrences in 16 patients. For first lesions, the recurrence incidence rate was 41.8 (95% CI, 25.6-68.2) per 100 person-years, and median time to recurrence was 50 days (IQR, 30-171 days). Recurrence occurred &le; 3 cm from the original lesion in 13 cases, and &gt;3 cm in nine. On univariable analysis, age &ge;60 years (RR 13.84; 95% CI, 2.21-86.68; P&lt; 0.01), distal lesions (RR, 20.43; 95% CI, 1.97-212.22; P&lt;0.01), positive histological margins (RR, 21.02; 95% CI, 5.51-80.26; P&lt; 0.001), immunosuppression (RR, 17.97; 95% CI, 4.17-77.47; P &lt;0.01) and duration of symptoms &gt;75 days (RR, 10.13; 95% CI, 1.76-58.23; P =0.02) were associated with treatment failure. On multivariable analysis, positive margins (RR, 7.72; 95% CI, 2.71-22.01; P&lt;0.001) and immunosuppression (RR, 6.45; 95% CI, 2.42-17.20; P =0.01) remained associated with treatment failure. Conclusions: Recurrence rates after exclusive surgical treatment of M. ulcerans disease in an Australian cohort are high, with increased rates associated with immunosuppression or positive histological margins.<br /><br />

Explaining the effects of a 1-year intervention promoting a low fat diet in adolescent girls : a mediation analysis

Background : Although it is important to investigate how interventions work, no formal mediation analyses have been conducted to explain behavioral outcomes in school-based fat intake interventions in adolescents. The aim of the present study was to examine mediation effects of changes in psychosocial determinants of dietary fat intake (attitude, social support, self-efficacy, perceived benefits and barriers) on changes in fat intake in adolescent girls. <br /><br />Methods : Data from a 1-year prospective intervention study were used. A random sample of 804 adolescent girls was included in the study. Girls in the intervention group (n = 415) were exposed to a multi-component school-based intervention program, combining environmental changes with a computer tailored fat intake intervention and parental support. Fat intake and psychosocial determinants of fat intake were measured with validated self-administered questionnaires. To assess mediating effects, a product-of-coefficient test, appropriate for cluster randomized controlled trials, was used. <br /><br />Results : None of the examined psychosocial factors showed a reliable mediating effect on changes in fat intake. The single-mediator model revealed a statistically significant suppression effect of perceived barriers on changes in fat intake (p = 0.011). In the multiple-mediator model, this effect was no longer significant, which was most likely due to changes in perceived barriers being moderately related to changes in self-efficacy (-0.30) and attitude (-0.25). The overall mediated-suppressed effect of the examined psychosocial factors was virtually zero (total mediated effect = 0.001; SE = 7.22; p = 0.992). <br /><br />Conclusion : Given the lack of intervention effects on attitudes, social support, self-efficacy and perceived benefits and barriers, it is suggested that future interventions should focus on the identification of effective strategies for changing these theoretical mediators in the desired direction. Alternatively, it could be argued that these constructs need not be targeted in interventions aimed at adolescents, as they may not be responsible for the intervention effects on fat intake. To draw any conclusions regarding mediators of fat-intake change in adolescent' girls and regarding optimal future intervention strategies, more systematic research on the mediating properties of psychosocial variables is needed.

Cytokine regulation of skeletal muscle fatty acid metabolism: effect of interleukin-6 and tumor necrosis factor-α

IL-6 and TNF-&alpha; have been associated with insulin resistance and type 2 diabetes. Furthermore, abnormalities in muscle fatty acid (FA) metabolism are strongly associated with the development of insulin resistance. However, few studies have directly examined the effects of either IL-6 or TNF-&alpha; on skeletal muscle FA metabolism. Here, we used a pulse-chase technique to determine the effect of IL-6 (50-5,000 pg/ml) and TNF-&alpha; (50-5,000 pg/ml) on FA metabolism in isolated rat soleus muscle. IL-6 (5,000 pg/ml) increased exogenous and endogenous FA oxidation by ≃50% (P &lt; 0.05) but had no effect on FA uptake or incorporation of FA into endogenous lipid pools. In contrast, TNF-&alpha; had no effect on FA oxidation but increased FA incorporation into diacylglycerol (DAG) by 45% (P &lt; 0.05). When both IL-6 (5,000 pg/ml) and insulin (10 mU/ml) were present, IL-6 attenuated insulin's suppressive effect on FA oxidation, increasing exogenous FA oxidation (+37%, P &lt; 0.05). Furthermore, in the presence of insulin, IL-6 reduced the esterification of FA to triacylglycerol by 22% (P &lt; 0.05). When added in combination with IL-6 or leptin (10 &mu;g/ml), the TNF-&alpha;-induced increase in DAG synthesis was inhibited. In conclusion, the results demonstrate that IL-6 plays an important role in regulating fat metabolism in muscle, increasing rates of FA oxidation, and attenuating insulin's lipogenic effects. In contrast, TNF-&alpha; had no effect on FA oxidation but increased FA incorporation into DAG, which may be involved in the development of TNF-&alpha;-induced insulin resistance in skeletal muscle.

Statin use and risk of depression: a Swedish national cohort study

Background : Statin medications, used to prevent heart disease by reducing cholesterol, also reduce inflammation and protect against oxidative damage. As inflammation and oxidative stress occur in depression, there is interest in their potential to reduce depression risk. We investigated whether use of statin medications was associated with a change in the risk of developing depression in a very large Swedish national cohort (n&iquest;=&iquest;4,607,990).MethodsNational register data for adults &iquest;40yr was analyzed to obtain information about depression diagnoses and prescriptions of statin medications between 2006 and 2008. Associations were tested using logistic regression.ResultsUse of any statin was shown to reduce the odds of depression by 8% compared to individuals not using statin medications (OR&iquest;=&iquest;0.92, 95% CI, 0.89-0.96; p&iquest;&lt;&iquest;0.001). Simvastatin had a protective effect (OR&iquest;=&iquest;0.93, 95% CI, 0.89-0.97; p&iquest;=&iquest;0.001), whereas atorvastatin was associated with increased risk of depression (OR&iquest;=&iquest;1.11, 95% CI, 1.01-1.22; p&iquest;=&iquest;0.032). There was a stepwise decrease in odds ratio with increasing age (OR&iquest;&iquest;&iquest;40 years&iquest;=&iquest;0.95, OR&iquest;&iquest;&iquest;50 years&iquest;=&iquest;0.91, OR&iquest;&iquest;&iquest;60 years&iquest;=&iquest;0.85, OR&iquest;&iquest;&iquest;70 years&iquest;=&iquest;0.81).ConclusionsThe use of any statin was associated with a reduction in risk of depression in individuals over the age of 40. Clarification of the strength of these protective effects, the clinical relevance of these effects and determination of which statins are most effective is needed.

C-reactive protein is increased in schizophrenia but is not altered by antipsychotics : meta-analysis and implications

The inflammatory hypothesis of schizophrenia (SZ) posits that inflammatory processes and neural-immune interactions are involved in its pathogenesis, and may underpin some of its neurobiological correlates. SZ is the psychiatric disorder causing the most severe burden of illness, not just owing to its psychiatric impairment, but also owing to its significant medical comorbidity. C-reactive protein (CRP) is a commonly used biomarker of systemic inflammation worldwide. There are some conflicting results regarding the behaviour of CRP in SZ. The aims of this study were to verify whether peripheral CRP levels are indeed increased in SZ, whether different classes of antipsychotics divergently modulate CRP levels and whether its levels are correlated with positive and negative symptomatology. With that in mind, we performed a meta-analysis of all cross-sectional studies of serum and plasma CRP levels in SZ compared to healthy subjects. In addition, we evaluated longitudinal studies on CRP levels before and after antipsychotic use. Our meta-analyses of CRP in SZ included a total of 26 cross-sectional or longitudinal studies comprising 85&thinsp;000 participants. CRP levels were moderately increased in persons with SZ regardless of the use of antipsychotics and did not change between the first episode of psychosis and with progression of SZ (g=0.66, 95% confidence interval (95% CI) 0.43 to 0.88, P&lt;0.001, 24 between-group comparisons, n=82&thinsp;962). The extent of the increase in peripheral CRP levels paralleled the increase in severity of positive symptoms, but was unrelated to the severity of negative symptoms. CRP levels were also aligned with an increased body mass index. Conversely, higher age correlated with a smaller difference in CRP levels between persons with SZ and controls. Furthermore, CRP levels did not increase after initiation of antipsychotic medication notwithstanding whether these were typical or atypical antipsychotics (g=0.01, 95% CI -0.20 to 0.22, P=0.803, 8 within-group comparisons, n=713). In summary, our study provides further evidence of the inflammatory hypothesis of SZ. Whether there is a causal relationship between higher CRP levels and the development of SZ and aggravation of psychotic symptoms, or whether they are solely a marker of systemic low-grade inflammation in SZ, remains to be clarified.