Self-Reported Psychotic-Like Experiences Are a Poor Estimate of Clinician-Rated Attenuated and Frank Delusions and Hallucinations

Background: One reason for the decision to delay the introduction of an Attenuated Psychosis Syndrome in the main text of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders was the concern that attenuated psychotic symptoms (APS) might in fact be common features in adolescents and young adults from the general population of no psychopathological significance in themselves. This concern was based on reports of high prevalence rates of psychotic-like experiences (PLEs) in the general population and the assumption that PLEs are a good estimate of APS. Although the criterion validity of self-reported PLEs had already been studied with respect to clinician-rated psychotic symptoms and found insufficient, it had been argued that PLEs might in fact be more comparable with mild, subclinical expressions of psychotic symptoms and, therefore, with APS. The present paper is the first to specifically study this assumption. Sampling and Methods: The sample consisted of 123 persons seeking help at a service for the early detection of psychosis, of whom 54 had an at-risk mental state or psychosis, 55 had a nonpsychotic mental disorder and 14 had no full-blown mental disorder. PLEs were assessed with the Peters Delusion Inventory and the revised Launay-Slade Hallucination Scale, and psychotic symptoms and APS were assessed with the Structured Interview for Prodromal Syndromes. Results: At a level of agreement between the presence of any PLE (in 98.4% of patients) and any APS (in 40.7%) just exceeding chance (κ = 0.022), the criterion validity of PLEs for APS was insufficient. Even if additional qualifiers (high agreement or distress, preoccupation and conviction) were considered, PLEs (in 52.8%) still tended to significantly overestimate APS, and agreement was only fair (κ = 0.340). Furthermore, the group effect on PLE prevalence was, at most, moderate (Cramer's V ≤ 0.382). Conclusions: The prevalence of APS cannot be deduced from studies of PLEs. Thus, the high population prevalence rate of PLEs does not allow the conclusion that APS are common features of no pathological significance and would lack clinical validity as an Attenuated Psychosis Syndrome in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Rather, the population prevalence rate of APS has to be assumed to be largely unknown at present but is likely lower than indicated by epidemiological studies of PLEs. Therefore, dedicated studies are warranted, in which APS are assessed in a way that equates to their clinical evaluation.

A multidisciplinary approach to the functional and esthetic rehabilitation of amelogenesis imperfecta and open bite deformity: a case report

The treatment of amelogenesis imperfecta (AI) with an anterior open bite (AOB) is a challenge for the clinician and often requires a multidisciplinary team of specialists. Most often, patients suffering from these conditions are young and a good functional and esthetic long-term result must be aspired. This clinical report illustrates the orthodontic, maxillofacial, restorative, and prosthodontic rehabilitation of a 20-year-old woman with a hypoplastic form of AI and an AOB malocclusion, having received treatment for the last 6 years. It included adhesive resin composite restorations, orthodontical and maxillofacial surgery with a one-piece Le Fort I osteotomy, and a genioplasty. Subsequent prosthodontic therapy consisted of 28 all-ceramic crowns whereby a solid interdigitation, a canine guidance, and consistent and regular contacts between tooth crowns could be achieved to assure a good functional and esthetic oral situation. The tooth preparation techniques guaranteed minimally invasive treatment. The patient was affected very positively. CLINICAL SIGNIFICANCE: This article describes an interdisciplinary approach to the successful treatment of a patient with a hypoplastic form of amelogenesis imperfecta over a period of 6 years. It starts with a discussion of the conservative steps taken during adolescence and concludes with the final prosthetic rehabilitation with all-ceramic crowns after reaching adulthood.

Prognostic factors in apical surgery with root-end filling: a meta-analysis

INTRODUCTION: Apical surgery has seen continuous development with regard to equipment and surgical technique. However, there is still a shortage of evidence-based information regarding healing determinants. The objective of this meta-analysis was to review clinical articles on apical surgery with root-end filling in order to assess potential prognostic factors. METHODS: An electronic search of PubMed and Cochrane databases was performed in 2008. Only studies with clearly defined healing criteria were included, and data for at least two categories per prognostic factor had to be reported. Prognostic factors were divided into patient-related, tooth-related, or treatment-related factors. The reported percentages of healed teeth ("the healed rate") were pooled per category. The statistical method of Mantel-Haenszel was applied to estimate the odds ratios and their 95% confidence intervals. RESULTS: With regard to tooth-related factors, the following categories were significantly associated with higher healed rates: cases without preoperative pain or signs, cases with good density of root canal filling, and cases with absence or size < or = 5 mm of periapical lesion. With regard to treatment-related factors, cases treated with the use of an endoscope tended to have higher healed rates than cases without the use of an endoscope. CONCLUSIONS: Although the clinician may be able to control treatment-related factors (by choosing a certain technique), patient- and tooth-related factors are usually beyond the surgeon's power. Nevertheless, patient- and tooth-related factors should be considered as important prognostic determinants when planning or weighing apical surgery against treatment alternatives.

Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI))

Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1(st) revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the "German Instrument for Methodological Guideline Appraisal" of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.

Posttraumatic stress disorder and soluble cellular adhesion molecules at rest and in response to a trauma-specific interview in patients after myocardial infarction

Posttraumatic stress disorder (PTSD) and circulating cellular adhesion molecules (CAMs) predict cardiovascular risk. We hypothesized a positive relationship between PTSD caused by myocardial infarction (MI) and soluble CAMs. We enrolled 22 post-MI patients with interviewer-rated PTSD and 22 post-MI patients with no PTSD. At 32±6months after index MI, all patients were re-scheduled to undergo the Clinician-Administered PTSD Scale (CAPS) interview and had blood collected to assess soluble CAMs at rest and after the CAPS interview. Relative to patients with no PTSD, those with PTSD had significantly higher levels of soluble vascular cellular adhesion molecule (sVCAM)-1 and intercellular adhesion molecule (sICAM)-1 at rest and, controlling for resting CAM levels, significantly higher sVCAM-1 and sICAM-1 after the interview. Greater severity of PTSD predicted significantly higher resting levels of sVCAM-1 and soluble P-selectin in patients with PTSD. At follow-up, patients with persistent PTSD (n=15) and those who had remitted (n=7) did not significantly differ in CAM levels at rest and after the interview; however, both these groups had significantly higher sVCAM-1 and sICAM-1 at rest and also after the interview compared to patients with no PTSD. Elevated levels of circulating CAMs might help explain the psychophysiologic link of PTSD with cardiovascular risk.

Treatment issues in spontaneous cervicocephalic artery dissections

The management of cervicocephalic arterial dissections raises many unsolved issues such as: how to best acutely treat patients who present with ischemic stroke or occasionally with sub-arachnoid hemorrhage? How to best prevent ischemic stroke in patients who present with purely local signs such as headache, painful Horner Syndrome or neck pain? How long and how should patients be treated after cervicocephalic arterial dissections? Can patients resume their sports activities and when? The consensus is that, given the well-established initial thromboembolic risk, an urgent antithrombotic treatment is required in patients with a recent nonhemorrhagic cervicocephalic arterial dissection, but the type of antithrombotic treatment - anticoagulants or aspirin - as well as the indication for a local arterial treatment such as angioplasty/stenting remain debated. Evidence from a randomized clinical trial would be welcome but such a trial raises major issues of methodology, feasibility and funding. Meanwhile, cervicocephalic arterial dissection remains a situation when a bedside clinician should use, on a case-by-case basis, best clinical judgment and adopt a stepped care approach in the minority of patients who deteriorate despite initial treatment.

Glucocorticoid treatment, immobility, and constipation are associated with nutritional risk

Purpose The hypothesis of this clinical study was to determine whether glucocorticoid use and immobility were associated with in-hospital nutritional risk. Methods One hundred and one patients consecutively admitted to the medical wards were enrolled. Current medical conditions, symptoms, medical history, eating and drinking habits, diagnosis, laboratory findings, medications, and anthropometrics were recorded. The Nutrition Risk Score 2002 (NRS-2002) was used as a screening instrument to identify nutritional risk. Results The results confirmed that glucocorticoid use and immobility are independently associated with nutritional risk determined by the NRS-2002. Constipation could be determined as an additional cofactor independently associated with nutritional risk. Conclusions Glucocorticoid treatment, immobility, and constipation are associated with nutritional risk in a mixed hospitalized population. The presence of long-time glucocorticoid use, immobility, or constipation should alert the clinician to check for nutritional status, which is an important factor in mortality and morbidity.

Sample size estimation: an overview with applications to orthodontic clinical trial designs

Proper sample size estimation is an important part of clinical trial methodology and closely related to the precision and power of the trial's results. Trials with sufficient sample sizes are scientifically and ethically justified and more credible compared with trials with insufficient sizes. Planning clinical trials with inadequate sample sizes might be considered as a waste of time and resources, as well as unethical, since patients might be enrolled in a study in which the expected results will not be trusted and are unlikely to have an impact on clinical practice. Because of the low emphasis of sample size calculation in clinical trials in orthodontics, it is the objective of this article to introduce the orthodontic clinician to the importance and the general principles of sample size calculations for randomized controlled trials to serve as guidance for study designs and as a tool for quality assessment when reviewing published clinical trials in our specialty. Examples of calculations are shown for 2-arm parallel trials applicable to orthodontics. The working examples are analyzed, and the implications of design or inherent complexities in each category are discussed.

Advanced heart failure - treatment options beyond medical management

Improvement of heart failure therapy has led to a far better survival and quality of life of patients. Treatment of the underlying disease, patient education and improvement of compliance and consequent upgrading of medical heart failure therapy often delays further progression to an advanced stage of heart failure. Nevertheless heart failure remains a chronic progressive disease and it is up to the treating clinician to identify the signs of advanced heart failure in a timely manner in order to evaluate patients for further treatment strategies such as heart transplantation. This article should help define advanced heart failure and illustrate how patients are evaluated for further therapy. Outcome of heart transplantation or mechanically assisted circulatory support is strongly associated to proper patient selection and timing.

Psychosocial stress and cardiovascular risk : current opinion

Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. Epidemiologic research of the last half-century has clearly shown that psychosocial factors related to the social environment, personality characteristics, and negative affect increase the risk of incident CVD and also impact prognosis of cardiac patients. Several mechanisms may explain this link, including a genetic predisposition, poor lifestyle choices, low adherence to health recommendations, and direct pathophysiologic perturbations. The latter include alteration of the hypothalamic-pituitary adrenal axis and autonomic dysfunction resulting in endothelial dysfunction, inflammation, and a prothrombotic state further downstream. Screening for psychosocial factors seems appropriate as part of the standard history and based on the clinician's knowledge of the patient and the purpose of the visit. Psychological interventions generally alleviate distress in cardiac patients, but whether they reduce the risk of hard cardiovascular endpoints and all-cause mortality is less evident. Cardiac patients with more severe depression may particularly profit from antidepressant medications. Due to their pharmacologic properties, selective serotonin reuptake inhibitors were shown to improve cardiovascular outcome. The most effective psychosocial treatment is multicomponent therapy that combines elements of cognitive behaviour therapy ("stress management") and changes in health behaviours, including the adoption of a regular exercise regimen. Gender-specific issues should probably be considered. The field of behavioural cardiology has accumulated a wealth of epidemiological, mechanistic and clinical knowledge that undoubtedly has furthered our understanding about the important role of psychosocial risk factors in patients with a heart disease.

Association of the (CA)n repeat polymorphism of insulin-like growth factor-I and -202 A/C IGF-binding protein-3 promoter polymorphism with adult height in patients with severe growth hormone deficiency

A number of mathematical models for predicting growth and final height outcome have been proposed to enable the clinician to 'individualize' growth-promoting treatment. However, despite optimizing these models, many patients with isolated growth hormone deficiency (IGHD) do not reach their target height. The aim of this study was to analyse the impact of polymorphic genotypes [CA repeat promoter polymorphism of insulin-like growth factor-I (IGF-I) and the -202 A/C promoter polymorphism of IGF-Binding Protein-3 (IGFBP-3)] on variable growth factors as well as final height in severe IGHD following GH treatment. DESIGN, PATIENTS AND CONTROLS: One hundred seventy eight (IGF-I) and 167 (IGFBP-3) subjects with severe growth retardation because of IGHD were studied. In addition, the various genotypes were also studied in a healthy control group of 211 subjects.

Genetic evaluation of short stature

After a proper medical history, growth analysis and physical examination of a short child, followed by radiological and laboratory screening, the clinician may decide to perform genetic testing. We propose several clinical algorithms that can be used to establish the diagnosis. GH1 and GHRHR should be tested in children with severe isolated growth hormone deficiency and a positive family history. A multiple pituitary dysfunction can be caused by defects in several genes, of which PROP1 and POU1F1 are most common. GH resistance can be caused by genetic defects in GHR, STAT5B, IGF1, IGFALS, which all have their specific clinical and biochemical characteristics. IGF-I resistance is seen in heterozygous defects of the IGF1R. If besides short stature additional abnormalities are present, these should be matched with known dysmorphic syndromes. If no obvious candidate gene can be determined, a whole genome approach can be taken to check for deletions, duplications and/or uniparental disomies.

Diffuse descending necrotizing mediastinitis: surgical therapy and outcome in a single-centre series

Descending necrotizing mediastinitis (DNM) is a rare but rapidly progressing disease with a potentially fatal outcome, originating from odontogenical or cervical infections. The aim of this article was to give an up-to-date overview on this still underestimated disease, to draw the clinician's attention and particularly to highlight the need for rapid diagnosis and adequate surgical treatment.

Drug hypersensitivity: flare-up reactions, cross-reactivity and multiple drug hypersensitivity

In drug hypersensitivity, change of drug treatment and continuation with a new drug may result in reappearance of drug hypersensitivity symptoms. This is not uncommon in patients with chronic infections requiring continued and long-lasting antibiotic treatments. For the clinician, the question arises whether these symptoms are due to cross-reactivity, are due to a new sensitization or are a reflection of a multiple drug hypersensitivity syndrome. Based on the p-i concept (pharmacological interaction with immune receptors), we propose that the efficient stimulation of T cells by a drug is the sum of drug-T-cell receptor affinity and readiness of the T cell to react, and therefore not constant. It heavily depends on the state of underlying immune activation. Consequently, drug hypersensitivity diseases, which go along with massive immune stimulations and often high serum cytokine values, are themselves risk factors for further drug hypersensitivity. The immune stimulation during drug hypersensitivity may, similar to generalized virus infections, lower the threshold of T-cell reactivity to drugs and cause rapid appearance of drug hypersensitivity symptoms to the second drug. We call the second hypersensitivity reaction a "flare-up" reaction; this is clinically important, as in most cases the second drug may be tolerated again, if the cofactors are missing. Moreover, the second treatment is often too short to cause a relevant sensitization.

Diagnosis and treatment of an obsessive-compulsive disorder following traumatic brain injury: A single case and review of the literature

A 27-year-old patient with traumatic brain injury and neuropsychiatric symptoms fitting the obsessive-compulsive disorder was investigated. Brain CT-scan revealed left temporal and bilateral fronto-basal parenchymal contusions. Main Outcome Measure was the Yale-Brown Obsessive Compulsive Scale at pre- and post-treatment and at 6 months follow-up. The combination of pharmacotherapy and psychotherapy resulted in lower intensity and frequency of symptoms. Our case illustrates the importance of a detailed diagnostic procedure in order to provide appropriate therapeutic interventions. Further studies are needed to guide the clinician in determining which patients are likely to benefit from a psychotherapeutic intervention in combination with pharmacotherapy.