An international research agenda for clozapine-resistant schizophrenia

Treatment-resistant symptoms occur in about a third of patients with schizophrenia and are associated with a substantial reduction in their quality of life. The development of new treatment options for clozapine-resistant schizophrenia constitutes a crucial, unmet need in psychiatry. Additionally, an overview of past and possible future research avenues to optimise the early detection, diagnosis, and management of clozapine-resistant schizophrenia is unavailable. In this Health Policy, we discuss the ongoing challenges associated with clozapine-resistant schizophrenia faced by patients and health-care providers worldwide to improve the understanding of this condition. We then revisit several clozapine guidelines, the diagnostic tests and treatment options for clozapine-resistant schizophrenia, and currently applied research approaches in clozapine-resistant schizophrenia. We also suggest methodologies and targets for future research, divided into innovative nosology-oriented field trials (eg, examining dimensional symptom staging), translational approaches (eg, genetics), epidemiological research (eg, real-world studies), and interventional studies (eg, non-traditional trial designs incorporating lived experiences and caregivers' perspectives). Finally, we note that low-income and middle-income countries are under-represented in studies on clozapine-resistant schizophrenia and propose an agenda to guide multinational research on the cause and treatment of clozapine-resistant schizophrenia. We hope that this research agenda will empower better global representation of patients living with clozapine-resistant schizophrenia and ultimately improve their functional outcomes and quality of life.

Understanding the relationship between patient language and outcomes in internet-enabled cognitive behavioural therapy: A deep learning approach to automatic coding of session transcripts

Objective: Understanding patient responses to psychotherapy is important in developing effective interventions. However, coding patient language is a resource-intensive exercise and difficult to perform at scale. Our aim was to develop a deep learning model to automatically identify patient utterances during text-based internet-enabled Cognitive Behavioural Therapy and to determine the association between utterances and clinical outcomes. Method: Using 340 manually annotated transcripts we trained a deep learning model to categorize patient utterances into one or more of five categories. The model was used to automatically code patient utterances from our entire data set of transcripts (∼34,000 patients), and logistic regression analyses used to determine the association between both reliable improvement and engagement, and patient responses. Results: Our model reached human-level agreement on three of the five patient categories. Regression analyses revealed that increased counter change-talk (movement away from change) was associated with lower odds of both reliable improvement and engagement, while increased change-talk (movement towards change or self-exploration) was associated with increased odds of improvement and engagement. Conclusions: Deep learning provides an effective means of automatically coding patient utterances at scale. This approach enables the development of a data-driven understanding of the relationship between therapist and patient during therapy.

Caregiver perceptions about the impact of caring for patients with wet age-related macular degeneration

PURPOSE

Caregivers of older persons with eye disease, namely age-related macular degeneration (AMD), have been reported to have a higher than expected distress. Very few studies have explored caregiver perceptions as to what is important when providing care. The aim of this study was to explore the perceptions of caregivers of persons with neovascular AMD in relation to the most important aspects of caring, as described in extended answers to self-administered survey questions.

METHODS

A cross-sectional, self-administered survey of 643 caregivers of people with neovascular AMD, comprising 27 closed-response questions and 2 open ended questions. The latter were analysed as part of this study utilising and 'inductive' Grounded Theory approach.

RESULTS

Six-hundred and forty-three caregiver responses to 2 open ended questions were analysed using an inductive approach and sorted into thematic networks. Three discrete categories arose: The Impact of Caring; Injections and Information and Activities of Daily Living.

CONCLUSIONS

Most caregivers were family caregivers and were found to be compassionate and self-sacrificing. They accepted additional responsibility whilst providing an encouraging environment for their care recipient. As a result, they experience distress and consider their own needs as secondary. Very few seek or receive respite and this added burden can have a negative impact upon the relationship between caregiver and care recipient.

The prognostic value of tumour regression grade following neoadjuvant chemoradiation therapy for rectal cancer

AIM

To date, there is no uniform consensus on whether tumour regression grade (TRG) is predictive of outcome in rectal cancer. Furthermore, the lack of standardization of TRG grading is a major source of variability in published studies. The aim of this study was to evaluate the prognostic impact of TRG in a cohort of patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation therapy (CRT). In addition to the Mandard TRG, we utilized four TRG systems modified from the Mandard TRG system and applied them to the cohort to assess which TRG system is most informative.

METHOD

One-hundred and fifty-three patients with a T3/T4 and/or a node-positive rectal cancer underwent neoadjuvant 5-fluorouracil-based CRT followed by surgical resection.

RESULTS

Thirty-six (23.5%) patients achieving complete pathological response (ypCR) had a 5-year disease-free survival (DFS) rate of 100% compared with a DFS rate of 74% for 117 (76.5%) patients without ypCR (P = 0.003). The Royal College of Pathologists (RCPath) TRG best condenses the Mandard five-point TRG by stratifying patients into three groups with distinct 5-year DFS rates of 100%, 86% and 67%, respectively (P = 0.001). In multivariate analysis, pathological nodal status and circumferential resection margin (CRM) status, but not TRG, remained significant predictors of DFS (P = 0.002, P = 0.035 and P = 0.310, respectively).

CONCLUSION

Our findings support the notion that ypCR status, nodal status after neoadjuvant CRT and CRM status, but not TRG, are predictors of long-term survival in patients with locally advanced rectal cancer.

Prognostic and therapeutic relevance of FLIP and procaspase-8 overexpression in non-small cell lung cancer

Non-small cell lung carcinoma remains by far the leading cause of cancer-related deaths worldwide. Overexpression of FLIP, which blocks the extrinsic apoptotic pathway by inhibiting caspase-8 activation, has been identified in various cancers. We investigated FLIP and procaspase-8 expression in NSCLC and the effect of HDAC inhibitors on FLIP expression, activation of caspase-8 and drug resistance in NSCLC and normal lung cell line models. Immunohistochemical analysis of cytoplasmic and nuclear FLIP and procaspase-8 protein expression was carried out using a novel digital pathology approach. Both FLIP and procaspase-8 were found to be significantly overexpressed in tumours, and importantly, high cytoplasmic expression of FLIP significantly correlated with shorter overall survival. Treatment with HDAC inhibitors targeting HDAC1-3 downregulated FLIP expression predominantly via post-transcriptional mechanisms, and this resulted in death receptor- and caspase-8-dependent apoptosis in NSCLC cells, but not normal lung cells. In addition, HDAC inhibitors synergized with TRAIL and cisplatin in NSCLC cells in a FLIP- and caspase-8-dependent manner. Thus, FLIP and procaspase-8 are overexpressed in NSCLC, and high cytoplasmic FLIP expression is indicative of poor prognosis. Targeting high FLIP expression using HDAC1–3 selective inhibitors such as entinostat to exploit high procaspase-8 expression in NSCLC has promising therapeutic potential, particularly when used in combination with TRAIL receptor-targeted agents.

PEA3/ETV4-related transcription factors coupled with active ERK signalling are associated with poor prognosis in gastric adenocarcinoma

Background:

Transcription factors often play important roles in tumourigenesis. Members of the PEA3 subfamily of ETS-domain transcription factors fulfil such a role and have been associated with tumour metastasis in several different cancers. Moreover, the activity of the PEA3 subfamily transcription factors is potentiated by Ras-ERK pathway signalling, which is itself often deregulated in tumour cells.

Methods:

Immunohistochemical patterns of PEA3 expression and active ERK signalling were analysed and mRNA expression levels of PEA3, ER81, MMP-1 and MMP-7 were determined in gastric adenocarcinoma samples.

Results:

Here, we have studied the expression of the PEA3 subfamily members PEA3/ETV4 and ER81/ETV1 in gastric adenocarcinomas. PEA3 is upregulated at the protein level in gastric adenocarcinomas and both PEA3/ETV4 and ER81/ETV1 are upregulated at the mRNA level in gastric adenocarcinoma tissues. This increased expression correlates with the expression of a target gene associated with metastasis, MMP-1. Enhanced ERK signalling is also more prevalent in late-stage gastric adenocarcinomas, and the co-association of ERK signalling and PEA3 expression also occurs in late-stage gastric adenocarcinomas. Furthermore, the co-association of ERK signalling and PEA3 expression correlates with decreased survival rates.

Conclusions:

This study shows that members of the PEA3 subfamily of transcription factors are upregulated in gastric adenocarcinomas and that the simultaneous upregulation of PEA3 expression and ERK pathway signalling is indicative of late-stage disease and a poor survival prognosis.

Impact of dose adjustment for normal eating in Australia (OzDAFNE) on subjective wellbeing, coping resources and negative affects in adults with type 1 diabetes: a prospective comparison study

AIM

This prospective study examined the impact of a structured education program (OzDAFNE) on subjective wellbeing, coping resources, and negative affects in adults with type 1 diabetes. Participants completing the OzDAFNE program were compared to those using continuous subcutaneous insulin (CSII) and multiple daily injections (MDI) over the same time period.

METHODS

Participants in the OzDAFNE group (N=144) were recruited from diabetes centres throughout Australia. The comparison groups were recruited from Diabetes Australia-Victoria's membership database and comprised 383 people using MDI and 64 people using CSII. All participants completed self-report questionnaires at baseline and 12-months later. Additional assessments for OzDAFNE participants were conducted at the end of the education program and at three and six-months following the training.

RESULTS

The results demonstrated that participants completing the OzDAFNE program experienced improved subjective wellbeing (p<.01), a greater sense of mastery and control in managing their diabetes (p<.001), and reduced diabetes-related distress (p<.001) compared to the CSII and MDI groups. However, the CSII group recorded a significant drop in self-esteem (p<.001) over the duration of the study.

CONCLUSIONS/INTERPRETATIONS

The OzDAFNE program provides a powerful mastery experience for participants, positively influencing subjective wellbeing and diabetes-related distress.

Human IgG antibody profiles differentiate between symptomatic patients with and without colorectal cancer

OBJECTIVE

Patients with cancer have antibodies against tumour antigens. Characterising the antibody repertoire may provide insights into aberrant cellular mechanisms in cancer development, ultimately leading to novel diagnostic or therapeutic targets. The aim of this study was to characterise the antibody profiles in patients whose symptoms warranted colonoscopy, to see if there was a difference in patients with and without colorectal cancer.

METHODS

Patients were recruited from a colonoscopy clinic. Individual serum samples from 43 patients with colorectal cancer and 40 patients with no cancer on colonoscopy were profiled on a 37 830 clone recombinant human protein array. Antigen expression was evaluated by quantitative reverse transcription-PCR and by immunohistochemistry on tissue microarrays.

RESULTS

Using a sex- and age-matched training set, 18 antigens associated with cancer and 4 associated with the absence of cancer (p<0.05) were identified and confirmed. To investigate the mechanisms triggering antibody responses to these antigens, antigen expression was examined in normal colorectal mucosa and colorectal carcinoma of the same patients. The identified antigens showed cellular accumulation (p53), aberrant cellular expression (high mobility group B1 (HMGB1)) and overexpression (tripartite motif-containing 28 (TRIM28), p53, HMGB1, transcription factor 3 (TCF3), longevity assurance gene homologue 5 (LASS5) and zinc finger protein 346 (ZNF346)) in colorectal cancer tissue compared with normal colorectal mucosa.

CONCLUSIONS

It is demonstrated for the first time that screening high-density protein arrays identifies unique antibody profiles that discriminate between symptomatic patients with and without colorectal cancer. The differential expression of identified antigens suggests their involvement in aberrant cellular mechanisms in cancer.

Reduction in heat-induced gastrointestinal hyperpermeability in rats by bovine colostrum and goat milk powders

Male Sprague-Dawley rats were assigned to one of three dietary groups [standard diet (Cont; n = 8), standard diet plus bovine colostrum powder (BColost 1.7 g/kg; n = 8), or goat milk powder (GMilk 1.7 g/kg; n = 8)] to determine the ability of these supplements to reduce gastrointestinal hyperpermeability induced by heat. Raising core body temperature of rats to 41.5 degrees C increased transfer of (51)Cr-EDTA from gut into blood 34-fold relative to the ambient temperature value (P < 0.05) in the Cont group of rats, indicative of increased gastrointestinal permeability. Significantly less (P < 0.01) (51)Cr-EDTA was transferred into the blood of rats in either the BColost (27% of Cont) or GMilk group (10% of Cont) after heating, showing that prior supplementation with either bovine colostrum or goat milk powder significantly reduced the impact of heat stress on gastrointestinal permeability. The changes in the BColost group were not significantly different than those of the GMilk group. The potential mechanism of the protective effect of bovine colostrum and goat milk powders may involve modulation of tight junction permeability, because both powders were able to maintain transepithelial resistance in Madin Darby canine kidney cells challenged with EGTA compared with cells maintained in media only. The results show that bovine colostrum powder can partially alleviate the effects of hyperthermia on gastrointestinal permeability in the intact animal. Moreover, goat milk powder was equally as effective as bovine colostrum powder, and both may be of benefit in other situations where gastrointestinal barrier function is compromised.

Tuberculosis of the breast presenting as carcinoma

Breast infections caused by Mycobacterium tuberculosis, although rare in western countries, should not be forgotten as a cause of a breast lump presenting clinically and radiologically as a carcinoma in the older patient who gives a history of previous tuberculosis. We report the case of an 84-year-old woman with a breast lump showing noncaseating granulomas on histology who developed a sinus track after excision biopsy of the lump. The patient responded to empiric treatment with anti-tuberculosis drugs and remains well 2 years after presentation.

Involvement of energy metabolism in the production of 'bystander effects' by radiation

These experiments were done to determine if interference with energy metabolism and REDOX biochemistry during low LET radiation exposure would alter the ability of medium harvested from the irradiated cells to induce a bystander effect in unirradiated cells. Human keratinocyte cells and CHO-K1 mutant cell lines were irradiated using cobalt 60. Clonogenic assays were used to determine the reproductive death of the cells exposed to direct irradiation or medium from irradiated cells. The persistence in progeny was also examined. Use of apoptosis inhibitors or medium from the LDH or G6PD null cell lines, reduced or prevented the bystander effect. Transfection with G6PD recovered the effect. Treatment with anti-oxidant substances, L-lactate and L-deprenyl prevented bystander factor associated cell kill. The lactate analogue, oxamate, was less effective. Data from experiments where media harvested from the different cell lines was exchanged suggest that signal production and cellular response may involve different mechanisms. The effects on exposed cells were transmitted to progeny which also showed excessive levels of cell death for several generations. The results suggest that energy/REDOX metabolism may be involved in the expression of a radiation induced bystander response. Given the aberrant energy metabolism in tumour cells, this may have implications for dose escalation in radiotherapy.

Biological preparedness and evolutionary explanation

It is commonly supposed that evolutionary explanations of cognitive phenomena involve the assumption that the capacities to be explained are both innate and modular. This is understandable: independent selection of a trait requires that it be both heritable and largely decoupled from other 'nearby' traits. Cognitive capacities realized as innate modules would certainly satisfy these contraints. A viable evolutionary cognitive psychology, however, requires neither extreme nativism nor modularity, though it is consistent with both. In this paper, we seek to show that rather weak assumptions about innateness and modularity are consistent with evolutionary explanations of cognitive capacities. Evolutionary pressures can affect the degree to which the development of a capacity is canalized by biasing acquisition/learning in ways that favor development of concepts and capacities that proved adaptive to an organism's ancestors.

Visual behaviour and dyadic interaction between people with intellectual disability and people who are non-disabled

Patterns of visual dominance in human interaction have been studied by a number of authors. The purpose of the present research was to investigate the implications of these studies for interaction between people who are disabled and people who are non-disabled. It was predicted that disability would differentiate the two groups, with non-disabled partners dominating the visual interaction. Two studies are reported. The first looked at visual interaction through the two looking modes of looking while listening and looking while speaking between 16 dyads where one partner was intellectually disabled and the other non-disabled. In the second study, eight subjects who were intellectually disabled and who had participated in the first study interacted with another person who had an intellectual disability. Their looking modes were then compared between conversing with a non-disabled partner in study 1 and with those of their partner with intellectual disability in study 2. The outcome of the studies showed that subjects who were intellectually disabled did not discriminate in looking mode between partners of different intellectual levels. Conversely, subjects who were non-disabled spoke and looked significantly more when conversing with their partner who was intellectually disabled. It has been argued that overlooking and overspeaking could arise from the need for the non-disabled person to gain some sign of affiliation from their partner, or alternatively, that it might reflect a dominant non-disabled person attempting to facilitate a cooperative style.

Future directions for resuscitation research. I. Advanced airway control measures

The efficacy of 'basic' airway control without equipment, using the combination of backward tilt of the head, forward displacement of the mandible, and separation of lips and teeth (i.e. the triple airway maneuver) has been well established. Direct mouth-to-mouth and mouth-to-nose ventilation must continue to be taught to the public. Further improvements are needed for pocket-size mouth-to-mouth barriers to combat infection risks. Dissemination of appropriate information on disease transmission is needed to ensure ventilation by health professionals, using exhaled air ventilation adjuncts and other devices. Much knowledge exists about the pathophysiology of airway obstruction. For patients in coma or anesthesia with airway obstruction, which resists basic airway control measures and standard tracheal intubation, available 'advanced' airway control measures should be mastered and improved. Preparedness for advanced airway control measures differs between elective management of the anticipated difficult airway for anesthesia and emergency airway control with unanticipated difficulties encountered during the ordinary sequential application of measures. Challenges include education research and development of new devices. For airway clearing, pharyngeal intubation, difficult tracheal intubation, cricothyrotomy, transtracheal jet ventilation and emergency use of oxygen - what could and should be taught, to whom, and how? Which new devices and training systems should be developed? The most important alternative to orotracheal or nasotracheal intubation recommended for the development of novel devices and teaching methods for health professionals, are cricothyrotomy (with wide enough airway to also enable spontaneous breathing of air), and translaryngeal or transtracheal oxygen jet ventilation. We recommend openness in communication and joint planning between anesthesiologists, emergency care providers, and appropriate educators, engineers and industries.

Social insecurity, anxiety, and stressful events as antecedents of depressive symptoms

This study examined the combined effects on 132 normal adults of social insecurity, anxiety symptoms, and daily hassles on changes in the level of depressive symptoms over a 1-month period. It was hypothesized that social insecurity, a factor linked to coronary heart disease and sympathetic arousal, is also an important antecedent of depression for those who have experienced a high level of anxiety and chronic stress. Results of multiple regression analysis indicate that these three factors in combination (a 3-way interaction) predict changes in depressive symptoms. The nature of this interaction was more complex than hypothesized.

Reversible middle cerebral artery occlusion without craniectomy in rats

To develop a simple, relatively noninvasive small-animal model of reversible regional cerebral ischemia, we tested various methods of inducing infarction in the territory of the right middle cerebral artery (MCA) by extracranial vascular occlusion in rats. In preliminary studies, 60 rats were anesthetized with ketamine and different combinations of vessels were occluded; blood pressure and arterial blood gases were monitored. Neurologic deficit, mortality rate, gross pathology, and in some instances, electroencephalogram and histochemical staining results were evaluated in all surviving rats. The principal procedure consisted of introducing a 4-0 nylon intraluminal suture into the cervical internal carotid artery (ICA) and advancing it intracranially to block blood flow into the MCA; collateral blood flow was reduced by interrupting all branches of the external carotid artery (ECA) and all extracranial branches of the ICA. In some groups of rats, bilateral vertebral or contralateral carotid artery occlusion was also performed. India ink perfusion studies in 20 rats documented blockage of MCA blood flow in 14 rats subjected to permanent occlusion and the restoration of blood flow to the MCA territory in six rats after withdrawal of the suture from the ICA. The best method of MCA occlusion was then selected for further confirmatory studies, including histologic examination, in five additional groups of rats anesthetized with halothane. Seven of eight rats that underwent permanent occlusion of the MCA had resolving moderately severe neurologic deficits (Grade 2 of 4) and unilateral infarcts averaging 37.6 +/- 5.5% of the coronal sectional area at 72 hours after the onset of occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Identification of cardiac arrest by emergency dispatchers

Prompt identification of cardiac arrest by emergency dispatchers can save valuable time and increase the likelihood of successful resuscitation. The authors reviewed 516 cardiac and 146 non-cardiac calls to identify features of a probable cardiac arrest call. The results indicate that information about sex, location, and activity is of little use in the identification of cardiac arrest. When the patient is over 50 years old and the caller is emotional, the possibility of cardiac arrest is high, suggesting that questions about consciousness and breathing should be asked immediately. Additional information can be obtained or telephone cardiopulmonary resuscitation (CPR) instructions can be given after dispatch of an emergency vehicle.

Evoked cortical potential correlates of rearing environment in rats

Evoked cortical potentials were recorded from rats reared in either a complex sensory environment or in isolation. Potentials from enriched animals showed a decrease in amplitude with repeated somatic stimuli, whereas those from isolated animals did not. One hour after this experiment both groups showed similar decreases in potential amplitude with repeated stimulus. The results are interpreted as an habituation process whose development is influenced by early environment.

Protoporphyrinogen oxidase and ferrochelatase in porphyria variegata

Protoporphyrinogen oxidase activity and ferrochelatase activity were measured in leucocytes from patients with porphyria variegata. The mean activity of protoporphyrinogen oxidase (PPO) in porphyria variegata (PV) was about 50% of normal (P less than 0.05). The mean activity of ferrochelatase with 59Fe2+ sulphate and protoporphyrin as substrates (in the presence of ascorbic acid) was reduced by 40% (P less than 0.009). The mean activity of ferrochelatase with 59Fe3+ chloride and protoporphyrin as substrates (in the presence of reduced glutathione) was increased by 65% (P less than 0.005). Both are statistically highly significant. The findings are interpreted as follows: (a) The occurrence of a low level of protoporphyrinogen oxidase in PV is confirmed. (b) The findings indicate a concurrent structural change in ferrochelatase (this may be structurally related to (a) but no evidence of this is at present available).

A new flexible sigmoidoscope for the generalist

The control of colorectal cancer has become increasingly important because of its high incidence in the United States of more than 115,000 cases annually. Although 50% of neoplastic lesions of the colon arise in the distal 25 cm of the bowel, endoscopic examination of this area has not been generally accepted. Recent studies with flexible sigmoidoscopes as substitutes for the rigid proctosigmoidoscope, primarily by endoscopists, have shown an increased yield of neoplastic lesions, with excellent patient acceptance. This study reports the development of an initial trial in 200 patients with a 30-cm flexible sigmoidoscope designed mainly for the nonendoscopist general physician for routine office use as a substitute for the rigid proctosigmoidoscope. The instrument provided an excellent examination in minimum time and with good patient and physician acceptance. Widespread application of such instruments by generalists in routine office practice could have a significant impact on the control of colorectal cancer.