Treatment of adolescents with early-onset schizophrenia spectrum disorders: in search of a rational, evidence-informed approach

Purpose of review: We aimed to review literature on the efficacy and tolerability of psychosocial and psychopharmacological interventions in youth with early-onset schizophrenia spectrum disorders (EOS). A rationale for pragmatic psychopharmacology in EOS, including dosing, switching and adverse effect monitoring and management, is provided. Recent findings: Three randomized controlled trials (RCTs) over the last 8 years demonstrated benefits of psychosocial interventions (i.e. psychoeducation, cognitive remediation, cognitive behavioural therapy) for EOS without clear advantages of one psychosocial treatment over another. Six large, placebo-controlled, short-term RCTs over the last 4 years demonstrated that aripiprazole, olanzapine, paliperidone, quetiapine and risperidone, but not ziprasidone, were superior to placebo. Except for clozapine's superiority in treatment-refractory EOS, efficacy appeared similar across studied first-generation and second-generation antipsychotics, but tolerability varied greatly across individual agents. Summary: Antipsychotics are efficacious in the treatment of EOS. Given the lack of efficacy differences between antipsychotics (except for clozapine for treatment-refractory EOS), we propose that tolerability considerations need to guide choice of antipsychotics. Further and longer-term efficacy and effectiveness studies are urgently needed that should also explore pharmacologic and nonpharmacologic augmentation strategies.

Heterogeneity of patients with intermediate (BCLC B) Hepatocellular Carcinoma: proposal for a subclassification to facilitate treatment decisions

The intermediate stage of hepatocellular carcinoma (HCC) comprises a highly heterogeneous patient population and therefore poses unique challenges for therapeutic management, different from the early and advanced stages. Patients classified as having intermediate HCC by the Barcelona Clinic Liver Cancer (BCLC) staging system present with varying tumor burden and liver function. Transarterial chemoembolization (TACE) is currently recommended as the standard of care in this setting, but there is considerable variation in the clinical benefit patients derive from this treatment.In April 2012, a panel of experts convened to discuss unresolved issues surrounding the application of current guidelines when managing patients with intermediate HCC. The meeting explored the applicability of a subclassification system for intermediate HCC patients to tailor therapeutic interventions based on the evidence available to date and expert opinion. The present report summarizes the proposal of the expert panel: four substages of intermediate HCC patients, B1 to B4.

Competence of Long-Term Care Residence to Participate in Decisions About Their Medical Care: A Brief, Objective Assessment

Data from 50 residents of a long-term care facility were used to examine the extent to which performance on a brief, objective inventory could predict a clinical psychologist's evaluation of competence to participate in decisions about medical care. Results indicate that the competence to participate in medical decisions of two-thirds of the residents could be accurately assessed using scores on a mental status instrument and two vignette-based measures of medical decision-making. These procedures could enable nursing home staff to objectively assess the competence of residents to participate in important decisions about their medical care.

Decision-making in amnesia: do advantageous decisions require conscious knowledge of previous behavioural choices?

Previous work has reported that in the Iowa gambling task (IGT) advantageous decisions may be taken before the advantageous strategy is known [Bechara, A., Damasio, H., Tranel, D., ; Damasio, A. R. (1997). Deciding advantageously before knowing the advantageous strategy. Science, 275, 1293-1295]. In order to test whether explicit memory is essential for the acquisition of a behavioural preference for advantageous choices, we measured behavioural performance and skin conductance responses (SCRs) in five patients with dense amnesia following damage to the basal forebrain and orbitofrontal cortex, six amnesic patients with damage to the medial temporal lobe or the diencephalon, and eight control subjects performing the IGT. Across 100 trials healthy participants acquired a preference for advantageous choices and generated large SCRs to high levels of punishment. In addition, their anticipatory SCRs to disadvantageous choices were larger than to advantageous choices. However, this dissociation occurred much later than the behavioural preference for advantageous alternatives. In contrast, though exhibiting discriminatory autonomic SCRs to different levels of punishment, 9 of 11 amnesic patients performed at chance and did not show differential anticipatory SCRs to advantageous and disadvantageous choices. Further, the magnitude of anticipatory SCRs did not correlate with behavioural performance. These results suggest that the acquisition of a behavioural preference--be it for advantageous or disadvantageous choices--depends on the memory of previous reinforcements encountered in the task, a capacity requiring intact explicit memory.

Comparing remote sensing and ground-based methods of quantifying cover type and carbon storage in an urban forest

Understanding the canopy cover of an urban environment leads to better estimates of carbon storage and more informed management decisions by urban foresters. The most commonly used method for assessing urban forest cover type extent is ground surveys, which can be both timeconsuming and expensive. The analysis of aerial photos is an alternative method that is faster, cheaper, and can cover a larger number of sites, but may be less accurate. The objectives of this paper were (1) to compare three methods of cover type assessment for Los Angeles, CA: handdelineation of aerial photos in ArcMap, supervised classification of aerial photos in ERDAS Imagine, and ground-collected data using the Urban Forest Effects (UFORE) model protocol; (2) to determine how well remote sensing methods estimate carbon storage as predicted by the UFORE model; and (3) to explore the influence of tree diameter and tree density on carbon storage estimates. Four major cover types (bare ground, fine vegetation, coarse vegetation, and impervious surfaces) were determined from 348 plots (0.039 ha each) randomly stratified according to land-use. Hand-delineation was better than supervised classification at predicting ground-based measurements of cover type and UFORE model-predicted carbon storage. Most error in supervised classification resulted from shadow, which was interpreted as unknown cover type. Neither tree diameter or tree density per plot significantly affected the relationship between carbon storage and canopy cover. The efficiency of remote sensing rather than in situ data collection allows urban forest managers the ability to quickly assess a city and plan accordingly while also preserving their often-limited budget.

ENHANCING COMMUNICATION THROUGH SUCCESSFUL REPAIR: EXAMINING FLUENCY AND MECHANISMS FOR SYNTACTIC PROGRESS IN APHASIC AND NON-APHASIC SPEECH

The fields of Rhetoric and Communication usually assume a competent speaker who is able to speak well with conscious intent; however, what happens when intent and comprehension are intact but communicative facilities are impaired (e.g., by stroke or traumatic brain injury)? What might a focus on communicative success be able to tell us in those instances? This project considers this question in examining communication disorders through identifying and analyzing patterns of (dis) fluent speech between 10 aphasic and 10 non-aphasic adults. The analysis in this report is centered on a collection of data provided by the Aphasia Bank database. The database’s collection protocol guides aphasic and non-aphasic participants through a series of language assessments, and for my re-analysis of the database’s transcripts I consider communicative success is and how it is demonstrated during a re-telling of the Cinderella narrative. I conducted a thorough examination of a set of participant transcripts to understand the contexts in which speech errors occur, and how (dis) fluencies may follow from aphasic and non-aphasic participant’s speech patterns. An inductive mixed-methods approach, informed by grounded theory, qualitative, and linguistic analyses of the transcripts functioned as a means to balance the classification of data, providing a foundation for all sampling decisions. A close examination of the transcripts and the codes of the Aphasia Bank database suggest that while the coding is abundant and detailed, that further levels of coding and analysis may be needed to reveal underlying similarities and differences in aphasic vs. non-aphasic linguistic behavior. Through four successive levels of increasingly detailed analysis, I found that patterns of repair by aphasics and non-aphasics differed primarily in degree rather than kind. This finding may have therapeutic impact, in reassuring aphasics that they are on the right track to achieving communicative fluency.