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The nature and degree of cognitive impairments in schizoaffective disorder is not well established. The aim of this meta-analysis was to characterise cognitive functioning in schizoaffective disorder and compare it with cognition in schizophrenia and bipolar disorder. Schizoaffective disorder was considered both as a single category and as its two diagnostic subtypes, bipolar and depressive disorder.
Following a thorough literature search (468 records identified), we included 31 studies with a total of 1685 participants with schizoaffective disorder, 3357 with schizophrenia and 1095 with bipolar disorder. Meta-analyses were conducted for seven cognitive variables comparing performance between participants with schizoaffective disorder and schizophrenia, and between schizoaffective disorder and bipolar disorder.
Participants with schizoaffective disorder performed worse than those with bipolar disorder (g = −0.30) and better than those with schizophrenia (g = 0.17). Meta-analyses of the subtypes of schizoaffective disorder showed cognitive impairments in participants with the depressive subtype are closer in severity to those seen in participants with schizophrenia (g = 0.08), whereas those with the bipolar subtype were more impaired than those with bipolar disorder (g = −0.23) and less impaired than those with schizophrenia (g = 0.29). Participants with the depressive subtype had worse performance than those with the bipolar subtype but this was not significant (g = 0.25, p = 0.05).
Cognitive impairments increase in severity from bipolar disorder to schizoaffective disorder to schizophrenia. Differences between the subtypes of schizoaffective disorder suggest combining the subtypes of schizoaffective disorder may obscure a study's results and hamper efforts to understand the relationship between this disorder and schizophrenia or bipolar disorder.
We report on the synthesis, properties, and ion conductivity of a solid polymer electrolyte produced from polytetrahydrofuran (PTHF) photo-crosslinked with 3,4-epoxycyclohexylmethyl 3ʹ,4ʹ-epoxycyclohexane carboxylate (Epoxy), via an active monomer mechanism that facilitates the reaction of the native hydroxyl and epoxide end-groups. Crosslinked samples were loaded with different quantities of lithium tetrafluoroborate (LiBF4) and evaluated by electrochemical spectroscopy impedance (EIS) to determine their ionic conductivity. An increase in lithium salt loading led to an increase in ionic transport, reaching competitive conductivities of up to 10-3 S/cm at temperatures typical for battery operation. Thermal analysis confirms the amorphous structure and high thermal stability (30-90°). The mechanical analysis shows the materials possess suitable stiffness for applications. The results demonstrate a new synthetic route to tunable crosslinked networks for a broad range of chemical building blocks to achieve high lithium-ion conduction and attain desirable thermal and mechanical properties.
Lewy body dementia, consisting of both dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD), is considerably under-recognised clinically compared with its frequency in autopsy series.
This study investigated the clinical diagnostic pathways of patients with Lewy body dementia to assess if difficulties in diagnosis may be contributing to these differences.
We reviewed the medical notes of 74 people with DLB and 72 with non-DLB dementia matched for age, gender and cognitive performance, together with 38 people with PDD and 35 with Parkinson's disease, matched for age and gender, from two geographically distinct UK regions.
The cases of individuals with DLB took longer to reach a final diagnosis (1.2 v. 0.6 years, P = 0.017), underwent more scans (1.7 v. 1.2, P = 0.002) and had more alternative prior diagnoses (0.8 v. 0.4, P = 0.002), than the cases of those with non-DLB dementia. Individuals diagnosed in one region of the UK had significantly more core features (2.1 v. 1.5, P = 0.007) than those in the other region, and were less likely to have dopamine transporter imaging (P < 0.001). For patients with PDD, more than 1.4 years prior to receiving a dementia diagnosis: 46% (12 of 26) had documented impaired activities of daily living because of cognitive impairment, 57% (16 of 28) had cognitive impairment in multiple domains, with 38% (6 of 16) having both, and 39% (9 of 23) already receiving anti-dementia drugs.
Our results show the pathway to diagnosis of DLB is longer and more complex than for non-DLB dementia. There were also marked differences between regions in the thresholds clinicians adopt for diagnosing DLB and also in the use of dopamine transporter imaging. For PDD, a diagnosis of dementia was delayed well beyond symptom onset and even treatment.
Wild sheep and many primitive domesticated breeds have two coats: coarse hairs covering shorter, finer fibres. Both are shed annually. Exploitation of wool for apparel in the Bronze Age encouraged breeding for denser fleeces and continuously growing white fibres. The Merino is regarded as the culmination of this process. Archaeological discoveries, ancient images and parchment records portray this as an evolutionary progression, spanning millennia. However, examination of the fleeces from feral, two-coated and woolled sheep has revealed a ready facility of the follicle population to change from shedding to continuous growth and to revert from domesticated to primitive states. Modifications to coat structure, colour and composition have occurred in timeframes and to sheep population sizes that exclude the likelihood of variations arising from mutations and natural selection. The features are characteristic of the domestication phenotype: an assemblage of developmental, physiological, skeletal and hormonal modifications common to a wide variety of species under human control. The phenotypic similarities appeared to result from an accumulation of cryptic genetic changes early during vertebrate evolution. Because they did not affect fitness in the wild, the mutations were protected from adverse selection, becoming apparent only after exposure to a domestic environment. The neural crest, a transient embryonic cell population unique to vertebrates, has been implicated in the manifestations of the domesticated phenotype. This hypothesis is discussed with reference to the development of the wool follicle population and the particular roles of Notch pathway genes, culminating in the specific cell interactions that typify follicle initiation.
A novel inpatient vocational counseling service (named “In-Voc”) was developed and evaluated in three Australian spinal cord injury (SCI) rehabilitation hospitals, aiming to improve vocational outcomes after SCI. The program provided a trained Vocational Counseling Coordinator who worked alongside the allied health team, medical, and nursing staff at each hospital. The Coordinators were interviewed to examine the role expectations and role behaviors associated with the introduction of their novel, vocationally focused, occupational role. The Coordinators’ descriptions of their role behavior were very similar to those defined by rehabilitation counselors in North America. They reported the novel role to be a productive and satisfying one. Encouragingly, the In-Voc program was associated with significantly higher post-injury employment outcomes.
Myopia is one of the leading causes of preventable blindness in the world. Its prevalence has risen drastically over recent decades, and it is estimated that close to half the world population will be myopic by 2050.The rise in myopia is lifestyle related. Myopia occurs as a consequence of excessive eye growth, which may be related to general growth. Diet, therefore, is a potential risk factor. A number of Asian studies have reported lower levels of zinc in myopic adolescents, when compared to controls. Currently, there are no reliable indicators of zinc status. This study explores the association between zinc status and myopia using a combination of zinc assessment methods.
Participants from two different population-based studies were used. Data from 1,095 adolescents aged 12–19 years, from the US National Health and Nutrition Examination Study were used to examine the relationship between dietary zinc intake and myopia. Data from 304 subjects of similar age from the Korean National Health and Nutrition Examination Study were used to examine the association between serum zinc levels and myopia using multivariate logistic regression.
43% (NHANES) and 84% (KNHANES) of subjects were found to be myopic. Mean dietary intake of zinc was lower among myopes relative to non-myopes, but not significantly. In multivariate logistic regression, dietary zinc was not significantly associated with myopia. Among Korean subjects mean serum zinc was found to be higher in non-myopes v. myopes (p = 0.809). Multiple logistic regression did not show any significant relationship between serum zinc and myopia, after adjustment for confounders.
In contrast to previous studies, no relationship was found between lower dietary zinc intake or lower serum zinc, and myopia. Currently the BOND Zinc Expert Panel recommend plasma zinc concentration to assess zinc status, despite its extreme sensitivity to both internal and external factors like; inflammation, fasting, pregnancy, oral contraception and diurnal rhythm. Biological samples are very easily contaminated, meaning strict quality controls and procedures are required. These factors severely impact reliability, and thus, comparison between studies is challenging, particularly in the case of contrasting findings.As zinc is a vital micronutrient and an estimated one-third of the population are affected by zinc deficiency. A reliable biomarker of status is important, for clinical and research needs.
This chapter offers a phenomenological analysis of changes in the structure of experience that fundamentally characterise both several main forms of neuropsychiatric illness and the nature of religious commitment. The use of the portmanteau term ‘neuropsychiatric’ acknowledges the fact that many of the conditions discussed in this chapter do not fit neatly within the shifting and unclear professional boundaries of psychiatry and neurology, a problem with which other chapters in this volume engage. In this chapter, in fact, I propose that these conditions are best understood phenomenologically in a way that challenges those professional partitions. Specifically, neuropsychiatric illness and religious commitment both involve distinctive changes to the structure of first-person experience that can be characterised phenomenologically in terms of altered existential feelings – a neglected set of affective states, currently a topic of research by philosophers, psychiatrists and cognitive scientists. Later in the chapter, I go on to make the further, stronger claim that the fundamentally phenomenological character of neuropsychiatric and religious experience assigns investigative and interpretive priority to phenomenology rather than to neuroscience. As a caveat before beginning, my claim is not that neuropsychiatric illness and religious commitment are identical or that religiosity is pathological, though doubtless they can be, and indeed surely are, complexly related in many cases.1 Instead, the claim is that what a person experiences during neuropsychiatric illness and in religious commitment ought to be understood phenomenologically in terms of alterations in their existential feeling.
New δ13Ccarb and microfacies data from Hereford–Worcestershire and the West Midlands allow for a detailed examination of variations in the Homerian carbon isotope excursion (Silurian) and depositional environment within the Much Wenlock Limestone Formation of the Midland Platform (Avalonia), UK. These comparisons have been aided by a detailed sequence-stratigraphic and bentonite correlation framework. Microfacies analysis has identified regional differences in relative sea-level change and indicates an overall shallowing of the carbonate platform interior from Hereford–Worcestershire to the West Midlands. Based upon the maximum δ13Ccarb values for the lower and upper peaks of the Homerian carbon isotope excursion (CIE), the shallower depositional setting of the West Midlands is associated with values that are 0.7 ‰ and 0.8 ‰ higher than in Hereford–Worcestershire. At the scale of parasequences the effect of depositional environment upon δ13Ccarb values can also be observed, with a conspicuous offset in the position of the trough in δ13Ccarb values between the peaks of the Homerian CIE. This offset can be accounted for by differences in relative sea-level change and carbonate production rates. While such differences complicate the use of CIEs as a means of high-resolution correlation, and caution against correlations based purely upon the isotopic signature, it is clear that a careful analysis of the depositional environment can account for such differences and thereby improve the use of carbon isotopic curves as a means of correlation.
Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.
To estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627).
We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life.
The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold.
In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.
Declaration of interest
R.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.
Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.
To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).
RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.
After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94–9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI –2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI –2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.
The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.
The majority of studies examining botulinum toxin A (BTX-A) in the management of upper limb muscle overactivity and pain focus on the distal arm and hand. Research has begun to look at BTX-A efficacy in more proximal upper limb muscles, with literature showing equivocal findings. This scoping review identified 15 studies meeting inclusion criteria whose data were examined against three outcome variables: muscle overactivity, range of movement and pain. Overall, while the majority of injected participants improved on these variables, between-study methodological variability such as research design potentially underpowered studies and arbitrary decision making gave a high likelihood of influencing the interpretation of their results. Future research is warranted, with a robust focus on functional anatomy, a critical appraisal of how BTX-A may help the individual being studied and utilising individualised rather than protocol-driven research paradigms.
This article argues for a cross-culturally pluralistic conception of spiritual exemplarity. Three main modes of exemplarity are identified, distinguished by their underlying aspirations, which I label ‘allegiance’, ‘enlightened insight’, and ‘emulation’. After challenging some attempts to privilege the modes of exemplarity characteristic of theistic religions, I argue that perhaps the fullest example of the aspiration to emulation is the form of Daoism presented in The Book of Zhuāngzǐ. I conclude that what one finds across different cultures and traditions is a plurality of modes of spiritual exemplarity that should be acknowledge and explored, rather than given more reductive analyses that narrow our sense of the variety of ways of living a spiritual life.
Exposure to stressful life events is an established risk factor for the development of adolescent mental disorder. Growing evidence also suggests that neighbourhood social environments, including strong social cohesion, could have a protective effect on mental health. However, little is known about how neighbourhood social cohesion may buffer against the effects of stressful life events on adolescent mental health. Our aim was to assess whether neighbourhood social cohesion modifies the association between stressful life events and adolescent mental health outcomes.
Data were drawn from a nationally-representative prospective sample of Canadian adolescents, including 5183 adolescents aged 12/13 years at T1 and 14/15 years at T2. Caregivers reported neighbourhood social cohesion at T1, and exposure to stressful life events between T1 and T2. Symptoms of mental health and behaviour problems were self-reported by adolescents at T1 and T2. Multivariable logistic regression was used to determine whether the relationship between stressful life events and outcomes was modified by neighbourhood social cohesion.
Associations between stressful life events and adolescent outcomes were statistically significantly lower in neighbourhoods with greater social cohesion for: depression/anxiety (high cohesion OR = 0.98 v. low cohesion OR = 3.11), suicidal ideation (ORhigh = 1.30 v. ORlow = 5.25), aggression/conduct disorder (ORhigh = 1.09 v. ORlow = 4.27), and property offence (ORhigh = 1.21 v. ORlow = 4.21).
Greater neighbourhood social cohesion appeared to buffer the effects of stressful life events on several domains of adolescent mental health. This potentially presents a target for public health intervention to improve adolescent mental health and behavioural outcomes.
Childhood maltreatment (CM) plays an important role in the development of major depressive disorder (MDD). The aim of this study was to examine whether CM severity and type are associated with MDD-related brain alterations, and how they interact with sex and age.
Within the ENIGMA-MDD network, severity and subtypes of CM using the Childhood Trauma Questionnaire were assessed and structural magnetic resonance imaging data from patients with MDD and healthy controls were analyzed in a mega-analysis comprising a total of 3872 participants aged between 13 and 89 years. Cortical thickness and surface area were extracted at each site using FreeSurfer.
CM severity was associated with reduced cortical thickness in the banks of the superior temporal sulcus and supramarginal gyrus as well as with reduced surface area of the middle temporal lobe. Participants reporting both childhood neglect and abuse had a lower cortical thickness in the inferior parietal lobe, middle temporal lobe, and precuneus compared to participants not exposed to CM. In males only, regardless of diagnosis, CM severity was associated with higher cortical thickness of the rostral anterior cingulate cortex. Finally, a significant interaction between CM and age in predicting thickness was seen across several prefrontal, temporal, and temporo-parietal regions.
Severity and type of CM may impact cortical thickness and surface area. Importantly, CM may influence age-dependent brain maturation, particularly in regions related to the default mode network, perception, and theory of mind.
Many ancient traditions recognise certain people as exemplars of virtue, the models for the good or flourishing human life. Certain traditions, however, incorporate a cosmic mode of emulation, where the virtues are manifestations, in human form, of qualities or aspects of the ground or source of the world. I defend this claim using the sustained case study of the forms of Daoist exemplarity found in the Book of Zhuangzi, then consider the charge that the aspiration to cosmic emulation is inhumane. It emerges that there are forms of emulation where the ultimate model for the good or flourishing life as manifested by the exemplar is nothing human.