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Shortages of personal protective equipment during the COVID-19 pandemic has led to the extended use or re-use of single-use respirators and surgical masks by frontline healthcare workers. The evidence base underpinning such practices warrants examination.
To synthesise current guidance and systematic review evidence on extended use, re-use, or reprocessing of single-use surgical masks or filtering facepiece respirators.
World Health Organization, European Centre for Disease Prevention and Control, the US Centers for Disease Control and Prevention, and Public Health England websites to identify guidance. Medline, Pubmed, Epistemonikos, Cochrane Database and preprint servers for systematic reviews.
Two reviewers conducted screening and data extraction. Quality of included systematic reviews was appraised using AMSTAR-2. Findings were narratively synthesised.
Six guidance documents were identified. Levels of detail and consistency across documents varied. Four high-quality systematic reviews were included: three focused on reprocessing (decontamination) of N95 respirators, one on reprocessing of surgical masks. Vaporised hydrogen peroxide and ultraviolet germicidal irradiation were highlighted as the most promising reprocessing methods, but evidence on the relative efficacy and safety of different methods was limited. We found no well-established methods for reprocessing respirators at scale.
There is limited evidence on the impact of extended use and re-use of surgical masks and respirators and gaps and inconsistencies exist in current guidance. Where extended use or re-use is being practiced, healthcare organisations should ensure that policies and systems are in place to ensure these practices are carried out safely and in line with available guidance.
There is growing interest globally in using real-world data (RWD) and real-world evidence (RWE) for health technology assessment (HTA). Optimal collection, analysis, and use of RWD/RWE to inform HTA requires a conceptual framework to standardize processes and ensure consistency. However, such framework is currently lacking in Asia, a region that is likely to benefit from RWD/RWE for at least two reasons. First, there is often limited Asian representation in clinical trials unless specifically conducted in Asian populations, and RWD may help to fill the evidence gap. Second, in a few Asian health systems, reimbursement decisions are not made at market entry; thus, allowing RWD/RWE to be collected to give more certainty about the effectiveness of technologies in the local setting and inform their appropriate use. Furthermore, an alignment of RWD/RWE policies across Asia would equip decision makers with context-relevant evidence, and improve timely patient access to new technologies. Using data collected from eleven health systems in Asia, this paper provides a review of the current landscape of RWD/RWE in Asia to inform HTA and explores a way forward to align policies within the region. This paper concludes with a proposal to establish an international collaboration among academics and HTA agencies in the region: the REAL World Data In ASia for HEalth Technology Assessment in Reimbursement (REALISE) working group, which seeks to develop a non-binding guidance document on the use of RWD/RWE to inform HTA for decision making in Asia.
Introduction: There are few large-scale studies assessing the true risk of epinephrine use during anaphylaxis in adults. We aimed to assess the demographics, clinical characteristics, and secondary effects of epinephrine treatment and to determine factors associated with major and minor secondary effects associated with epinephrine use among adults with anaphylaxis. Methods: From May 2012 to February 2018, adults presenting to the Hôpital du Sacré-Coeur de Montréal (HSCM) emergency department (ED) with anaphylaxis were recruited prospectively as part of the Cross-Canada Anaphylaxis Registry (C-CARE). Missed cases were identified through a previously validated algorithm. Data were collected on demographics, clinical characteristics, and management of anaphylaxis using a structured chart review. Multivariate logistic regression models were compared to estimate factors associated with side effects of epinephrine administration. Results: Over a 6-year period, 402 adult patients presented to the ED at HSCM with anaphylaxis. The median age was 38 years (Interquartile Range [IQR]: 27, 52) and 40.4% were males. The main trigger for anaphylaxis was food (53.0%). A total of 286 patients (71.1%) received epinephrine treatment, of which 23.9% were treated in the pre-hospital setting, 47.0% received treatment in the ED, and 5.0% received epinephrine in both settings. Among patients treated with epinephrine, major secondary effects were rare (1.4% of patients), including new changes to electrocardiogram, arrhythmia, and neurological symptoms. Minor secondary effects due to epinephrine were reported in 50.0% of patients, mainly inappropriate sinus tachycardia (defined as a rate over 100 beats/minute in 30.1%). Major cardiovascular secondary effects were associated with regular use of beta-blockers (aOR 1.10 [95%CI, 1.02, 1.18]), regular use of ACE-inhibitors (aOR 1.16 [95%CI, 1.07, 1.27]), and receiving more than two doses of epinephrine (aOR 1.09 [95%CI, 1.00, 1.18]). The model was adjusted for age, history of ischemic heart disease, trigger of anaphylaxis, presence of asthma, sex, and reaction severity. Inappropriate sinus tachycardia was more likely in females (aOR 1.18 [95%CI, 1.04, 1.33]) and palpitations, tremors, and psychomotor agitation were more likely in females (aOR 1.09 [95%CI, 1.00, 1.19]) and among those receiving more than two doses of epinephrine (aOR 1.49 [95%CI, 1.14, 1.96]). The models were adjusted for age, regular use of medications, history of ischemic heart disease, triggers of anaphylaxis, presence of asthma, reaction severity, and IV administration of epinephrine. Conclusion: The low rate of occurrence of major secondary effects of epinephrine in the treatment of anaphylaxis in our study demonstrates the overall safety of epinephrine use.
Introduction: With the transition of Emergency Medicine into competency based medical education (CBME), entrustable professional activities (EPAs) are used to evaluate residents on performed clinical duties. This study aimed to determine if implementing a case-based orientation, designed to increase recognition of available EPAs, into CBME orientation would help residents increase the number of EPAs completed. Methods: We designed an intervention consisting of clinical cases that were reviewed by national EPA experts who identified which EPAs could be assessed from each case. A case-based session was incorporated into the 2019 CBME orientation for The McMaster Emergency Medicine Program. Postgraduate Year (PGY)1 residents read the cases and discussed which EPAs could be obtained with PGY2/faculty facilitators. The number of EPAs completed in the first two blocks of PGY1 was determined from local program data and Student's t-test was used to compare averages between cohorts. Results: We analyzed data from 22 trainees (7 in 2017, 8 in 2018, and 7 in 2019). In the first two blocks of PGY1, the intervention cohort (2019) had a significantly higher average number of EPAs completed per trainee (47.4 [SD 11.8]) than the historical cohort (25.3 [SD 6.7]) (p < 0.001) (Cohen's d = 2.3). No significant difference existed in the number EPAs obtained between the 2017/2018 cohorts, with averages of 24.3 [SD 6.8] and 26.1 [SD 7.0] per trainee respectively (p = 0.6). Conclusion: Implementation of a case-based orientation led by CBME-experienced facilitators nearly doubled the EPA acquisition rate of our PGY1s. The consistent EPA acquisition by the 2017/2018 cohorts suggest that the post-intervention increase was not solely due to developed familiarity with the CBME curriculum.
Introduction: Time-to-treatment plays a pivotal role in survival from sudden cardiac arrest (SCA). Every minute delay in defibrillation results in a 7-10% reduction in survival. This is particularly problematic in rural and remote regions, where bystander and EMS response is often prolonged and automated external defibrillators (AED) are often not available. Our objective was to examine the feasibility of a novel AED drone delivery method for rural and remote SCA. A secondary objective was to compare times between AED drone delivery and ambulance response to various mock SCA resuscitations. Methods: We conducted 6 simulations in two different rural communities in southern Ontario. During phase 1 (4 simulations) a “mock” call was placed to 911 and a single AED drone and an ambulance were simultaneously dispatched from the same location to a pre-determined destination. Once on scene, trained first responders retrieved the AED from the drone and initiated resuscitative efforts on a manikin. The second phase (2 scenarios) were done in a similar manner save for the drone being dispatched from a regionally optimized location for drone response. Results: Phase 1: The distance from dispatch location to scene varied from 6.6 km to 8.8 km. Mean (SD) response time from 911 call to scene arrival was 11.2 (+/- 1.0) minutes for EMS compared to 8.1 (+/- 0.1) for AED drone delivery. In all four simulations, the AED drone arrived before EMS, ranging from 2.1 to 4.4 minutes faster. The mean time for trained responders to retrieve the AED and apply it to the manikin was 35 (+/- 5) sec. No difficulties were encountered in drone activation by dispatch, drone lift off, landing or removal of the AED from the drone by responders. Phase 2: The ambulance response distance was 20km compared to 9km for the drone. Drones were faster to arrival at the scene by 7 minutes and 8 minutes with AED application 6 and 7 minutes prior to ambulance respectively. Conclusion: This implementation study suggests AED drone delivery is feasible with improvements in response time during a simulated SCA scenario. These results suggest the potential for AED drone delivery to decrease time to first defibrillation in rural and remote communities. Further research is required to determine the appropriate distance for drone delivery of an AED in an integrated EMS system as well as optimal strategies to simplify bystander application of a drone delivered AED.
Introduction: Despite studies highlighting the inaccuracies of self-assessment, practicing physicians continue to rely on self-perception to maintain clinical competence. Many approaches have been proposed to augment physician performance. In the realm of Quality Improvement (QI), Audit and Feedback (A&F) has a modest effect. Educators have proposed coaching interventions and academic constructs have invoked training for early-career clinicians. Very few of these are driven by the perceptions and the needs of the end-user - the physicians. We currently lack a model to understand physicians’ perceptions of their own practice data and an understanding of the factors which would enable practice change. In this study, we sought to develop a model for data feedback which may best help physicians change practice. Methods: In a previous study, we conducted a needs analysis of 105 physicians in the Hamilton-Niagara area in order to understand which data metrics were most valuable to physicians. Using the survey results, we designed an interview guide that was used as a qualitative study of physicians’ perspectives on A&F. By intentional sampling, we recruited 15 physicians amongst gender groups, types of practice (academic vs community) and durations of practice. We conducted this interview with all 15 participants which were then transcribed. We then performed thematic analysis and extraction of all interviews using a realist framework. These were then translated into broader themes and, by using a grounded theory framework, created a model to understand how physicians relate practice data to their own sense of self. Interviews were anonymized and no identifying data was shared as part of the interview. All interviewees consented to participation at the outset and could withdraw at any time. Results: Via stakeholder interviews from 15 key informants, we developed a model for the understanding of how a physician's sense of self and the nature of the data (quantity and quality) may be combined to understand the likelihood of practice change and the adoption of the change strategy. Using this model, it is possible to understand the conditions under which A&F would provide the greatest opportunity for practice change. Conclusion: Physician identity intersects with A&F data to shed insights on practice improvement. Understanding the core identity constructs of different physician groups may allow for increased uptake in A&F processes.
Background: Emergency physicians (EPs) can choose from several evidence-based pathways to diagnose pulmonary embolism (PE), however literature suggests that EPs frequently use computer tomography (CT) scanning as a stand-alone test for PE. This is a program of research to improve adherence to evidence-based PE diagnosis in the emergency department (ED). Aim Statement: To create a novel approach to PE diagnosis in the ED based on a framework explaining EP diagnostic PE behaviour and barriers to using evidence-based PE testing. Measures & Design: We conducted two types of qualitative interviews: 1). EPs in 5 Canadian cities watched videos of 2 simulated cases and then explained how they would test the patient. 2). Semi-structured EP interviews using the theoretical domains framework (TDF). The results of our analyses informed the construction of an explanatory framework for common EP diagnostic PE behaviours. Barriers to evidence-based behaviour were classified into domains. A Canadian EP expert group reviewed these results along with the existing evidence on ED PE diagnostic implementation. We developed a new approach to diagnosis of PE in the ED which addresses each of our domains. Evaluation/Results: We conducted 71 interviews. We identified 4 domains, each addressed in our pathway. ‘PE in a mythical and deadly beast’ PE kills and can masquerade so EPs look for PE in places where it does not exist and are rewarded for ‘over-testing’. Response: Creating a departmental conversation about missing PE, talking about the facts, busting the myths. EP feedback on PE testing including positive rate. ‘The end goal is CTPE’ PE creates anxiety for EPs and ordering a CTPE hands over responsibility to the radiologist. Response: A departmental protocol for PE testing which starts with D-dimer for every patient. Shifting focus to ruling out PE with D-dimer. Protocol is automated once initiated by EP. ‘PERC eases anxiety’ PERC is documented when it is negative and allows EP to stop. Response: EPs can choose to use and document PERC. ‘No-one has been fighting for the Wells score’ Poor understanding of purpose and function. Often at odds to Gestalt. Response: Protocol does not use Wells score. Discussion/Impact: We have developed a new diagnostic PE pathway which addresses current barriers to evidence-based practice which we will evaluate further.
The risk factors of criminal behavior in patients with schizophrenia are not well explored. This study is to explore the risk factors for criminal behavior in patients with schizophrenia in rural China.
We used data from a 14-year prospective follow-up study (1994-2008) of criminal behavior among a cohort (n=510) of patients with schizophrenia in Xinjin County, Chengdu, China.
There were 489 patients (95.9%) who were followed up from 1994 to 2008. The rate of criminal behavior was 13.5% among these patients with schizophrenia during the follow-up period. Compared with female subjects (6 cases, 20.0%), male patients had significantly higher rate of violent criminal behavior (e.g., arson, sexual assault, physical assault, and murder) (24 cases, 80.0%) (p< 0.001). Bivariate analyses showed that the risk of criminal behavior was significantly associated with being unmarried, of younger age, previous violent behavior, homelessness, lower family economic status, no family caregivers, and higher scores on measures (PANSS) of positive, negative, and total symptoms of illness. In multiple logistic regression analyses being unmarried and previous violent behavior were identified as independent predictors of increased criminal behavior in persons with schizophrenia.
The risk factors for criminal behavior among patients with schizophrenia should be understood within a particular social context. Criminal behavior may be predicted by specific characteristics of patients with schizophrenia in rural community. The findings of risk factors for criminal behavior should be considered in planning community mental health care and interventions for high-risk patients and their families.
Currently there is no consensus regarding how long anti-psychotics medication should be continued following a first/single psychotic episode. Clinically patients often request discontinuation after a period of remission. This is one of the first double-blind randomized-controlled studies designed to address the issue.
Patients with DSM-IV schizophrenia and related psychoses (excluding substance induced psychosis) who remitted well following a first/single-episode, and had remained well on maintenance medication for one year, were randomized to receive either maintenance therapy with quetiapine (400 mg/day), or placebo for 12 months. Relapse was defined by the presence of (i) an increase in at least one of the following PANSS psychotic symptom items to a threshold score (delusion, hallucinatory behaviour, conceptual disorganization, unusual thought content, suspiciousness); (ii) CGI Severity of Illness 3 or above; and (iii) CGI Improvement 5 or above.
178 patients were randomized. 144 patients completed the study (80.9%). The relapse rate was 33.7% (30/89) for the maintenance group and 66.3% (59/89) for the placebo group (log-rank test, chi-square=13.328, p<0.001). Relapse was not related to age or gender. Other significant predictors of relapse include medication status, pre-morbid schizotypal traits, verbal memory and soft neurological signs.
There is a substantial risk of relapse if medication is discontinued in remitted first-episode psychosis patients following one year of maintenance therapy. On the contrary 33.7% of patients discontinued medication and remained well.
Medication discontinuation in remitted single episode patients after a period of maintenance therapy is a major clinical decision and thus the identification of risk factors controlling for medication status is important.
Following a first/single episode with DSM-IV schizophrenia and related psychoses, remitted patients who had remained well on maintenance medication for at least one year were randomized to receive either maintenance therapy (with quetiapine 400 mg/day), or placebo for 12 months.
178 patients were randomized. Relapse rates were 33.7% (30/89) in maintenance group and 66.3% (59/89) in placebo group. Potential predictors were initially identified in univariate Cox regression models (p<0.1) and were subsequently entered into a multivariate Cox regression model for measuring the relapse risk. Significant predictors included patients on placebo (hazard ratio, 0.41; CI, 0.25 – 0.68; p=0.001); having more pre-morbid schizotypal traits (hazard ratio, 2.32; CI, 1.33 – 4.04; p=0.003); scoring lower in the logical memory test (hazard ratio, 0.94; CI, 0.9 – 0.99; p=0.028); and having more soft neurological signs (disinhibition) (hazard ratio, 1.33; CI, 1.02 – 1.74; p=0.039).
Relapse predictors may help to inform clinical decisions about discontinuation of maintenance therapy specifically for patients with a first/single episode psychosis following at least one year of maintenance therapy.
We are grateful to Dr TJ Yao at the Clinical Trials Center, University of Hong Kong, for statistical advice. The study was supported by investigator initiated trial award from AstraZeneca and the Research Grants Council Hong Kong (Project number: 765505).
Social anxiety disorder (SAD) is a strong risk factor for the development of depressive disorders (major depressive disorder or dysthymia).
Identification of blood-based molecular predictors of a subsequent depressive episode in SAD.
Objectives: To screen SAD patient serum for biomarkers which predict the onset of depressive disorders over a 2-year follow-up period.
Multiplexed-immunoassay data obtained from 143 SAD patients without co-morbid depressive disorders, recruited within the Netherlands Study of Depression and Anxiety (NESDA), were investigated. The serum screen included 165 mainly immunological, metabolical and hormonal analytes. Predictive performance of identified biomarkers and clinical variables (e.g. Beck Anxiety Inventory) was assessed using receiver operating characteristics curves (ROC) and represented by the area under the ROC curve (AUC). Stepwise logistic regression was used to select an optimal set of patient parameters, combining predictive serum analytes and clinical variables.
A set of four serum analytes and four associated clinical variables reached an AUC of 0.86 for the identification of SAD individuals, who developed a subsequent depressive episode. Throughout our analyses, biomarker panels yielded superior discriminative performance compared to clinical variables alone.
We report the discovery of a serum marker panel with good predictive performance to identify SAD individuals prone to develop depressive disorders in a naturalistic cohort design. Furthermore, we emphasise the importance to combine biological markers and clinical parameters for disease course predictions in psychiatry. Validated biomarkers could help to identify SAD patients at risk of a depressive episode, thus facilitating early treatment and improving clinical outcome.
Studies have shown that mental health problems during pregnancy have adverse effects on fetal growth. The impact of depressive and anxiety symptoms during pregnancy on the fetus have not yet been examined in Singapore.
To examine the association between mental health problems during the second trimester of pregnancy on the quality of the pregnancy, reflected by birth weight and birth length of the newborn.
This study aims to understand the importance of mental health during pregnancy on the development of the child in an Asian population.
Preliminary data of a prospective cohort study of pregnant women (GUSTO), were followed from pregnancy onwards. At 26 weeks of the pregnancy, the Edinburgh Postnatal Depression Scale (EPDS), the Beck Depression Inventory (BDI) and the State Trait Anxiety Inventory (STAI) were administered. Data on birth parameters were collected from medical records.
Linear regression analyses of preliminary data show negative correlations between depressive symptoms measured with EPDS (n = 1025, P = 0.54), BDI (n = 1012, P = 0.001), and anxiety symptoms measured with STAI (n = 1023, P = 0.002) and birth length (corrected for gestational age and gender). No associations were found for birth weight.
There is an association between depressive and anxiety symptoms reported at the end of the second trimester of the pregnancy and birth length, but not birth weight, of the newborn. As it is known that fetal length increases mainly in the second trimester, it suggests that stress of the mother influences the development of the fetus during this trimester.
Chronic non-communicable diseases (NCD) are a public health problem in Brazil. In addition, NCDs is more strongly associated with common mental disorders than was each NCD individually. This study is about the implementation and execution through the university extension project “harm reduction and mental health: hypertation control and health education” developed at Images of the Unconscious Museum, Brazil.
Measure the prevalence of hypertation, verify the association with chronic NCDs, educate about risk behavior and improve to psychosocial rehabilitation.
A socio-demographic and blood pressure profile was constructed. We identify hypertation on 33 patients. After the diagnosis, the family health unit was contact to construct a clinical care plan. We distribute health educational material about clinical diseases.
Thirty-six percent patients was identify with hypertation; once had high blood pleasure and rejected any intervention; 68% have family rates of hypertation and 100% referred low salt on diet. A book storytelling was constructed to give orientations about health lifestyle. We conducted therapeutic workshop to highlighting the creative, imaginative and expressive potential of the users on health behavior.
We identify low blood pressure after the activities and a new health style after the orientation process.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Advances in immunohistochemistry have spearheaded major developments in our understanding and classification of sinonasal tumours. In the last decade, several new distinct histopathological entities of sinonasal cancer have been characterised.
This review aims to provide a clinical update of the major emerging subtypes for the ENT surgeon and an overview of the management strategies available for this heterogeneous group of pathologies.
Although rare, knowledge of sinonasal neoplasm subtypes has implications for prognosis, treatment strategies and the development of novel therapeutic targets.
The national implementation of competency-based medical education (CBME) has prompted an increased interest in identifying and tracking clinical and educational outcomes for emergency medicine training programs. For the 2019 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, we developed recommendations for measuring outcomes in emergency medicine training in the context of CBME to assist educational leaders and systems designers in program evaluation.
We conducted a three-phase study to generate educational and clinical outcomes for emergency medicine (EM) education in Canada. First, we elicited expert and community perspectives on the best educational and clinical outcomes through a structured consultation process using a targeted online survey. We then qualitatively analyzed these responses to generate a list of suggested outcomes. Last, we presented these outcomes to a diverse assembly of educators, trainees, and clinicians at the CAEP Academic Symposium for feedback and endorsement through a voting process.
Academic Symposium attendees endorsed the measurement and linkage of CBME educational and clinical outcomes. Twenty-five outcomes (15 educational, 10 clinical) were derived from the qualitative analysis of the survey results and the most important short- and long-term outcomes (both educational and clinical) were identified. These outcomes can be used to help measure the impact of CBME on the practice of Emergency Medicine in Canada to ensure that it meets both trainee and patient needs.
Studies suggest that alcohol consumption and alcohol use disorders have distinct genetic backgrounds.
We examined whether polygenic risk scores (PRS) for consumption and problem subscales of the Alcohol Use Disorders Identification Test (AUDIT-C, AUDIT-P) in the UK Biobank (UKB; N = 121 630) correlate with alcohol outcomes in four independent samples: an ascertained cohort, the Collaborative Study on the Genetics of Alcoholism (COGA; N = 6850), and population-based cohorts: Avon Longitudinal Study of Parents and Children (ALSPAC; N = 5911), Generation Scotland (GS; N = 17 461), and an independent subset of UKB (N = 245 947). Regression models and survival analyses tested whether the PRS were associated with the alcohol-related outcomes.
In COGA, AUDIT-P PRS was associated with alcohol dependence, AUD symptom count, maximum drinks (R2 = 0.47–0.68%, p = 2.0 × 10−8–1.0 × 10−10), and increased likelihood of onset of alcohol dependence (hazard ratio = 1.15, p = 4.7 × 10−8); AUDIT-C PRS was not an independent predictor of any phenotype. In ALSPAC, the AUDIT-C PRS was associated with alcohol dependence (R2 = 0.96%, p = 4.8 × 10−6). In GS, AUDIT-C PRS was a better predictor of weekly alcohol use (R2 = 0.27%, p = 5.5 × 10−11), while AUDIT-P PRS was more associated with problem drinking (R2 = 0.40%, p = 9.0 × 10−7). Lastly, AUDIT-P PRS was associated with ICD-based alcohol-related disorders in the UKB subset (R2 = 0.18%, p < 2.0 × 10−16).
AUDIT-P PRS was associated with a range of alcohol-related phenotypes across population-based and ascertained cohorts, while AUDIT-C PRS showed less utility in the ascertained cohort. We show that AUDIT-P is genetically correlated with both use and misuse and demonstrate the influence of ascertainment schemes on PRS analyses.
This study aimed to highlight the key studies that have led to the current understanding and treatment of head and neck cancer.
The Thomson Reuters Web of Science database was used to identify relevant manuscripts. The results were ranked according to the number of citations. The 100 most cited papers were analysed.
A total of 63 538 eligible papers were returned. The median number of citations was 626. The most cited paper compared radiotherapy with and without cetuximab (3205 citations). The New England Journal of Medicine had the most citations (23 514), and the USA had the greatest number of publications (n = 66). The most common topics of publication were the treatment (n = 45) and basic science (n = 19) of head and neck cancer, followed by the role of human papillomavirus (n = 16).
This analysis highlighted key articles that influenced head and neck cancer research and treatment. It serves as a guide as to what makes a ‘citable’ paper in this field.
We undertook a quality improvement project to address challenges with pulmonary artery catheter (PAC) line maintenance in a setting of low-baseline central-line infection rates. We observed a subsequent reduction in Staphylococcal PAC line infections and a trend toward a reduction in overall PAC infection rates over 1 year.
Abnormal effort-based decision-making represents a potential mechanism underlying motivational deficits (amotivation) in psychotic disorders. Previous research identified effort allocation impairment in chronic schizophrenia and focused mostly on physical effort modality. No study has investigated cognitive effort allocation in first-episode psychosis (FEP).
Cognitive effort allocation was examined in 40 FEP patients and 44 demographically-matched healthy controls, using Cognitive Effort-Discounting (COGED) paradigm which quantified participants’ willingness to expend cognitive effort in terms of explicit, continuous discounting of monetary rewards based on parametrically-varied cognitive demands (levels N of N-back task). Relationship between reward-discounting and amotivation was investigated. Group differences in reward-magnitude and effort-cost sensitivity, and differential associations of these sensitivity indices with amotivation were explored.
Patients displayed significantly greater reward-discounting than controls. In particular, such discounting was most pronounced in patients with high levels of amotivation even when N-back performance and reward base amount were taken into consideration. Moreover, patients exhibited reduced reward-benefit sensitivity and effort-cost sensitivity relative to controls, and that decreased sensitivity to reward-benefit but not effort-cost was correlated with diminished motivation. Reward-discounting and sensitivity indices were generally unrelated to other symptom dimensions, antipsychotic dose and cognitive deficits.
This study provides the first evidence of cognitive effort-based decision-making impairment in FEP, and indicates that decreased effort expenditure is associated with amotivation. Our findings further suggest that abnormal effort allocation and amotivation might primarily be related to blunted reward valuation. Prospective research is required to clarify the utility of effort-based measures in predicting amotivation and functional outcome in FEP.