Systematic review reveals heterogeneity in the use of the Scale to Assess Unawareness of Mental Disorder (SUMD).

The Scale to Assess Unawareness of Mental Disorder (SUMD) is one of the most widely used instruments to measure insight into mental disorders. The aim of this study was to review all studies using the SUMD in the last 20 years. We performed an electronic search of MEDLINE using PubMed to identify all relevant studies published from 1993 to 2012. The following data were extracted from each article: characteristics of the SUMD (version, rating scale, scoring, and item/dimension used), methodological aspects (country, language, subject inclusion criteria, and sample size), and statistical methods to analyse insight. Of the 133 articles screened, 100 studies were included in the review. Fifty-two studies were published over the past five years. The SUMD was rarely used in its entirety, and the use of selected items or subscales was heterogeneous across studies. The studies also varied in terms of response modalities and in the use of 3- or 5-point Likert scales. The calculation of insight scores was highly variable and included the following: treating items as categorical or continuous variables, separate analysis of individual items, items expressed in terms of the sum total or the mean scores, and a range of score values used to define insight. This paper provides a systematic review of studies using the SUMD and reveals important differences in the versions used, the methods of calculation, and the interpretation of scores across studies. The use of a modified SUMD may compromise the psychometric properties of the scale, lead to erroneous conclusions, and prevents comparison of results across studies. Our review underlines the need for the standardised use of the SUMD.

Psychometric properties of the abbreviated version of the Scale to Assess Unawareness in Mental Disorder in schizophrenia.

BACKGROUND: The Scale to Assess Unawareness in Mental Disorder (SUMD) is widely used in clinical trials and epidemiological studies but more rarely in clinical practice because of its length (74 items). In clinical practice, it is necessary to provide shorter instruments. The aim of this study was to investigate the validity and reliability of the abbreviated version of the SUMD. DESIGN: We used data from four cross-sectional studies conducted in several psychiatric hospitals in France. INCLUSION CRITERIA: a diagnosis of schizophrenia based on DSM-IV criteria. DATA COLLECTION: socio-demographic and clinical data (including duration of illness, Positive and Negative Syndrome Scale, and the Calgary Depression Scale); quality of life; SUMD. STATISTICAL ANALYSIS: confirmatory factor analyses, item-dimension correlations, Cronbach's alpha coefficients, Rasch statistics, relationships between the SUMD and other parameters. We tested two different scoring models and considered the response 'not applicable' as '0' or as missing data. RESULTS: Five hundred and thirty-one patients participated in this study. The 3-factor structure of the SUMD (awareness of the disease, consequences and need for treatment; awareness of positive symptoms; and awareness of negative symptoms) was confirmed using LISREL confirmatory factor analysis for the two models. Internal item consistency and reliability were satisfactory for all dimensions. External validity testing revealed that dimension scores correlated significantly with all PANSS scores, especially with the G12 item (lack of judgement and awareness). Significant associations with age, disease duration, education level, and living arrangements showed good discriminant validity. CONCLUSION: The abbreviated version of the SUMD appears to be a valid and reliable instrument for measuring insight in patients with schizophrenia and may be used by clinicians to accurately assess insight in clinical settings.

Quantification of Hypotony Maculopathy Using Spectral-Domain Optical Coherence Tomography.

PRCIS: We provide a free-to-use, open-source algorithm to quantify macular hypotony based on optical coherence tomography (OCT) images. This numerical approach calculates a metric that measures the deviations of Bruch's membrane from a smooth ideal retinal layer. PURPOSE: Hypotony maculopathy is a recurrent complication of glaucoma surgical interventions in which extremely low intraocular pressure triggers changes in the shape of retinal layers. Abnormal folds can often be observed in the retina using standard fundoscopy, but OCT is particularly important to appreciate the severity of symptoms at different depths. Despite the need for metrics that could be used for the informed clinical decision to evaluate the progression and resolution of macular hypotony, algorithms that quantify the retinal folds are not available in the literature or included in clinical imaging equipment. The purpose of this work is to introduce a simple algorithm that can be used to assess hypotony maculopathy from OCT B-Scans and volumes and a free, open-source implementation. METHODS: The pipeline we present is based on a straightforward segmentation of Bruch's membrane complex. The principal idea of quantification is to compute a smoothed version of this complex and analyze the deviations from an ideal interface. Such deviations are then measured and added to create a metric that characterizes each OCT B-Scan. A full OCT volume reconstruction is thus characterized by the average metric obtained from all planes. RESULTS: We tested the metric we proposed against the assessment of 3 experts and obtained a very good correspondence, with Pearson correlation coefficients higher than 0.8. Furthermore, agreement with automatic analysis seemed better than between experts. We describe the pipeline in detail and illustrate the results with a group of patients, comparing baseline images, severe hypotony maculopathy, and a variety of outcomes. CONCLUSION: The tool we introduce and openly provide fills a clinical gap to quantitatively grade hypotony maculopathy. It offers a metric of relatively simple interpretation that can be used to help clinicians in cases where the regression of symptoms is not obvious to the naked eye. Our pilot study demonstrates reliable results, and an open-source implementation facilitates easy improvements to our algorithm.

Ocular rigidity and choroidal thickness changes in response to microgravity: A case study.

Purpose: To evaluate ocular rigidity and choroidal thickness changes in response to microgravity and the Valsalva maneuver in a private astronaut. Methods: Ophthalmological examination and Optical Coherence Tomography were performed before, during, and after space flight. Choroidal thickness was measured at all time points at rest and during the Valsalva maneuver. Ocular rigidity was obtained before and after flight using a non-invasive method enhanced with deep learning-based choroid segmentation. Results: Ocular rigidity decreased after space flight compared to baseline. There was an increase in average choroidal thickness during the Valsalva maneuver compared to the resting condition before, during, and after space flight, and such increase was greater when the Valsalva maneuver was performed during space flight. Conclusions and importance: The data indicates biomechanical changes to ocular tissues because of space flight and greater choroidal thickness increase. The findings could lead to a better understanding of space flight-associated neuro-ocular syndrome and may have repercussions for short duration missions in a nascent industry.

Improvement of health-related quality of life in depression after transcranial magnetic stimulation in a naturalistic trial is associated with decreased perfusion in precuneus.

BACKGROUND: Assessing Health-related Quality of life (HRQoL) is necessary to evaluate care and treatments provided to patients with major depressive disorder (MDD), in addition to the traditional assessment of clinical outcomes. However, HRQoL remains under-utilized to assess the effectiveness of repetitive transcranial magnetic stimulation (rTMS) in research or in a routine clinical setting. The primary objective of this exploratory study on MDD was to investigate the impact of low-frequency rTMS on HRQoL using the SF-36 questionnaire. A secondary objective was to study the functional neural substrate underlying HRQoL changes using neuroimaging. METHODS: Fifteen right-handed patients who met DSM-IV criteria for MDD participated in the study. HRQoL was assessed using the SF-36, and regional cerebral blood (rCBF) flow using 99mTc-ECD-SPECT. Voxel based correlation was searched between concomitant changes in rCBF and in HRQoL after rTMS. RESULTS: Role-Physical Problems dimension showed a statistical significant improvement of 73.2% (p = 0.001) and an effect size (Cohen's d) of 0.43, indicating moderate effect. Five SF-36 dimension scores and the two composite scores showed effect sizes ranged from 0.28 to 0.43. Improvement of Mental Composite Score (MCS)-SF-36 after rTMS was correlated with a concomitant decrease of precuneus perfusion (p < 0.001). Post-hoc analyses confirmed that decreased perfusion in precuneus was correlated with improvement of HRQoL, especially for MCS (r = -0.71; p < 0.001), Mental Health (r = -0.81; p < 0.001) and Social Functioning (r = -0.57; p = 0.026) dimensions. CONCLUSIONS: This study suggests low-frequency rTMS can improve HRQoL, through its role-physical problems dimension, in patients with MDD. This improvement is associated with a decreased perfusion of the precuneus, a brain area involved in self-focus and self-processing, arguing for a neural substrate to the impact of rTMS on HRQoL.

Prolonged exposure to highly rhythmic music affects brain dynamics and perception.

Rhythmic stimulation is a powerful tool to improve temporal prediction and parsing of the auditory signal. However, for long duration of stimulation, the rhythmic and repetitive aspects of music have often been associated to a trance state. In this study we conceived an auditory monitoring task that allows tracking changes of psychophysical auditory thresholds. Participants performed the task while listening to rhythmically regular and an irregular (scrambled but spectrally identical) music that were presented with an intermittent (short) and continuous (long) type of stimulation. Results show that psychophysical auditory thresholds increase following a Continuous versus Intermittent stimulation and this is accompanied by a reduction of the amplitude of two event-related potentials to target stimuli. These effects are larger with regular music, thus do not simply derive from the duration of stimulation. Interestingly, they seem to be related to a frequency selective neural coupling as well as an increase of network connectivity in the alpha band between frontal and central regions. Our study shows that the idea that rhythmic presentation of sensory stimuli facilitates perception might be limited to short streams, while long, highly regular, repetitive and strongly engaging streams may have an opposite perceptual impact.

Frequency of Past and Current Psychiatric Disorders in Patients Referred for Polysomnography: A Pilot Study.

STUDY OBJECTIVES: The aim of this study was to assess the frequency of past and current psychiatric disorders among patients referred to a sleep unit for polysomnography. METHODS: A total of 152 patients referred to the Sleep Center of Timone Hospital in Marseille were included from January 12 to March 31, 2015. Clinical data were collected using the Mini International Neuropsychiatric Interview. RESULTS: The final sample consisted of 102 patients. Polysomnography helped diagnose the following common sleep disorders: obstructive sleep apnea, restless legs syndrome, insomnia, and non-rapid eye movement sleep arousal disorder. Ninety patients (88%) had psychiatric disorders. All patients (27) without a common sleep disorder diagnosis had psychiatric disorders and among patients with a common sleep disorder diagnosis 84% had psychiatric disorders. Among the psychiatric disorders a past major depressive episode was the most frequent pathology. CONCLUSIONS: This study shows that patients referred to a sleep unit have a high prevalence of psychiatric disorders. This may be explained by residual symptoms of psychiatric illnesses, a diagnostic misdirection, a denial of psychiatric diagnosis, or an undiagnosed somatic symptom disorder. Finally, this study shows the importance of cross-disciplinary communication considering the diagnostic heterogeneity that may represent a sleep complaint.

Endoscopic insertion of biliary stents in 18 patients with metallic duodenal stents who developed secondary malignant obstructive jaundice.

AIM: The aim of this work was to evaluate the feasibility of endoscopic insertion of biliary stents in patients with duodenal stents who develop secondary malignant obstructive jaundice. PATIENTS AND METHODS: The study population included 133 patients with unresectable malignant duodenal obstruction. In 106 patients a biliary stent was inserted before or at the same time as the duodenal stent. Malignant biliary obstruction appeared secondarily in 18 patients; fifteen of these patients already had a biliary stent. We present our experience of biliary stent insertion in these 18 patients with metallic duodenal stents. RESULTS: Biliary obstruction was successfully alleviated in 17 out of 18 patients (94%) without complication. Insertion of a new biliary stent failed in one patient because the mesh of the duodenal stent passed over the metallic biliary stent already in place. Mean duration of endoscopic insertion was 95 minutes (range: 60 - 180). All patients remained free of biliary complications to death (57 days, range: 30 - 120). CONCLUSION: Our report shows that endoscopic insertion of a biliary stent is feasible in patients who have metallic duodenal stents. Technical difficulties exist especially if the mesh of the duodenal stent passes over the papilla.

Neurocognition, insight and medication nonadherence in schizophrenia: a structural equation modeling approach.

OBJECTIVE: The aim of this study was to examine the complex relationships among neurocognition, insight and nonadherence in patients with schizophrenia. DESIGN: Cross-sectional study. INCLUSION CRITERIA: Diagnosis of schizophrenia according to the DSM-IV-TR criteria. DATA COLLECTION: Neurocognition was assessed using a global approach that addressed memory, attention, and executive functions; insight was analyzed using the multidimensional 'Scale to assess Unawareness of Mental Disorder;' and nonadherence was measured using the multidimensional 'Medication Adherence Rating Scale.' ANALYSIS: Structural equation modeling (SEM) was applied to examine the non-straightforward relationships among the following latent variables: neurocognition, 'awareness of positive symptoms' and 'negative symptoms', 'awareness of mental disorder' and nonadherence. RESULTS: One hundred and sixty-nine patients were enrolled. The final testing model showed good fit, with normed χ(2) = 1.67, RMSEA = 0.063, CFI = 0.94, and SRMR = 0.092. The SEM revealed significant associations between (1) neurocognition and 'awareness of symptoms,' (2) 'awareness of symptoms' and 'awareness of mental disorder' and (3) 'awareness of mental disorder' and nonadherence, mainly in the 'attitude toward taking medication' dimension. In contrast, there were no significant links between neurocognition and nonadherence, neurocognition and 'awareness of mental disorder,' and 'awareness of symptoms' and nonadherence. CONCLUSIONS: Our findings support the hypothesis that neurocognition influences 'awareness of symptoms,' which must be integrated into a higher level of insight (i.e., the 'awareness of mental disorder') to have an impact on nonadherence. These findings have important implications for the development of effective strategies to enhance medication adherence.

EMR of large sessile colorectal polyps.

BACKGROUND: EMR optimizes histopathologic assessment of resected lesions. This study evaluated the outcome of EMR of large sessile colorectal polyps in terms of complications and recurrence. METHODS: An uncontrolled prospective study was conducted of a cohort of 136 patients with sessile colorectal polyps referred for EMR. After submucosal injection, EMR was performed piecemeal by either snare polypectomy alone or with cap aspiration. RESULTS: In 136 patients, a total of 139 sessile polyps were resected, 86 of which were in the right colon. Median polyps diameter was 20 mm in the right colon and 30 mm in the other colonic segments. Intraprocedure bleeding occurred after 15 polypectomies (10.8%) and was controlled endoscopically in all cases; there was no delayed bleeding. Post-polypectomy syndrome occurred in 5 patients (3.7%). There was no perforation. Invasive carcinoma was found in 17 sessile colorectal polyps, and surgery was performed in 10 of 17 cases. Follow-up colonoscopy in 93 patients without invasive carcinoma (96 polyps), over a median of 12.3 months, disclosed local recurrence of 21 adenomatous polyps (21.9%). Colonoscopic follow-up in 5 of the 7 patients, who had sessile colorectal polyps with invasive carcinoma and did not undergo surgery, disclosed no local recurrence. CONCLUSIONS: EMR, including EMR with cap aspiration, is effective and safe for removal of sessile colorectal polyps throughout the colon.