Long-term results after operations for active infective endocarditis in native and prosthetic valves

The objective of this study was to evaluate the midterm results of patients who underwent operations for active infective endocarditis.

Epileptogenic developmental venous anomaly: insights from simultaneous EEG/fMRI

Developmental venous anomalies (DVAs) are associated with epileptic seizures; however, the role of DVA in the epileptogenesis is still not established. Simultaneous interictal electroencephalogram/functional magnetic resonance imaging (EEG/fMRI) recordings provide supplementary information to electroclinical data about the epileptic generators, and thus aid in the differentiation of clinically equivocal epilepsy syndromes. The main objective of our study was to characterize the epileptic network in a patient with DVA and epilepsy by simultaneous EEG/fMRI recordings. A 17-year-old woman with recently emerging generalized tonic-clonic seizures, and atypical generalized discharges, was investigated using simultaneous EEG/fMRI at the university hospital. Previous high-resolution MRI showed no structural abnormalities, except a DVA in the right frontal operculum. Interictal EEG recordings showed atypical generalized discharges, corresponding to positive focal blood oxygen level dependent (BOLD) correlates in the right frontal operculum, a region drained by the DVA. Additionally, widespread cortical bilateral negative BOLD correlates in the frontal and parietal lobes were delineated, resembling a generalized epileptic network. The EEG/fMRI recordings support a right frontal lobe epilepsy, originating in the vicinity of the DVA, propagating rapidly to both frontal and parietal lobes, as expressed on the scalp EEG by secondary bilateral synchrony. The DVA may be causative of focal epilepsies in cases where no concomitant epileptogenic lesions can be detected. Advanced imaging techniques, such as simultaneous EEG/fMRI, may thus aid in the differentiation of clinically equivocal epilepsy syndromes.

The Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY): Practicability and discriminative validity

Background Basic symptom (BS) criteria have been suggested to complement ultra-high risk (UHR) criteria in the early detection of psychosis in adults and in children and adolescents. To account for potential developmental particularities and a different clustering of BS in children and adolescents, the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) was developed. Aims The SPI-CY was evaluated for its practicability and discriminative validity. Method The SPI-CY was administered to 3 groups of children and adolescents (mean age 16; range=8–18; 61% male): 23 at-risk patients meeting UHR and/or BS criteria (AtRisk), 22 clinical controls (CC), and 19 children and adolescents from the general population (GPS) matched to AtRisk in age, gender, and education. We expected AtRisk to score highest on the SPI-CY, and GPS lowest. Results The groups differed significantly on all 4 SPI-CY subscales. Pairwise post-hoc comparisons confirmed our expectations for all subscales and, at least on a descriptive level, most items. Pairwise subscale differences indicated at least moderate group effects (r≥0.37) which were largest for Adynamia (0.52≤r≥0.70). Adynamia also performed excellent to outstanding in ROC analyses (0.813≤AUC≥0.981). Conclusion The SPI-CY could be a helpful tool for detecting and assessing BS in the psychosis spectrum in children and adolescents, by whom it was well received. Furthermore, its subscales possess good discriminative validity. However, these results require validation in a larger sample, and the psychosis-predictive ability of the subscales in different age groups, especially the role of Adynamia, will have to be explored in longitudinal studies.

The significance of at-risk symptoms for psychosis in children and adolescents

The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy in fighting the devastating consequences of psychotic disorders. Currently, the 2 most broadly used sets of at-risk criteria, that is, ultra-high risk (UHR) and basic symptom criteria, were developed mainly in adult samples. We review the data regarding the presence and relevance of at-risk symptoms for psychosis in children and adolescents. The few existing studies suggest that attenuated psychotic symptoms (APS) and brief limited intermittent psychotic symptoms (BLIPS) do have some clinical relevance in young adolescents from the general population. Nevertheless, their differentiation from atypical psychotic symptoms or an emerging schizotypal personality disorder, as well as their stability and predictive accuracy for psychosis, are still unclear. Further, standard interviews for UHR criteria do not define a minimum age for the assessment of APS and BLIPS or guidelines as to when and how to include information from parents. APS and basic symptoms may be predictive of conversion to psychosis in help-seeking young adolescents. Nevertheless, the rate and timing, and thus the required observation time, need further study. Moreover, no study has yet addressed the issue of how to treat children and adolescents presenting with at-risk symptoms and criteria. Further research is urgently needed to examine if current at-risk criteria and approaches have to be tailored to the special needs of children and adolescents. A preliminary rationale for how to deal with at-risk symptoms for psychosis in clinical practice is provided.

'A rose is a rose is a rose', but at-risk criteria differ

Background: Over the last 15 years, efforts to detect psychoses early in their prodromal states have greatly progressed; meanwhile, ultra-high risk (UHR) criteria have been the subject of such consensus that parts of them have been proposed for inclusion in DSM-5 in terms of an attenuated psychosis syndrome. However, it is frequently unacknowledged that the definitions and operationalizations of UHR-related at-risk criteria, including the relevant attenuated psychotic symptoms, vary considerably across centers and time and, thus, between prediction studies. Methods: These variations in UHR criteria are described and discussed with reference to the rates of transition to psychosis, their prevalence in the general population and the proposed new operationalization of the attenuated psychosis syndrome. Results: A comparison of samples recruited according to different UHR operationalizations reveals differences in the distribution of UHR criteria and transition rates as well as in the prevalence rates of at-risk criteria in the general population. Conclusion: The evidence base for the introduction of such a new syndrome is weaker than the number of studies using supposedly equal UHR criteria would at first suggest. Thus, studies comparing the effects of different (sub-)criteria not only on transition rates and outcomes but also on other important aspects, such as neurocognitive performance and brain imaging results, are necessary. Meanwhile, the preliminary attenuated psychosis syndrome in DSM-5 should not follow an altogether new definition but, rather, the currently most reliable UHR definition, which must still demonstrate its reliability and validity outside specialized psychiatric services.

Challenges in the early detection of psychosis in children and adolescents

The early detection and treatment of persons at-risk for psychosis is currently regarded a promising strategy in fighting the devastating consequences of psychotic disorders. The two current at-risk approaches, i.e., the "ultra high risk" and the "basic symptom" criteria, were mainly developed on adult samples. Initial evidence suggests, however, that they cannot simply be applied to children and adolescents. For ultra high risk criteria, there is indication of some attenuated psychotic symptoms being potentially non-specific in adolescents and of brief limited intermittent symptoms being difficult to clinically classify in children when observable behavioral correlates are missing. For basic symptoms, too, only preliminary indication of their usefulness in children and adolescents exists. Since developmental peculiarities in the assessment of basic symptoms should be considered, a child and youth version of the Schizophrenia Proneness Instrument (SPI-CY) was developed. In conclusion, research on the clinical-prognostic validity of the at-risk criteria and their potential adoption to the special needs of children and adolescents is needed. If a Prodromal Risk Syndrome for Psychosis or Attenuated Psychotic Symptoms Syndrome will be included into DSM-V, it has to be highlighted that its suitability for children and adolescents is only insufficiently known.

Comparing the prodrome of schizophrenia-spectrum psychoses and affective disorders with and without psychotic features

Following encouraging results in the early detection of psychotic disorders, interest in the early detection of affective, especially bipolar disorders, has recently been renewed. However, the differentiation between affective disorders with and without psychotic features is often missing, although it has been suggested that affective disorders with psychotic features may be distinct from those without psychotic features and closely linked to non-affective psychoses.

Cost-effectiveness of 12-month therapeutic assertive community treatment as part of integrated care versus standard care in patients with schizophrenia treated with quetiapine immediate release (ACCESS trial)

To compare the 1-year cost-effectiveness of therapeutic assertive community treatment (ACT) with standard care in schizophrenia. ACT was specifically developed for patients with schizophrenia, delivered by psychosis experts highly trained in respective psychotherapies, and embedded into an integrated care system.

Pharmacological prevention and treatment in clinical at-risk states for psychosis

Over the last couple of decades, the treatment of psychoses has much advanced; yet, despite all progress, the individual and societal burden associated with psychosis and particularly schizophrenia has largely remained unchanged. Therefore, much hope is currently placed on indicated prevention as a mean to fight these burdens before they set in. Though the number of studies investigating pharmacological interventions is still limited, encouraging results have been reported from the pioneering trials, despite several methodological limitations. Furthermore, it has become clear that persons characterized by the at-risk criteria are already ill and do not only need preventive intervention, but also treatment. In consequence, outcome criteria have to be broadened to cover the current needs of the patients. As is indicated by a recent study successfully using Omega-3 fatty acids for both purposes, it may be promising to develop and investigate interventions especially for the at-risk state, independent of their effectiveness in manifest disease states. Treatment studies may become promoted by the proposed introduction of a new disorder category into DSM-V. Future prevention studies, however, need to solve the challenge of changing immediate transition rates, demanding for new risk enrichment strategies as a prerequisite for feasible trial designs.

Basic symptoms and the prediction of first-episode psychosis

Recent focus on early detection and intervention in psychosis has renewed interest in subtle psychopathology beyond positive and negative symptoms. Such self-experienced sub-clinical disturbances are described in detail by the basic symptom concept. This review will give an introduction into the concept of basic symptoms and describe the development of the current instruments for their assessment, the Schizophrenia Proneness Instrument, Adult (SPI-A) and Child and Youth version (SPI-CY), as well as of the two at-risk criteria: the at-risk criterion Cognitive-Perceptive Basic Symptoms (COPER) and the high-risk criterion Cognitive Disturbances (COGDIS). Further, an overview of prospective studies using both or either basic symptom criteria and transition rates related to these will be given, and the potential benefit of combining ultra-high risk criteria, particularly attenuated psychotic symptoms, and basic symptom criteria will be discussed. Finally, their prevalence in psychosis patients, i.e. the sensitivity, as well as in general population samples will be described. It is concluded that both COPER and COGDIS are able to identify subjects at a high risk of developing psychosis. Further, they appear to be sufficiently frequent prior to onset of the first psychotic episode as well as sufficiently rare in persons of general population to be considered as valuable for an early detection of psychosis.

[Pathways-to-Care for First-Episode psychotic patients--an overview of international studies]

A longer duration of untreated psychosis (DUP) as well as of untreated illness (DUI) was found to be associated with a negative course of psychosis. Thus, increasing efforts are made to reduce the DUP and provide adequate treatment as early as possible. But, in order to overcome obstacles to early help-seeking, these have to be identified first. Thus, an overview on initial help-seeking behaviour and predictors of DUP is given. Across 25 identified studies, the DUP, at about one year on average, is still unfavourably long and includes on average of three help-seeking contacts prior to the initiation of adequate treatment. Since negative factors in pathways-to-care involve features on all relevant levels (patient, social environment and health-care system), an optimisation of pathways-to-care will require the integration of services and continuous awareness programmes targeting the general population and mental health-care professionals.

Prediction of psychosis in clinical high-risk patients by the Schizotypal Personality Questionnaire. Results of the EPOS project

OBJECTIVE: Schizotypal features indicate proneness to psychosis in the general population. It is also possible that they increase transition to psychosis (TTP) among clinical high-risk patients (CHR). Our aim was to investigate whether schizotypal features predict TTP in CHR patients. METHODS: In the EPOS (European Prediction of Psychosis Study) project, 245 young help-seeking CHR patients were prospectively followed for 18 months and their TTP was identified. At baseline, subjects were assessed with the Schizotypal Personality Questionnaire (SPQ). Associations between SPQ items and its subscales with the TTP were analysed in Cox regression analysis. RESULTS: The SPQ subscales and items describing ideas of reference and lack of close interpersonal relationships were found to correlate significantly with TTP. The co-occurrence of these features doubled the risk of TTP. CONCLUSIONS: Presence of ideas of reference and lack of close interpersonal relations increase the risk of full-blown psychosis among CHR patients. This co-occurrence makes the risk of psychosis very high.