Fear of recurrence: results of a randomized trial of relapse detection in schizophrenia.

OBJECTIVE: We aimed to develop and establish the reliability and validity of a measure of Fear of Recurrence, measuring cognitive appraisals of relapse rather than standard early signs of relapse. We also aimed to establish the sensitivity and specificity to relapse. METHOD: Participants diagnosed with schizophrenia or a related disorder were randomized to one of two early signs monitoring conditions, using either the Early Signs Scale or the Fear of Recurrence Scale (FoRSe). Participants were followed up for 6-months or until relapse. RESULTS: A total of 169 participants were randomized to Standard (n = 86) or FoRSe (n = 83) monitoring. We found good evidence supporting reliability and validity of the FoRSe. In addition, a cut-off point of ≥ 5 was associated with an optimal sensitivity in both Standard (n = 26:79%, 95% CI = 62-89) and FoRSe (n = 18:72%, 95% CI = 52-86) monitoring. However, this degree of sensitivity was associated with a lower specificity in Standard (n = 30:35%, 96% CI = 23-50) and FoRSe (n = 25:46%, 95% CI = 32-60). Finally, Fear of Relapse was a significant predictor of time to relapse [Exp(ß) = 1.20, 95% CI = 1.01-1.42, p < .05]. CONCLUSION: The study provides evidence that Fear of Recurrence may be an important clinical construct linked to increased risk of relapse and poorer emotional recovery in people diagnosed with schizophrenia. PRACTITIONER POINTS: Monitoring Fear of Recurrence is as sensitive to relapse detection as monitoring early signs alone. Greater Fear of Relapse was associated with shorter duration to actual relapse. Fear of recurrence may be an important clinical feature linked to poorer emotional recovery and increased risk of relapse. Fear of Recurrence may be an important focus of psychological therapy to promote emotional recovery and prevention of relapse.

Impact of the COVID-19 pandemic on patients with pre-existing mood disorders.

OBJECTIVES: To examine the psychological and social impact of the COVID-19 pandemic on patients with established mood disorders during a period of stringent mandated social restrictions. METHODS: Semi-structured interviews were conducted with 36 individuals attending the Galway-Roscommon Mental Health Services with an International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) diagnosis of either Bipolar Affective Disorder (BPAD) (n = 20) or Emotionally Unstable Personality Disorder (EUPD) (n = 16) in this cross-sectional study. We determined the impact of the COVID-19 restrictions on anxiety and depressive symptoms, impulsivity, thoughts of self-harm, social and occupational functioning and quality of life. RESULTS: The COVID-19 pandemic deleteriously impacted mental health (56.3% v. 15.0%, χ2 = 7.42, p = 0.02), and mood (75.0% v. 20.0%, χ2 = 11.17, p = 0.002) to a greater extent in the EUPD compared to the bipolar disorder cohort, with 43.8% of individuals with EUPD reporting an increase in suicidal ideation. Psychometric rating scales [Beck Anxiety Inventory (BAI), Beck Depression Scale (BDS), Beck Hopelessness Scale (BHS), Barratt Impulsivity Scale (BIS)] and Likert scales for anxiety, mood and quality of life noted significantly higher levels of psychopathology in the EUPD cohort (p < 0.01). Qualitative analysis reflected quantitative data with themes of the employment of maladaptive coping mechanisms and reduced mental health supports notable. CONCLUSIONS: Individuals with EUPD are experiencing significant mental health difficulties related to the COVID-19 pandemic. The provision and recommencement of therapeutic interventions to this cohort, in particular, are warranted given the significant distress and symptoms being experienced.

New ways of working: COVID-19 as a catalyst for change in acute mental health services.

Background: A need arose to divert patients with psychiatric complaints from the emergency department to alternative settings for psychiatric consultations to reduce footfall during COVID-19. We assessed the effectiveness of alternative referral pathway in reducing COVID-19 infection in our service and its effect on service quality: response time and number of patients leaving before the review. We evaluated the satisfaction of patients, general practitioners (GPs) and mental health service staff with the pathway. Methods: All patients referred to the mental health service over a 2-month period following the introduction of the pathway were included. Findings were compared against the cohort referred for emergency assessment during the same period in 2019. Feedback surveys were distributed to patients, staff and GPs. χ2 and independent sample t-test were used to compare the variables. Results: Over 2 months, 255 patients received an emergency assessment via the pathway, representing a 22.3% decrease in the volume of presentations from the same period in 2019. There were no COVID-19 cases among our patients or staff on the roster for assessing patients. In comparison to 2019, response times were improved (p<0.001), and the numbers of patients who left the hospital before the review were reduced by 3.2% during the study period (p<0.001). Patients and GPs were highly satisfied with the referral pathway and believed that the pathway should be retained post-COVID-19. Mental health service staff were divided in their opinions about its sustainability. Conclusion: The pathway was successful in reducing the spread of infection, improving response times and reducing the numbers of patients who left without an assessment. Given the improved outcomes and acceptability, this is a preferable pathway for emergency referrals into the future.

Early intervention for relapse in schizophrenia: impact of cognitive behavioural therapy on negative beliefs about psychosis and self-esteem.

OBJECTIVES: The study aimed to test two hypotheses. Firstly, that participants who relapsed during the 12-month follow-up period of our randomized controlled trial, would show increased negative beliefs about their illness and reduced self-esteem, in comparison to the non-relapsed participants. Secondly, that cognitive behavioural therapy (CBT) for early signs of relapse would result in a reduction in negative beliefs about psychosis and an improvement in self-esteem at 12 months. DESIGN AND METHODS: A total of 144 participants with schizophrenia or a related disorder were randomized to receive either treatment as usual (TAU; N=72) or CBT (N=72). Participants completed the Personal Beliefs about Illness Questionnaire (PBIQ; Birchwood, Mason, MacMillan, & Healy, 1993) and the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) at entry, 3 months, 6 months, and 12 months. RESULTS: At 12 months, relapsers showed greater increase in scores for PBIQ entrapment compared with non-relapsers. In addition, after controlling for baseline covariates (treatment group and PBIQ self versus illness), relapsers also showed greater increase in scores for PBIQ self versus illness at 12 months. Furthermore, in comparison to treatment as usual, participants who received CBT showed greater improvement in PBIQ loss and in Rosenberg self-esteem. CONCLUSIONS: The study provides evidence that relapse is associated with the development of negative appraisals of entrapment and self-blame (self vs. illness). In addition, this is the first study to show that CBT reduces negative appraisals of loss arising from psychosis and improvements in self-esteem. Implications for future research and treatment are discussed.

Assessing compliance with national comprehensive cancer network guidelines for elderly patients with stage III colon cancer: the Fox Chase Cancer Center Partners' initiative.

BACKGROUND: Fox Chase Cancer Center Partners (FCCCP) performs an annual quality review of affiliate practices based on National Comprehensive Cancer Network (NCCN) guidelines. Given recent treatment advances, we initiated this medical record review in elderly patients with stage III colon cancer to measure compliance with these guidelines. METHODS: Medical records of 124 patients age ≥ 65 diagnosed with stage III colon cancer between 2003 and 2006 were reviewed. Metrics were developed and based on NCCN guidelines for workup and staging, treatment, and gerontology. Documentation was reviewed via paper (13 sites) and electronic record (2 sites). RESULTS: High compliance with staging and workup guidelines was noted with chest imaging (100%), stage (98%), computed tomography (CT) of the abdomen/pelvis (93%), pathology (91%), and carcinoembryonic antigen (CEA; 91%). Activities of daily living were documented commonly (83%) but colonoscopy less (75%). Age and life expectancy were discussed with the patient in only 49%. Nearly all patients (123 of 124 patients) received adjuvant chemotherapy, with 76 patients (61%) receiving oxaliplatin. Common regimens were FOLFOX (oxaliplatin plus infusional/bolus 5-fluorouracil and folinic acid) 54%, 5-fluorouracil/leucovorin (5-FU/LV; 19%), and capecitabine (12%). Reasons for excluding oxaliplatin were comorbidity (68%), age (19%), and not specified (13%). Three-quarters of the patients had ≥ 12 lymph nodes sampled and 56% identified the radial margin. Nearly all patients (115 = 93%) received surveillance with history and physical and CEA. Surveillance CT was performed in 78% of the patients. CONCLUSIONS: A quality review of community oncology practices can assess implementation of treatment advances. Guideline compliance for elderly patients with stage III colon cancer is generally high. Forty percent did not receive oxaliplatin and documentation of life expectancy was infrequent. Further study of oncologist decision making for elderly colon cancer patients is warranted.

Illness appraisals and self-esteem as correlates of anxiety and affective comorbid disorders in schizophrenia.

Comorbidity of anxiety and affective disorders in people with a diagnosis of schizophrenia is common. This study investigated the hypothesis that greater negative beliefs about illness and lower self-esteem will be significantly associated with the presence of anxiety or affective comorbidity in a sample of persons (n = 138) diagnosed with schizophrenia. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; the Positive and Negative Syndrome Scale; the Global Assessment of Functioning Scale; the Personal Beliefs about Illness Questionnaire; and the Rosenberg Self-Esteem Scale were all completed for each participant. Of the total sample, 62 (44.9%) had a comorbid anxiety or affective disorder. Logistic regression revealed that those with a comorbid anxiety or affective disorder had significantly lower levels of functioning (Global Assessment of Functioning), more negative appraisals of entrapment in psychosis (Personal Beliefs about Illness Questionnaire), and lower levels of self-esteem (Rosenberg Self-Esteem Scale). Although further research is required, the strong association between personal beliefs about self and illness and comorbidity suggests that negative beliefs about psychotic experiences and self-esteem may be linked to the development and maintenance of anxiety and affective comorbid conditions among people with a diagnosis of schizophrenia or the like.

Development and implementation of a medical oncology quality improvement tool for a regional community oncology network: the Fox Chase Cancer Center Partners initiative.

Fox Chase Cancer Center Partners (FCCCP) is a community hospital/academic partnership consisting of 25 hospitals in the Delaware Valley. Originally created in 1986, FCCCP promotes quality community cancer care through education, quality assurance, and access to clinical trial research. An important aspect of quality assurance is a yearly medical oncology audit that benchmarks quality indicators and guidelines and provides a roadmap for quality improvement initiatives in the community oncology clinical office setting. Each year, the FCCCP team and the Partner Medical Oncologists build disease site- and stage-specific indicators based on National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Concordance with multiple indicators is assessed on 20 charts from each community practice. A report for each FCCCP medical oncology practice summarizes documentation, screening recommendations, new drug use, and research trends in a particular disease site. Descriptive statistics reflect indicators met, number of new cases seen per year, number of disease site cases from tumor registry information, and clinical trial accrual total. Education and documentation tools are provided to physicians and oncology office nursing staff. The FCCCP Clinical Operations Team, consisting of medical oncologists and oncology-certified nurses, has conducted quality audits in medical oncology offices for 7 years using NCCN-derived indicators. Successful audits comprising gastric, colorectal, and breast cancer have been the focus of recent evaluations. For the 2005 stage II/III breast cancer evaluation, mean compliance per parameter was 88%, with 15 of 16 practices achieving mean compliance greater than 80%. A large-scale quality assurance audit in a community cancer partner network is feasible. Recent evaluation of localized breast cancer shows high compliance with guidelines and identifies areas for focused education. Partnership between academic and community oncologists produces a quality review process that is broadly applicable and adaptable to changing medical knowledge.

Using comparative genomics to reorder the human genome sequence into a virtual sheep genome.

BACKGROUND: Is it possible to construct an accurate and detailed subgene-level map of a genome using bacterial artificial chromosome (BAC) end sequences, a sparse marker map, and the sequences of other genomes? RESULTS: A sheep BAC library, CHORI-243, was constructed and the BAC end sequences were determined and mapped with high sensitivity and low specificity onto the frameworks of the human, dog, and cow genomes. To maximize genome coverage, the coordinates of all BAC end sequence hits to the cow and dog genomes were also converted to the equivalent human genome coordinates. The 84,624 sheep BACs (about 5.4-fold genome coverage) with paired ends in the correct orientation (tail-to-tail) and spacing, combined with information from sheep BAC comparative genome contigs (CGCs) built separately on the dog and cow genomes, were used to construct 1,172 sheep BAC-CGCs, covering 91.2% of the human genome. Clustered non-tail-to-tail and outsize BACs located close to the ends of many BAC-CGCs linked BAC-CGCs covering about 70% of the genome to at least one other BAC-CGC on the same chromosome. Using the BAC-CGCs, the intrachromosomal and interchromosomal BAC-CGC linkage information, human/cow and vertebrate synteny, and the sheep marker map, a virtual sheep genome was constructed. To identify BACs potentially located in gaps between BAC-CGCs, an additional set of 55,668 sheep BACs were positioned on the sheep genome with lower confidence. A coordinate conversion process allowed us to transfer human genes and other genome features to the virtual sheep genome to display on a sheep genome browser. CONCLUSION: We demonstrate that limited sequencing of BACs combined with positioning on a well assembled genome and integrating locations from other less well assembled genomes can yield extensive, detailed subgene-level maps of mammalian genomes, for which genomic resources are currently limited.

Negative beliefs about self and illness: a comparison of individuals with psychosis with or without comorbid social anxiety disorder.

OBJECTIVE: This study set out to investigate whether socially anxious individuals with psychosis will perceive more loss, entrapment, shame and humiliation, will blame themselves more for their illness and have lower self-esteem than non-socially anxious individuals with psychosis. METHOD: Two groups of participants with psychosis with (n=19) and without (n=19) social anxiety disorder were matched on the basis of gender and diagnosis. RESULTS: There were no differences between the two groups in terms of positive and negative symptoms. Participants with social anxiety had significantly higher levels of self-blame, entrapment, shame and lower self-esteem. Differences in entrapment, shame and self-esteem remained significant after controlling for depression. CONCLUSIONS: Negative beliefs about self and psychosis may be associated with the development of concurrent social anxiety disorder. The clinical and research implications of the findings are discussed.

Pharmacokinetics of linezolid in subjects with renal dysfunction.

Linezolid is a member of a new, unique class of synthetic antibacterial agents called oxazolidinones that are effective against gram-positive bacteria, including vancomycin-resistant organisms. We tested the hypothesis that the linezolid clearance would not be altered in subjects with renal dysfunction. Twenty-four subjects with renal function that ranged from normal to severe chronic impairment were enrolled, including patients with end-stage renal disease who were maintained on hemodialysis. Hemodialysis subjects were studied while they were both on and off dialysis. Linezolid was administered as a single oral 600-mg dose, and plasma and urine samples were assayed for linezolid and metabolites for 48 h for all subjects and for up to 96 h for those subjects with impaired renal function not on dialysis. The total apparent oral clearance of linezolid did not change with renal function and ranged from 92.5 to 109.6 ml/min for subjects not requiring dialysis. For subjects on dialysis, the total apparent oral clearance increased from 76.6 ml/min on their off-dialysis day to 130.0 ml/min on their on-dialysis day. Approximately one-third of the dose was removed by dialysis. However, those subjects with severe renal insufficiency (creatinine clearance, <40 ml/min) and those with end-stage renal disease maintained on hemodialysis had higher concentrations of both metabolites. We conclude that no adjustment of the linezolid dosage is needed in subjects with renal dysfunction or subjects on hemodialysis.