Optimizing Care for High-Risk Multiple Pregnancy with POCUS - A Case of Quadruplet Pregnancy Early Diagnosis.

Managing multiple pregnancies is challenging and requires careful evaluation. Point of care ultrasound (POCUS) has emerged as a potentially crucial tool in assessing suspected first-trimester pregnancies. However, its role in evaluating multiple pregnancies remains uncertain. We present the case of a 36-year-old Ghanaian female who presented with acute vaginal bleeding after undergoing in vitro fertilization. A bedside transabdominal POCUS identified four intrauterine gestations with fetal poles and cardiac activity, suggesting a quadruplet viable pregnancy. A subsequent transvaginal ultrasound confirmed the findings. The patient was discharged with a follow-up appointment with an Obstetrician-Gynecologist. This case highlights the significance of POCUS in early pregnancy diagnosis, facilitating accurate identification and appropriate referral for further management. It also demonstrates the utility of POCUS in determining gestational age and viability. To our knowledge, no published case reports specifically address the diagnosis of a quadruplet pregnancy, emphasizing the role of POCUS in optimizing care for high-risk multiple pregnancies.

Use of a Gluten-Free Diet in Schizophrenia: A Systematic Review.

We performed a systematic review of the literature to determine whether adherence to a gluten-free diet (GFD) leads to improved outcomes for patients with schizophrenia. We searched the AMED (Allied and Complementary Medicine; 1985-June 2016), MEDLINE (1946-June 2016), and Embase (1980-2016 week 24) databases using the terms "wheat" or "glutenin" or "gliadin" or "gluten" AND "schizophrenia." A total of 9 studies met the inclusion criteria for this review: 1 randomized controlled trial, 7 crossover studies, and 1 open-label pilot study. Six of the included studies demonstrated beneficial effects including improved functioning and decreased symptom severity after the course of a GFD, whereas 3 studies found no benefits. All of the included studies found that a GFD is well tolerated and can be adhered to by patients with schizophrenia. The findings of this systematic review should be interpreted with caution due to limitations inherent to nonrandomized trials, as well as the heterogeneity in the study design and the length of the GFD applied in each study. Publication bias is another potential limitation. Further research is required to examine the biomarkers of gluten sensitivity and inflammation to effectively target those patients with schizophrenia who will benefit most from this dietary intervention.

Anticholinergic Burden and Cognition in Older Patients With Schizophrenia.

OBJECTIVE: Older individuals with schizophrenia are at risk of being treated with anticholinergic medications due to the prevalence of medical comorbidities and polypharmacy. High anticholinergic burden impairs cognition and is a risk factor for Alzheimer's dementia. Thus, we assessed the impact of anticholinergic burden on Alzheimer's dementia-related and schizophrenia-related cognitive functions in older patients with schizophrenia. METHODS: Anticholinergic burden was measured using the Anticholinergic Cognitive Burden scale (ACB) in 60 community-dwelling patients aged ≥ 50 years who met DSM-IV criteria for schizophrenia between May 2007 and November 2011. Cognitive domains affected early in the course of Alzheimer's dementia were assessed using the Cambridge Neuropsychological Test Automated Battery (CANTAB) Alzheimer's Dementia Battery and the Repeatable Battery for the Assessment of Neuropsychological Status. Two CANTAB tests of executive function were used to assess deficits common in schizophrenia. Regression analyses were used to assess the relationships between anticholinergic burden and cognition. A receiver operating characteristic curve was constructed to determine an ACB cutoff score to identify those at risk of cognitive impairment. RESULTS: ACB scores were associated with spatial working (P = .04) and immediate (P = .004) memory and visuospatial ability (P = .02) and showed a trend toward association with impaired learning (P = .06), but were not associated with attention, executive function, language, or reaction time. An ACB cutoff score of ≤ 1.5 can detect cognitive impairment with a sensitivity of 90.3% and specificity of 48.3%. CONCLUSIONS: High anticholinergic burden contributes to specific cognitive deficits in older individuals with schizophrenia that resemble those commonly observed early in the course of Alzheimer's dementia. The ACB is a potentially useful screening tool that can help identify patients at risk of developing anticholinergic-related cognitive impairment.

An optimal combination of MCCB and CANTAB to assess functional capacity in older individuals with schizophrenia.

INTRODUCTION: Cognitive deficits predict functional capacity in patients with schizophrenia including in late life. The MATRICS Consensus Cognitive Battery (MCCB) and the Cambridge Neuropsychological Test Automated Battery (CANTAB) are widely used to assess cognition in this population. The aim of this study was to determine a minimal set of subtests across the two batteries that would be strongly associated with functional capacity in older patients with schizophrenia. METHODS: Sixty participants age 50 years or older with a diagnosis of schizophrenia or schizoaffective disorder and 30 control participants were enrolled. Cognition was assessed using the MCCB and the CANTAB. Functional capacity was assessed using the USCD Performance-based Skills Assessment (UPSA). Stepwise linear regressions were performed to determine the best set of cognitive tests associated with functional capacity. RESULTS: UPSA total score was negatively correlated with age and positively correlated with education and the MCCB global score. Most of the MCCB domains and subtests, and several of the CANTAB subtests correlated with UPSA total score. In the regression model, MCCB global score accounted for 42.5% of UPSA variance. In contrast, a combination of only four subtests (processing speed and verbal learning from the MCCB, and affective information processing and working memory from the CANTAB) accounted for 60% of UPSA variance. CONCLUSIONS: Performance on MCCB and CANTAB is strongly associated with functional capacity in older patients with schizophrenia. A selective combination of MCCB and CANTAB subtests may be as effective in assessing functional capacity in late life schizophrenia. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

The influence of medical burden severity and cognition on functional competence in older community-dwelling individuals with schizophrenia.

OBJECTIVE: Cognition predicts functional competence among individuals with schizophrenia across the lifespan. However, as these individuals age, increasing levels of medical burden may also contribute to functional deficits both directly and indirectly through cognition. Thus, we assessed the relationship among, cognition, medical burden, and functional competence in older individuals with schizophrenia. METHODS: We analyzed data obtained from 60 community-dwelling participants with schizophrenia and 30 control participants aged 50 or above. Cognition was assessed using the MATRICS Consensus Cognitive Battery (MCCB), functional competence was assessed using the USCD Performance-Based Skills Assessment (UPSA), and medical burden was assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Group differences were assessed using independent samples t-tests or chi-square tests. Mediation analyses using bootstrapping techniques were used to assess whether cognition mediated the effects of medical burden on functional competence. RESULTS: Participants with schizophrenia had higher levels of medical burden, cognitive deficits, and functional impairments. In participants with schizophrenia, cognition, but not medical burden, predicted functional competence after adjusting for age, education, gender, clinical symptoms, and anticholinergic burden of medications. In control participants, cognition and medical burden both predicted functional competence after adjusting for age, education, and gender. Further, cognition was found to fully mediate the association between medical burden and functional competence in control participants. CONCLUSION: Cognition is a robust predictor of functional competence among older individuals with schizophrenia, regardless of medical burden. Cognitive deficits associated with schizophrenia may mask any further cognitive impairment associated with medical burden and its impact on function.

Cognitive remediation for older community-dwelling individuals with schizophrenia: a pilot and feasibility study.

OBJECTIVE: Cognitive deficits are among the strongest predictors of function in individuals with schizophrenia. This relationship continues to be strong as these individuals grow older into their eight decade. Cognitive remediation (CR) improves cognition in individuals with schizophrenia. This study aims at assessing the feasibility and potential effect of CR in patients with schizophrenia 60 years of age or older. METHODS: We adapted a CR protocol involving restorative and strategy-based methods over four cohorts of older outpatients with schizophrenia to target cognitive deficits associated with aging and schizophrenia. CR was provided in eight, 2-h weekly didactic sessions and online at-home exercises. Computerized drill and practice exercises were used with bridging to activities of daily life. Computer exercise selection and difficulty level parameters optimized adherence. Progression individually determined difficulty levels. We modified computer laboratory ergonomics to accommodate mobility needs. Participants were assessed at baseline and end-of-study using clinical and cognitive assessments. RESULTS: Twenty-two participants enrolled: 18 (mean [SD] age: 69.8 [5.3]) completed CR. Mean (SD) global cognition T score from the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery was 27.7 (10) at baseline and 28.8 (9.7) at the completion of the study. These means are over 2 SD below the norms. The change in global cognition was not statistically significant (paired t(17) = -1.18, p = 0.25). CONCLUSIONS: Our pilot study suggests that CR is well tolerated by most older outpatients with schizophrenia. Future studies need to assess whether increasing the frequency or the number of CR sessions leads to significant improvement in cognition.

Prediction of working memory performance in schizophrenia by plasma ratio of clozapine to N-desmethylclozapine.

OBJECTIVE: Clozapine's potent antagonism of muscarinic M1 receptors is thought to worsen working memory deficits associated with schizophrenia. In contrast, its major metabolite, N-desmethylclozapine (NDMC), is thought to enhance working memory via its M1 receptor agonist activity. The authors hypothesized that the ratio of serum clozapine and NDMC concentrations would be inversely associated with working memory performance in schizophrenia. METHOD: Thirty patients with schizophrenia or schizoaffective disorder who were receiving clozapine monotherapy at bedtime completed the MATRICS Consensus Cognitive Battery (MCCB) on the day their blood was collected to assess concentrations of clozapine and NDMC as well as serum anticholinergic activity. RESULTS: The clozapine/NDMC ratio was significantly and negatively associated with working memory performance after controlling for age, gender, education, and symptom severity. No significant associations were found between individual clozapine and NDMC concentrations and working memory performance. Serum anticholinergic activity was significantly associated with clozapine concentration, but not with working memory performance or NDMC concentration. No significant associations were found between any pharmacological measure and performance on other MCCB cognitive domains. CONCLUSIONS: This hypothesis-driven study confirms that clozapine/NDMC ratio is a strong predictor of working memory performance in patients with schizophrenia. This finding suggests that manipulating the clozapine/NDMC ratio could enhance cognition in patients with schizophrenia treated with clozapine. It also supports the study of procholinergic agents, such as M1 receptor-positive allosteric modulators, to enhance cognition in schizophrenia.

Happiness in first-episode schizophrenia.

UNLABELLED: Happiness is a core dimension of a person's life, related to both functioning and success. As patients with schizophrenia experience marked functional deficits, it would be informative to investigate their level of happiness. There are limited data currently available, perhaps due to the longstanding belief that anhedonia is an inherent feature of this illness. The present study set out to specifically assess happiness in schizophrenia in relation to both clinical and functional measures of outcome. METHOD: Thirty-one first-episode remitted patients and 29 age- and sex-matched controls participated in the study. Patients' clinical status was assessed and a series of self-report questionnaires were used to measure levels of happiness, life satisfaction, success and functioning in both patients and controls. RESULTS: Patients experienced marked functional impairment versus healthy controls (p<0.001), while reporting comparable levels of happiness (p=0.113) and satisfaction with life (p=0.350). In the patient group, we found that higher happiness ratings were significantly associated with less depression, less negative symptoms, less social withdrawal, greater life satisfaction, and higher social and occupational functioning. Both cognitive functioning and insight had no significant direct effects on ratings of happiness in the patient group. CONCLUSIONS: Despite marked functional impairment, individuals with first-episode schizophrenia are as happy as controls. Mechanisms that might allow for this are discussed, as are the implications for rehabilitation efforts that assume an individual holds to the same drives and goals as before the illness onset and/or is unhappy with their present functional status.