Evidence of advanced parental age linked to sporadic schizophrenia.

Νovel emergence of schizophrenia (SCZ) in its sporadic type has been linked, among many candidate epigenetic factors, with advanced paternal age (PA) and advanced maternal age (MA). The most common hypothesis to the paternal age effect is the increased "de novo mutations" during spermatogenesis, while the maternal age hypothesis, though controversial, is at most based on studies that support higher frequency of perinatal complications. Our sample consisted of 462 subjects with DSM-IV-TR SCZ spectrum disorders from the outpatient unit of Eginition Hospital in Athens, Greece, who were further screened for heritability and were divided in a group of sporadic cases (no reported family history for SCZ related disorders up to 2nd degree relatives) and a group of familial SCZ-spectrum disorder cases (positive reported history for SCZ spectrum). These two groups of patients were compared regarding either paternal or maternal age, while the familial type band was used as a control group. The aim of this retrospective file study was to examine whether advanced parental age may contribute in novel appearance of non-affective psychosis in offspring. Using logistic regression analysis, we found that the risk for the sporadic type, as compared to familial type, showed a significant increase for both advanced MA (OR=4.39, p=0.001) and PA (OR=1.92, p=0.012). After adjusting for confounding effects for the other parent's age and gender, the risk effect for the sporadic type of SCZ remained statistically significant for both advanced MA (OR=4.04, p=0.002) and advanced PA, but with a loss of statistical power (OR=1.72, p=0.049). Few studies have been conducted in Greece concerning the role of parental age in SCZ. Our study is consistent with current literature which indicates that both advanced MA and PA may contribute to an increased risk for emergence of sporadic type of SCZ. Furthermore, it is implied that this risk for the sporadic type as compared to the familial type could be higher for advanced MA than advanced PA. Patients with the sporadic type of SCZ, though clinically indistinguishable from the patients with the familial type of the disorder, may share other pathophysiological underlying mechanisms in which parental age, especially advanced MA, may be a candidate mediator. However, future studies could help clarify the role of both PA and MA in the pathophysiology of the disorder.

[Attenuated psychosis syndrome: A new diagnostic category for further study in DSM-5].

In recent years an increasing number of studies focus on the issue of early diagnosis and intervention. At the same time, a large number of special service units for early psychosis have been established around the world especially in Australia, USA, UK, Germany etc. Recently, similar units operate in Greece also. The Diagnostic Manual of Mental Disorders of the American Psychiatric Association in its latest edition in 2013 (DSM-5), introduced the category "Attenuated Psychosis Syndrome" (APS) for people with early psychotic experiences in the section: "Conditions for further study '. This new category has specific criteria and describes a situation, in which a person displays psychotic symptoms in an attenuated form, with quite unaffected reality testing, but not qualifying a diagnosis of schizophrenic spectrum. The clinical expression of APS should be differentiated with several well known psychiatric disorders such as: brief psychotic disorder, schizotypal personality disorder, major depression with psychotic features, adolescence adjustment disorders, drug use, etc. The "Attenuated Psychosis Syndrome" occurs mainly in adolescence and in young adulthood. The mean percentage of transition to psychosis for these individuals is estimated at 36%, three years after the onset of initial symptoms, while the risk of transition to psychosis, although smaller, seems to remain up to ten years later. For some other individuals, transition to other psychiatric disorders occurs, such as depression with psychotic elements, or bipolar disorder, while a significant number of them will not transmit to even more serious disorders. At the biological level, studies focused in brain's neuroimaging, suggest significant volumetric differences among people at high risk for psychosis who later develop psychosis compared to those who don't, while studies of psychophysiological indicators or / and genetic markers show promising results for the identification of relevant parameters indicating the transition to psychosis. Αlthough an heterogeneous population, people with APS, show significant difficulties in social, professional and cognitive level, that should be therapeutically addressed. In an attempt to improve the clinical status of these individuals, to delay or even to prevent a psychotic episode, a series of interventions have been used by psychiatrists. These interventions include: (a) administration of drugs, especially atypical antipsychotics or antidepressants in low dosage, (b) administration of non-pharmaceutical supplements (e.g. omega-3 ), (c) psychotherapeutic interventions, mainly cognitive behavior therapy and (d) a combination of the above. Many questions need to be answered such as, the period of therapeutic intervention, identification of indicators (biological or/and clinical) that may determine the most suited for the APS individuals therapeutic interventions or, that may foresee, to prevent the transition to psychosis. Thus, the continuation of research in populations of APS individuals in multiple levels is necessary.

Inter-rater reliability of the Greek version of CAARMS among two groups of mental health professionals.

There is increasing interest within the Greek psychiatric community in the early detection and prevention of psychotic disorders. To support this, there is a need for a valid and reliable tool to identify young people that may be at risk of developing a psychotic disorder. Our team has previously translated the Comprehensive Assessment of At-Risk Mental States (CAARMS). The validity of the CAARMS was ensured by the procedure of translation and the aim of the current study was to estimate the interrater reliability of the CAARMS Greek translation among residents in psychiatry and specialized mental health professionals. 43 mental health workers (27 residents in psychiatry and 16 specialized mental health professionals (i.e. 11 psychiatrists and 5 psychologist) participated in two seminars that covered theoretical information about the ultra high risk concept and training in the CAARMS. During the seminars, 10 vignettes with psychiatric history cases were presented, including healthy, ultra high risk and first episode psychosis. The mean correlated percentage of agreement with the correct answers regarding diagnosis of the presented history cases among all our subjects was 81.42, among specialized mental health professionals 77.88, and among residents 84.46. Intraclass correlation co-efficients were 0.994 for specialized mental health professionals and 0.997 for residents. The translated Greek version of CAARMS presents a satisfying interrater reliability when used by both residents and specialized mental health professionals. Residents declare even higher intraclass correlation co-efficients and mean correlated percentage of agreement than specialized mental health professionals, which indicate that residents are capable of using the CAARMS in early intervention units.

Early psychotic experiences: Interventions, problems and perspectives.

Psychotic or psychotic-like experiences and symptoms may precede and be indicative of later psychosis emergence. DSM-5 has introduced Attenuated Psychosis Syndrome (APS) as a condition for further study, arguing for its clinical validity and the need for identifying sub- threshold psychotic states. Early psychosis intervention has an already established role in reducing the Duration of Untreated Psychosis (DUP), delaying psychosis onset and relieving Ultra High Risk (UHR) individuals from their presenting symptoms. Pharmacological and mainly psycho-therapeutical approaches are suggested for this purpose. Cognitive Behavior Therapy (CBT) seems to have clear evidence of favorable outcome concerning transition to psychosis rates, omega-3 fatty acids lower but promising evidence, while low-dose antipsychotic medication or antidepressant treatment may seem beneficial, but it remains unclear if the reported favorable effects persist in the long term and how long intervention in UHR subjects should be given for. Case management and close monitoring based on principles of social psychiatry are considered key elements for the management of UHR individuals. However, the blazing case about early psychosis concerns the accurate specification of the prodromal stage of psychosis, which may set the basis for meaningful and effective early intervention. Although psychometric tools have been developed and provide a common criteria-based recognition method, debate is alive and well regarding "false positive" cases, since most UHR subjects will not finally develop psychosis. Moreover, transition rates to psychosis have been declining over the years, leading to fierce criticism over the validity of the UHR/ APS state and legitimacy of its treatment. On this framework, ethical issues of stigmatizing through unnecessary diagnosing and antipsychotics' prescribing are matters of serious questioning. Clinical heterogeneity and high comorbidity are further implications of the UHR state. Current research emphasizes on improving validity of inclusion criteria and formulating personalised and clinical stage- based intervention strategies. In order to do that, early psychosis recognition and intervention services are established throughout the world, trying to contribute in research by applying clinical, cognitive or neuropsychological criteria. Nevertheless, in the majority of so far conducted studies, samples sizes are considered small and duration of follow-up short, which are limitations yet to overcome. Other scientific voices argue that the UHR state might represent a non-specific risk factor for psychiatric disorders in general and not necessarily for psychosis and tend to examine the UHR and early intervention idea under the prism of subthreshold or early mental distress state. Either way, recognizing and intervening early in emerging psychiatric states, especially in those with psychotic or psychotic-like symptomatology, share indisputable benefits under the broader concept of prevention, setting a strong scientific-clinical rationale for service provision to help-seeking people and the possibility of changing the course for those with vulnerability to psychotic illnesses.

Factors involved in selection of a career in surgery and orthopedics for medical students in Malawi.

AIMS: There is a critical shortage of Orthopedic Surgeons in Malawi as well as all countries in sub-Saharan Africa. To date, there is no published literature that has investigated surgical or Orthopedic career selection amongst African medical trainees. With the goal of facilitating recruitment into Surgery and Orthopedics in Malawi, we explored the key aspects of Malawian Medical Students' choice of careers in surgical disciplines. METHODS: An on-line survey of all students in clinical years at the College of Medicine in Blantyre, Malawi was performed. The survey was anonymous and constructed de novo by a stringent process including Item Generation, Item reduction, Survey composition, Pre-testing, Assessment of Validity by a recognized survey expert, Pilot testing in on-line format by several Malawian Medical Students, and then formal survey testing. RESULTS: Surgery was the most popular specialty choice among the medical trainees (46%). General Surgery was the popular surgical specialty (27%), followed by Neurosurgery (22%) and Orthopedics (19%). The majority of students (67%) feared occupational exposure to HIV but this did not appear to be a factor in specialty choice (p = 0.9). Students with Orthopedic mentors were significantly more likely to choose Orthopedics as their first choice surgical specialty (p = 0.01). Despite limited resources and surgeons in sub-Saharan Africa, surgical specialties are desirable career choices. CONCLUSIONS: This is the first evaluation of factors involved in surgical or Orthopedic career selection in any African context. Future initiatives to improve exposure and mentorship in Orthopedics are fundamental to recruitment into the specialty.

Attitudes on euthanasia and physician-assisted suicide among medical students in Athens.

Attitudes towards assisted death activities among medical students, the future health gatekeepers, are scarce and controversial. The aims of this study were to explore attitudes on euthanasia and physician-assisted suicide among final year medical students in Athens, to investigate potential differences in attitudes between male and female medical students and to review worldwide attitudes of medical students regarding assisted death activities. A 20- item questionnaire was used. The total number of participants was 251 (mean age 24.7±1.8 years). 52.0% and 69.7% of the respondents were for the acceptance of euthanasia and physician-assisted suicide, respectively. Women's attitudes were more often influenced by religious convictions as well as by the fact that there is a risk that physician-assisted suicide might be misused with certain disadvantaged groups. On the other hand, men more often believed that a request for physician-assisted suicide from a terminally ill patient is prima-facie evidence of a mental disorder, usually depression. Concerning attitudes towards euthanasia among medical students in various countries there are contradictory results. In USA, the Netherlands, Hungary and Switzerland most of the students supported euthanasia and physician-assisted suicide. However, in many other countries such as Norway, Sweden, Yugoslavia, Italy, Germany, Sudan, Malaysia and Puerto Rico most students expressed negative positions regarding euthanasia and physician assisted suicide.

The Greek version of the calgary depression scale for schizophrenia.

The aim of this study was to evaluate the reliability and validity, as well as the specificity, of the Greek version of the Calgary Depression Scale for Schizophrenia (CDSS). Schizophrenic inpatients consecutively admitted at the Eginition Hospital, University of Athens, were included in the study. Patients were assessed on admission using the CDSS, the Hamilton Depression Rating Scale (HDRS), the Positive and Negative Syndrome Scale (PANSS), the Rating Scale for Extrapyramidal Side Effects (RSESE), the Rating Scale for Drug-Induced Akathisia (RSDIA) and the Abnormal Involuntary Movement Scale (AIMS). The CDSS was found to have a high inter-rater reliability, as well as test-retest reliability or split-half reliability. The internal consistency of the CDSS was good (a=0.87). There were positive correlations between the CDSS and the HDRS, or the depression cluster of the PANSS. The mean score on the CDSS showed no significant correlations with that of the PANSS negative subscale (r=0.123); a negative but not significant correlation with that of the PANSS positive subscale (r=-0.036); a weak correlation with that of the PANSS general psychopathology subscale (r=0.218); and no significant correlations with that of the RSESE (r=0.197), the RSDIA (r=0.160) or the AIMS (r=0.031). Our results give further support to the reliability, the validity, and the specificity of the CDSS.