The relationship between the resting state functional connectivity and social cognition in schizophrenia: Results from the Italian Network for Research on Psychoses.

Deficits in social cognition (SC) interfere with recovery in schizophrenia (SZ) and may be related to resting state brain connectivity. This study aimed at assessing the alterations in the relationship between resting state functional connectivity and the social-cognitive abilities of patients with SZ compared to healthy subjects. We divided the brain into 246 regions of interest (ROI) following the Human Healthy Volunteers Brainnetome Atlas. For each participant, we calculated the resting-state functional connectivity (rsFC) in terms of degree centrality (DC), which evaluates the total strength of the most powerful coactivations of every ROI with all other ROIs during rest. The rs-DC of the ROIs was correlated with five measures of SC assessing emotion processing and mentalizing in 45 healthy volunteers (HVs) chosen as a normative sample. Then, controlling for symptoms severity, we verified whether these significant associations were altered, i.e., absent or of opposite sign, in 55 patients with SZ. We found five significant differences between SZ patients and HVs: in the patients' group, the correlations between emotion recognition tasks and rsFC of the right entorhinal cortex (R-EC), left superior parietal lobule (L-SPL), right caudal hippocampus (R-c-Hipp), and the right caudal (R-c) and left rostral (L-r) middle temporal gyri (MTG) were lost. An altered resting state functional connectivity of the L-SPL, R-EC, R-c-Hipp, and bilateral MTG in patients with SZ may be associated with impaired emotion recognition. If confirmed, these results may enhance the development of non-invasive brain stimulation interventions targeting those cerebral regions to reduce SC deficit in SZ.

Pancreatojejunostomy: standing on the shoulders of giants. A single centre retrospective analysis.

Gaining experience in pancreatic surgery could be demanding especially when minimally invasive approach is used. Pancreatojejunostomy (PJ) is one of the most critical steps during pancreatoduodenectomy (PD). Our aim was to investigate the impact of a surgeon's experience in performing PJ, especially in a subgroup of patients undergoing laparoscopic PD (LPD). Data of consecutive patients undergoing PD from 2017 to 2022 were prospectively collected and retrospectively analyzed. Patients were divided into two groups: M group included patients in which PJ was performed by an experienced surgeon, D group included those receiving PJ by a less experienced one. The groups were compared in terms of postoperative outcomes. 187 patients were selected (157 in group M and 30 in group D). The cohorts differed in terms of median age (68 vs 74 years, p = 0.016), and previous abdominal surgery (41.4% vs 66.7%, p = 0.011), while no difference was found regarding risk of postoperative pancreatic fistula (POPF). The groups did not differ in terms of surgical outcomes. POPF rate was 15.9% and 10% in the M and D group (p = 0.578), respectively. Among patients undergoing laparoscopic PJ POPF rate was 16.0% and 17.7% in the M and D group (p = 0.867), respectively, without difference. No difference was found in terms of POPF in patients undergoing PD independently from the surgeon who performed the PJ, even during LPD. Moderate/high FRS, BMI > 30 kg/m2 and male sex, but not the surgeon who performed the PJ anastomosis, were independent predictors of POPF.

Physical activity influences adherence to pharmacological treatments in patients with severe mental disorders: results from the multicentric, randomized controlled LIFESTYLE trial.

Introduction: Poor adherence to pharmacological treatment is frequent in people with severe mental disorders and it often causes lack of effectiveness of many psychotropic drugs. Thus, efforts should be made to improve adherence to pharmacological treatments in patients with these disorders. Methods: In this paper, based on the LIFESTYLE randomized, controlled multicentric trial, we aim to: 1) assess the level of adherence in a real-world sample of patients with severe mental disorders; 2) evaluate differences in treatment adherence according to patients' socio-demographic and clinical characteristics; 3) evaluate the impact of an innovative psychosocial intervention, on patients' adherence to treatments. The Lifestyle Psychosocial Group Intervention consists of group sessions, focused on different lifestyle behaviours, including healthy diet; physical activity; smoking habits; medication adherence; risky behaviours; and regular circadian rhythms. At end of each session a 20-min moderate physical activity is performed by the whole group. Results: The sample consists of 402 patients, mainly female (57.1%, N = 229), with a mean age of 45.6 years (±11.8). Less than 40% of patients reported a good adherence to pharmacological treatments. Adherence to treatments was not influenced by gender, age, diagnosis and duration of illness. At the end of the intervention, patients receiving the experimental intervention reported a significant improvement in the levels of adherence to treatments (T0: 35.8% vs. T3: 47.6%, p < 0.005). Patients practicing moderate physical activity reported a two-point improvement in the levels of adherence [odds ratio (OR): 1,542; 95% confidence intervals (CI): 1,157-2,055; p < 0.001], even after controlling for several confounding factors. Discussion: The experimental lifestyle intervention, which can be easily implemented in the routine clinical practice of mental health centres, was effective in improving adherence to pharmacological treatments.

Discrepancy Between Patient and Caregiver Estimate of Apathy Predicts Dementia in Patients with Amnestic Mild Cognitive Impairment.

BACKGROUND: Apathy is a frequent behavioral symptom of Alzheimer's disease (AD). The Apathy Evaluation Scale (AES) is a tool exploring the perception of apathy by both caregivers (CG-AES) and patients (PT-AES), and the discrepancy in their ratings is a proxy of patients' disease unawareness. OBJECTIVE: To assess in a cohort study of patients with amnesic mild cognitive impairment (aMCI) whether apathy and awareness of apathy predict progression to dementia and timing. METHODS: From the global AES scores of 110 patients with aMCI and their caregivers, we obtained two principal indices for analysis: 1) 'Apathy', the mean of PT-AES and CG-AES, and 2) 'Discrepancy', obtained by subtracting CG-AES from PT-AES. Patients were followed with visits every six months for three years or until dementia. AES indices and the principal demographical/neuropsychological variables were filtered from multicollinearity. The most robust variables entered a logistic regression model and survival analyses (Cox regression, log-rank test of Kaplan-Meier curves) to estimate which predicted the risk and timing of progression, respectively. RESULTS: Sixty patients (54.5%) developed dementia (57 AD) after 6.0-36.0 months, 22 (20%) remained in an MCI stage, and 28 (25.5%) dropped out. 'Discrepancy' was a robust and accurate predictor of the risk of progression (AUC = 0.73) and, after binarization according to a computed cutoff, of timing to dementia. CONCLUSION: A structured evaluation of apathy, both self-assessed and estimated by caregivers, can provide useful information on the risk and timing of progression from aMCI to dementia. The discrepancy between the two estimates is a fairly reliable index for prediction purposes as a proxy of disease unawareness.

Linguistic profile automated characterisation in pluripotential clinical high-risk mental state (CHARMS) conditions: methodology of a multicentre observational study.

INTRODUCTION: Language is usually considered the social vehicle of thought in intersubjective communications. However, the relationship between language and high-order cognition seems to evade this canonical and unidirectional description (ie, the notion of language as a simple means of thought communication). In recent years, clinical high at-risk mental state (CHARMS) criteria (evolved from the Ultra-High-Risk paradigm) and the introduction of the Clinical Staging system have been proposed to address the dynamicity of early psychopathology. At the same time, natural language processing (NLP) techniques have greatly evolved and have been successfully applied to investigate different neuropsychiatric conditions. The combination of at-risk mental state paradigm, clinical staging system and automated NLP methods, the latter applied on spoken language transcripts, could represent a useful and convenient approach to the problem of early psychopathological distress within a transdiagnostic risk paradigm. METHODS AND ANALYSIS: Help-seeking young people presenting psychological distress (CHARMS+/- and Clinical Stage 1a or 1b; target sample size for both groups n=90) will be assessed through several psychometric tools and multiple speech analyses during an observational period of 1-year, in the context of an Italian multicentric study. Subjects will be enrolled in different contexts: Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa-IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Mental Health Department-territorial mental services (ASL 3-Genoa), Genoa, Italy; and Mental Health Department-territorial mental services (AUSL-Piacenza), Piacenza, Italy. The conversion rate to full-blown psychopathology (CS 2) will be evaluated over 2 years of clinical observation, to further confirm the predictive and discriminative value of CHARMS criteria and to verify the possibility of enriching them with several linguistic features, derived from a fine-grained automated linguistic analysis of speech. ETHICS AND DISSEMINATION: The methodology described in this study adheres to ethical principles as formulated in the Declaration of Helsinki and is compatible with International Conference on Harmonization (ICH)-good clinical practice. The research protocol was reviewed and approved by two different ethics committees (CER Liguria approval code: 591/2020-id.10993; Comitato Etico dell'Area Vasta Emilia Nord approval code: 2022/0071963). Participants will provide their written informed consent prior to study enrolment and parental consent will be needed in the case of participants aged less than 18 years old. Experimental results will be carefully shared through publication in peer-reviewed journals, to ensure proper data reproducibility. TRIAL REGISTRATION NUMBER: DOI:10.17605/OSF.IO/BQZTN.

Improving physical activity and diet in patients with severe mental disorders: Results from the LIFESTYLE multicentric, real-world randomized controlled trial.

Aims of the present study are to test the efficacy of a lifestyle group intervention, compared to a brief psychoeducational intervention, on levels of physical activity and dietary habits in a real-world sample of patients with severe mental disorders. The study, funded by the Italian Ministry of Education, has been carried out in six Italian University psychiatric outpatient units. All patients were randomly assigned to the experimental or control group and were assessed through standardized assessment instruments at baseline and six months after randomization. Of the 401 recruited patients, 43.3% had a diagnosis of bipolar disorder, 29.9% of psychosis and 26.9% of major depression. Patients were mainly female (57%), with a mean age of 45.6±11.8 years. Treated patients have almost 8 times the likelihood to show an increase of the total MET (OR: 8.02; p < .001) and of the walking MET (OR: 7.68; p < .001) and are more likely to increase the weekly consumption of vegetables (OR= 1.98, p < .05) and to reduce that of junk food (OR:0.23; p < .05). The present study support the notion that patients with severe mental disorders can improve their lifestyle behaviours and that, with appropriate support, they can achieve a healthy living.

Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis.

PURPOSE: The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications. METHODS: Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed. RESULTS: A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations. CONCLUSIONS: Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.

How to improve the physical health of people with severe mental illness? A multicentric randomized controlled trial on the efficacy of a lifestyle group intervention.

BACKGROUND: People with severe mental illnesses (SMI) have a mortality rate two times higher compared to the general population, with a decade of years of life lost. In this randomized controlled trial (RCT), we assessed in a sample of people with bipolar disorder, major depressive disorder, and schizophrenia spectrum disorder, the efficacy of an innovative psychosocial group intervention compared to a brief psychoeducational group intervention on patients' body mass index (BMI), body weight, waist circumference, Framingham and HOMA-IR indexes. METHODS: This is a multicentric RCT with blinded outcome assessments carried out in six Italian university centers. After recruitment patients were randomized to receive a 6-month psychosocial intervention to improve patients' physical health or a brief psychoeducational intervention. All recruited patients were assessed with standardized assessment instruments at baseline and after 6 months. Anthropometric parameters and blood samples have also been collected. RESULTS: Four-hundred and two patients with a diagnosis of bipolar disorder (43.3%), schizophrenia or other psychotic disorder (29.9%), or major depression (26.9%) were randomly allocated to the experimental (N = 206) or the control group (N = 195). After 6 months, patients from the experimental group reported a significant reduction in BMI (odds ratio [OR]: 1.93, 95% confidence intervals [CI]: 1.31-2.84; p < 0.001), body weight (OR = 4.78, 95% CI: 0.80-28.27, p < 0.05), and waist circumference (OR = 5.43, 95% CI: 1.45-20.30, p < 0.05). Participants with impaired cognitive and psychosocial functioning had a worse response to the intervention. CONCLUSIONS: The experimental group intervention was effective in improving the physical health in SMI patients. Further studies are needed to evaluate the feasibility of this intervention in real-world settings.

[Lifestyle in patients with severe mental disorders: a new target for psychosocial interventions?] / Stili di vita nei pazienti con disturbi mentali gravi: quali opportunità per il trattamento?

INTRODUCTION: Patients with severe mental disorders (namely schizophrenia, major depression and bipolar disorder) have a reduced life expectancy of at least 10 to 25 years compared with the general population. This mortality gap is due to the higher prevalence of comorbid physical disorders (such as diabetes, hypertension and cardiovascular diseases) in these patients compared to the general population. Factors contributing to the mortality gap include lack of access to primary care services, severity of clinical symptoms, internalized stigma and discrimination by healthcare professionals, pharmacological treatments and unhealthy lifestyle behaviours. Several international studies have highlighted the high prevalence of unhealthy lifestyle behaviours in patients with severe mental disorders, but a few data are available from Italian real-world settings. AIM: The present study aims to: 1) describe the lifestyle behaviours adopted by a sample of real-world patients affected by severe mental disorders; 2) identify differences in lifestyle behaviours according to diagnostic category. MATERIALS: The final sample consisted of 402 patients, mainly female (57%), with a mean age of 45.8±11.8 years. 35% of them suffers from moderate obesity and 40% of them is affected by hyperinsulinemia, hypercolestereloemia and hypertrygliceridemia. 70% of patients has sedentary behaviours. Moderate to severe nicotine dependence is reported by 42% of patients. Patients with bipolar disorders are more frequently smokers compared to other patients. No significant differences in lifestyle behaviours have been found among the three diagnostic groups. RESULTS AND CONCLUSIONS: Our data confirm that patients with severe mental disorders adopt unhealthy lifestyle behaviours, regardless their diagnosis. New psychosocial interventions, including motivational and psychoeducational components and targeting lifestyle behaviours, should be developed and disseminated in order to reduce the mortality gap.

The association between insight and depressive symptoms in schizophrenia: Undirected and Bayesian network analyses.

BACKGROUND: Greater levels of insight may be linked with depressive symptoms among patients with schizophrenia, however, it would be useful to characterize this association at symptom-level, in order to inform research on interventions. METHODS: Data on depressive symptoms (Calgary Depression Scale for Schizophrenia) and insight (G12 item from the Positive and Negative Syndrome Scale) were obtained from 921 community-dwelling, clinically-stable individuals with a DSM-IV diagnosis of schizophrenia, recruited in a nationwide multicenter study. Network analysis was used to explore the most relevant connections between insight and depressive symptoms, including potential confounders in the model (neurocognitive and social-cognitive functioning, positive, negative and disorganization symptoms, extrapyramidal symptoms, hostility, internalized stigma, and perceived discrimination). Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association between insight and depression. RESULTS: After adjusting for confounders, better levels of insight were associated with greater self-depreciation, pathological guilt, morning depression and suicidal ideation. No difference in global network structure was detected for socioeconomic status, service engagement or illness severity. The DAG confirmed the presence of an association between greater insight and self-depreciation, suggesting the more probable causal direction was from insight to depressive symptoms. CONCLUSIONS: In schizophrenia, better levels of insight may cause self-depreciation and, possibly, other depressive symptoms. Person-centered and narrative psychotherapeutic approaches may be particularly fit to improve patient insight without dampening self-esteem.•Better insight seems associated with depressive symptoms in schizophrenia.•Network analyses were used to explore this association in a large sample.•Insight was associated with self-depreciation, guilt, and suicidal ideation.•Although cross-sectional, data suggest causal direction from insight to depression.

Effectiveness of Cerebellar Circuitry Modulation in Schizophrenia: A Systematic Review.

Structural and functional abnormalities of the cerebellum have been observed in schizophrenia since the first neuroimaging studies. More recently, the functions of the cerebellum have been extended beyond sensorimotor control to include participation in higher-level cognition and affective regulation. Consistently, the "cognitive dysmetria" theory posits that dysfunctions of cortical-subcortical-cerebellar circuitry may be crucial for the pathogenesis of different clinical features of schizophrenia. This conceptual framework offers a set of testable hypotheses, now that various tools to exert direct modulation of cerebellar activity are available. We conducted a systematic review of studies examining the effects of cerebellar modulation in schizophrenia. Two independent authors conducted a search within PubMed for articles published up to April 2019 and identified 10 studies (three randomized controlled trials, two open-label studies, two case reports, one preclinical study) describing the effects of cerebellar circuitry modulation in patients with schizophrenia or animal models. The majority of interventions were uncontrolled and used stimulation of the cerebellar vermis, using transcranial magnetic stimulation or transcranial direct-current stimulation. Most studies detected improvements after cerebellar modulation. Clinical changes mostly pertained the domains of negative symptoms, depressive symptoms and cognitive functions. In conclusion, few studies examined the effects of cerebellar modulation in schizophrenia but yielded promising results. This approach may hold therapeutic potential, pending further methodologically robust replication.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population.

BACKGROUND: Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide. AIM: The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population. MATERIAL AND METHODS: The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences. RESULTS: The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain. DISCUSSION AND CONCLUSIONS: The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

A standardised and simplified technique for laparoscopic resection of the splenic flexure.

The splenic flexure is an uncommon location of colorectal cancer, being involved in 2%-3% of cases. The low chance of being engaged in resecting cancer of the splenic flexure can make it difficult for surgeons to build their learning curve and to achieve a reliable experience. As the majority of colectomies are still performed by low-volume surgeons, there is growing agreement that providing local services with adequate surgical education and training could be an effective strategy to improve outcomes and global health. Arming surgeons with simplified and easy-to-learn surgical techniques could be an important step of this strategy. A novel simplified technique for laparoscopic resection of the splenic flexure is presented, which combines laparoscopic mobilisation of the right colon with extracorporeal vascular ligation and bowel anastomosis.

Intestinal obstruction caused by endometriosis: Endoscopic stenting and expedited laparoscopic resection avoiding stoma. A case report and review of the literature.

INTRODUCTION: Endometriosis is the growth of endometrium outside the uterine cavity. In 5-15% of cases the disease can affect the colon and small bowel, causing complete obstruction and requiring resection in about 1% of cases. CASE SUMMARY: We describe a case of sigmoid obstruction due to endometriosis in a 38 years old woman with personal history of endometriosis. She was admitted for abdominal pain and constipation. The patient was treated with endoscopic stenting and subsequent laparoscopic sigmoidectomy. DISCUSSION: Bowel obstruction caused by endometriosis is a rare event. Its diagnosis can thus be a clinical and radiological challenge but it may be suspected in all young woman with colonic obstruction. At present, the management of endometriosis is an integrate approach of both medical and surgical therapy. In case of irreversible colonic obstruction surgery is mandatory. The treatment of choice is usually an emergency procedure (either Hartmann procedure or resection and anastomosis with stoma placement). This approach entails all the risks related to emergency procedures and can have important psychological and biological drawbacks. CONCLUSION: Endoscopic prosthesis placement as bridge to surgery is a feasible therapeutic strategy in colonic obstruction due to endometriosis. It brings about all the advantages of an expedited one step laparoscopic surgical procedure. Laparoscopic elective resection has a lower rate of stoma placement and has a postoperative pregnancy rate grater than open surgery.

Physical Exercise in Major Depression: Reducing the Mortality Gap While Improving Clinical Outcomes.

Major depression shortens life while the effectiveness of frontline treatments remains modest. Exercise has been shown to be effective both in reducing mortality and in treating symptoms of major depression, but it is still underutilized in clinical practice, possibly due to prevalent misperceptions. For instance, a common misperception is that exercise is beneficial for depression mostly because of its positive effects on the body ("from the neck down"), whereas its effectiveness in treating core features of depression ("from the neck up") is underappreciated. Other long-held misperceptions are that patients suffering from depression will not engage in exercise even if physicians prescribe it, and that only vigorous exercise is effective. Lastly, a false assumption is that exercise may be more harmful than beneficial in old age, and therefore should only be recommended to younger patients. This narrative review summarizes relevant literature to address the aforementioned misperceptions and to provide practical recommendations for prescribing exercise to individuals with major depression.

Emergency Presentation of Gastric Ectopic Pancreas.

Ectopic pancreas is a rare embryological abnormality apparently not in association with others. Stomach and duodenum are the most common organs involved. Symptoms are nonspecific. Patients may complain of dyspepsia, abdominal pain or intestinal obstruction. Malignant evolution of ectopic pancreatic cells has been reported. Diagnosis can be very challenging due to the rarity of the disease and the absence of specific symptoms and radiological findings. We report two cases of young-adult men admitted to the emergency department due to acute upper gastro-intestinal and pancreatic symptoms. In both cases, during upper gastrointestinal endoscopy no mucosal vegetations were found. Endoscopic ultrasonography revealed gastric lesions originating from the muscularis propria, with a pattern suspected but not conclusive for malignancy. Fine needle aspiration was inconclusive in both cases. The patients underwent abdominal computed tomography, that showed gastric masses originating from the antrum and the lesser curvature of the stomach, with enlarged locoregional lymph nodes. According to the patients' symptoms, family history, radiological and cytological findings, the patients were scheduled for an explorative laparoscopy. In both cases, gastric ectopic pancreas was found. Clinical presentation of ectopic pancreas is heterogeneous and the diagnosis can be challenging, especially in an emergency setting. Endoscopic ultrasonography and fine needle aspiration can be useful for the diagnosis and clinical staging, but they can be unspecific. Diagnostic-therapeutic laparoscopy should be considered in symptomatic patients.

Laparoscopic Repair of a Sciatic Hernia Containing the Ipsilateral Ovary: Case Report and Review of the Literature.

BACKGROUND: Sciatic hernia is a very rare pelvic floor hernia, but apparently its incidence has been growing in the past few years. The symptomatology is usually aspecific or absent, but in some cases complications such as intestinal obstruction, intractable pain, or urinary sepsis can occur. The usual treatment is the surgical correction of the defect, mainly with an open approach. CASE SUMMARY: We describe a case of sciatic hernia causing intermittent abdominal pain and subocclusive symptoms. The hernia has been treated with a laparoscopic technique using a polypropylene extraperitoneal mesh fixed with biological glue. The postoperative course of our patient was uneventful and at 3 months follow-up, no relapse or symptoms occurred. CONCLUSION: The laparoscopic treatment of this rare type of hernia appears to be a feasible and safe surgical option with all the advantages of the mini-invasive technique.

Suicide Risk in Alzheimer's Disease: A Systematic Review.

Suicidal behavior is a common cause of death in the elderly and is often accompanied in this population by disabilities and psychosocial impairment. Alzheimer's-related neuropathological changes are commonly found in the brains of older people. Although Alzheimer's disease (AD) has been reported to be a potential predictor for suicidal behavior, the relationship between suicidal behavior and AD has not been systematically explored. The aim of this paper is to review the current literature regarding the association between suicide risk and AD in an effort to identify the most relevant risk and protective factors for suicide. A detailed strategy was used to search for relevant articles in Pubmed, Scopus, PsycINFO, and Science Direct on suicidal behavior and AD for the period of January 1980 to August 2015. The search yielded 164 articles, of which 21 met our inclusion criteria. Eight crosssectional, two longitudinal, 3 retrospective, and eight case reports (of 11 patients) examined the association between suicide risk and AD. Suicide occurs in AD even many years after the diagnosis of dementia, and patients who have attempted suicide once are at a higher risk of dying from suicide. AD is associated with a moderate risk of suicide, and clinicians working with AD patients should undertake an appropriate assessment of their suicidal risk. However, more prospective studies are needed to clarify the association between AD and suicide risk.

The "Insight Paradox" in Schizophrenia: Magnitude, Moderators and Mediators of the Association Between Insight and Depression.

The so-called "insight paradox" posits that among patients with schizophrenia higher levels of insight are associated with increased levels of depression. Although different studies examined this issue, only few took in account potential confounders or factors that could influence this association. In a sample of clinically stable patients with schizophrenia, insight and depression were evaluated using the Scale to assess Unawareness of Mental Disorder and the Calgary Depression Scale for Schizophrenia. Other rating scales were used to assess the severity of psychotic symptoms, extrapyramidal symptoms, hopelessness, internalized stigma, self-esteem, and service engagement. Regression models were used to estimate the magnitude of the association between insight and depression while accounting for the role of confounders. Putative psychological and sociodemographic factors that could act as mediators and moderators were examined using the PROCESS macro. By accounting for the role of confounding factors, the strength of the association between insight into symptoms and depression increased from 13% to 25% explained covariance. Patients with lower socioeconomic status (F = 8.5, P = .04), more severe illness (F = 4.8, P = .03) and lower levels of service engagement (F = 4.7, P = .03) displayed the strongest association between insight and depression. Lastly, hopelessness, internalized stigma and perceived discrimination acted as significant mediators. The relationship between insight and depression should be considered a well established phenomenon among patients with schizophrenia: it seems stronger than previously reported especially among patients with lower socioeconomic status, severe illness and poor engagement with services. These findings may have relevant implications for the promotion of insight among patients with schizophrenia.

Second-generation antipsychotics and neuroleptic malignant syndrome: systematic review and case report analysis.

BACKGROUND: Neuroleptic malignant syndrome (NMS) is a rare, severe, idiosyncratic adverse reaction to antipsychotics. Second-generation antipsychotics (SGAs) were originally assumed to be free from the risk of causing NMS, however several cases of NMS induced by SGAs (SGA-NMS) have been reported. OBJECTIVES: The aim of this study was to systematically review available studies and case reports on SGA-NMS and compare the presentation of NMS induced by different SGAs. DATA SOURCES: Citations were retrieved from PubMed up to November 2013, and from reference lists of relevant citations. STUDY ELIGIBILITY CRITERIA: Eligibility criteria included (a) primary studies reporting data on NMS, with at least 50 % of the sample receiving SGAs; or (b) case reports and case reviews reporting on NMS induced by SGA monotherapy, excluding those due to antipsychotic withdrawal. STUDY APPRAISAL AND SYNTHESIS METHODS: A standardized method for data extraction and coding was developed for the analysis of eligible case reports. RESULTS: Six primary studies and 186 individual cases of NMS induced by SGAs were included. Primary studies suggest that SGA-NMS is characterized by lower incidence, lower clinical severity, and less frequent lethal outcome than NMS induced by first-generation antipsychotics. Systematic analysis of case reports suggests that even the most recently marketed antipsychotics are not free from the risk of inducing NMS. Furthermore, clozapine-, aripiprazole- and amisulpride-induced NMS can present with atypical features more frequently than other SGA-NMS, i.e. displaying less intense extrapyramidal symptoms or high fever. LIMITATIONS: Case reports report non-systematic data, therefore analyses may be subject to bias. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Clinicians should be aware that NMS is virtually associated with all antipsychotics, including those most recently marketed. Although apparently less severe than NMS induced by older antipsychotics, SGA-NMS still represent a relevant clinical issue.