Ultra high risk (UHR) for psychosis criteria: are there different levels of risk for transition to psychosis?

INTRODUCTION

The ultra high risk (UHR) for psychosis criteria have been validated in a number of studies. However, it is not known whether particular UHR criteria (Attenuated Psychotic Symptoms (APS), Brief Limited Intermittent Psychotic Symptoms (BLIPS) or Trait vulnerability criteria), or combination of criteria, is associated with a higher risk of transition to psychosis. The current study investigated this issue over a 6-month follow-up period. We hypothesised that the risk of transition would increase in the following order: Trait alone<APS alone < APS+Trait<BLIPS.

METHOD

Data on UHR intake criteria and transition to psychosis status at 6 months were analysed for UHR patients seen at the PACE clinic, Orygen Youth Health between January 2000 and November 2008.

RESULTS

A total of 928 new referrals were accepted into the PACE clinic over this period of whom 817 (88%) had baseline information available for analysis. The percentage of subjects who presented with APS, Trait and BLIPS were 83%, 27% and 4%, respectively. When the two intermediate groups (APS alone and APS+Trait) were combined, there was evidence that the risk of transition increased in the order of Trait alone<APS<BLIPS (p=0.024, adjusted analysis).

CONCLUSIONS

Our data suggest that UHR intake criteria predict transition over 6 months in the order of Trait alone<APS<BLIPS. The fact that BLIPS patients are at the highest risk of transition over the short term is consistent with the "early" versus "late" prodrome model. It also indicates that particular clinical attention may need to be paid to BLIPS patients, especially early in the course of treatment.

Who needs antipsychotic medication in the earliest stages of psychosis? A reconsideration of benefits, risks, neurobiology and ethics in the era of early intervention

In recent years, early intervention services have attempted to identify people with a first episode of psychosis as early as possible, reducing the duration of untreated psychosis and changing the timing of delivery of interventions. The logic of early intervention is based partly on accessing people in a more treatment responsive stage of illness in which psychosocial damage is less extensive, and partly on remediating a putatively active process of neuroprogression that leads to pathophysiological, symptomatic and structural changes, hence improving symptomatic and functional outcomes. However, as in other areas of health care, earlier identification of new patients may mean that different treatment approaches are indicated. The corollary of early detection is that the sequence and complexion of treatment strategies for first episode psychosis has been revaluated. Examples include the minimal effective dosage of antipsychotic medication and the content of psychosocial interventions. With the substantial reductions of DUP now seen in many early psychosis services, based on clinical staging and stepped care principles, it is even possible that the immediate introduction of antipsychotic medication may not be necessary for all first episode psychosis cases, but that potentially safer interventions, which may be more acceptable to many patients, such as comprehensive psychosocial intervention, may constitute effective treatment at least for a subgroup of patients. In this paper, we review this theoretical background and describe a randomised controlled trial currently underway at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne designed to test outcomes for first episode psychosis patients in response to two different treatments: intensive psychosocial intervention plus antipsychotic medication versus intensive psychosocial intervention plus placebo. This is a theoretically and pragmatically novel study in that it will provide evidence as to whether intensive psychosocial intervention alone is sufficient for a subgroup of first episode psychosis patients in a specialised early intervention service, and provide a test of the heuristic clinical staging model. By experimentally manipulating duration of untreated psychosis, the study will also provide a methodologically strong test of the effect of delaying the introduction of antipsychotic medication, as well as helping to disentangle the effects of antipsychotic medications and the putative neurobiological processes associated with brain changes and symptom profiles in the early phase of psychotic disorders. The study has been carefully crafted to satisfy critical ethical demands in this challenging research domain.

Relating schizotypy and personality to the phenomenology of creativity

INTRODUCTION

Although a considerable amount of research has addressed psychopathological and personality correlates of creativity, the relationship between these characteristics and the phenomenology of creativity has been neglected. Relating these characteristics to the phenomenology of creativity may assist in clarifying the precise nature of the relationship between psychopathology and creativity. The current article reports on an empirical study of the relationship between the phenomenology of the creative process and psychopathological and personality characteristics in a sample of artists.

METHOD

A total of 100 artists (43 males, 57 females, mean age = 34.69 years) from a range of disciplines completed the Experience of Creativity Questionnaire and measures of "positive" schizotypy, affective disturbance, mental boundaries, and normal personality.

RESULTS

The sample of artists was found to be elevated on "positive" schizotypy, unipolar affective disturbance, thin boundaries, and the personality dimensions of Openness to Experience and Neuroticism, compared with norm data. Schizotypy was found to be the strongest predictor of a range of creative experience scales (Distinct Experience, Anxiety, Absorption, Power/Pleasure), suggesting a strong overlap of schizotypal and creative experience.

DISCUSSION

These findings indicate that "positive" schizotypy is associated with central features of "flow"-type experience, including distinct shift in phenomenological experience, deep absorption, focus on present experience, and sense of pleasure. The neurologically based construct of latent inhibition may be a mechanism that facilitates entry into flow-type states for schizotypal individuals. This may occur by reduced latent inhibition providing a "fresh" awareness and therefore a greater absorption in present experience, thus leading to flow-type states.

A disturbed sense of self in the psychosis prodrome: linking phenomenology and neurobiology

Interest in the early phase of psychotic disorders has risen dramatically in recent years. Neurobiological investigations have focused specifically on identifying brain changes associated with the onset of psychosis. The link between these neurobiological findings and the complex phenomenology of the early psychosis period is not well understood. In this article, we re-cast some of these observations, primarily from neuroimaging studies, in the context of phenomenological models of "the self" and disturbance thereof in psychotic illness. Specifically, we argue that disturbance of the basic or minimal self ("ipseity"), as articulated in phenomenological literature, may be associated with abnormalities in midline cortical structures as observed in neuroimaging studies of pre-onset and early psychotic patients. These findings are discussed with regards to current ideas on the neural basis of self-referential mental activity, including the notion of a putative "default-mode" of brain function, and its relation to distinguishing between self- and other-generated stimuli. Further empirical work examining the relationship between neurobiological and phenomenological variables may be of value in identifying risk markers for psychosis onset.

A Pilot Study of at-risk Criteria for Bipolar Disorders in Help Seeking Adolescents and Young Adults

Introduction:

We have developed ultra-high risk criteria for bipolar affective disorder (bipolar at-risk - BAR) which include general criteria such as being in the peak age range of the onset of the disorder and a combination of specific criteria including sub-threshold mania, depressive symptoms, cyclothymic features and genetic risk. In the current study, the predictive and discriminant validity of these criteria were tested in help seeking adolescents and young adults.

Method:

This medical file-audit study was conducted at ORYGEN Youth Health (OYH), a public mental health program for young people aged between 15 and 24 years and living in metropolitan Melbourne, Australia. BAR criteria were applied to the intake assessments of all non-psychotic patients who were being treated in OYH on 31 January.08. All entries were then checked for conversion criteria. Hypomania/mania related additions or alterations to existing treatments or initiation of new treatment by the treating psychiatrist served as conversion criteria to mania.

Results:

The BAR criteria were applied to 173 intake assessments. Of these, 22 patients (12.7%) met BAR criteria. The follow-up period of the sample was 265.5 days on average (SD 214.7). There were significantly more cases in the BAR group (22.7%, n = 5) than in the non-BAR group (0.7%, n = 1) who met conversion criteria (p < .001).

Conclusions:

These findings support the notion that people who develop a first episode of mania can be identified during the prodromal phase. The proposed criteria need further evaluation in prospective clinical trials.

Genetic modification of T cell clones to improve the safety and efficacy of adoptive T cell therapy

Our laboratory has developed methods to isolate human antigen-specific cytolytic CD8+ T cell clones and to expand such clones in vitro to numbers sufficient for T cell therapy of human diseases. Studies in immunocompromised bone marrow transplant patients at high risk for disease associated with cytomegalovirus have demonstrated that administration of more than 10(9) CD8+ T cell clones is safe and can effectively reconstitute a deficient human immune response. Our laboratory is applying this strategy of adoptive therapy to the treatment of human cancer, starting with the subset of patients with Hodgkin's disease who show expression of proteins encoded by the Epstein-Barr virus in their malignant Reed-Sternberg cells. The development of efficient systems such as retroviral vectors for the introduction of genes into primary cells has made it possible to consider overcoming some of the limitations of the effector T cells that normally mediate response to an antigen. Our laboratory is attempting to modify T cell clones by the introduction of genes before transfer as a means to improve the safety and/or efficacy of T cell therapy.

Evaluation of the plaque removal efficacy of two commercially available dental floss devices

OBJECTIVE

This single blind, crossover design, clinical trial provided a comparative assessment of the oral cleaning of two dental devices as demonstrated through the removal of dental plaque when used according to marketed product-use directions.

METHODOLOGY

Twenty-six subjects, both male and female between the ages of 19 and 64 years, completed this two-cell crossover study. Subjects were assessed for whole mouth plaque levels, both before and after use of each of the randomly assigned floss devices, by assessing disclosed plaque using the Modified Turesky Plaque Index. The two floss devices were a Mint Floss Pick and a standard rolled floss. Subjects abstained from brushing the night before appearing in the clinic, and based upon meeting the minimum plaque criteria of 1.5 at the first phase of the crossover, used one of the two floss devices according to the directions for use found on the product packaging. Both pre- and post-device use plaque levels were recorded with calculations made of both the actual difference in plaque level, as well as the percent plaque removed. Data were subjected to an analysis of covariance (ANCOVA), and employed a model consistent with crossover design.

RESULTS

Overall results from both phases of the crossover showed the Mint Floss Pick product removed 19.4% of the plaque. The standard rolled floss product removed 15% of the plaque. Both products removed statistically significant plaque when assessed versus pre-treatment levels. Although the ANCOVA identified a statistically significant difference between treatments favoring the Floss Pick product, further statistical examination revealed a significant sequence effect, which led to a conservative product comparison of equivalence. This analysis confirmed that the Floss Pick product was "at least as good as" the standard floss product for plaque removal. Additional analyses of various sites in the mouth, i.e., interproximal, anterior, posterior, etc., also confirmed similarity of performance for both products in this test.

CONCLUSION

A two-way crossover assessment of the cleaning capability of a Mint Floss Pick product compared to a standard rolled floss product was performed through assessment of the removal of dental plaque. Results of this clinical investigation support the Floss Pick product to be "at least as good as" standard rolled floss in cleaning capability when both products were used according to their product-use directions.

Biomarkers of exposure and potential harm in adult smokers of 3-7 mg tar yield (Federal Trade Commission) cigarettes and in adult non-smokers

The paper reports levels of 24-h urine nicotine and five of its major metabolites (expressed as nicotine-equivalents) and blood carboxyhaemoglobin as biomarkers of exposure to particulate- and gas-phase cigarette smoke, respectively, from an exploratory pilot study of adult smokers of 3.0-6.9 mg tar delivery (Federal Trade Commission (FTC) method) cigarettes. On multiple occasions over 6 weeks, blood high-sensitivity C-reactive protein (hs-CRP), fibrinogen, HDL- and LDL-cholesterol, and 24-h urine 8-epi-prostaglandin F2alpha (8-epi-PGF2alpha) and 11-dehydro-thromboxane B2 (11-dehydro-TxB2) were also evaluated as biomarkers of potential harm. All the biomarkers examined, except for LDL-cholesterol, discriminated with high sensitivity and specificity between adult smokers and non-smokers overall. Except for HDL-cholesterol, all biomarker medians were greater in adult smokers than in non-smokers: urine nicotine-equivalents 64.514 versus < 0.034 nmol mg-1 creatinine (p<0.001), carboxyhaemoglobin 4.0 versus 0.4% saturation (p<0.001), hs-CRP 0.27 versus 0.12 mg dl-1 (p=0.05), fibrinogen 292 versus 248 mg dl-1 (p<0.001), HDL-cholesterol 46 versus 53 mg dl-1 (p=0.003), LDL-cholesterol 119 versus 109 mg dl-1 (p=0.18), urine 8-epi-PGF2alpha 1935 versus 1034 pg mg-1 creatinine (p<0.001) and urine 11-dehydro-TxB2 973 versus 710 pg mg-1 creatinine (p<0.001). All the biomarkers of exposure and most of the biomarkers of potential harm showed no time of sampling (by visit week) effect.

Isolation of gene sets affected specifically by polyglutamine expression: implication of the TOR signaling pathway in neurodegeneration

Transcriptional dysregulation as a result of sequestration of essential transcription factors into protein aggregates formed by polyglutamine (polyQ) expansions can lead to late-onset progressive neurodegeneration. DNA microarray analysis of Drosophila expressing polyQ in the compound eye over time revealed large numbers of transcriptional changes at the earliest stages of the disease including repression of the transient receptor potential calcium channels in a polyQ-induced cell death specific manner. While significant differences in expression profiles were found between the Drosophila compound eye and polyQ-sensitive neural cells, a number of possible key overlapping regulators were extracted. Among these, PDK1 was shown to act as a mediator for polyQ-toxicity, suggesting the involvement of the TOR pathway in polyQ-induced neurodegeneration.

Most lay people can correctly identify indigenous venomous snakes

We attempted to determine how accurately members of the public can identify venomous snakes. Six different snakes indigenous to southern California were displayed in cages for 265 people to view at a street fair. These included 4 nonvenomous snakes and 2 venomous snakes. People were asked whether the snake was venomous and the name of the snake, if they knew it. Overall, people recognized whether a snake was venomous or nonvenomous 81% of the time. They were most accurate at identifying rattlesnakes as being venomous (95%) but incorrectly identified nonvenomous snakes as being venomous 25% of the time. Men were more accurate than women, and adults were more accurate than children. Subjects were less well able to identify the exact species of snakes. The results suggest that there may be no need to capture, kill, or bring a snake to the hospital for identification, at least in this geographic area.

Data acquisition, data storage, and data presentation in a modern genetics laboratory

Modern genetic analysis can be divided into three main areas of investigation. The first is data acquisition, in the form of genomic sequence and the cataloguing of polymorphism data of the single nucleotide polymorphism variety (so called SNPs). Once identified, such genetic information can be adapted into high throughput tests to examine genetic information in large populations, making the analysis of sufficiently large numbers both cost and time effective so that relatively low-penetrant genetic effects can be accurately detected. The third step is correlating variation with phenotype (e.g. disease susceptibility or resistance) for a variety of disorders is paramount in our motivation and indeed is a common goal of modern human genetic analysis. While the technology to acquire vast amounts of genetic data is now well established and continues to expand, the ability to deal with such data, from the process of acquisition, storage, and analysis depends fundamentally on a solid informatics infrastructure as an essential component. Indeed, most of the major gains in productivity in this field are to be realized on the informatics front, and involve automating data acquisition, defining and sorting data in databases for quality control and analysis and facilitating access to data for the large variety of data analyses. Informatics-related issues including those relating to data acquisition, database structure, and analysis tools are summarized here in an effort to define some of the issues relevant to establishing informatics infrastructure in a small genetics laboratory focused on resequencing human immune response genes. From inherited diseases to drug efficacy to the specific genetic changes occurring during tumor development, this new field of medical genetics promises a profound impact on the state of human health. Ultimately, any and all advances in this field will continue to depend on major investments in informatics.