A Meta-Analysis of Hippocampal and Amygdala Volumes in Patients Diagnosed With Dissociative Identity Disorder.

Dissociative Identity Disorder (DID), an illness characterized by multiple personality states, has long been a controversial diagnosis within the psychiatric community. Demonstrating a neuroanatomical basis for the disorder may help to resolve the controversy. Current literature on the neuroanatomy associated with DID has focused on the hippocampus and amygdala and are inconclusive. This meta-analysis pools the results from n = 3 studies to compare the mean size of these two structures between DID patients, non-DID patients, and healthy controls. Patients diagnosed with both DID & PTSD were found to have smaller hippocampi bilaterally (p< .001) compared to healthy controls; no significant difference was seen in the amygdala. When comparing DID to PTSD patients, the left hippocampus was smaller (p< .001), with a trend for a smaller right hippocampus (p = .06). A comparison of the amygdala was not possible due to a lack of data. These findings suggest that a smaller hippocampus is seen in DID patients beyond what is seen for PTSD, provides neuroanatomical evidence for the memory impairment often seen in DID patients (i.e., amnesia experienced by the host and alters), and presents a potentially novel means to understand this disorder.

Efficacy and safety of febuxostat for treatment of asymptomatic hyperuricemia among kidney transplant patients: A meta-analysis of observational studies.

BACKGROUND: The objective of this meta-analysis of observational studies was to evaluate the efficacy and safety profiles of febuxostat in treating hyperuricemia among kidney transplant patients. METHODS: We conducted electronic searches in PubMed, Embase, and Cochrane Central Register of Controlled Trials from January 1960 to July 2019 to identify studies that investigated the effects of febuxostat in kidney transplant patients on uric acid as well as safety profiles including estimated glomerular filtration rate (eGFR), hemoglobin level (Hb), white blood cell counts (WBC), liver enzymes, and trough level of tacrolimus. RESULTS: Seven observational studies with 367 participants were included in this meta-analysis. Compared with allopurinol, the febuxostat group demonstrated a higher odds of achieving target uric acid levels lower than 6 mg/dL within 12 months (OR = 2.9, P = .004). However, there was no statistical difference in change of uric acid (WMD = -1.0 mg/dL/y, P = .32) and change in allograft eGFR within a year (WMD = 0.01 mL/min/1.73 m2 /y, P = .98) between febuxostat and allopurinol. Regarding safety profiles, there were no statistical differences in eGFR, Hb, WBC, liver enzymes (AST, ALT), and trough level of tacrolimus between baseline and at the study end. Only one study reported suspected graft loss among febuxostat group. CONCLUSION: Among kidney transplant patients, treating hyperuricemia with febuxostat showed a higher odds of reaching the target of serum uric acid < 6 mg/dL compared with allopurinol without causing significant side effects including change in tacrolimus level, liver function, decline in renal graft function, and bone marrow function.

Associations Between Two Domains of Social Adversity and Recovery Among Persons with Serious Mental Illnesses Being Treated in Community Mental Health Centers.

As mental health services are increasingly embracing the recovery model, we conducted a study to better understand how social adversity impacts recovery. We also examined how associations between social adversity and recovery are influenced (moderated or mediated) by symptom severity. Data on seven social adversity measures, eight recovery measures, and symptom severity were collected from 300 English-speaking participants, ages 18-65 years, with a diagnosis of a psychotic or mood disorder, from five community mental health agencies in diverse neighborhoods in Washington, D.C. We employed standard correlation, exploratory factor analyses, analysis of variance, and hierarchic regression procedures. Diagnostic category and gender impacted Home Environment Adversities (e.g., food insecurity, perceived neighborhood disorder), the diagnostic category-by-gender interaction influenced Social and Economic Adversities (e.g., years of education and income), and gender affected Recovery. Controlling for diagnostic category and gender, Social and Economic Adversities accounted for 1.7% of variance in Recovery, while Home Environment Adversities accounted for 8.6% (their joint influence was 3.4%). Although symptom severity did not moderate these associations, it partially mediated the effect of Social and Economic Adversities on Recovery, and substantially mediated the effect of Home Environment Adversities on Recovery. The extent to which patients with serious mental illnesses experience recovery may be meaningfully influenced not only by symptoms, but by their social and environmental circumstances.

Impact of Varying Active Learning Time on Student Performance on a Standardized Exam in the Psychiatry Clerkship.

OBJECTIVE: As medical schools reform clinical curricula, an increasing amount of time is spent in active learning activities. The authors hypothesized that students who spent more time in active learning educational activities (e.g., team-based learning, small group activities, clinical simulation) would receive higher NBME Subject Exam scores compared to students with less. METHODS: This cohort study included 518 students from 2014 to 2016 who completed at least six contiguous weeks of a psychiatry clerkship. Active learning time percent was calculated by dividing the amount of time in active learning by the total in-classroom time during the clerkship. Analysis was conducted using ANOVA and linear regression. RESULTS: Analysis found that increasing the amount of active learning was not significantly associated with student scores on the NBME Subject Exam in psychiatry (F = 0.91, p = 0.402). However, when controlling for possible confounding variables (including clerkship length and order), clerkship order was a significant predictor of student performance (r = 0.19, ß = 0.18, p < 0.0001); students who took the clerkship later in the academic year-and after the internal medicine rotation-performed significantly better on the exam. CONCLUSIONS: This study found that increasing the amount of active learning did not improve student performance on the NBME Subject Exam in psychiatry. This study provides preliminary, but unexpected, evidence of interest to medical educators and curriculum reformers that increasing the amount of active learning is not significantly associated with improved student test performance.

Acute Kidney Injury in Patients Undergoing Cardiac Transplantation: A Meta-Analysis.

Background: Acute kidney injury (AKI) is a common complication following solid-organ transplantation. However, the epidemiology of AKI and mortality risk of AKI among patients undergoing cardiac transplantation is not uniformly described. We conducted this study to assess the incidence of AKI and mortality risk of AKI in adult patients after cardiac transplantation. Methods: A systematic review of EMBASE, MEDLINE, and Cochrane Databases was performed until June 2019 to identify studies evaluating the incidence of AKI (by standard AKI definitions), AKI requiring renal replacement therapy (RRT), and mortality risk of AKI in patients undergoing cardiac transplantation. Pooled AKI incidence and mortality risk from the included studies were consolidated by random-effects model. The protocol for this study is registered with PROSPERO (no. CRD42019134577). Results: 27 cohort studies with 137,201 patients undergoing cardiac transplantation were identified. Pooled estimated incidence of AKI and AKI requiring RRT was 47.1% (95% CI: 37.6-56.7%) and 11.8% (95% CI: 7.2-18.8%), respectively. The pooled ORs of hospital mortality and/or 90-day mortality among patients undergoing cardiac transplantation with AKI and AKI requiring RRT were 3.46 (95% CI, 2.40-4.97) and 13.05 (95% CI, 6.89-24.70), respectively. The pooled ORs of 1-year mortality among patients with AKI and AKI requiring RRT were 2.26 (95% CI, 1.56-3.26) and 3.89 (95% CI, 2.49-6.08), respectively. Conclusion: Among patients undergoing cardiac transplantation, the incidence of AKI and severe AKI requiring RRT are 47.1% and 11.8%, respectively. AKI post cardiac transplantation is associated with reduced short term and 1-year patient survival.

The aprosody of schizophrenia: Computationally derived acoustic phonetic underpinnings of monotone speech.

OBJECTIVE: Acoustic phonetic methods are useful in examining some symptoms of schizophrenia; we used such methods to understand the underpinnings of aprosody. We hypothesized that, compared to controls and patients without clinically rated aprosody, patients with aprosody would exhibit reduced variability in: pitch (F0), jaw/mouth opening and tongue height (formant F1), tongue front/back position and/or lip rounding (formant F2), and intensity/loudness. METHODS: Audiorecorded speech was obtained from 98 patients (including 25 with clinically rated aprosody and 29 without) and 102 unaffected controls using five tasks: one describing a drawing, two based on spontaneous speech elicited through a question (Tasks 2 and 3), and two based on reading prose excerpts (Tasks 4 and 5). We compared groups on variation in pitch (F0), formant F1 and F2, and intensity/loudness. RESULTS: Regarding pitch variation, patients with aprosody differed significantly from controls in Task 5 in both unadjusted tests and those adjusted for sociodemographics. For the standard deviation (SD) of F1, no significant differences were found in adjusted tests. Regarding SD of F2, patients with aprosody had lower values than controls in Task 3, 4, and 5. For variation in intensity/loudness, patients with aprosody had lower values than patients without aprosody and controls across the five tasks. CONCLUSIONS: Findings could represent a step toward developing new methods for measuring and tracking the severity of this specific negative symptom using acoustic phonetic parameters; such work is relevant to other psychiatric and neurological disorders.

Video Modeling of SBIRT for Alcohol Use Disorders Increases Student Empathy in Standardized Patient Encounters.

OBJECTIVES: The purpose of this study was to assess the usefulness of adding video models of brief alcohol assessment and counseling to a standardized patient (SP) curriculum that covers and tests acquisition of this skill. METHODS: The authors conducted a single-center, retrospective cohort study of third- and fourth-year medical students between 2013 and 2015. All students completed a standardized patient (SP) encounter illustrating the diagnosis of alcohol use disorder, followed by an SP exam on the same topic. Beginning in August 2014, the authors supplemented the existing formative SP exercise on problem drinking with one of two 5-min videos demonstrating screening, brief intervention, and referral for treatment (SBIRT). P values and Z tests were performed to evaluate differences between students who did and did not see the video in knowledge and skills related to alcohol use disorders. RESULTS: One hundred ninety-four students were included in this analysis. Compared to controls, subjects did not differ in their ability to uncover and accurately characterize an alcohol problem during a standardized encounter (mean exam score 41.29 vs 40.93, subject vs control, p = 0.539). However, the SPs' rating of students' expressions of empathy were significantly higher for the group who saw the video (81.63 vs 69.79%, p < 0.05). CONCLUSIONS: The findings did not confirm the original hypothesis that the videos would improve students' recognition and knowledge of alcohol-related conditions. However, feedback from the SPs produced the serendipitous finding that the communication skills demonstrated in the videos had a sustained effect in enhancing students' professional behavior.

Associations of acoustically measured tongue/jaw movements and portion of time speaking with negative symptom severity in patients with schizophrenia in Italy and the United States.

This is the first cross-language study of the effect of schizophrenia on speech as measured by analyzing phonetic parameters with sound spectrography. We hypothesized that reduced variability in pitch and formants would be correlated with negative symptom severity in two samples of patients with schizophrenia, one from Italy, and one from the United States. Audio recordings of spontaneous speech were available from 40 patients. From each speech sample, a file of F0 (pitch) and formant values (F1 and F2, resonance bands indicating the moment-by-moment shape of the oral cavity), and the portion of the recording in which there was speaking ("fraction voiced," FV), was created. Correlations between variability in the phonetic indices and negative symptom severity were tested and further examined using regression analyses. Meaningful negative correlations between Scale for the Assessment of Negative Symptoms (SANS) total score and standard deviation (SD) of F2, as well as variability in pitch (SD F0) were observed in the Italian sample. We also found meaningful associations of SANS affective flattening and SANS alogia with SD F0, and of SANS avolition/apathy and SD F2 in the Italian sample. In both samples, FV was meaningfully correlated with SANS total score, avolition/apathy, and anhedonia/asociality.

Marijuana use in the immediate 5-year premorbid period is associated with increased risk of onset of schizophrenia and related psychotic disorders.

OBJECTIVES: Several studies suggest that adolescent marijuana use predicts earlier age at onset of schizophrenia, which is a crucial prognostic indicator. Yet, many investigations have not adequately established a clear temporal relationship between the use and onset. METHODS: We enrolled 247 first-episode psychosis patients from six psychiatric units and collected data on lifetime marijuana/alcohol/tobacco use, and ages at onset of prodrome and psychosis in 210 of these patients. Cox regression (survival analysis) was employed to quantify hazard ratios (HRs) for effects of diverse premorbid use variables on psychosis onset. RESULTS: Escalation of premorbid use in the 5years prior to onset was highly predictive of an increased risk for onset (e.g., increasing from no use to daily use, HR=3.6, p<0.0005). Through the analysis of time-specific measures, we determined that daily use approximately doubled the rate of onset (HR=2.2, p<0.0005), even after controlling for simultaneous alcohol/tobacco use. Building on previous studies, we were able to determine that cumulative marijuana exposure was associated with an increased rate of onset of psychosis (p=0.007), independent of gender and family history, and this is possibly the reason for age at initiation of marijuana use also being associated with rate of onset in this cohort. CONCLUSIONS: These data provide evidence of a clear temporal relationship between escalations in use in the five years pre-onset and an increased rate of onset, demonstrate that the strength of the association is similar pre- and post-onset of prodromal symptoms, and determine that early adult use may be just as important as adolescent use in these associations.

Personality domains, duration of untreated psychosis, functioning, and symptom severity in first-episode psychosis.

OBJECTIVES: Early-course psychotic disorders have been extensively studied in terms of phenomenology, but little is known about the influence of personality traits on clinical features of first-episode psychosis. The aim of this study was to explore how the "big five" personality domains (neuroticism, extraversion, openness, agreeableness, and conscientiousness) are associated with treatment delay (duration of untreated psychosis, DUP), functioning, and positive and negative symptom severity. METHODS: Data for these analyses were obtained from 104 participants enrolled from psychiatric inpatient units in Atlanta, Georgia, between August 2008 and March 2011. The NEO Five-Factor Inventory (NEO-FFI) was used to assess personality domains, and all other variables were measured in a standardized and rigorous manner using psychometrically sound instruments. Correlational analyses and multiple linear regressions were carried out to examine the strength of associations between variables of interest. RESULTS: Findings indicated that except for openness, all of the other personality variables contributed to some extent to the variance in DUP. Conscientiousness was positively correlated with functioning. Agreeableness was independently negatively associated with positive symptom severity and extraversion was independently negatively correlated with negative symptom severity. CONCLUSIONS: We report the first evidence suggesting that DUP is in part driven by personality domains. Functioning and symptom severity are also associated with those domains. Personality should be taken into account in order to better understand the phenomenology of early-course psychotic disorders as well as treatment-seeking behaviors.

Surveys of Police Chiefs and Sheriffs and of Police Officers About CIT Programs.

OBJECTIVE: Two surveys were conducted on the crisis intervention team (CIT) model, a police-based program designed to improve responses to individuals with mental illnesses. METHODS: Data were collected between July and September 2013 from 171 police chiefs and sheriffs (42 had implemented CIT in their agency), and 353 law enforcement officers (273 had CIT training) in Georgia. RESULTS: Police chiefs and sheriffs reported barriers to implementing CIT, such as not having enough officers and insufficient access to mental health services. CIT-trained officers differed from non-CIT-trained officers only with regard to being less likely to use force in response to a man with psychotic agitation described in a vignette, when the analysis controlled for whether the officer carried an electronic control device. CONCLUSIONS: Some hypothesized differences, such as in job satisfaction and work burnout, were not observed. However, CIT-trained officers appeared to be less likely to revert to force in a situation involving psychotic agitation.

Demographic, socio-environmental, and substance-related predictors of duration of untreated psychosis (DUP).

OBJECTIVE: Longer duration of untreated psychosis (DUP) is associated with poorer early-course and long-term outcomes, and is a target of early detection and intervention efforts. Given the paucity of research on childhood and adolescent stressors (e.g., maltreatment and neighborhood disorder) as potential predictors of DUP, limited research on premorbid substance use as a determinant of DUP, and inconclusive findings on the association between DUP and neurocognition, we conducted three sets of analyses to address these issues. Mode of onset of psychosis was also considered, given its established role as an illness-level correlate of DUP. METHODS: We rigorously assessed DUP and other pertinent variables in 180 predominantly African American, low-income, and socially disadvantaged first-episode psychosis patients hospitalized in five psychiatric units. RESULTS: Mode of onset of psychosis, prior incarceration, and the level of childhood/adolescent maltreatment were all significant independent predictors of DUP. Regarding premorbid substance use, having ever used cannabis and the amount of premorbid alcohol use were significantly associated with DUP. None of the seven neurocognitive domains assessed were even modestly, or clinically meaningfully, associated with DUP. CONCLUSIONS: These and other findings on DUP may be informative for early detection and intervention services. For example, such services might benefit from special outreach to criminal justice settings and disadvantaged neighborhoods, and to young people likely to have a history of childhood/adolescent maltreatment and gradually developing psychotic symptoms.