The relationship between substance use and self-reported aspects of social functioning in patients with a psychotic disorder

BACKGROUND

In patients with a psychotic disorder, rates of substance use (tobacco, cannabis, and alcohol) are higher compared to the general population. However, little is known about associations between substance use and self-reported aspects of social functioning in patients with a psychotic disorder.

METHODS

In this cross-sectional study of 281 community-dwelling patients with a psychotic disorder, linear regression models were used to assess associations between substance use (tobacco, cannabis, or alcohol) and self-reported aspects of social functioning (perceived social support, stigmatization, social participation, or loneliness) adjusting for confounders (age, gender, and severity of psychopathology).

RESULTS

Compared to nonsmokers, both intermediate and heavy smokers reported lower scores on loneliness (E = -0.580, SE = 0.258, p = 0.025 and E = -0.547, SE = 0,272, p = 0.046, respectively). Daily cannabis users reported less social participation deficits than non-cannabis users (E = -0.348, SE = 0.145, p = 0.017). Problematic alcohol use was associated with more perceived social support compared to non-alcohol use (E = 3.152, SE = 1.102, p = 0.005). Polysubstance users reported less loneliness compared to no users (E = -0.569, SE = 0.287, p = 0.049).

CONCLUSIONS

Substance use in patients with psychosis is associated with more favorable scores on various self-reported aspects of social functioning.

The association between childhood trauma and tobacco smoking in patients with psychosis, unaffected siblings, and healthy controls

In patients with psychosis, rates of tobacco smoking and childhood trauma are significantly higher compared to the general population. Childhood trauma has been proposed as a risk factor for tobacco smoking. However, little is known about the relationship between childhood trauma and smoking in psychosis. In a subsample of the Genetic Risk and Outcome of Psychosis study (760 patients with psychosis, 991 unaffected siblings, and 491 healthy controls), tobacco smoking was assessed using the Composite International Diagnostic Interview and childhood trauma was measured with the Childhood Trauma Questionnaire. Logistic regression models were used to assess associations between trauma and smoking, while correcting for confounders. Positive associations were found between total trauma, abuse, and neglect, and an increased risk for smoking in patients, while correcting for age and gender (ORtrauma 1.77, 95% CI 1.30-2.42, p < 0.001; ORabuse 1.69, 95% CI 1.23-2.31, p = 0.001; ORneglect 1.48, 95% CI 1.08-2.02, p = 0.014). In controls, total trauma and abuse were positively associated with smoking, while correcting for age and gender (ORtrauma 2.40, 95% CI 1.49-3.88, p < 0.001; ORabuse 2.02, 96% CI 1.23-3.32, p = 0.006). All associations lost their significance after controlling for additional covariates and multiple testing. Findings suggest that the association between childhood trauma and tobacco smoking can be mainly explained by confounders (gender, cannabis use, and education) in patients with psychosis. These identified aspects should be acknowledged in tobacco cessation programs.

Cognitive behavioural therapy for the treatment of schizophrenia spectrum disorders: an umbrella review of meta-analyses of randomised controlled trials

Background

Cognitive behavioural therapy (CBT) forms the standard psychotherapy for schizophrenia spectrum disorders (SSD). We aimed to summarize and evaluate the evidence on the effectiveness of CBT for SSD.

Methods

In this umbrella review, we searched PubMed, Embase, Cochrane Database, and PsychInfo, for meta-analyses of randomised controlled trials (RCTs) of CBT in SSD published between database inception up to Aug 18, 2023. Inclusion criteria were RCTs investigating individually provided CBT in a population of patients with SSD, compared to either standard care, treatment as usually, or any other psychosocial therapies. No restrictions concerning follow-up or language were applied. We used the "assessment of multiple systematic reviews" (AMSTAR-2) appraisal checklist for the evaluation of methodological quality of meta-analysis. We extracted summary metrics from eligible studies in duplicate. The strength of evidence was classified by the sample size, p-value, excess significance bias, prediction intervals, significance of largest study, and heterogeneity. The strength of evidence was ranked according to established criteria as: convincing, highly suggestive, suggestive, weak, or not significant. Primary outcomes were general psychopathology, positive and negative symptoms. This study is registered in PROSPERO, CRD42022334671.

Findings

We found 26 eligible meta-analyses, of which 16 meta-analyses provided sufficient data. Using the AMSTAR-2, we found limitations in details concerning the selection of study design, quality of the search and reporting of funding in included meta-analyses. A minority of 42.9% of the comparisons showed a significant result in favor of CBT; 57.1% were non-significant with no convincing or highly suggestive evidence. Suggestive evidence was found in favor of CBT for general psychopathology (6.2%, N = 34 RCTs, effect size (ES) = -0.33 (-0.47; -0.19), I2 = 67.93), delusions (16.7%, N = 27, ES = 0.36 (0.22; 0.51), I2 = 50.47), and hallucinations (33.3%, N = 28, ES = 0.32 (0.19; 0.46), I2 = 45.14) at the end of treatment (EoT). Weak (N = 34 RCTs, ES = -0.13 (-0.24; -0.02), I2 = 51.28), or non-significant evidence (N = 28 RCTs, ES = 0.12 (-0.03; 0.27) I2 = 64.63) was found for negative symptoms at EoT. At longer follow-up, evidence became weak or non-significant.

Interpretation

Findings suggest that the effectiveness of CBT on general and positive symptoms in SSD at EoT was small to medium, while we found inconsistent evidence for a sustainable effect. CBT has no convincing impact on other relevant outcomes. Guidelines may use these results to specify their recommendations.

Funding

None.

The potential role of gray matter volume differences in the association between smoking and depression: A narrative review

Tobacco use and major depression are both leading contributors to the global burden of disease and are also highly comorbid. Previous research indicates bi-directional causality between tobacco use and depression, but the mechanisms that underlie this causality are unclear, especially for the causality from tobacco use to depression. Here we narratively review the available evidence for a potential causal role of gray matter volume in the association. We summarize the findings of large existing neuroimaging meta-analyses, studies in UK Biobank, and the Enhancing NeuroImaging Genetics through MetaAnalysis (ENIGMA) consortium and assess the overlap in implicated brain areas. In addition, we review two types of methods that allow us more insight into the causal nature of associations between brain volume and depression/smoking: longitudinal studies and Mendelian Randomization studies. While the available evidence suggests overlap in the alterations in brain volumes implicated in tobacco use and depression, there is a lack of research examining the underlying pathophysiology. We conclude with recommendations on (genetically-informed) causal inference methods useful for studying these associations.

Longitudinal associations between alcohol use, smoking, genetic risk scoring and symptoms of depression in the general population: a prospective 6-year cohort study

BACKGROUND

Alcohol consumption, smoking and mood disorders are leading contributors to the global burden of disease and are highly comorbid. Yet, their interrelationships have remained elusive. The aim of this study was to examine the multi-cross-sectional and longitudinal associations between (change in) smoking and alcohol use and (change in) number of depressive symptoms.

METHODS

In this prospective, longitudinal study, 6646 adults from the general population were included with follow-up measurements after 3 and 6 years. Linear mixed-effects models were used to test multi-cross-sectional and longitudinal associations, with smoking behaviour, alcohol use and genetic risk scores for smoking and alcohol use as independent variables and depressive symptoms as dependent variables.

RESULTS

In the multi-cross-sectional analysis, smoking status and number of cigarettes per day were positively associated with depressive symptoms (p < 0.001). Moderate drinking was associated with less symptoms of depression compared to non-use (p = 0.011). Longitudinally, decreases in the numbers of cigarettes per day and alcoholic drinks per week as well as alcohol cessation were associated with a reduction of depressive symptoms (p = 0.001-0.028). Results of genetic risk score analyses aligned with these findings.

CONCLUSIONS

While cross-sectionally smoking and moderate alcohol use show opposing associations with depressive symptoms, decreases in smoking behaviour as well as alcohol consumption are associated with improvements in depressive symptoms over time. Although we cannot infer causality, these results open avenues to further investigate interventions targeting smoking and alcohol behaviours in people suffering from depressive symptoms.

Association between characteristics of nursing teams and patients' aggressive behavior in closed psychiatric wards

PURPOSE

Estimate the effect of nursing, shift, and patient characteristics on patients' aggression.

DESIGN AND METHODS

Follow-up study on a closed psychiatric ward was performed to estimate the effect of nursing team characteristics and patient characteristics on the incidence of aggression.

FINDINGS

The incidence of aggression (n = 802 in sample) was lower in teams with >75% male nurses. Teams scoring high on extraversion experienced more verbal aggression and teams scoring high on neuroticism experienced more physical aggression. Younger patients and/or involuntarily admitted patients were more frequently aggressive.

PRACTICE IMPLICATIONS

These findings could stimulate support for nurses to prevent aggression.

Laparoscopic peritoneal lavage versus sigmoidectomy for perforated diverticulitis with purulent peritonitis: three-year follow-up of the randomised LOLA trial

Background

This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial.

Methods

Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group.

Results

Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy.

Conclusion

Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option.

Graphical abstract

Impact of coping styles on substance use in persons with psychosis, siblings, and controls

BACKGROUND

Substance use is overrepresented in patients with psychosis. Maladaptive coping has been proposed as one of the mechanisms which might underlie this high prevalence. Patients are known to apply more maladaptive coping compared to the healthy population. However, it is unknown whether coping is associated with the use of different substances across those with different vulnerability for psychosis, and whether coping mediates the possible association between life events and substance use.

METHODS

In this multicenter, cohort study, 429 patients, 504 siblings, and 220 controls were included. We determined whether coping was associated with tobacco smoking, cannabis use, or alcohol consumption. Multivariable logistic regression models were applied whilst correcting for potential confounders. We performed post-hoc analyses to explore the association between negative life events, tobacco smoking, and the role of coping as a mediator in patients with psychosis.

RESULTS

A positive association was found in patients between passive coping and tobacco smoking (fully adjusted OR 1.65, 95% CI 1.18-2.31). Tobacco smoking patients experienced more negative life events compared to non-smoking patients and passive coping mediated this association. In siblings and controls, none of the coping strategies were associated with substance use.

CONCLUSIONS

The coping style of patients with psychosis is associated with tobacco smoking and mediates the association between negative events and tobacco smoking. No significant associations were found in siblings, controls or concerning other substance use. Future research is required to examine whether enhancing healthy coping strategies decreases tobacco use in patients with psychosis.

Developing a Smoking Cessation Intervention for People With Severe Mental Illness Treated by Flexible Assertive Community Treatment Teams in the Netherlands: A Delphi Study

BACKGROUND

There is still limited evidence on the effectiveness and implementation of smoking cessation interventions for people with severe mental illness (SMI) in Dutch outpatient psychiatric settings. The present study aimed to establish expert consensus on the core components and strategies to optimise practical implementation of a smoking cessation intervention for people treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands.

DESIGN

A modified Delphi method was applied to reach consensus on three core components (behavioural counselling, pharmacological treatment and peer support) of the intervention. The Delphi panel comprised five experts with different professional backgrounds. We proposed a first intervention concept. The panel critically examined the evolving concept in three iterative rounds of 90 min each. Responses were recorded, transcribed verbatim and thematically analysed.

RESULTS

Overall, results yielded that behavioural counselling should focus on preparation for smoking cessation, guidance, relapse prevention and normalisation. Pharmacological treatment consisting of nicotine replacement therapy (NRT), Varenicline or Bupropion, under supervision of a psychiatrist, was recommended. The panel agreed on integrating peer support as a regular part of the intervention, thus fostering emotional and practical support among patients. Treatment of a co-morbid cannabis use disorder needs to be integrated into the intervention if indicated. Regarding implementation, staff's motivation to support smoking cessation was considered essential. For each ambulatory team, two mental health care professionals will have a central role in delivering the intervention.

CONCLUSIONS

This study provides insight into expert consensus on the core components of a smoking cessation intervention for people with SMI. The results of this study were used for the development of a comprehensive smoking cessation program.

Influence of nursing staff characteristics on seclusion in acute mental health care-A prospective two-year follow-up study

INTRODUCTION

Seclusion still occurs on mental health wards, despite absence of therapeutic efficacy and high risks of adverse patient effects. Literature on the effect of nursing teams, and the role of psychological characteristics in particular, on frequency of seclusion is scarce.

AIM

To explore the influence of demographic, professional or psychological, nursing team-level, and shift characteristics on the frequency of use of seclusion.

METHODS

Prospective two-year follow-up study.

RESULTS

We found that the probability of seclusion was lower when nursing teams with at least 75% males were on duty, compared to female only teams, odds ratio (OR = 0.283; 95% CrI 0.046-0.811). We observed a trend indicating that teams scoring higher on the openness personality dimension secluded less, (OR = 0.636; 95% CrI 0.292-1.156).

DISCUSSION

Higher proportions of male nurses in teams on duty were associated with lower likelihood of seclusion. We found an indication that teams with a higher mean openness personality trait tended to seclude less. These findings, if causal, could serve as an incentive to reflect on staff mix if circumstances demand better prevention of seclusion.

Risk factors for psychotic relapse in chronic schizophrenia after dose-reduction or discontinuation of antipsychotics. A systematic review and meta-analysis

Introduction

Patients are often treated with high doses or combinations of antipsychotics, which may hamper recovery. Dose-reduction (DR) or discontinuation of antipsychotic medication in chronic patients carries the risk of psychotic relapse.

Objectives

To identify risk factors of psychotic relapse after DR or discontinuation, we (i) determined the rate of relapse after DR or discontinuation in patients with chronic schizophrenia, and (ii) assessed risk factors for psychotic relapse.

Methods

From studies on dose-reduction from January 1950 through June 2019 we calculated event rates per person-years including 95% confidence intervals. We extracted: (1) patient characteristics (age, percentage of male subjects, setting, duration of illness), (2) dose-reduction/discontinuation characteristics (start-dose, end-dose, dose-reduction in milligrams and percentage of start-dose, time-period of dose-reduction), (3) follow-up characteristics (time after dose-reduction), and (4) study characteristics (blinding, publication-year and relapse definition).

Results

46 unique cohorts, presenting 1677 patients in which doses were reduced/discontinued were included in meta-analysis. We found an overall event rate per person-years on psychotic relapse of 0.55 (CI95% 0.46-0.65;p<0.0001;I2 =79). Most robust event rates for psychotic relapse were seen for discontinuing antipsychotics, and if not discontinuing, dose-reduction till under 5mg haloperidol equivalents daily (HE). Abrupt reduction yielded higher rates than gradual reduction. During short follow-up time more relapses occurred than in studies with long follow-up time.

Conclusions

In patients with chronic schizophrenia discontinuing, and to a lesser extent DR till end-dose<5mgHE, patients who reduce doses abrupt, inpatients, and patients with a short duration of illness carry highest relapse risk. Most relapses occur during the first half year after DR.

Growing up with a pacemaker

 

Indications for pacemakers in young children are rare. In our university hospitals, on average 8 patients/year received a pacemaker in this age group between 2001 and 2015 for a drainage area of 4 million people. In 28% this is for congenital heart block and in 69% for bradycardia after surgical repair of congenital structural heart disease. Despite the extensive range of patient information about pacemakers, we felt a need for targeted material for young patients, who have an indication for a pacemaker, and their family. We wanted to provide this information to this specific group in a creative, accessible and clear way, taking into account their way of thinking. In addition, we also wanted to involve the near and wider environment of the child (family, school, sports club, etc.), and to provide them with tools to better deal with the medical situation.

For the little children we created a stop-motion story in which sinus node disease (SND) and AV block (AVB) are represented by a character: Bob Sparkle (Bob Prikkel in Dutch for SND) and Boris Sparkle (Boris Prikkel for AVB). Bob and Boris get into trouble and are rescued by Pacemaker, the third character in the films. This story is preceded by an informative part for parents and older children in which the normal functioning and conduction system of the heart is explained. Based on the films, we designed customized information brochures for +12 and −12 year-old children. The brochure for +12 includes the same information as the adult version, but in more comprehensible language. The figures Bob and Boris were added throughout this brochure as a sort of common thread. For the −12 group we designed 2 reading books in which the story of Bob / Boris is told. The −12 booklets can be included in a cover along with the +12 brochure, so that the parents can estimate for themselves what is most suitable for their child.

We conducted a survey on how this information was received by patients and their relatives.61 families were contacted by e-mail to fill in a questionnaire using a 5-point Likert Scale. The survey assessed the following three items: graphic design, intelligibility and aid in coping with illness. Currently we have received answers from 12 patients or their relatives.

Overall, there was a positive reception of the different informative tools (agree or strongly agree: booklets: 92.6%; brochure: 77.2%; films: 81.3%).

Funding Acknowledgement

Type of funding source: None

Influence of nursing staff attitudes and characteristics on the use of coercive measures in acute mental health services-A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Aggressive behaviour is a major problem in clinical practice of mental health care and can result in the use of coercive measures. Coercive measures are dangerous for psychiatric patients and international mental healthcare works on the elimination of these interventions. There is no previous review that summarizes the attitude of nursing staff towards coercive measures and the influence of nursing staff characteristics on attitude towards and the use of coercive measures. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The attitude of nurses shifted from a therapeutic paradigm (coercive measures have positive effects on patients) to a safety paradigm (coercive measures are undesirable, but necessary for the wards' safety). Nurses express the need for less coercive interventions to prevent seclusion and restraint, but their perception of intrusiveness is influenced by how often they use specific coercive measures. The knowledge from scientific literature on the influence of nursing staff on coercive measures is highly inconclusive, although the feeling of safety of nurses might prove to be promising for further research. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is need for increased attention specifically for the feeling of safety of nurses, to better equip nurses for their difficult work on acute mental health wards. ABSTRACT: Introduction The use of coercive measures generally has negative effects on patients. To help prevent its use, professionals need insight into what nurses believe about coercion and which staff determinants may influence its application. There is need for an integrated review on both attitude and influence of nurses on the use of coercion. Aim To summarize literature concerning attitude of nurses towards coercive measures and the influence of staff characteristics on the use of coercive measures. Method Systematic review. Results The attitude of nurses changed during the last two decades from a therapeutic to a safety paradigm. Nurses currently view coercive measures as undesirable, but necessary to deal with aggression. Nurses express the need for less intrusive interventions, although familiarity probably influences its perceived intrusiveness. Literature on the relation between staff characteristics and coercive measures is inconclusive. Discussion Nurses perceive coercive measures as unwanted but still necessary to maintain safety on psychiatric wards. Focussing on the determinants of perception of safety might be a promising direction for future research. Implications for practice Mental health care could improve the focus on the constructs of perceived safety and familiarity with alternative interventions to protect patients from unnecessary use of coercive interventions.

Risk Factors for Psychotic Relapse After Dose Reduction or Discontinuation of Antipsychotics in Patients With Chronic Schizophrenia: A Systematic Review and Meta-analysis

High doses of antipsychotics in patients with chronic schizophrenia might lead to more severe side effects and possibly hamper recovery, but dose reduction carries the risk of psychotic relapse. It would be helpful to establish risk factors for relapse during dose reduction. We systematically searched MEDLINE, EMBASE, and PsycINFO from January 1950 through June 2019 and reviewed studies that reported on relapse rates (event rates [ERs]) after dose reduction or discontinuation of antipsychotics in cohorts of patients with chronic schizophrenia. We calculated ERs (with 95% CIs) per person-year and sought to identify potential risk factors, such as patient characteristics, dose reduction/discontinuation characteristics, and study characteristics. Of 165 publications, 40 describing dose reduction or discontinuation in 46 cohorts (1677 patients) were included. The pooled ER for psychotic relapse was 0.55 (95% CI 0.46–0.65) per person-year. The ER was significantly higher in inpatients, patients with a shorter duration of illness, patients in whom antipsychotics were discontinued or in whom the dose was reduced to less than 5 mg haloperidol equivalent, studies with a short follow-up or published before 1990, and studies in which relapse was based on clinical judgment (ie, rating scales were not used). Clinicians should consider several robust risk factors for psychotic relapse in case of dose reduction in chronic schizophrenia.

Stressful experiences affect the course of co-occurring obsessive-compulsive and psychotic symptoms: A focus on within-subject processes

OBJECTIVE

Obsessive-compulsive symptoms (OCS) frequently occur in patients with psychotic disorders and are associated with higher burden and poorer prognosis. This study prospectively investigated the effect of stressful experiences on the severity of OCS and co-occurring psychotic and affective symptoms, with a focus on within-subject processes.

METHOD

Monthly assessments over 6 months in patients with a psychotic disorder (n = 56) and unaffected siblings (n = 49) resulted in 309 and 277 observations, respectively. Linear mixed-effects models investigated the disaggregated effects of within-subject changes and between-subject differences in stressful events on OCS, positive, negative and depressive symptoms. Subsequently, moderating effects of coping strategies and dysfunctional metacognitive beliefs were assessed. Mediation analyses investigated direct and indirect effects of stressful events on OCS four weeks later.

RESULTS

Stressful experiences were associated with severity in almost all symptom domains on the between- and within-subject levels. Dysfunctional coping and metacognitive beliefs moderated these associations. Patients and siblings with a tendency for passive coping showed higher within-subject increase in depressive symptoms, whereas passive coping and dysfunctional beliefs moderated the association between stressful experiences and severity of positive symptoms and OCS on the between-subject level. Effects of stressful experiences on OCS four weeks later were partially mediated by depressive and positive symptoms in patients and siblings.

CONCLUSIONS

Findings suggest that severity and variability of co-occurring psychopathology can partly be explained by recent stressful events and the way individuals cope with these experiences. The implementation of coping-oriented interventions could possibly help to prevent development and/or aggravation of co-occurring symptom severity.

Functional outcome of implant removal following fracture fixation below the level of the knee: a prospective cohort study

AIMS

The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee.

PATIENTS AND METHODS

All adult patients (18 to 75 years) undergoing IR after fracture fixation below the level of the knee between November 2014 and September 2016 were included as part of the WIFI (Wound Infections Following Implant Removal Below the Knee) trial, performed in 17 teaching hospitals and two university hospitals in The Netherlands. In this multicentre prospective cohort, the primary outcome was the difference in functional status before and after IR, measured by the Lower Extremity Functional Scale (LEFS), with a minimal clinically important difference of nine points.

RESULTS

A total of 179 patients were included with a median age of 50 years (interquartile range (IQR) 37 to 60), of whom 71 patients (39.7%) were male. With a median score of 60 before IR (IQR 45 to 72) and 66 after IR (IQR 51 to 76) on the LEFS, there was a statistically significant improvement in functional outcome (p < 0 .001). A total of 31 surgical site infections (17.3%) occurred.

CONCLUSION

Although IR led to a statistically significant improvement of functional outcome, the minimal clinically important difference was not reached. In conclusion, this study shows that IR does not result in a clinically relevant improvement in functional outcome. These results, in combination with the high complication rate, highlight the importance of carefully reviewing the indication for IR. Cite this article: Bone Joint J 2019;101-B:447-453.

Non- or Minimally Displaced Distal Radial Fractures in Adult Patients: Three Weeks versus Five Weeks of Cast Immobilization-A Randomized Controlled Trial

Background  Patients with non- or minimally displaced distal radial fractures, that do not need repositioning, are mostly treated by a short-arm cast for a period of 4 to 6 weeks. A shorter period of immobilization may lead to a better functional outcome. Purpose  We conducted a randomized controlled trial to evaluate whether the duration of cast immobilization for patients with non- or minimally displaced distal radial fractures can be safely shortened toward 3 weeks. Materials and Methods  The primary outcomes were patient-reported outcomes measured by the Patient-Related Wrist Evaluation (PRWE) and Quick Disability of Arm, Shoulder and Hand (QuickDASH) score after 1-year follow-up. Secondary outcome measures were: PRWE and QuickDASH earlier in follow-up, pain (Visual Analog Scale), and complications like secondary displacement. Results  Seventy-two patients (male/female, 23/49; median age, 55 years) were included and randomized. Sixty-five patients completed the 1-year follow-up. After 1-year follow up, patients in the 3 weeks immobilization group had significantly better PRWE (5.0 vs. 8.8 points, p  = 0.045) and QuickDASH scores (0.0 vs. 12.5, p  = 0.026). Secondary displacement occurred once in each group. Pain did not differ between groups ( p  = 0.46). Conclusion  Shortening the period of immobilization in adult patients with a non- or minimally displaced distal radial fractures seems to lead to equal patient-reported outcomes for both the cast immobilization groups. Also, there are no negative side effects of a shorter period of cast immobilization. Therefore, we recommend a period of 3 weeks of immobilization in patients with distal radial fractures that do not need repositioning.

Smoking, symptoms, and quality of life in patients with psychosis, siblings, and healthy controls: a prospective, longitudinal cohort study

BACKGROUND

The self-medication hypothesis postulates that the high prevalence of smoking in patients with psychosis can be explained by the ameliorating effect of smoking on symptoms. However, there are few large prospective studies testing this hypothesis. We aimed to examine the multi-cross-sectional and prospective associations of changes in smoking behaviour with symptoms and quality of life.

METHODS

In this prospective cohort study we recruited patients with a non-affective psychosis (n=1094), unaffected siblings (n=1047), and healthy controls (n=579). Patients aged between 16 and 50 years and diagnosed with a non-affective psychosis according to DSM-IV were recruited by clinicians from four university medical centres and 36 associated mental health-care institutions in the Netherlands and Belgium between Jan 13, 2004, and March 6, 2014. Smoking status and number of cigarettes per day were assessed at baseline, and at 3-year and 6-year follow-up using the Composite International Diagnostic Interview (CIDI). Symptom frequency was self-rated with the Community Assessment of Psychotic Experience (CAPE), and quality of life was assessed by the WHO Quality of Life (WHOQOL) schedule. Multiple linear mixed-effects regression analyses were done accounting for multiple confounders.

FINDINGS

At baseline, 729 (67%) of 1094 of patients smoked (mean 17·5 cigarettes per day, SD 8·8) compared with 401 (38%) of 1047 siblings and 145 (25%) of 579 healthy controls. Multi-cross-sectional results of linear mixed-effects analyses showed that smoking in patients and siblings was associated with more frequent positive symptoms (estimate 0·14, SE 0·02, p<0·0001 in patients; 0·03, 0·01, p=0·0019 in siblings), negative symptoms (0·15, 0·03, p<0·0001 in patients; 0·09, 0·02, p<0·0001 in siblings), and depressive symptoms (0·12, 0·03 p<0·0001 in patients; 0·08, 0·02 p<0·0001 in siblings) and lower quality of life (-0·59, 0·11, p<0·0001 in patients; -0·31, 0·09, p=0·0002 in siblings) than non-smokers. In controls, smoking was associated with significantly higher frequency of subclinical positive symptoms (0·03, 0·01, p=0·0016) and depressive symptoms (0·05, 0·03, p=0·0432) than in participants who did not smoke. Patients who started to smoke during follow-up showed a significant increase in self-reported symptoms, particularly positive symptoms (0·161, 0·077, p=0·0381), whereas smoking cessation was not associated with changes in symptoms or quality of life compared with those who showed no change in smoking behaviour. Similar results were obtained for the changes in the number of cigarettes smoked.

INTERPRETATION

Our findings do not empirically support the self-medication hypothesis. The absence of long-term symptomatic relief from smoking should encourage clinicians to help patients with psychosis to quit smoking.

FUNDING

Dutch Health Research Council, Lundbeck, AstraZeneca, Eli Lilly, Janssen Cilag, Academic Psychiatric Center of the Academic Medical Center, GGZ inGeest, Arkin, Dijk en Duin, GGZ Rivierduinen, Erasmus Medical Center Amsterdam, GGZ Noord Holland Noord, University Medical Center Groningen, Lentis, GGZ Friesland, GGZ Drenthe, Dimence, Mediant, GGNet Warnsveld, Yulius Dordrecht, Parnassia Psycho-medical Center, Maastricht University Medical Center, GGzE, GGZ Breburg, GGZ Oost-Brabant, Vincent van Gogh voor Geestelijke Gezondheid, Mondriaan, Virenze riagg, Zuyderland GGZ, MET GGZ, Universitair Centrum Sint-Jozef Kortenberg, CAPRI University of Antwerp, PC Ziekeren Sint-Truiden, PZ Sancta Maria Sint-Truiden, GGZ Overpelt, OPZ Rekem, University Medical Center Utrecht, Altrecht, GGZ Centraal, and Delta.

Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial)

BACKGROUND

Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome.

DESIGN

This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up.

DISCUSSION

If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs.

TRIAL REGISTRATION

This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov ( NCT02896998 ) on July 15th 2016.

Antipsychotic medication and long-term mortality risk in patients with schizophrenia; a systematic review and meta-analysis

Patients with schizophrenia have a higher mortality risk than patients suffering from any other psychiatric disorder. Previous research is inconclusive regarding the association of antipsychotic treatment with long-term mortality risk. To this aim, we systematically reviewed the literature and performed a meta-analysis on the relationship between long-term mortality and exposure to antipsychotic medication in patients with schizophrenia. The objectives were to (i) determine long-term mortality rates in patients with schizophrenia using any antipsychotic medication; (ii) compare these with mortality rates of patients using no antipsychotics; (iii) explore the relationship between cumulative exposure and mortality; and (iv) assess causes of death. We systematically searched the EMBASE, MEDLINE and PsycINFO databases for studies that reported on mortality and antipsychotic medication and that included adults with schizophrenia using a follow-up design of more than 1 year. A total of 20 studies fulfilled our inclusion criteria. These studies reported 23,353 deaths during 821,347 patient years in 133,929 unique patients. Mortality rates varied widely per study. Meta-analysis on a subgroup of four studies showed a consistent trend of an increased long-term mortality risk in schizophrenia patients who did not use antipsychotic medication during follow-up. We found a pooled risk ratio of 0.57 (LL:0.46 UL:0.76 p value <0.001) favouring any exposure to antipsychotics. Statiscal heterogeneity was found to be high (Q = 39.31, I 2 = 92.37%, p value < 0.001). Reasons for the increased risk of death for patients with schizophrenia without antipsychotic medication require further research. Prospective validation studies, uniform measures of antipsychotic exposure and classified causes of death are commendable.

Rare complication of pediatric inguinal hernia repair: case report of transection of the femoral vein

INTRODUCTION

The incidence of pediatric inguinal hernias ranges up to 13 %. Currently, many different techniques are being used to successfully perform herniotomy and risks of complications are minor.

CASE REPORT

This case report describes a 4-year-old male patient who underwent routine herniotomy during which the femoral vein was mistaken for hernial sac and thereby the femoral vein was transected. Postoperative vascular duplex ultrasonography revealed a complete transection of the right common femoral vein. Multiple treatment options such as venous reconstruction and interposition were considered, but a conservative treatment was chosen. At 6 months postoperative, the patient only shows minor complaints. Long-term results remain uncertain, especially since no similar case has previously been described in the current literature.

Trajectory Planning for the Walking Biped “Lucy”

A real-time joint trajectory generator for planar walking bipeds is proposed. In the near future this trajectory planner will be implemented on the robot “Lucy”, which is actuated by pleated pneumatic artificial muscles. The trajectory planner generates dynamically stable motion patterns by using a set of objective locomotion parameters as its input, and by tuning and exploiting the natural upper body dynamics. The latter can be determined and manipulated by using the angular momentum equation. Basically, trajectories for hip and swing foot motion are generated, which guarantee that the objective locomotion parameters attain certain prescribed values. Additionally, the hip trajectories are slightly modified such that the upper body motion is steered naturally, meaning that it requires practically no actuation. This has the advantage that the upper body actuation hardly influences the position of the Zero Moment Point. The effectiveness of the strategy developed is demonstrated by simulation results. A first simulation is performed under the assumption of perfect tracking by the controllers of the different actuators. This allows one to verify the effectiveness of the trajectory planner and to evaluate the postural stability. A second simulation is performed while taking the control architecture of the real robot into account. In order to have a more realistic simulation the proposed control architecture is evaluated with a full hybrid dynamic simulation model of the biped “Lucy”. This simulator combines the dynamical behaviour of the robot with the thermodynamical effects that take place in the muscle-valves actuation system. The observed hardware limitations of the real robot and expected model errors are taken into account in order to give a realistic qualitative evaluation of the control performance and to test the robustness.

Minimizing right ventricular pacing in pacemaker patients with intact and compromised atrioventricular conduction : Results from the EVITA Trial

INTRODUCTION

Unnecessary ventricular pacing is associated with increased morbidity and mortality. Over the years different algorithms have been developed to reduce right ventricular pacing.

OBJECTIVES

Goal of the present study was to test the efficacy of the ventricular intrinsic preference (VIP) algorithm in patients with atrioventricular intact (AVi) and atrioventricular compromised (AVc) AV-conduction.

METHODS

Evaluation of VIP feature in pacemaker patients (EVITA) was a multicenter, prospective, randomized trial (Trials.gov Identifier: NCT00366158). In total, 389 patients were randomized to AVc group: n = 140/132 VIP OFF/VIP On, AVi group: n = 54/63 VIP OFF/VIP ON). One-month post-implantation AV conduction testing (AVc: PR/AR interval > 210 ms) was performed. Follow-up visits occurred 6 and 12 months after DDD-pacemaker implantation.

RESULTS

In AVi and AVc-patients initiation of the VIP feature significantly reduced incidence of ventricular pacing (AVi: 53 ± 38 vs. 9 ± 21%, p = 0.0001; AVc: 79 ± 31 vs. 28 ± 35%, p = 0.0001). DDD-pacemaker implantation per se significantly reduced incidence of AF in VIP ON (AVi 27 vs. 0%, p < 0.0001; AVc 29 vs. 3%, p < 0.0001) and VIP OFF patients (AVi 43 vs. 4%, p < 0.0001; AVc 33 vs. 3, p < 0.0001), without significant differences between VIP ON and OFF groups (p > 0.05). In the AVc group activation of VIP significantly reduced incidence of adverse events (AE). All-cause mortality was not significantly different in VIP ON (n = 5) and VIP OFF (n = 4, p > 0.05) patients.

CONCLUSION

AV search hysteresis (VIP) markedly reduces ventricular pacing both in patients with normal AV conduction and in patients with prolonged PR interval or intermittent AV block.

Treatment of rectal war wounds

Treatment strategies for penetrating rectal injuries (PRI) in civilian settings are still not uniformly agreed, in part since high-energy transfer PRI, such as is frequently seen in military settings, are not taken into account. Here, we describe three cases of PRI, treated in a deployed combat environment, and outline the management strategies successfully employed. We also discuss the literature regarding PRI management. Where there is a major soft tissue component, repetitive debridement and vacuum therapy is useful. A loop or end colostomy should be used, depending on the degree of damage to the anal sphincter complex.

Exon-level expression analyses identify MYCN and NTRK1 as major determinants of alternative exon usage and robustly predict primary neuroblastoma outcome

Background:

Using mRNA expression-derived signatures as predictors of individual patient outcome has been a goal ever since the introduction of microarrays. Here, we addressed whether analyses of tumour mRNA at the exon level can improve on the predictive power and classification accuracy of gene-based expression profiles using neuroblastoma as a model.

Methods:

In a patient cohort comprising 113 primary neuroblastoma specimens expression profiling using exon-level analyses was performed to define predictive signatures using various machine-learning techniques. Alternative transcript use was calculated from relative exon expression. Validation of alternative transcripts was achieved using qPCR- and cell-based approaches.

Results:

Both predictors derived from the gene or the exon levels resulted in prediction accuracies >80% for both event-free and overall survival and proved as independent prognostic markers in multivariate analyses. Alternative transcript use was most prominently linked to the amplification status of the MYCN oncogene, expression of the TrkA/NTRK1 neurotrophin receptor and survival.

Conclusion:

As exon level-based prediction yields comparable, but not significantly better, prediction accuracy than gene expression-based predictors, gene-based assays seem to be sufficiently precise for predicting outcome of neuroblastoma patients. However, exon-level analyses provide added knowledge by identifying alternative transcript use, which should deepen the understanding of neuroblastoma biology.

The influence of mechanical bowel preparation in elective colorectal surgery for diverticulitis

Background

Mechanical bowel preparation (MBP) has been shown to have no influence on the incidence of anastomotic leakage in overall colorectal surgery. The role of MBP in elective surgery in combination with an inflammatory component such as diverticulitis is yet unclear. This study evaluates the effects of MBP on anastomotic leakage and other septic complications in 190 patients who underwent elective surgery for colonic diverticulitis.

Methods

A subgroup analysis was performed in a prior multicenter (13 hospitals) randomized trial comparing clinical outcome of MBP versus no MBP in elective colorectal surgery. Primary endpoint was the occurrence of anastomotic leakage in patients operated on for diverticulitis, and secondary endpoints were septic complications and mortality.

Results

Out of a total of 1,354 patients, 190 underwent elective colorectal surgery (resection with primary anastomosis) for (recurrent or stenotic) diverticulitis. One hundred and three patients underwent MBP prior to surgery and 87 did not. Anastomotic leakage occurred in 7.8 % of patients treated with MBP and in 5.7 % of patients not treated with MBP (p = 0.79). There were no significant differences between the groups in septic complications and mortality.

Conclusion

Mechanical bowel preparation has no influence on the incidence of anastomotic leakage, or other septic complications, and may be safely omitted in case of elective colorectal surgery for diverticulitis.

Management of penetrating neck injuries

BACKGROUND

Routine surgical exploration after penetrating neck injury (PNI) leads to a large number of negative neck explorations and potential iatrogenic injury. Selective non-operative management (SNOM) of PNI is gaining favour. The present study assessed the feasibility of SNOM in PNI.

METHODS

Seventy-seven consecutive patients with PNI presenting to a tertiary trauma centre were included in this prospective study from September 2009 to December 2009. All patients were managed according to Advanced Trauma Life Support guidelines, and either underwent emergency surgery or were managed without surgery, based on clinical presentation and/or outcome of special investigations.

RESULTS

Eight patients (10 per cent) were haemodynamically unstable at presentation. Foley catheter balloon tamponade (FCBT) was successful in stopping active bleeding in six of these patients, and diagnostic angiography revealed an arterial injury in five. The remaining 69 patients were managed using SNOM. Angiography or computed tomography was done in 41 patients (53 per cent), and showed arterial injury in 15. These injuries were treated surgically (7 patients), radiologically (stenting in 3) or conservatively. Contrast swallow and/or endoscopy were performed in 37 patients (48 per cent) for suspected oesophageal injury, but yielded no positive results. During follow-up no missed injuries were detected.

CONCLUSION

FCBT was useful in patients with PNI and active bleeding. Stable patients should undergo additional investigation based on clinical findings only.

Long-term survival after perforated diverticulitis

AIM

Short-term survival after emergency surgery for perforated diverticulitis is poor. Less is known about long-term survival. The aims of this study were to evaluate long-term survival after discharge from hospital and to identify factors associated with prognosis.

METHOD

All patients who underwent emergency surgery for perforated diverticulitis in five hospitals in Rotterdam, the Netherlands, between 1990 and 2005, were included. The association between type of surgery (Hartmann's procedure or primary anastomosis) and long-term survival was analysed using multivariate Cox regression analysis, taking into account age American Society of Anesthesiology (ASA) classification, Hinchey score, Mannheim Peritonitis Index (MPI) and surgeon's experience. In addition, survival of the patients was compared with that of the matched general Dutch population.

RESULTS

Of 340 patients included in the study, 250 were discharged alive from hospital. The overall 5-year survival was 53%. Survival was significantly impaired compared with the expected matched gender-, age- and calendar time-specific survival. Overall survival was significantly related to age and ASA classification. Hinchey score, MPI, number of re-interventions, the surgeon's experience and type of procedure did not influence long-term survival, although a trend was found for Hartmann's procedure to be a risk factor for poorer survival compared with primary anastomosis (hazard ratio for mortality: 1.88; 95% confidence interval, 0.96-3.67; P = 0.07).

CONCLUSION

Long-term survival of patients after perforated diverticulitis is limited and mainly caused by the poor general condition of the patients, rather than by the severity of the primary disease or calendar-time and type of procedure.

Reversal of Hartmann's procedure after perforated diverticulitis through the stomal side without additional incisions: the SIR procedure

AIMS

Reversal of Hartmann's procedure (HP) is a complex operation and only performed in 50-60% of the patients. Stomal incision reversal (SIR), a new minimally invasive procedure for HP reversal, was assessed and compared to the standard surgical approach.

METHODS

16 patients who had undergone HP for perforated diverticulitis underwent HP reversal by SIR. The only incision in SIR is the one to release the end colostomy. Intra-abdominal adhesiolysis is done manually. A stapled end-to-end colorectal anastomosis is created. The 16 patients who underwent SIR were compared with 32 control patients who were matched according to gender, age, American Society of Anesthesiologists (ASA) classification and Hinchey stage.

RESULTS

The operation time was shorter after SIR than after reversal by laparotomy [75 min (58-208) vs. 141 min (85-276); p < 0.001]. Patients after SIR had a shorter hospital stay than patients after laparotomy [4 days (2-22) vs. 9 days (4-64); p < 0.001]. The numbers of total postoperative surgical complications (early and late) were not different (p = 0.13). The anastomotic leakage rate was similar in both groups (6%). The conversion rate in the SIR group was 19% (n = 3).

CONCLUSION

SIR compared favorably with HP reversal by laparotomy in terms of operation time and hospital stay, without increasing the number of postoperative complications.