Phosphorylation of Cardiac Sodium Channel at Ser571 Anticipates Manifestations of the Aging Myopathy

Diastolic dysfunction and delayed ventricular repolarization are typically observed in the elderly, but whether these defects are intimately associated in the progressive manifestation of the aging myopathy remains to be determined. In this regard, aging in experimental animals is coupled with increased late Na+ current (INaL) in cardiomyocytes, raising the possibility that INaL conditions the modality of electrical recovery and myocardial relaxation of the aged heart. For this purpose, aging male and female wild-type (WT) C57Bl/6 mice were studied together with genetically engineered mice with phosphomimetic (gain-of-function, GoF) or ablated (loss-of-function, LoF) mutations of the sodium channel Nav1.5 at Ser571 associated with, respectively, increased and stabilized INaL. At ~18 months (m) of age, WT mice developed prolonged duration of the QT interval of the electrocardiogram and impaired diastolic left ventricular (LV) filling, defects that were reversed by INaL inhibition. Prolonged repolarization and impaired LV filling occurred prematurely in adult (~5 m) GoF mutant mice, whereas these alterations were largely attenuated in aging LoF mutant animals. Ca2+ transient decay and kinetics of myocyte shortening/relengthening were delayed in aged (~24 m) WT myocytes, with respect to adult cells. In contrast, delayed Ca2+ transients and contractile dynamics occurred at adult stage in GoF myocytes and further deteriorated at old age. Conversely, myocyte mechanics were minimally affected in aging LoF cells. Collectively, these results document that Nav1.5 phosphorylation at Ser571 and the late Na+ current modulates the modality of myocyte relaxation, constituting the mechanism linking delayed ventricular repolarization and diastolic dysfunction.

Quantifying abnormal emotion processing: A novel computational assessment method and application in schizophrenia

Abnormal emotion processing is a core feature of schizophrenia spectrum disorders (SSDs) that encompasses multiple operations. While deficits in some areas have been well-characterized, we understand less about abnormalities in the emotion processing that happens through language, which is highly relevant for social life. Here, we introduce a novel method using deep learning to estimate emotion processing rapidly from spoken language, testing this approach in male-identified patients with SSDs (n = 37) and healthy controls (n = 51). Using free responses to evocative stimuli, we derived a measure of appropriateness, or "emotional alignment" (EA). We examined psychometric characteristics of EA and its sensitivity to a single-dose challenge of oxytocin, a neuropeptide shown to enhance the salience of socioemotional information in SSDs. Patients showed impaired EA relative to controls, and impairment correlated with poorer social cognitive skill and more severe motivation and pleasure deficits. Adding EA to a logistic regression model with language-based measures of formal thought disorder (FTD) improved classification of patients versus controls. Lastly, oxytocin administration improved EA but not FTD among patients. While additional validation work is needed, these initial results suggest that an automated assay using spoken language may be a promising approach to assess emotion processing in SSDs.

Identifying mechanisms of persecutory ideation maintenance with smartphone technology: Examining threat importance, certainty, rumination, and behavior change

Previous cross-sectional and laboratory research has identified risk factors for persecutory ideation including rumination, negative affect, and safety-seeking behaviors. Questions remain about what in-the-moment factors link general negative affect to PI as well as which maintain PI over time. In the present study, N = 219 individuals completed momentary assessments of PI as well as four factors (attributing threats as certain and important, ruminating, and changing one's behavior in response) proposed to maintain PI over time. Linear mixed effects models were used to analyze multiple time-varying relationships, including these factors predicting negative affect and vice versa, as well as factors predicting maintenance of PI over time. Linear mixed effects models were used to analyze multiple time-varying relationships, examining each PI-related factor predicting negative affect, negative affect predicting each PI-related factor, as well as each factor predicting maintenance of PI over time. All four factors were associated with increases in subsequent day self-reported severity of PI, suggesting all four increased the likelihood of maintaining or worsening next-day PI. Results of this study confirm that the proposed factors are key in maintaining a cycle by which PI and negative affect are maintained over time. These factors may represent targets for momentary interventions.

User-Centered Development of Bolster, an mHealth Intervention for Early Psychosis Caregivers: Needs Assessment, Prototyping, and Field Trial

BACKGROUND

Caregivers play a critical role in the treatment and recovery of youth and young adults at risk for psychosis. Caregivers often report feeling isolated, overwhelmed, and lacking in resources. Mobile health (mHealth) has the potential to provide scalable, accessible, and in-the-moment support to caregivers. To date, few if any mHealth resources have been developed specifically for this population.

OBJECTIVE

The aim of this study was to conduct user-centered design and testing of an mHealth intervention to support early psychosis caregivers.

METHODS

We conducted a multiphase user-centered development process to develop the Bolster mobile app. In phase 1, a total of 21 caregivers were recruited to participate in a qualitative needs assessment and respond to an initial prototype of the Bolster platform. Content analysis was used to identify key needs and design objectives, which guided the development of the Bolster mobile app. In phase 2, a total of 11 caregivers were recruited to participate in a 1-week field trial wherein they provided qualitative and quantitative feedback regarding the usability and acceptability of Bolster; in addition, they provided baseline and posttest assessments of the measures of distress, illness appraisals, and family communication.

RESULTS

In phase 1, participants identified psychoeducation, communication coaching, a guide to seeking services, and support for coping as areas to address. Live prototype interaction sessions led to multiple design objectives, including ensuring that messages from the platform were actionable and tailored to the caregiver experience, delivering messages in multiple modalities (eg, video and text), and eliminating a messaging-style interface. These conclusions were used to develop the final version of Bolster tested in the field trial. In phase 2, of the 11 caregivers, 10 (91%) reported that they would use Bolster if they had access to it and would recommend it to another caregiver. They also reported marked changes in their appraisals of illness (Cohen d=0.55-0.68), distress (Cohen d=1.77), and expressed emotion (Cohen d=0.52).

CONCLUSIONS

To our knowledge, this study is the first to design an mHealth intervention specifically for early psychosis caregivers. Preliminary data suggest that Bolster is usable, acceptable, and promising to improve key targets and outcomes. A future fully powered clinical trial will help determine whether mHealth can reduce caregiver burdens and increase engagement in services among individuals affected by psychosis.

Alcohol septal ablation in patients aged 75 years or older with hypertrophic obstructive cardiomyopathy

OBJECTIVE

Outcome data for patients ≥75 years with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA) are lacking. Therefore, a retrospective single-centre analysis was conducted.

METHODS

The data of all consecutive ASAs, that were performed at our institution between 1 September 1997 and 31 July 2021 in patients with HOCM with left ventricular outflow tract gradients (LVOTG) ≥50 mm Hg, were collected from patient reports. ASA was performed per institutional standards with 95% ethanol infused into a feasible septal branch. Differences regarding echocardiographic, procedural and clinical parameters at baseline and after 6 months between patients ≥75 years and <75 years were assessed.

RESULTS

We found 208 ASAs in patients ≥75 years (85.1% female; age 78.0 years (IQR 76.0-80.0)) and 1430 ASAs in patients <75 years (42.0% female; age 56.0 years (IQR 46.0-65.0)). Patients ≥75 years had lower distances in 6 min walk test (baseline: 317.0 m (IQR 242.0-389.0) vs 438.0 m (IQR 353.3-504.0); p<0.0001). Exercise-induced LVOTG calculated at follow-up was lower in patients ≥75 years (29.5 mm Hg (IQR 18.0-54.0) vs 39.5 mm Hg (IQR 23.0-73.8); p=0.0007). There were more high-degree AV blocks after ASA in patients ≥75 years (25.5% vs 13.6%; p<0.0001). The in-hospital mortality did not differ between the groups (age ≥75 years: 1.0%; age <75 years: 0.6%; p=0.6580).

CONCLUSION

ASA had similar efficacy and intrahospital mortality in patients ≥75 years compared with younger patients. Higher rates of AV block with need for permanent pacemaker implantation were observed in patients ≥75 years of age.

A preliminary study examining terminology used by individuals with lived experience describing beliefs about being targeted or harmed by others

While recent studies have prompted re-evaluation of the term "schizophrenia," few have examined the use of terms to describe persecutory ideation (PI) or paranoia. This study examines the preferences and terms used by a cross-diagnostic population of individuals (N = 184) with lived experience using an online survey. Participants most commonly described their PI in terms of the perceived source of threat, followed by clinical language, most commonly variants of "paranoia" and "anxiety." Of five selected terms assessed quantitatively - "anxiety," "paranoia," "persecutory thoughts," "suspiciousness," and "threat thoughts" - participants were more likely to report that "anxiety" aligned with their experience of PI, followed by "suspiciousness." Endorsement of terms more specific to PI was associated with self-report PI severity, while a preference for "anxiety" over other terms was both associated with less severe PI and lower scores on a measure of stigma. These results suggest that the heterogeneity of terms used by individuals with lived experience support a person-centered approach to language describing such experiences.

Cardiovascular Magnetic Resonance Imaging in Patients With Ibrutinib-Associated Cardiotoxicity

Importance

Ibrutinib has been associated with serious cardiotoxic arrhythmias. In preclinical models, these events are paralleled or proceeded by diffuse myocardial injury (inflammation and fibrosis). Yet whether this is seen in patients or has implications for future cardiotoxic risk is unknown.

Objective

To assess the incidence and outcomes of myocardial injury among patients with ibrutinib-related cardiotoxicity.

Design, Setting, and Participants

This cohort study included consecutive patients treated with ibrutinib from 2012 to 2019, phenotyped using cardiovascular magnetic resonance (CMR) from a large US Comprehensive Cancer Center registry.

Exposures

Ibrutinib treatment for cancer control.

Main Outcomes and Measures

The primary outcome was the presence of late gadolinium enhancement (LGE) fibrosis. The secondary outcome was the occurrence of major adverse cardiac events (MACE), defined as atrial fibrillation, heart failure, symptomatic ventricular arrhythmias, and sudden death of probable or definite ibrutinib association after CMR. We also assessed parametric-mapping subclinical fibrosis (native-T1, extracellular volume fraction) and inflammation/edema (max-T2) measures. Cardiovascular magnetic resonance measures were compared with those obtained in similar consecutive patients with cancer without ibrutinib treatment (pretreatment controls). Observed measures were also compared with similar-aged broad population rates (general-population controls) and a broader pool of cardiovascular disease (CVD) risk-matched cancer controls. Multivariable regression was used to assess the association between CMR measures and MACE.

Results

Overall, 49 patients treated with ibrutinib were identified, including 33 imaged after treatment initiation (mean [SD] age, 65 [10] years, 9 [27%] with hypertension, and 23 [69.7%] with index-arrhythmias); median duration of ibrutinib-use was 14 months. The mean (SD) pretreatment native T1 was 977.0 (73.0) ms, max-T2 56.5 (4.0) ms, and 4 (13.3%) had LGE. Posttreatment initiation, mean (SD) native T1 was 1033.7 (48.2) ms, max-T2 61.5 (4.8) ms, and 17 (54.8%) had LGE (P < .001, P = .01, and P < .001, respectively, pre- vs post-ibrutinib treatment). Native T12SDs was elevated in 9 (28.6%), and max-T22SDs in 21 (63.0%), respectively. Cardiovascular magnetic resonance measures were highest in those with suspected toxic effects (P = .01 and P = .01, respectively). There was no association between traditional CVD-risk or cancer-treatment status and abnormal CMR measures. Among those without traditional CVD, 16 (58.6%) had LGE vs 38 (13.3%) in matched-controls (relative-risk, 4.8; P < .001). Over a median follow-up of 19 months, 13 (39.4%) experienced MACE. In multivariable models inclusive of traditional CVD risk factors, LGE (hazard ratio [HR], 4.9; P = .04), and native-T12SDs (HR, 3.3; P = .05) associated with higher risks of MACE.

Conclusions and Relevance

In this cohort study, myocardial injury was common in ibrutinib users, and its presence was associated with higher cardiotoxic risk.

Hostile attribution bias in schizophrenia-spectrum disorders: narrative review of the literature and persisting questions

BACKGROUND

Social cognition is often aberrant or impaired in psychotic disorders and related to functional outcomes. In particular, one core social cognitive bias - hostile attribution bias - is proposed to be implicated in paranoia, anxiety, mood disturbances and interpersonal conflict outcomes. However, questions remain about this domain's specificity to psychosis and its relationship to general functional outcomes.

AIMS

The present paper offers a descriptive and critical review of the literature on hostile attribution bias in psychotic disorders, in order to examine (1) its impact on persecutory symptoms in schizophrenia-spectrum disorders, (2) impact on other related psychopathology among those experiencing psychosis and (3) relationship to functioning.

METHODS

Twenty-eight studies included in this review after parallel literature searches of PsycINFO and PubMed.

RESULTS

Evidence from these studies highlighted that hostile attribution bias is elevated in schizophrenia, and that it is related to anxiety, depression and interpersonal conflict outcomes.

CONCLUSION

While results suggest that hostile attributions are elevated in schizophrenia and associated with symptoms and functioning, there exist numerous persisting questions in the study of this area, including identifying which measures are most effective and determining how it presents: as a state or trait-like characteristic, via dual processes, and its situational variation.

Using Smartphones to Identify Momentary Characteristics of Persecutory Ideation Associated With Functional Disability

Objectives

Though often a feature of schizophrenia-spectrum disorders, persecutory ideation (PI) is also common in other psychiatric disorders as well as among individuals who are otherwise healthy. Emerging technologies allow for a more thorough understanding of the momentary phenomenological characteristics that determine whether PI leads to significant distress and dysfunction. This study aims to identify the momentary phenomenological features of PI associated with distress, dysfunction, and need for clinical care.

Methods

A total of 231 individuals with at least moderate PI from 43 US states participated in a study involving 30 days of data collection using a smartphone data collection system combining ecological momentary assessment and passive sensors, wherein they reported on occurrence of PI as well as related appraisals, responses, and cooccurring states. Most (N = 120, 51.9%) participants reported never having received treatment for their PI, while 50 participants had received inpatient treatment (21.6%), and 60 (26.4%) had received outpatient care only.

Results

Individuals with greater functional disability did not differ in PI frequency but were more likely at the moment to describe threats as important to them, to ruminate about those threats, to experience distress related to them, and to change their behavior in response. Groups based on treatment-seeking patterns largely did not differ in baseline measures or momentary phenomenology of PI as assessed by self-report or passive sensors.

Conclusions

Smartphone data collection allows for granular assessment of PI-related phenomena. Functional disability is associated with differences in appraisals of and responses to PI at the moment.

The relationship between appraisals of auditory verbal hallucinations and real-time affect and social functioning

In addition to being a hallmark symptom of schizophrenia-spectrum disorders, auditory verbal hallucinations (AVH) are present in a range of psychiatric disorders as well as among individuals who are otherwise healthy. People who experience AVH are heterogeneous, and research has aimed to better understand what characteristics distinguish, among those who experience AVH, those who experience significant disruption and distress from those who do not. The cognitive model of AVH suggests that appraisals of voices determine the extent to which voices cause distress and social dysfunction. Previous work has relied largely on comparisons of "clinical" and "non-clinical" voice hearers, and few studies have been able to provide insight into the moment-to-moment relationships between appraisals and outcomes. The current study examines longitudinal data provided through ecological momentary assessment and passive sensors of 465 individuals who experience cross-diagnostic AVH. Results demonstrated associations of AVH appraisals to negative affect and social functioning. Above and beyond within-individual averages, when a participant reported increased appraisals of their voices as powerful and difficult to control, they were more likely to feel increased negative affect and reduced feelings of safety. AVH power appraisals were also associated with next-day number and duration of phone calls placed, and AVH controllability appraisals were associated with increased time near speech and reduced next-day time away from primary location. These results suggest that appraisals are state-like characteristics linked with day-to-day and moment-to-moment changes in impactful affective and behavioral outcomes; intervention approaches should aim to address these domains in real-time.

Carfilzomib-induced Cardiotoxicity: An Analysis of the FDA Adverse Event Reporting System (FAERS)

Background

Carfilzomib and other proteasome inhibitors (PIs) have revolutionized treatment of multiple myeloma (MM). PIs have proven to be highly effective, but are associated with significant cardiovascular adverse events (AEs). No prior study has compared the cardiotoxicity of carfilzomib against other PI’s and all other classes of medications.

Objectives

The purpose of this study is to characterize the cardiotoxicity of carfilzomib with respect to other PIs and all classes of medications using the US Food and Drug Administration Adverse Events Reporting System (FAERS) database and to define the observed cardiotoxicity profile.

Methods

The FAERS database was queried between years 2017 and 2020 to identify AEs associated with PIs. Data extracted included concomitant medications used, type and severity of AEs and patient characteristics including age, sex, and time from medication initiation to adverse event. Cardiotoxicities assessed included acute myocardial infarction, heart failure, and supraventricular tachycardia. The reporting odds ratio (ROR) and information component assessed the strength of association between PIs and cardiotoxicity.

Results

Over the study period, 21,026 adverse events were reported in patients taking carfilzomib among 55,195 total adverse events in patients taking PI’s were identified from 6,548,048 total events reported in the FAERS database. The most common AE associated with carfilzomib was development of heart failure (1116 adverse events); disproportionality analysis revealed a stronger association with hypertension and QT prolongation with carfilzomib than other PI’s.

Conclusions

While they have demonstrated efficacy and revolutionized treatment of MM, carfilzomib and other PI’s are associated with cardiotoxicities.

Developing the Workforce of the Digital Future: Leveraging Technology to Train Community-Based Mobile Mental Health Specialists

Challenges in training, dissemination, and implementation have impeded the ability of providers to integrate promising digital health tools in real-world services. There is a need for generalizable strategies to rapidly train real-world providers at scale to support the adoption of digital health. This study describes the development of principles guiding rapid training of community-based clinicians in the support of digital health. This training approach was developed in the context of an ongoing trial examining implementation strategies for FOCUS, a mobile mental health intervention designed for people with serious mental illness. The SAIL (Simple, Accessible, Inverted, Live) model introduces how digital tools can be leveraged to facilitate rapid training of community agency-based personnel to serve as digital mental health champions, promoters, and providers. This model emphasizes simple and flexible principles of intervention delivery, accessible materials in a virtual learning environment, inverted or "flipped" live training structure, and live consultation calls for ongoing support. These initial insights lay the groundwork for future work to test and replicate generalizable training strategies focused on real-world delivery of digital mental health services. These strategies have the potential to remove key obstacles to the implementation and dissemination of digital health interventions for mental health.

A systematic search and critical review of studies evaluating psychometric properties of patient-reported outcome measures for schizophrenia

Measurement-based care (MBC) involves the regular administration of outcome assessments to track and evaluate treatment progress and requires psychometrically sound instruments. While there are widely used patient-reported outcome measures (PROMs) for several psychiatric disorders and symptom categories (e.g., depression, anxiety), there is less consensus about self-report assessments for measurement-based care of schizophrenia. The present review provides an initial guide to this area by reporting on psychometric studies that introduce or evaluate PROMs designed for the ongoing treatment of schizophrenia. Out of an initial database of 6,153 articles, and review of 141 full-text articles, an analysis of 21 articles examining 12 measures is presented in this review. Findings suggest robust options exist for clinical and research institutions aiming to assess symptom outcomes in schizophrenia, with most measures showing strengths in internal consistency, test-retest reliability, and a number of measures with evidence of convergent or criterion validity. While there exist heterogeneous options, multiple measures demonstrated promising psychometric strengths. Future work validating consistent psychometric validity could involve measures which could be valuable in context of MBC for schizophrenia.

FOCUS mHealth Intervention for Veterans With Serious Mental Illness in an Outpatient Department of Veterans Affairs Setting: Feasibility, Acceptability, and Usability Study

BACKGROUND

Veterans with serious mental illnesses (SMIs) face barriers to accessing in-person evidence-based interventions that improve illness management. Mobile health (mHealth) has been demonstrated to be feasible, acceptable, effective, and engaging among individuals with SMIs in community mental health settings. mHealth for SMIs has not been tested within the Department of Veterans Affairs (VA).

OBJECTIVE

This study examines the feasibility, acceptability, and preliminary effectiveness of an mHealth intervention for SMI in the context of VA outpatient care.

METHODS

A total of 17 veterans with SMIs were enrolled in a 1-month pilot trial of FOCUS, a smartphone-based self-management intervention for SMI. At baseline and posttest, they completed measures examining symptoms and functional recovery. The participants provided qualitative feedback related to the usability and acceptability of the intervention.

RESULTS

Veterans completed on an average of 85.0 (SD 96.1) interactions with FOCUS over the 1-month intervention period. They reported high satisfaction, usability, and acceptability, with nearly all participants (16/17, 94%) reporting that they would recommend the intervention to a fellow veteran. Clinicians consistently reported finding mHealth-related updates useful for informing their care. Qualitative feedback indicated that veterans thought mHealth complemented their existing VA services well and described potential opportunities to adapt FOCUS to specific subpopulations (eg, combat veterans) as well as specific delivery modalities (eg, groups). In the 1-month period, the participants experienced small improvements in self-assessed recovery, auditory hallucinations, and quality of life.

CONCLUSIONS

The FOCUS mHealth intervention is feasible, acceptable, and usable among veterans. Future work should develop and examine VA-specific implementation approaches of FOCUS for this population.

A Smartphone Intervention for People With Serious Mental Illness: Fully Remote Randomized Controlled Trial of CORE

Background

People with serious mental illness (SMI) have significant unmet mental health needs. Development and testing of digital interventions that can alleviate the suffering of people with SMI is a public health priority.

Objective

The aim of this study is to conduct a fully remote randomized waitlist-controlled trial of CORE, a smartphone intervention that comprises daily exercises designed to promote reassessment of dysfunctional beliefs in multiple domains.

Methods

Individuals were recruited via the web using Google and Facebook advertisements. Enrolled participants were randomized into either active intervention or waitlist control groups. Participants completed the Beck Depression Inventory-Second Edition (BDI-II), Generalized Anxiety Disorder-7 (GAD-7), Hamilton Program for Schizophrenia Voices, Green Paranoid Thought Scale, Recovery Assessment Scale (RAS), Rosenberg Self-Esteem Scale (RSES), Friendship Scale, and Sheehan Disability Scale (SDS) at baseline (T1), 30-day (T2), and 60-day (T3) assessment points. Participants in the active group used CORE from T1 to T2, and participants in the waitlist group used CORE from T2 to T3. Both groups completed usability and accessibility measures after they concluded their intervention periods.

Results

Overall, 315 individuals from 45 states participated in this study. The sample comprised individuals with self-reported bipolar disorder (111/315, 35.2%), major depressive disorder (136/315, 43.2%), and schizophrenia or schizoaffective disorder (68/315, 21.6%) who displayed moderate to severe symptoms and disability levels at baseline. Participants rated CORE as highly usable and acceptable. Intent-to-treat analyses showed significant treatment×time interactions for the BDI-II (F_1,313=13.38; P<.001), GAD-7 (F_1,313=5.87; P=.01), RAS (F_1,313=23.42; P<.001), RSES (F_1,313=19.28; P<.001), and SDS (F_1,313=10.73; P=.001). Large effects were observed for the BDI-II (d=0.58), RAS (d=0.61), and RSES (d=0.64); a moderate effect size was observed for the SDS (d=0.44), and a small effect size was observed for the GAD-7 (d=0.20). Similar changes in outcome measures were later observed in the waitlist control group participants following crossover after they received CORE (T2 to T3). Approximately 41.5% (64/154) of participants in the active group and 60.2% (97/161) of participants in the waitlist group were retained at T2, and 33.1% (51/154) of participants in the active group and 40.3% (65/161) of participants in the waitlist group were retained at T3.

Conclusions

We successfully recruited, screened, randomized, treated, and assessed a geographically dispersed sample of participants with SMI entirely via the web, demonstrating that fully remote clinical trials are feasible in this population; however, study retention remains challenging. CORE showed promise as a usable, acceptable, and effective tool for reducing the severity of psychiatric symptoms and disability while improving recovery and self-esteem. Rapid adoption and real-world dissemination of evidence-based mobile health interventions such as CORE are needed if we are to shorten the science-to-service gap and address the significant unmet mental health needs of people with SMI during the COVID-19 pandemic and beyond.

Trial Registration

ClinicalTrials.gov NCT04068467; https://clinicaltrials.gov/ct2/show/NCT04068467

Temporal Changes and Clinical Implications of Delayed Peridevice Leak Following Left Atrial Appendage Closure

OBJECTIVE

The aim of this study was to assess temporal changes and clinical implications of peridevice leak (PDL) after left atrial appendage closure.

BACKGROUND

Endocardial left atrial appendage closure devices are alternatives to long-term oral anticoagulation (OAC) for patients with atrial fibrillation. PDL > 5 mm may prohibit discontinuation of OAC.

METHODS

Patients included in the study had: 1) successful Watchman device implantation without immediate PDL; 2) new PDL identified at 45 to 90 days using transesophageal echocardiography; 3) eligibility for OAC; and 4) 1 follow-up transesophageal echocardiographic study for PDL surveillance. Relevant clinical and imaging data were collected by chart review. The combined primary outcome included failure to stop OAC after 45 to 90 days, transient ischemic attack or stroke, device-related thrombi, and need for PDL closure.

RESULTS

Relevant data were reviewed for 1,039 successful Watchman device implantations. One hundred eight patients (10.5%) met the inclusion criteria. The average PDL at 45 to 90 days was 3.2 ± 1.6 mm. On the basis of a median PDL of 3 mm, patients were separated into ≤3 mm (n = 73) and >3 mm (n = 35) groups. In the ≤3 mm group, PDL regressed significantly (2.2 ± 0.8 mm vs 1.6 ± 1.4 mm; P = 0.002) after 275 ± 125 days. In the >3 mm group, there was no significant change in PDL (4.9 ± 1.4 mm vs 4.0 ± 3.0 mm; P = 0.12) after 208 ± 137 days. The primary outcome occurred more frequently (69% vs 34%; P = 0.002) in the >3 mm group. The incidence of transient ischemic attack or stroke in patients with PDL was significantly higher compared with patients without PDL, irrespective of PDL size.

CONCLUSIONS

New PDL detected by transesophageal echocardiography at 45 to 90 days occurred in a significant percentage of patients and was associated with worse clinical outcomes. PDL ≤ 3 mm tended to regress over time.

Mobile Health for Caregivers of Young Adults With Early Psychosis: A Survey Study Examining User Preferences

OBJECTIVE

Caregivers play a key role in supporting the recovery of young adults with early psychosis. This role often involves considerable responsibilities and burden. Despite the considerable needs of caregivers, troubling service gaps addressing these needs remain. Digital technologies may increase caregivers' access to supportive resources; however, technologies developed specifically for caregivers lag far behind those developed for their relatives affected by early psychosis. In particular, little is known about the mobile health (mHealth) features that may be most acceptable to caregivers.

METHODS

The authors surveyed a sample of 43 caregivers on their interests regarding various features of a proposed mHealth intervention.

RESULTS

Caregivers of young adults with early psychosis were highly interested in a caregiver-facing mHealth intervention, specifically one providing information about psychosis, treatments, and communication with their affected family member.

CONCLUSIONS

Future caregiver-focused mHealth intervention interventions may be highly acceptable to this population and may address pressing service gaps.

Early toxicity and clinical outcomes after chimeric antigen receptor T-cell (CAR-T) therapy for lymphoma

BACKGROUND

Chimeric antigen receptor T-cell (CAR-T) infusion is associated with early toxicity. Yet, whether early toxicity development holds ramifications for long-term outcomes is unknown.

METHODS

From a large cohort of consecutive adult patients treated with CAR-T therapies for relapsed or refractory lymphomas from 2016 to 2019, we assessed progression-free survival (PFS), by toxicity development (cytokine release syndrome (CRS), neurotoxicity, or cardiotoxicity]. We also assessed the relationship of toxicity development to objective disease response, and overall survival (OS). Multivariable regression was utilized to evaluate relationships between standard clinical and laboratory measures and disease outcomes. Differences in outcomes, by toxicity status, were also assessed via 30-day landmark analysis. Furthermore, we assessed the effects of early anti-CRS toxicity therapy use (at ≤grade 2 toxicity) on maximum toxicity grade observed, and long-term disease outcomes (PFS and OS).

RESULTS

Overall, from 102 CAR-T-treated patients, 90 were identified as treated with single-agent therapy, of which 88.9% developed toxicity (80 CRS, 41 neurotoxicity, and 17 cardiotoxicity), including 28.9% with high-grade (≥3) events. The most common manifestations were hypotension at 96.6% and fever at 94.8%. Among patients with cardiac events, there was a non-significant trend toward a higher prevalence of concurrent or preceding high-grade (≥3) CRS. 50.0% required tocilizumab or corticosteroids. The median time to toxicity was 3 days; high grade CRS development was associated with cardiac and neurotoxicity. In multivariable regression, accounting for disease severity and traditional predictors of disease response, moderate (maximum grade 2) CRS development was associated with higher complete response at 1 year (HR: 2.34; p=0.07), and longer PFS (HR: 0.41; p=0.02, in landmark analysis), and OS (HR: 0.43; p=0.03). Among those with CRS, relative blood pressure (HR: 2.25; p=0.004), respectively, also associated with improved PFS. There was no difference in disease outcomes, or maximum toxicity grade (CRS, neurotoxicity, or cardiotoxicity) observed, based on the presence or absence of the use of early CRS-directed therapies.

CONCLUSIONS

Among adult lymphoma patients, moderate toxicity manifest as grade 2 CRS after CAR-T infusion may associate with favorable clinical outcomes. Further studies are needed to confirm these findings.

Metacognition, social cognition, and mentalizing in psychosis: are these distinct constructs when it comes to subjective experience or are we just splitting hairs?

Research using the integrated model of metacognition has suggested that the construct of metacognition could quantify the spectrum of activities that, if impaired, might cause many of the subjective disturbances found in psychosis. Research on social cognition and mentalizing in psychosis, however, has also pointed to underlying deficits in how persons make sense of their experience of themselves and others. To explore the question of whether metacognitive research in psychosis offers unique insight in the midst of these other two emerging fields, we have offered a review of the constructs and research from each field. Following that summary, we discuss ways in which research on metacognition may be distinguished from research on social cognition and mentalizing in three broad categories: (1) experimental procedures, (2) theoretical advances, and (3) clinical applications or indicated interventions. In terms of its research methods, we will describe how metacognition makes a unique contribution to understanding disturbances in how persons make sense of and interpret their own experiences within the flow of life. We will next discuss how metacognitive research in psychosis uniquely describes an architecture which when compromised - as often occurs in psychosis - results in the loss of persons' sense of purpose, possibilities, place in the world and cohesiveness of self. Turning to clinical issues, we explore how metacognitive research offers an operational model of the architecture which if repaired or restored should promote the recovery of a coherent sense of self and others in psychosis. Finally, we discuss the concrete implications of this for recovery-oriented treatment for psychosis as well as the need for further research on the commonalities of these approaches.

Strength of Association between Infarct Volume and Clinical Outcome Depends on the Magnitude of Infarct Size: Results from the ESCAPE-NA1 Trial

BACKGROUND AND PURPOSE

Infarct volume is an important predictor of clinical outcome in acute stroke. We hypothesized that the association of infarct volume and clinical outcome changes with the magnitude of infarct size.

MATERIALS AND METHODS

Data were derived from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, in which patients with acute stroke with large-vessel occlusion were randomized to endovascular treatment plus either nerinetide or a placebo. Infarct volume was manually segmented on 24-hour noncontrast CT or DWI. The relationship between infarct volume and good outcome, defined as mRS 0-2 at 90 days, was plotted. Patients were categorized on the basis of visual grouping at the curve shoulders of the infarct volume/outcome plot. The relationship between infarct volume and adjusted probability of good outcome was fitted with linear or polynomial functions as appropriate in each group.

RESULTS

We included 1099 individuals in the study. Median infarct volume at 24 hours was 24.9 mL (interquartile range [IQR] = 6.6-92.2 mL). On the basis of the infarct volume/outcome plot, 4 infarct volume groups were defined (IQR = 0-15 mL, 15.1-70 mL, 70.1-200 mL, >200 mL). Proportions of good outcome in the 4 groups were 359/431 (83.3%), 219/337 (65.0%), 71/201 (35.3%), and 16/130 (12.3%), respectively. In small infarcts (IQR = 0-15 mL), no relationship with outcome was appreciated. In patients with intermediate infarct volume (IQR = 15-200 mL), there was progressive importance of volume as an outcome predictor. In infarcts of > 200 mL, outcomes were overall poor.

CONCLUSIONS

The relationship between infarct volume and clinical outcome varies nonlinearly with the magnitude of infarct size. Infarct volume was linearly associated with decreased chances of achieving good outcome in patients with moderate-to-large infarcts, but not in those with small infarcts. In very large infarcts, a near-deterministic association with poor outcome was seen.

Expanding the Reach of Research: Quantitative Evaluation of a Web-Based Approach for Remote Recruitment of People Who Hear Voices

Background

Similar to other populations with highly stigmatized medical or psychiatric conditions, people who hear voices (ie, experience auditory verbal hallucinations [AVH]) are often difficult to identify and reach for research. Technology-assisted remote research strategies reduce barriers to research recruitment; however, few studies have reported on the efficiency and effectiveness of these approaches.

Objective

This study introduces and evaluates the efficacy of technology-assisted remote research designed for people who experience AVH.

Methods

Our group developed an integrated, automated and human complementary web-based recruitment and enrollment apparatus that incorporated Google Ads, web-based screening, identification verification, hybrid automation, and interaction with live staff. We examined the efficacy of that apparatus by examining the number of web-based advertisement impressions (ie, number of times the web-based advertisement was viewed); clicks on that advertisement; engagement with web-based research materials; and the extent to which it succeeded in representing a broad sample of individuals with AVH, assessed through the self-reported AVH symptom severity and demographic representativeness (relative to the US population) of the sample recruited.

Results

Over an 18-month period, our Google Ads advertisement was viewed 872,496 times and clicked on 11,183 times. A total amount of US $4429.25 was spent on Google Ads, resulting in 772 individuals who experience AVH providing consent to participate in an entirely remote research study (US $0.40 per click on the advertisement and US $5.73 per consented participant) after verifying their phone number, passing a competency screening questionnaire, and providing consent. These participants reported high levels of AVH frequency (666/756, 88.1% daily or more), distress (689/755, 91.3%), and functional interference (697/755, 92.4%). They also represented a broad sample of diversity that mirrored the US population demographics. Approximately one-third (264/756, 34.9%) of the participants had never received treatment for their AVH and, therefore, were unlikely to be identified via traditional clinic-based research recruitment strategies.

Conclusions

Web-based procedures allow for time saving, cost-efficient, and representative recruitment of individuals with AVH and can serve as a model for future studies focusing on hard-to-reach populations.

mHealth-Assisted Detection of Precursors to Relapse in Schizophrenia

Theoretical views and a growing body of empirical evidence suggest that psychiatric relapses in schizophrenia-spectrum disorders (SSDs) have measurable warning signs. However, because they are time- and resource-intensive, existing assessment approaches are not well-suited to detect these warning signs in a timely, scalable fashion. Mobile technologies deploying frequent measurements-i.e., ecological momentary assessment-could be leveraged to detect increases in symptoms that may precede relapses. The present study examined EMA measurements with growth curve models in the 100 days preceding and following 27 relapses (among n = 20 individuals with SSDs) to identify (1) what symptoms changed in the periods gradually preceding, following, and right as relapses occur, (2) how large were these changes, and (3) on what time scale did they occur. Results demonstrated that, on average, participants reported elevations in negative mood (d = 0.34), anxiety (d =0.49), persecutory ideation (d =0.35), and hallucinations (d =0.34) on relapse days relative to their average during the study. These increases emerged gradually on average from significant and steady increases (d = 0.05 per week) in persecutory ideation and hallucinations over the 100-day period preceding relapse. This suggests that brief (i.e., 1-2 item) assessments of psychotic symptoms may detect meaningful signals that precede psychiatric relapses long before they occur. These assessments could increase opportunities for relapse prevention as remote measurement-based care management platforms develop.

Augmenting Evidence-Based Care With a Texting Mobile Interventionist: A Pilot Randomized Controlled Trial

OBJECTIVE

This study aimed to evaluate the feasibility and clinical utility of training intensive psychiatric community care team members to serve as "mobile interventionists" who engage patients in recovery-oriented texting exchanges.

METHODS

A 3-month pilot randomized controlled trial was conducted to compare the mobile interventionist approach as an add-on to assertive community treatment (ACT) versus ACT alone. Participants were 49 individuals with serious mental illness (62% with schizophrenia/schizoaffective disorder, 24% with bipolar disorder, and 14% with depression). Clinical outcomes were evaluated at baseline, posttreatment, and 6-month follow-up, and satisfaction was evaluated posttreatment.

RESULTS

The intervention appeared feasible (95% of participants assigned to the mobile interventionist arm initiated the intervention, texting on 69% of possible days and averaging four messages per day), acceptable (91% reported satisfaction), and safe (no adverse events reported). Exploratory posttreatment clinical effect estimations suggested greater reductions in the severity of paranoid thoughts (Cohen's d=-0.61) and depression (d=-0.59) and improved illness management (d=0.31) and recovery (d=0.23) in the mobile interventionist group.

CONCLUSIONS

Augmentation of care with a texting mobile interventionist proved to be feasible, acceptable, safe, and clinically promising. The findings are encouraging given the relative ease of training practitioners to serve as mobile interventionists, the low burden placed on patients and practitioners, and the simplicity of the technology. The technical resources are widely accessible to patients and practitioners, boding well for potential intervention scalability. When pandemics such as COVID-19 block the possibility of in-person patient-provider contact, evidence-based texting interventions can serve a crucial role in supporting continuity of care.

Assessing the relationship between routine and schizophrenia symptoms with passively sensed measures of behavioral stability

Increased stability in one's daily routine is associated with well-being in the general population and often a goal of behavioral interventions for people with serious mental illnesses like schizophrenia. Assessing behavioral stability has been limited in clinical research by the use of retrospective scales, which are susceptible to reporting biases and memory inaccuracies. Mobile passive sensors, which are less susceptible to these sources of error, have emerged as tools to assess behavioral patterns in a range of populations. The present study developed and examined a metric of behavioral stability from data generated by a passive sensing system carried by 61 individuals with schizophrenia for one year. This metric-the Stability Index-appeared orthogonal from existing measures drawn from passive sensors and matched the predictive performance of state-of-the-art features. Specifically, greater stability in social activity (e.g., calls and messages) were associated with lower symptoms, and greater stability in physical activity (e.g., being still) appeared associated with elevated symptoms. This study provides additional support for the predictive value of individualized over population-level data in psychiatric populations. The Stability Index offers also a promising tool for generating insights about the impact of behavioral stability in schizophrenia-spectrum disorders.

Incidence of pacing-induced cardiomyopathy in pacemaker-dependent patients is lower with leadless pacemakers compared to transvenous pacemakers

Introduction

Frequent right AQ4ventricular pacing (≥40%) with a transvenous pacemaker (TVP) is associated with the risk of pacing‐induced cardiomyopathy (PICM). Leadless pacemakers (LPs) have distinct physical and mechanical differences from TVP. The risk of PICM with LP is not known. To identify incidence, predictors, and long‐term outcomes of PICM in LP and TVP patients.

Methods

The study comprised all pacemaker‐dependent patients with LP or TVP who had left ventricular ejection fraction (LVEF) of ≥50 from 2014 to 2019. The incidence of PICM (≥10% LVEF drop) was assessed with an echocardiogram. Predictors for PICM were identified using multivariate analysis. Long‐term outcomes after cardiac resynchronization (CRT) were assessed in both groups.

Results

A total of 131 patients with TVP and 67 with LP comprised the study. All patients in the TVP group and the majority in the LP group underwent atrioventricular node ablation. The mean follow‐up duration in TVP and LP groups was 592 ± 549 and 817 ± 600 days, respectively. A total of 18 (13.7%) patients in TVP and 2 (3%) in LP developed PICM after a median duration of 254 (interquartile range: 470) days. The incidence of PICM was significantly higher with TVP compared with LP (p = .02). TVP as pacing modality was a positive (odds ratio [OR]: 1.07) while age was negative (OR: 0.94) predictor for PICM on multivariable analysis. Both patients in LP and all except two in the TVP group responded to CRT.

Conclusion

Incidence of PICM is significantly lower with LP compared with TVP in pacemaker‐dependent patients. Age and TVP as pacing modality were predictors for PICM.

Mobile RDoC: Using Smartphones to Understand the Relationship Between Auditory Verbal Hallucinations and Need for Care

Objective

Auditory verbal hallucinations (AVH) are common in multiple clinical populations but also occur in individuals who are otherwise considered healthy. Adopting the National Institute of Mental Health's Research Domain Criteria (RDoC) framework, the aim of the current study was to integrate a variety of measures to evaluate whether AVH experience varies across clinical and nonclinical individuals.

Methods

A total of 384 people with AVH from 41 US states participated in the study; 295 participants (77%) who received inpatient, outpatient, or combination treatments for AVH and 89 participants (23%) who never received care. Participants used a multi-modal smartphone data collection system to report on their AVH experiences and co-occurring psychological states multiple times daily, over 30 days. In parallel, smartphone sensors recorded their physical activity, geolocation, and calling and texting behavior continuously.

Results

The clinical sample experienced AVH more frequently than the nonclinical group and rated their AVH as significantly louder and more powerful. They experienced more co-occurring negative affect and were more socially withdrawn, spending significantly more time at home and significantly less time near other people. Participants with a history of inpatient care also rated their AVH as infused with significantly more negative content. The groups did not differ in their physical activity or use of their smartphones for digital communication.

Conclusion

Smartphone-assisted remote data collection revealed real-time/real-place phenomenological, affective, and behavioral differences between clinical and nonclinical samples of people who experience AVH. The study provided strong support for the application of RDoC-informed approaches in psychosis research.

Facilitating pathways to care: A qualitative study of the self-reported needs and coping skills of caregivers of young adults diagnosed with early psychosis

WHAT IS KNOWN ON THE SUBJECT?: In clinical psychiatry and mental health nursing practice, family caregivers are known to provide the bulk of care and play an important role in facilitating recovery outcomes for their loved ones diagnosed with psychosis. Providing services and interventions to family caregivers is as important as to patients in the early stage of psychotic experience for having a beneficial impact on the patients' clinical and social outcomes. Limited qualitative research has focused on family caregivers' subjective views of what they need during the critical period to identify early warning signs and connect their loved ones to professional help as they have no prior experience in caring for persons with psychosis. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Using qualitative analysis of family caregiver focus groups, this manuscript provides readers in clinical nursing practice with an understanding of family caregivers' lived experiences of supporting their loved one diagnosed with early psychosis. Understanding family caregivers' caregiving unmet needs in supporting their loved one diagnosed with early psychosis could inform both the technology-assisted intervention development and nursing practice in improving family-centred care and facilitate self-management practice. IMPLICATIONS FOR MENTAL HEALTH NURSING: Psychiatry and mental health nursing has long been engaged with the health and well-being of individuals with psychosis and supporting their families in the development, evaluation and implementation of innovative approaches to patient and family education. Digital technologies designed to deliver tailored intervention for family caregivers are underdeveloped, and the present study identifies a number of potential features that could comprise technology to meet the needs of this population. ABSTRACT: Introduction Caregivers play a critical role in detecting and managing psychotic symptoms before young people diagnosed with early psychosis present to care. Little is known about the specific needs of caregivers in navigating pathways to care for their loved one. Aim The purpose of this study was to understand the needs of family caregivers and their ways of coping on the pathway to care for early psychosis. Method Twenty family caregivers of individuals diagnosed with early psychosis participated in three focus groups that explored caregiving needs provision for early psychosis. Thematic analysis was conducted. Results We identified four major themes: education and skill training; raising wider awareness, such as police offers and teachers; adopting technologies for coping; and effective coping strategies. Implications for practice These findings provide important insights into caregiving needs and the ways for nurses to address those needs and better equip carers to recognize early symptoms, monitor behaviour changes and navigate care to support people with first-episode psychosis. Nursing researchers can use the information to develop on-demand and tailored family-centred intervention in addressing caregivers' needs in education, increasing awareness of early psychosis and fostering effective coping strategies.

The impact of exposure therapy on stigma and mental health treatment attitudes among active duty U.S. soldiers with combat related PTSD

Although cognitive behavioral interventions improve attitudes toward mental health treatment and reduce stigma, little is known about which types of attitudes change, or how this change occurs. Active duty soldiers with PTSD (N = 162) were randomized to 10 sessions of exposure therapy or a waitlist. Soldiers were assessed for PTSD and completed measures of stigma and attitudes towards mental health services before randomization and after 5- and 10- sessions of therapy. At post-treatment, soldiers in exposure therapy demonstrated significant improvements in openness to talking about mental health problems and concerns about what others may think if they knew they were seeking mental health treatment, relative to those in the waitlist. There were significant indirect effects from treatment to changes in stigma and attitudes towards mental health treatment through changes in PTSD symptoms at post-treatment. There was also a significant indirect effect from treatment to changes in stigma at post-treatment through changes in attitudes towards mental health treatment at mid-treatment, suggesting attitude change may occur first. Baseline characteristics did not moderate treatment's change in stigma or attitudes. Improvements in PTSD symptoms and positive changes in attitudes towards mental health treatment appear to separately predict later reductions in stigma.

Changes in physiological reactivity in response to the trauma memory during prolonged exposure and virtual reality exposure therapy for posttraumatic stress disorder

OBJECTIVE

A key symptom of posttraumatic stress disorder (PTSD) is hyperreactivity to trauma-relevant stimuli. Though physiological arousal is reliably elevated in PTSD, the question remains whether this arousal responds to treatment. Virtual reality (VR) has been posited to increase emotional engagement during prolonged exposure therapy (PE) for PTSD by augmenting imaginal exposures with trauma-relevant sensory information. However, the comparative effects of VR exposure therapy (VRE) have received limited empirical inquiry.

METHOD

Ninety active-duty soldiers with combat-related PTSD participating in a randomized-controlled trial to receive PE, VRE, or a waitlist-control (WL) condition had their physiological reactivity, indexed by galvanic skin response (GSR), to their trauma memories assessed at pre-, mid-, and posttreatment.

RESULTS

Although both VRE and PE conditions showed reduced GSR reactivity to trauma memories from pre- to posttreatment, only the VRE group differed significantly from WL. Across the sample, reductions in GSR were significantly correlated with reductions in self-reported PTSD and anxiety symptoms.

CONCLUSIONS

This was the first study comparing effects of VRE and PE on psychophysiological variables. Given previous research finding limited differences between VRE and PE in PTSD symptom reduction, these findings lend support to the rationale for including VR in exposure therapy protocols while raising important questions about the potential benefits of VRE. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Extreme Obesity is Associated with Low Success Rate of Atrial Fibrillation Catheter Ablation

BACKGROUND

Catheter ablation (CA) is an established treatment for patients with symptomatic atrial fibrillation (AF). The purpose of this study was to evaluate the safety and efficacy of single CA in AF patients with extreme obesity (body mass index [BMI] ≥ 40 kg/m2) and its long-term impact on body weight.

METHODS

Patients with BMI ≥40 kg/m2 who underwent CA at the Ohio State University between 2012 and 2016 were included. The primary efficacy endpoint was no atrial arrhythmia lasting > 30 seconds without anti-arrhythmic drugs during 1-year follow-up after a single procedure.

RESULTS

Out of 230 AF patients with BMI ≥ 40 kg/m2 undergoing CA, pulmonary vein isolation was achieved in 226 (98%) patients.Seventeen patients (7.4%) experienced acute major complications, including pericardial effusion, vascular complications and respiratory failure. Patient characteristics for 135 patients with complete 1-year follow-up were as follows: mean age 58.6 ± 9.6 years, mean BMI 44.5±4.7 kg/m2, female 63 (47%), non-paroxysmal AF 100 (74%), median CHA2DS2-VASc score 2 (IQR:1-3). In this cohort, the primary efficacy endpoint was achieved in 44 (33%) patients. Paroxysmal AF was associated with higher CA success compared to non-paroxysmal (51 vs. 26% [p < 0.01]).There was no significant weight change even in patients with successful AF CA.

CONCLUSIONS

Extreme obesity is associated with low AF CA success, particularly in those with non-paroxysmal AF. Successful AF CA was not associated with long-term weight reduction. A better treatment strategy is needed in this population of AF and extreme obesity.

Dynamic relationships between emotional distress, persecutory ideation, and metacognition in schizophrenia

OBJECTIVE

Determine whether metacognitive capacity (i.e., a range of abilities that involve recognition, reflection, and integration of mental states) influences the relationships between emotional distress and persecutory ideation (PI).

METHODS

The present study examined emotional distress, metacognition and PI in a sample (n = 337) of individuals with schizophrenia or schizoaffective disorder and clinician-rated PI. Pearson and partial correlations were used to examine relationships between variables, as well as between-subjects analysis of variances to compare groups characterized based on emotional distress and persecutory ideation scores.

RESULTS

While emotional distress and PI are associated with one another, metacognition is negatively associated with PI and positively associated with emotional distress. Subgroup comparisons demonstrated that individuals with high emotional distress and low PI had significantly higher metacognitive capacity than those elevated in PI or reduced in both emotional distress and PI.

CONCLUSIONS

Findings suggest metacognitive capacity may relate to improved awareness of distress and reduced PI.

Recurrence quantification analysis of complex-fractionated electrograms differentiates active and passive sites during atrial fibrillation

OBJECTIVES

To differentiate electrograms representing sites of active atrial fibrillation (AF) drivers from passive ones.

BACKGROUND

Ablation of complex-fractionated atrial electrograms (CFAEs) is controversial due to difficulty in distinguishing CFAEs representing sites of active AF drivers from passive mechanisms. We hypothesized that active CFAE sites exhibit repetitive wavefront directionality, thereby inscribing an electrogram conformation (Egm-C) that is more recurrent compared with passive CFAE sites; and that can be differentiated from passive CFAEs using nonlinear recurrence quantification analysis (RQA).

METHODS

We developed multiple computer models of active CFAE mechanisms (ie, rotors) and passive CFAE mechanisms (ie, wavebreak, slow conduction, and double potentials). CFAE signals were converted into discrete time-series representing Egm-C. The RQA algorithm was used to compare signals derived from active CFAE sites to those from passive CFAEs sites. The RQA algorithm was then applied to human CFAE signals collected during AF ablation (n  =  17 patients).

RESULTS

RQA was performed in silico on simulated bipolar CFAEs within active (n = 45) and passive (n = 60) areas. Recurrence of Egm-C was significantly higher in active compared with passive CFAE sites (31.8% ± 19.6% vs 0.3% ± 0.5%, respectively, P < .0001) despite no difference in mean cycle length (CL). Similarly, for human AF (n = 39 signals), Egm-C recurrence was higher in active vs passive CFAE areas despite similar CLs (%recurrence 13.6% ± 15.5% vs 0.1% ± 0.3%, P < .002; mean CL 102.5 ± 14.3 vs 106.6 ± 14.4, P = NS).

CONCLUSION

Active CFAEs critical to AF maintenance exhibit higher Egm-C recurrence and can be differentiated from passive bystander CFAE sites using RQA.

A technology-assisted life of recovery from psychosis

Developments in digital health technologies have the potential to expedite and strengthen the path towards recovery for people with psychosis. This perspective piece provides a snapshot of how a range of digital technologies can be deployed to support a young adult’s efforts to cope with schizophrenia-spectrum illness. In conjunction with a day in the life of this individual, we provide examples of innovations in digital health research designed for this clinical population, as well as brief summaries of the evidence supporting the usability, feasibility, or effectiveness of each approach. From early detection to ongoing symptom management and vocational rehabilitation, this day-in-the-life vignette provides an overview of the ways in which digital health innovations could be used in concert to augment, scaffold, and enhance schizophrenia-spectrum illness management and recovery.

Recipient natural killer cells alter the course of rejection of allogeneic heart grafts in rats

Rejection of solid organ grafts is regarded to be dependent on T cell responses. Nonetheless, numerous studies have focused on the contribution of NK cells in this process, resulting in contradictory theories. While some conclude that there is no participation of NK cells, others found an inflammatory or regulative role of NK cells. However, the experimental settings are rarely comparable with regard to challenged species, strain combinations or the nature of the graft. Thus, clear definition of NK cell contribution might be impeded by these circumstances. In this study we performed heterotopic heart transplantation (HTx) in rats, choosing one donor-recipient-combination leading to a fast and a second leading to a prolonged course of graft rejection. We intervened in the rejection process, by depletion of recipient NK cells on the one hand and by injection of activated NK cells syngeneic to the recipients on the other. The fast course of rejection could not be influenced by any of the NK cell manipulative treatments. However, the more prolonged course of rejection was highly susceptible to depletion of NK cells, resulting in significant acceleration of rejection, while injection of NK cells induced acceptance of the grafts. We suggest that, depending on the specific setting, NK cells can attenuate the first trigger of immune response, which allows establishing the regulatory activity leading to tolerance of the graft.

Lifetime trauma exposure among those with combat-related PTSD: Psychiatric risk among U.S. military personnel

Research has described the association between lifetime trauma exposure and psychiatric symptoms among various cohorts, but little is known about the effect of lifetime trauma histories on the symptom expression of active-duty military personnel diagnosed with combat-related posttraumatic stress disorder (PTSD). Active-duty soldiers (N = 162) were diagnosed with PTSD from deployments to Iraq or Afghanistan using the Clinician Administered PTSD Scale. Soldiers then completed self-report measures of depression, anxiety, and PTSD. Lifetime exposure to categories of trauma types and the intensity of exposure was reported on the Life Events Checklist. The number of categories of trauma that happened to them significantly predicted the severity of depression, anxiety, and PTSD symptoms, as well as a positive screen for likely depression diagnosis based on self-reported symptoms. Direct exposure to trauma explained most of the association, as witnessing trauma and hearing about trauma did not explain symptoms beyond events that happened to participants. Interpersonal traumatic events were not associated with psychiatric functioning after controlling for non-interpersonal traumatic events. Assessment of trauma history among post-9/11 service members and veterans should include the frequency and variety of lifetime trauma exposure, given the association with psychiatric functioning.

Contemporary impacts of a cancer diagnosis on survival following in-hospital cardiac arrest

AIM

The objective of this study was to determine whether survival and post-arrest procedural utilization following in-hospital cardiac arrest (IHCA) differ in patients with and without comorbid cancer.

METHODS

We retrospectively reviewed all adult (age ≥18 years old) hospital admissions complicated by IHCA from 2003 to 2014 using the National Inpatient Sample (NIS) dataset. Utilizing propensity score matching using age, gender, race, insurance, all hospital level variables, HCUP mortality score, diabetes, hypertension and cardiopulmonary resuscitation use, rates of survival to hospital discharge and post-arrest procedural utilization were compared.

RESULTS

From 2003 to 2014, there were a total of 1,893,768 hospitalizations complicated by IHCA, of which 112,926 occurred in patients with history of cancer. In a propensity matched cohort from 2012 to 2014, those with cancer were less likely to survive the hospitalization (31% vs. 46%, p < 0.0001). Following an IHCA, rates of procedural utilization in patients with cancer were significantly less when compared to those without a concurrent malignancy: coronary angiography (4.0% vs. 13.0%), percutaneous coronary intervention (2.2% and 8.0%), targeted temperature management (0.8% vs. 6.0%); p < 0.0001 for all comparisons. This patient population was less likely to have acute coronary syndrome (12.6% vs. 27.0%) or congestive heart failure (24.5% vs. 38.2%); p < 0.0001 for both comparisons. Survival improved in both groups over the study period (p < 0.0001).

CONCLUSIONS

Patients with a history of cancer who sustain IHCA are less likely to receive post-arrest procedures and survive to hospital discharge. Given the expected rise in the rates of cancer survivorship, these findings highlight the need for broader application of potentially life-saving interventions to lower risk cancer patients who have sustained a cardiac arrest.

Effect of Mobile Health on In-person Service Use Among People With Serious Mental Illness

OBJECTIVE

This study examined whether mobile health (mHealth) affects the use of in-person services among people with serious mental illness.

METHODS

This randomized comparative effectiveness trial evaluated minutes of service use among 163 participants for 3 months before, during, and after exposure to mHealth or clinic-based care.

RESULTS

mHealth and clinic-based care participants used fewer services during the intervention (9% and 14%, respectively) and follow-up (2% and 12%) periods than during the preintervention phase. During treatment, mHealth treatment responders (participants who experienced recovery gains and maintained them at follow-up) reduced service use more than nonresponders (12% vs. 10%). Postintervention, service use by mHealth treatment responders continued to drop (an additional 11%), whereas service use by mHealth nonresponders increased by 8%.

CONCLUSIONS

mHealth and clinic-based illness management interventions may reduce the need for other in-person services among people with serious mental illness, particularly among mHealth users who experience sustained recovery.

Relationships between smartphone social behavior and relapse in schizophrenia: A preliminary report

Social dysfunction is a hallmark of schizophrenia. Social isolation may increase individuals' risk for psychotic symptom exacerbation and relapse. Monitoring and timely detection of shifts in social functioning are hampered by the limitations of traditional clinic-based assessment strategies. Ubiquitous mobile technologies such as smartphones introduce new opportunities to capture objective digital indicators of social behavior. The goal of this study was to evaluate whether smartphone-collected digital measures of social behavior can provide early indication of relapse events among individuals with schizophrenia. Sixty-one individuals with schizophrenia with elevated risk for relapse were given smartphones with the CrossCheck behavioral sensing system for a year of remote monitoring. CrossCheck leveraged the device's microphone, call record, and text messaging log to capture digital socialization data. Relapse events including psychiatric hospitalizations, suicidal ideation, and significant psychiatric symptom exacerbations were recorded by trained assessors. Exploratory mixed effects models examined relationships of social behavior to relapse, finding that reductions in number and duration of outgoing calls, as well as number of text messages were associated with relapses. Number and duration of incoming phone calls and in-person conversations were not. Smartphone enabled social activity may provide an important metric in determining relapse risk in schizophrenia and provide access to sensitive, meaningful and ecologically valid data streams never before available in routine care.

Transdiagnostic Mobile Health: Smartphone Intervention Reduces Depressive Symptoms in People With Mood and Psychotic Disorders

BACKGROUND

Depression is the most prevalent mental health problem. The need for effective treatments for depression far outstrips the availability of trained mental health professionals. Smartphones and other widely available technologies are increasingly being leveraged to deliver treatments for depression. Whether there are patient characteristics that affect the potency of smartphone interventions for depression is not well understood.

OBJECTIVE

This study aimed to evaluate whether patient characteristics including clinical diagnosis, depression severity, psychosis status, and current use of antidepressant medications impact the effects of an evidence-based smartphone intervention on depressive symptoms.

METHODS

Data were collected as part of a 2-arm randomized controlled trial comparing a multimodal smartphone intervention called FOCUS with a clinic-based intervention. Here, we report on 82 participants assigned to 12 weeks of FOCUS treatment. We conducted assessments of depressive symptoms using the Beck Depression Inventory-second edition (BDI-II) at baseline, postintervention (3 months), and follow-up (6 months). We tested for differences in the amount of improvement in BDI-II scores from baseline to posttreatment and 6-month follow-up between each of the following patient subgroups using 2 (group) × 2 (time) mixed effects models: diagnosis (ie, schizophrenia spectrum disorder vs bipolar disorder vs major depressive disorder), depression severity (ie, minimal-mild vs moderate-severe depression), psychosis status (ie, presence vs absence of psychotic symptoms), and antidepressant use (ie, taking antidepressants vs not taking antidepressants).

RESULTS

The majority of participants were male (60%, 49/82), African American (65%, 53/82), and middle-aged (mean age 49 years), with a high school education or lower (62%, 51/82). There were no differences in patient demographics across the variables that were used to stratify the analyses. There was a significant group × time interaction for baseline depression severity (F1,76.8=5.26, P=.02 [posttreatment] and F1,77.4=6.56, P=.01 [6-month follow-up]). Participants with moderate or severe depression had significant improvements (t42=3.20, P=.003 [posttreatment] and t42=4.20, P<.001 [6-month follow-up]), but participants with minimal or mild depression did not (t31=0.20, P=.84 [posttreatment] and t30=0.43, P=.67 [6-month follow-up]). There were no significant group × time interactions for diagnosis, psychosis status, or antidepressant medication use. Participants with minimal or mild depression had negligible nonsignificant improvements (<1 point on the BDI-II). Reduction in depression in all other groups was larger (range 1.7-6.5 points on the BDI-II).

CONCLUSIONS

Our results suggest that FOCUS can be deployed to treat moderate to severe depressive symptoms among people with schizophrenia spectrum disorders, bipolar disorder, and major depressive disorder, in concert with antidepressant medications or without them, in both people with and without active psychotic symptoms. The study results are consistent with research on transdiagnostic models in psychotherapy and extend our knowledge about the potential of transdiagnostic mobile health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02421965; http://clinicaltrials.gov/ct2/show/NCT02421965 (Archived by WebCite at http://www.webcitation.org/76pyDlvAS).

The bias toward intentionality in schizophrenia: Automaticity, context, and relationships to symptoms and functioning

Previous research on attributions in schizophrenia has focused on whether individuals make hostile, intentional attributions for ambiguous negative events. It is unclear, however, whether individuals with schizophrenia differ from controls in their general judgments of intentionality judgments in nonconflict and emotionally neutral situations. Research in social psychology suggests that nonclinical individuals present with an automatic bias to see intentionality and that this bias is regulated by the operation of controlled processes. The present study examined whether this general intentionality bias distinguishes individuals with schizophrenia (n = 213) from nonpatient controls (n = 151). Indeed, individuals with schizophrenia were more likely to attribute intentional motives to others' actions relative to controls. This intentionality bias was related to hostility, role functioning, and independent living skills. These findings may provide one domain to examine in future approaches to social cognition in schizophrenia. (PsycINFO Database Record

A Disorder by Any Other Name: Metacognition, Schizophrenia, and Diagnostic Practice

Humanistic psychology has made us aware that any understanding of schizophrenia must see persons diagnosed with this condition as whole persons who are making sense of what wellness and recovery mean to them. This has raised questions about what the diagnosis of schizophrenia means and whether the diagnostic label of schizophrenia is helpful when we try to conceptualize the actions and aims of treatment. To examine this issue we propose it is essential to consider what is systematically occuring psychologicaly in recovery when persons experience, interpret and agentically respond to emerging challenges. We then review how the integrated model of metacognition provides a systematic, person-centered, evidence-based approach to understanding psychological processes which impact recovery, and discuss how this guides a form of psychotherapy, metacognitive reflection and insight therapy, which promotes metacognitive abilities and support recovery. We suggest this work indicates that metacognitive capacity is something that can be diagnosed without stigmatizing persons. It can be used to meaningfully inform clinical practice across various theoretical models and offers concrete implications for rehabilitation.