Reclassification of aortic stenosis by fusion of echocardiography and computed tomography in low-gradient aortic stenosis.

BACKGROUND: The integration of computed tomography (CT)-derived left ventricular outflow tract area into the echocardiography-derived continuity equation results in the reclassification of a significant proportion of patients with severe aortic stenosis (AS) into moderate AS based on aortic valve area indexed to body surface area determined by fusion imaging (fusion AVAi). The aim of this study was to evaluate AS severity by a fusion imaging technique in patients with low-gradient AS and to compare the clinical impact of reclassified moderate AS versus severe AS. METHODS: We included 359 consecutive patients who underwent transcatheter aortic valve implantation for low-gradient, severe AS at two academic institutions and created a joint database. The primary endpoint was a composite of all-cause mortality and rehospitalisations for heart failure at 1 year. RESULTS: Overall, 35% of the population (n = 126) were reclassified to moderate AS [median fusion AVAi 0.70 (interquartile range, IQR 0.65-0.80) cm2/m2] and severe AS was retained as the classification in 65% [median fusion AVAi 0.49 (IQR 0.43-0.54) cm2/m2]. Lower body mass index, higher logistic EuroSCORE and larger aortic dimensions characterised patients reclassified to moderate AS. Overall, 57% of patients had a left ventricular ejection fraction (LVEF) <50%. Clinical outcome was similar in patients with reclassified moderate or severe AS. Among patients reclassified to moderate AS, non-cardiac mortality was higher in those with LVEF <50% than in those with LVEF ≥50% (log-rank p = 0.029). CONCLUSIONS: The integration of CT and transthoracic echocardiography to obtain fusion AVAi led to the reclassification of one third of patients with low-gradient AS to moderate AS. Reclassification did not affect clinical outcome, although patients reclassified to moderate AS with a LVEF <50% had worse outcomes owing to excess non-cardiac mortality.

[Determinants of seclusion in a psychiatric institution: a naturalistic and exploratory study]. / De determinanten van separaties in een psychiatrische instelling: een naturalistisch en exploratief onderzoek.

BACKGROUND: Seclusion of a psychiatric patient is a multifactorial process in which patient, staff and ward variables all play a role. So far, few studies have investigated to what extent these variables in combination can be the determinants of seclusion. AIM: To investigate, in a multivariate study, what influence certain patient, staff and ward variables had on the decision to seclude a psychiatric patient and to use the findings to support specific interventions which could reduce the total number of seclusions in our institution. METHOD: We based our study on 78 secluded patients and 96 similar control-patients (not secluded at that time) and we collected data from these patients with regard to some quantified patient, staff and ward variables. In this retrospective cross-sectional study we performed a multivariate logistic regression analysis on the data. This enabled us to study associative links but not causal links. RESULTS: Seclusion was found to be a multifactorial process which revealed significant associations with several patients variables (nosie-variables irritability and motor retardation) and one staff variable (subjective feeling of safety among nursing staff on the day of the patient's seclusion). We also found many more non-significant associations. CONCLUSION: Interventions that might reduce the number of seclusions (in our institution) should perhaps be directed towards the irritability and motor retardation of the patient and towards feelings of safety among the nursing staff.

[Is the MiniScan a useful psychiatric intervention? A pilot study of the incremental validity of a computerised classification system]. / De MiniScan als psychiatrische interventie; pilotonderzoek naar de toegevoegde waarde van een gecomputeriseerd classificatiesysteem.

BACKGROUND: Psychiatric classification based on clinical judgement is not very reliable. Reliability can be increased by the use of standardised interviews. Maximum standardisation of the classification process can both improve reliability and affect treatment. AIM: To determine the effect that the use of a highly standardised and automated classification procedure (MiniScan) can have on the length of stay in hospital and on the course of symptoms. METHODS: Participants were allocated to a test group and a control group. The test group was classified via the MiniScan, the control group on the basis of clinical judgement. Length of hospital stay and symptom course were determined. RESULTS: The use of the MiniScan had no effect on the length of hospital stay, but seemed to play a role in symptom reduction. CONCLUSION: There are indications that the use of the MiniScan contributes to symptom reduction.

Movement disorders are associated with schizotypy in unaffected siblings of patients with non-affective psychosis.

BACKGROUND: Movement disorders and schizotypy are both prevalent in unaffected siblings of patients with schizophrenia and both are associated with the risk of developing psychosis or schizophrenia. However, to date there has been no research into the association between these two vulnerability factors in persons with an increased genetic risk profile. We hypothesized that unaffected siblings of patients with non-affective psychosis have more movement disorders and schizotypy than healthy controls and that these co-occur. METHOD: In a cross-sectional design we assessed the prevalence and inter-relationship of movement disorders and schizotypy in 115 unaffected siblings (mean age 27 years, 44% males) and 100 healthy controls (mean age 26 years, 51% males). Movement disorders were measured with the Abnormal Involuntary Movement Scale (AIMS), the Unified Parkinson Disease Rating Scale (UPDRS), the Barnes Akathisia Rating Scale (BARS), and one separate item for dystonia. Schizotypy was assessed with the Structured Interview for Schizotypy--Revised (SIS-R). RESULTS: There were significant differences in the prevalence of movement disorders in unaffected siblings versus healthy controls (10% v. 1%, p<0.01) but not in the prevalence of schizotypy. Unaffected siblings with a movement disorder displayed significantly more positive and total schizotypy (p=0.02 and 0.03 respectively) than those without. In addition, dyskinesia correlated with positive schizotypy (r=0.51, p=0.02). CONCLUSIONS: The association between movement disorders (dyskinesia in particular) with positive and total schizotypy in unaffected siblings suggests that certain vulnerability factors for psychosis or schizophrenia cluster in a subgroup of subjects with an increased genetic risk of developing the disease.

Evidence for instrument and family-specific variation of subclinical psychosis dimensions in the general population.

It is unknown to what degree dimensions of schizotypy (subclinical psychosis) show independent, family-specific variation in the general population. Psychologists administered the Community Assessment of Psychic Experiences, the Structured Interview for Schizotypy-Revised (SIS-R), and the Brief Psychiatric Rating Scale to 257 subjects pertaining to 82 general population families. All 3 instruments showed family-specific variation for positive and negative subclinical psychosis dimensions with between-families proportions of total variance between 10% and 40%. However, only the SIS-R showed family-specific variation of the negative dimension independent of its correlation with the positive dimension. The positive dimension of subclinical psychosis shows familial-specific variation in samples unselected for psychiatric disorder, suggesting dimensional liability in the population. The SIS-R additionally captures family-specific variation in the negative domain.

Does the Schizotypal Personality Questionnaire reflect the biological-genetic vulnerability to schizophrenia?

We investigated whether the Schizotypal Personality Questionnaire (SPQ) [Schizophr. Bull. 17 (1991) 555.] could be an indicator of the biological-genetic vulnerability to schizophrenia. We hypothesized that the mean scores on three dimensions of the SPQ of different groups of relatives of patients with schizophrenia would parallel their risk for developing schizophrenia. The SPQ was administered to 51 first-episode schizophrenia patients, 63 parents of schizophrenia patients, 42 siblings of schizophrenia patients and 12 children of schizophrenia patients. Patients differed from the relatives on all three dimensions. Siblings and children scored significantly higher than parents on Positive Schizotypy, and the insignificant difference between the siblings and children was in the expected direction. The results could not be explained by the differences in age, sex, IQ or substance abuse. No differences were found for Disorganization Schizotypy between the relatives. Children scored higher than parents on Negative Schizotypy. The current study offers support to the hypothesis that the positive dimension of SPQ reflects the genetic vulnerability to schizophrenia.

The multidimensionality of self-report schizotypy in a psychiatric population: an analysis using multidimensional Rasch models.

There is increasing empirical evidence from factor analytical studies that schizotypy is composed of three dimensions. All studies into the multidimensionality of schizotypy used common factor analysis of scales, either exploratory or confirmatory. We argue that for research into the multidimensionality of schizotypy with dichotomous item responses on questionnaires (as with the Schizotypal Personality Questionnaire [SPQ], Raine 1991) much can be learned using generalized multidimensional Rasch models (GMRMs). GMRMs require a priori postulated models of schizotypy, which can be tested in confirmatory analyses. We hypothesized four competing models of schizotypy, based on the literature and clinical impressions-two two-dimensional models and two three-dimensional models. We also hypothesized that items differ in the degree they are indicative of a particular dimension of schizotypy. The sample was 418 psychiatric inpatients and outpatients, with moderate levels of psychopathology, who filled in the SPQ. Both three-dimensional models yielded a much better fit to the data than both two-dimensional models. Our revised three-dimensional model, a revision of that by Raine et al. (1994) and Gruzelier (1996), yielded the best fit. It consisted of positive schizotypy, disorganization, and negative schizotypy. The results strongly suggest that schizotypy, as measured with the SPQ, is a three-dimensional construct.

The reliability of the structured interview for schizotypy-revised.

We investigated the reliability of the Structured Interview for Schizotypy-Revised (SIS-R). The original interview (SIS) was developed by Kendler. We revised the SIS, primarily by standardizing the rating procedures. Operational definitions and explicit criteria for rating were given. We introduced a four-point scale and provided clear criteria for rating severity of symptoms and signs (frequency, duration, and level of conviction) to operationalize schizotypal features. We divided schizotypal signs of global affect and global organization of speech into three separate signs of affect and five separate signs of thinking and speech. The main goal of this study was the assessment of test-retest reliability of the SIS-R. A robust test-retest design using different interviewers at both times, with a mean interval of 19 days, was used. The sample consisted of 42 psychiatric patients, almost all with personality disorders. The strong linear-weighted kappa statistic was used to evaluate reliability. The first conclusion is that most schizotypal symptoms can be reliably assessed with the SIS-R. The second conclusion is that most schizotypal signs do not reach sufficient levels of reliability. After unreliable items are excluded, the shortened SIS-R is a reliable research instrument for measuring schizotypal features (as far as it concerns our mixed samples). It covers all three dimensions of schizotypy.

Durable improvements in Wisconsin Card Sorting Test performance in schizophrenic patients.

We examined the potential reversibility of cognitive deficits of schizophrenic patients in performing the Wisconsin Card Sorting Test (WCST), a neuropsychological measure of frontal lobe performance. The sample comprised 34 DSM III-R schizophrenic patients, who were randomly assigned to one of three groups, viz. two experimental groups and one control group, and were tested on six consecutive occasions. The results show that schizophrenic patients, selected on their poor WCST performance, could dramatically improve their performances by an elaborate procedural test training. They were even able to sustain these improvements over a 2-week period. The addition of monetary reinforcement to the test training was less effective than training alone. This reinforcement had an inhibiting effect on the training. Our results suggest that frontal lobe deficits in schizophrenia can be reduced and that a central deficit in schizophrenic WCST performance is a stable dysfunction in concept formation. For now it remains to be seen that this deficit in concept formation is remediable.

The multidimensionality of schizotypy.

We present an overview of self-report scales for measuring schizotypy and a review of factor-analytical studies of these scales. These studies show that schizotypy is a multidimensional construct consisting of three or four factors. Positive Schizotypy, Negative Schizotypy, Nonconformity, and possibly Social Anxiety/Cognitive Disorganization. Clinical and external validation studies provide support for the construct validity of the Positive Schizotypy and Negative Schizotypy factors, but as yet fail to support the Nonconformity and Social Anxiety/Cognitive Disorganization factors. In accordance with this multidimensional structure, the scales for measuring schizotypy can be classified as factor-specific scales. We consider the striking similarities between the multidimensionality of schizotypal traits and the multidimensionality of schizophrenic symptoms. We also look at the similarities and differences between schizotypy and normal personality traits. Some practical and theoretical implications of these relationships are discussed.