Mucosectomy device-assisted endoscopic resection of gastric subepithelial lesions.

OBJECTIVE: Some gastrointestinal subepithelial tumors (SETs) have malignant potential and complete resection may be required. However, endoscopic submucosal dissection (ESD) can be a tedious procedure and requires a long and extensive training to master. Devices for endoscopic full-thickness resection (EFTR) are limited and are not widely available. We report here a simpler endoscopic method to resect small SETs using a commercially available endoscopic mucosal resection (EMR) kit and enucleation technique. METHODS: All patients with SET who underwent device-assisted resection at our tertiary care hospital from April 2015 to November 2016 were enrolled in this retrospective study. All procedures were performed by a single expert endoscopist with an advanced endoscopy trainee. A mucosectomy and a limited dissection under mucosa were performed to preserve the mucosa before a device-assisted enucleation of the tumor to facilitate endoscopic closure of the defect closure in all cases. RESULTS: A total of 12 patients aged 38-70 y, of whom six were males, were included. Most of the tumors originated from the muscularis propria and were located at the proximal gastric body. The mean procedural duration was 53 minutes (range 23-91 min). The average size of the lesions was 13 mm (range 9-21 mm). The mean duration of hospitalization was 1.3 days. Bleeding and intentional perforation were all successfully managed during the procedure and did not result in any clinically significant adverse event. CONCLUSION: A device-assisted EFTR using a commercially available EMR kit is a safe and feasible method for the endoscopic resection of small gastric extrovert SETs.

Incidence, Survival, and Predictors of Lymph Node Involvement in Early-Stage Gastric Signet Ring Cell Carcinoma in the US.

INTRODUCTION: The incidence, survival, and propensity for nodal metastasis in early-stage gastric signet ring cell carcinoma have not been defined in the United States. These data are critical determinants for treatment allocation. METHODS: Cases of gastric signet ring cell carcinoma were extracted from the national SEER database for the years 2004-2013. Age-standardized incidence was derived. Survival was calculated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify predictors of nodal metastasis. Exclusion criteria included neoadjuvant radiotherapy and lack of histologic or nodal data. RESULTS: A total of 10,624 cases were initially identified. The analysis cohort included 506 cases with early T-stage N0M0 disease following exclusions. The incidence was 0.094 per 100,000 person-years. The 5-year survival rate was 82.8%. Tumor stage (p < 0.001) and size (p < 0.001) were independent predictors of nodal metastasis. The incidence of nodal involvement for T1a tumors <2 cm was 5.4% (p < 0.004). CONCLUSION: The incidence of potentially resectable signet ring gastric carcinoma has not changed significantly over the past decade. While presenting with predominantly high-grade histology, early T-stage disease has a high survival rate. Small T1a tumors have low rates of nodal metastasis, suggesting that an endoscopic resection could be considered in this subset.

Lymph node metastasis in early gastric adenocarcinoma in the United States of America.

BACKGROUND AND STUDY AIMS: Localized approaches are being increasingly used in the management of early gastric adenocarcinoma; however, there are limited data on lymph node metastasis in the US population. This study examined the incidence and predictors of lymph node involvement for early-stage gastric adenocarcinomas in the USA. PATIENTS AND METHODS: Data were abstracted from the national SEER database from 2004 to 2013. Exclusion criteria included: cases with unknown tumor characteristics, unknown patient characteristics, metastatic disease, neoadjuvant radiation, and lack of surgical resection or lymph node evaluation. Univariate and multivariable analyses were conducted to assess the relationship of tumor stage, grade, and size, and patient sex, race, and age with nodal involvement. RESULTS: 43 769 cases of gastric adenocarcinoma were initially abstracted. After exclusions, 1577 patients remained for analysis. Multivariable analysis revealed that tumor stage (P < 0.001), grade (P = 0.008), and size (P < 0.001) were independent predictors of nodal metastasis. For low grade T1a tumors, nodal metastasis was present in 1.7 %, 1.7 %, 4.5 %, 4.1 %, and 20 % of tumors 0 - 1 cm, 1 - 2 cm, 2 - 3 cm, 3 - 4 cm, and ≥ 4 cm in size, respectively (P < 0.001), and in 8.4 %, 18.0 %, 19.5 %, 22.0 %, and 35.8 % of T1b tumors, respectively (P < 0.001). CONCLUSIONS: Low grade T1a tumors < 4 cm in size have low rates of nodal metastasis in the US population and may warrant consideration for local resection. Larger, higher grade T1b tumors have high rates of nodal metastasis in the US population and lymph node dissection may be indicated for patients who are surgical candidates.

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.

Measuring insight through patient self-report: an in-depth analysis of the factor structure of the Birchwood Insight Scale.

Little research has focused on item analysis and factor structure of the most commonly used measures of insight. We examined the factorial structure of the Birchwood Insight Scale (BIS), a brief, easy-to-administer, self-report measure. We studied the BIS in 327 first-episode psychosis patients, including a test sample (n=163) and a validation sample (n=164). We then used data from 100 patients with chronic serious mental illnesses as a second, external validation sample. Exploratory factor analysis was conducted with the test subsample, and confirmatory factor analyses with the two validation samples. Confirmatory factor analyses (in both the first-episode psychosis validation sample and the chronic serious mental illness sample) indicated that a single-factor solution, with seven items loading on a single factor-with item 1 ("Some of your symptoms are made by your mind") eliminated-was the best-fitting model. Seven of the eight original BIS items loading on a single factor fit the data well in these samples. Researchers using this efficient measure of patient-reported insight should assess the item distributions and factor structure of the BIS in their samples, and potentially consider eliminating item 1.

The influence of neighborhood characteristics on police officers' encounters with persons suspected to have a serious mental illness.

OBJECTIVE: Police officers' decisions and behaviors are impacted by the neighborhood context in which police encounters occur. For example, officers may use greater force and be more likely to make arrests in disadvantaged neighborhoods. We examined whether neighborhood characteristics influence police encounters with individuals suspected to have a serious mental illness, addictive disorder, or developmental disability. METHOD: We obtained data on 916 encounters from 166 officers in six jurisdictions in Georgia, USA and abstracted geographical data pertaining to the location of these encounters from United States Decennial Census data. Encounters were nested within 163 census tracts. Officer-reported data covered general encounter characteristics, the officer's perception of the subject's condition, subject demographics, use of force, and disposition of the encounter (e.g., arrest v. referral or transport to treatment services). Geographical data included 17 variables representing population and housing characteristics of the census tracts, from which three indices pertaining to neighborhood income, stability, and immigration status were derived using factor-analytic techniques. We then examined associations of these indices with various encounter-related variables using multi-level analysis. RESULTS: Encounters taking place in higher-income and higher-stability census tracts were more likely to be dispatch-initiated and take place in a private home compared to those in lower-income and lower-stability neighborhoods. In higher-income neighborhoods, encounters were more likely to involve a subject suspected to have a mental illness (as opposed to an addictive disorder or developmental disability) and less likely to involve a subject suspected to have alcohol problems. The officer's level of force used was not associated with neighborhood factors. Regarding disposition, although the likelihood of arrest was unrelated to neighborhood characteristics, encounters taking place in higher-immigrant neighborhoods were more likely to result in referral or transport to services than those in lower-immigrant neighborhoods. CONCLUSION: Neighborhood characteristics are important to consider in research on police interactions with individuals with serious mental illnesses, addictive disorders, or developmental disabilities. Such research could inform departmental training policies and procedures based on the needs of the jurisdictions served.

Measuring trauma and stressful events in childhood and adolescence among patients with first-episode psychosis: initial factor structure, reliability, and validity of the Trauma Experiences Checklist.

Past trauma and stressful events, especially in childhood and adolescence, are common among individuals with serious mental illnesses like schizophrenia. Traumatic experiences are thought to be a socio-environmental risk factor not only for poorer outcomes, but also potentially for the onset of these disorders. Because improved measurement tools are needed, we developed and studied, among 205 first-episode psychosis patients, the factor structure, internal consistency reliability, and initial validity of the Trauma Experiences Checklist (TEC), our measure of trauma and stressful events during childhood/adolescence. We assessed validity of subscales using correlations with Childhood Trauma Questionnaire-Short Form, Parental Harsh Discipline, Violence Exposure, and TEC-Informant Version scores. Exploratory factor analysis resulted in two internally consistent subscales (Cronbach's α=0.79 and 0.80, respectively), interpersonal abuse and family stress, and violence, death, and legal involvement. Scores from the former subscale were substantially associated with CTQ-SF physical, emotional, and sexual abuse (r=0.42-0.57, all p<0.001) and Violence Exposure (r=0.49, p<0.001). On the other hand, violence, death, and legal involvement scores were most highly correlated with Violence Exposure (r=0.49, p<0.001), and not with most CTQ-SF subscales. The TEC is a potentially useful tool in assessing diverse traumatic life events across various social contexts during childhood and adolescence.

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.

An examination of associations between the inability to taste phenylthiocarbamide (PTC) and clinical characteristics and trait markers in first-episode, nonaffective psychotic disorders.

Research findings are mixed as to whether or not the inability to taste phenylthiocarbamide (PTC) might represent an endophenotypic trait marker for schizophrenia. We hypothesized associations between PTC-tasting status and select clinical characteristics and trait markers in patients with psychotic disorders that, if present, would provide support for the inability to taste PTC as a trait marker. In a first-episode psychosis sample (n=93), we measured PTC tasting, family history of psychosis, age at onset of prodrome and psychosis, severity of positive and negative symptoms, global impairment in functioning, neurological soft signs, and four neurocognitive domains (verbal learning/memory, visual learning/memory, verbal working memory, and spatial working memory). Associations between PTC-non-tasting and clinical/neurocognitive variables were examined with χ(2) tests and independent samples t tests. Among participants, 67.7% tasted PTC in comparison to a strip of control paper, and 25.8% were non-tasters. Tasters and non-tasters did not show statistically significant differences with respect to family history, age at onset, severity of symptoms, neurological soft signs, or the four neurocognitive domains. In conjunction with other findings, it is unlikely that PTC-non-tasting is a trait marker of schizophrenia, though a conclusive study is warranted.

Phonetic measures of reduced tongue movement correlate with negative symptom severity in hospitalized patients with first-episode schizophrenia-spectrum disorders.

BACKGROUND: Aprosody, or flattened speech intonation, is a recognized negative symptom of schizophrenia, though it has rarely been studied from a linguistic/phonological perspective. To bring the latest advances in computational linguistics to the phenomenology of schizophrenia and related psychotic disorders, a clinical first-episode psychosis research team joined with a phonetics/computational linguistics team to conduct a preliminary, proof-of-concept study. METHODS: Video recordings from a semi-structured clinical research interview were available from 47 first-episode psychosis patients. Audio tracks of the video recordings were extracted, and after review of quality, 25 recordings were available for phonetic analysis. These files were de-noised and a trained phonologist extracted a 1-minute sample of each patient's speech. WaveSurfer 1.8.5 was used to create, from each speech sample, a file of formant values (F0, F1, F2, where F0 is the fundamental frequency and F1 and F2 are resonance bands indicating the moment-by-moment shape of the oral cavity). Variability in these phonetic indices was correlated with severity of Positive and Negative Syndrome Scale negative symptom scores using Pearson correlations. RESULTS: A measure of variability of tongue front-to-back position-the standard deviation of F2-was statistically significantly correlated with the severity of negative symptoms (r=-0.446, p=0.03). CONCLUSION: This study demonstrates a statistically significant and meaningful correlation between negative symptom severity and phonetically measured reductions in tongue movements during speech in a sample of first-episode patients just initiating treatment. Further studies of negative symptoms, applying computational linguistics methods, are warranted.

Life and treatment goals of individuals hospitalized for first-episode nonaffective psychosis.

First-episode psychosis typically emerges during late adolescence or young adulthood, interrupting achievement of crucial educational, occupational, and social milestones. Recovery-oriented approaches to treatment may be particularly applicable to this critical phase of the illness, but more research is needed on the life and treatment goals of individuals at this stage. Open-ended questions were used to elicit life and treatment goals from a sample of 100 people hospitalized for first-episode psychosis in an urban, public-sector setting in the southeastern United States. Employment, education, relationships, housing, health, and transportation were the most frequently stated life goals. When asked about treatment goals, participants' responses included wanting medication management, reducing troubling symptoms, a desire to simply be well, engaging in counseling, and attending to their physical health. In response to queries about specific services, most indicated a desire for both vocational and educational services, as well as assistance with symptoms and drug abuse. These findings are interpreted and discussed in light of emerging or recently advanced treatment paradigms-recovery and empowerment, shared decision-making, community and social reintegration, and phase-specific psychosocial treatment. Integration of these paradigms would likely promote recovery-oriented tailoring of early psychosocial interventions, such as supported employment and supported education, for first-episode psychosis.

Prevalence and psychosocial correlates of prior incarcerations in an urban, predominantly African-American sample of hospitalized patients with first-episode psychosis.

High rates of incarceration and criminal justice system recidivism among individuals with serious mental illnesses have long been topics of concern, but few studies have examined rates of prior incarceration at the point of first treatment contact. In a sample of 109 urban, low-income, predominantly African-American patients hospitalized for first-episode psychosis, 57.8 percent reported a history of incarceration. Among those who reported having ever been incarcerated, 58.1 percent had more than one past incarceration, and the mean number of incarcerations was 2.9 ± 3.4. Patients with a history of incarceration had completed fewer years of education, had poorer late-adolescence premorbid academic functioning, reported an earlier age at initiation of cannabis use, and were more likely to have cannabis and alcohol dependence or abuse. Incarceration was also associated with a greater number of psychosocial problems and more severe general psychopathology symptoms. These findings of excessively high rates of past incarceration among urban, predominantly African-American, first-episode psychosis patients, along with the associations between past incarceration and diverse adverse psychosocial and clinical characteristics, serve as a call to action for researchers in early psychosis, program developers, policy-makers, and clinical and forensic psychiatrists.