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The common recommendation that adults with onset of mental illness after the age of 65 should receive specialised psychogeriatric treatment is based on limited evidence.
To compare factors related to psychiatric acute admission in older adults who have no previous psychiatric history (NPH) with that of those who have a previous psychiatric history (PPH).
Cross-sectional cohort study of 918 patients aged ≥65 years consecutively admitted to a general adult psychiatric acute unit from 2005 to 2014.
Patients in the NPH group (n = 526) were significantly older than those in the PPH group (n = 391) (77.6 v. 70.9 years P < 0.001), more likely to be men, married or widowed and admitted involuntarily. Diagnostic prevalence in the NPH and PPH groups were 49.0% v. 8.4% (P < 0.001) for organic mental disorders, 14.6% v. 30.4% (P < 0.001) for psychotic disorders, 30.2% v. 55.5% (P < 0.001) for affective disorders and 20.7% v. 13.3% (P = 0.003) for somatic disorders. The NPH group scored significantly higher on the Health of the Nation Outcome Scale (HoNOS) items agitated behaviour; cognitive problems; physical illness or disability and problems with activities of daily living, whereas those in the PPH group scored significantly higher on depressed mood. Although the PPH group were more likely to report suicidal ideation, those in the NPH group were more likely to have made a suicide attempt before the admission.
Among psychiatric patients >65 years, the subgroup with NPH were characterised by more physical frailty, somatic comorbidity and functional and cognitive impairment as well as higher rates of preadmission suicide attempts. Admitting facilities should be appropriately suited to manage their needs.
Crime rates are higher among patients with schizophrenia than in the general population. Denmark has seen a substantial increase in the number of forensic patients since 1980 with annual growth rates reaching 7%. In the same period, the population of forensic patients with schizophrenia has increased from 50% to 75%. Evidence-based care for patients with schizophrenia is well-established in international and national guidelines. However, a possible association between quality of care and risk of crime among patients with schizophrenia has not previously been studied.
To study the association between quality of care and risk of crime among patients with schizophrenia.
This nationwide population-based follow-up study is based on the Danish National Indictor Project (DNIP), a national clinical database for patients with schizophrenia, and the Danish Crime Register, a national register of criminal offences. We include all incident and prevalent patients diagnosed with schizophrenia (ICD-10: F20.00-F20.99), who are Danish citizens and older than 18 years. All patients have been admitted as inpatients at a psychiatric ward in the period 1 January 2004 to 31 December 2007 (approx 20,000 patients). In DNIP quality of care is assessed as fulfilment of a set of quality of care criteria related to the diagnostic process, contact with the health care system, use of antipsychotic medication, evaluation of side effects, family intervention, psycho education, planned outpatient treatment by discharge and suicide prevention. All patients will be followed up for 1-year after discharge. We identified all convictions for both violent and property crimes in the population.
The effectiveness of systematic quality improvement initiatives in psychiatric care remains unclear.
To elucidate the adherence to recommended evidence-based guidelines in clinical practice.
To examine whether the quality of care among patients hospitalized with schizophrenia has changed following the implementation of a systematic monitoring and auditing program of hospital performance measures.
In a nationwide population-based cohort study, we identified 14,228 patients admitted to Danish psychiatric departments between 2004 and 2011 and registered in The Danish Schizophrenia Registry. The registry systematically monitors and audits the adherence to clinical guideline recommended processes of care at all Danish psychiatric hospital departments treating patients with schizophrenia.
The overall proportion of all relevant recommended processes of care delivered to the patients increased from 64 % to 76 % between 2004 and 2011. The adherence to a number of individual processes of care increased over time, including assessment of psychopathology using a diagnostic interview (Relative risk (RR) 2.01, 95 % CI: 1.50; 2.69), contact with relatives (RR 1.44, 95 % CI: 1.27; 1.62), psychoeducation (RR 1.33, 95 % CI: 1.18; 1.48), psychiatric aftercare (RR 1.06 95 % CI: 1.01; 1.11) and suicide risk assessment (RR 1.31, 95 % CI: 1.20; 1.43). However, improvements were not observed for all assessed processes of care and substantial variation remained between the hospitals.
Quality of care improved substantially from 2004 to 2011 among patients hospitalized with schizophrenia at Danish hospitals. However, continued efforts to reduce performance variation between hospitals are warranted.
Smaller auditory cortex volume in schizophrenia patients with auditory hallucinations (AH) may be a result of reduced cortical surface area and/or cortical thickness. A neuro–imaging study from our group demonstrated that adult schizophrenia spectrum patients with AH had significantly thinner cortex in the left side Heschl's gyrus (HG), compared to patients without AH, and healthy controls (HC).
This study aims to investigate if adolescents with early-onset psychosis (EOP) and AH demonstrate thinner cortices in HG, as found in Mørch-Johnsen et al. in 2016, compared to EOP patients without AH, and HC.
EOP patients (schizophrenia spectrum, psychotic disorder not otherwise specified) (n = 29) underwent MRI. Mean volume, cortical thickness and surface area in auditory cortex regions (HG, superior temporal gyrus [STG]) were compared between patients with AH (n = 20) and without AH (n = 9), measured with item P3 from the Positive And Negative Syndrome Scale (PANSS), and 48 HC.
Preliminary results show no significant differences between patients with and without AH and HC in mean volume, cortical thickness, or surface area in HG or STG. There were no significant side differences across hemispheres for these structures.
AH in EOP were not related to smaller volume, thinner cortex or reduced surface area in auditory cortex regions. To overcome the limitation of having a relatively small sample size, the sample will be expanded with other EOP cohorts. Investigations into HG structure variation in relation to AH in EOP will also be conducted.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The association between schizophrenia and quality of care for medical comorbidities in universal health care systems remains unclear.
To elucidate whether equal access also implies equivalent and sufficient care.
To compare the quality of care for heart failure, diabetes and chronic obstructive pulmonary disease (COPD) among patients with and without schizophrenia in Denmark.
In a nationwide population-based cohort study, we used Danish national registries to estimate the risk of receiving guideline recommended disease-specific processes of care between 2004 and 2013.
Compared to patients without schizophrenia, patients with schizophrenia had lower chance of receiving high overall quality of care (≥ 80% of recommended processes of care) for heart failure (Relative risk [RR] 0.67, 95% CI: 0.48-0.92), diabetes (RR 0.84, 95% CI: 0.79-0.89) and COPD (RR 0.82, 95% CI: 0.72-0.93) as well as lower chance of receiving individual disease-specific processes of care including treatment with beta-blockers (RR 0.87, 95% CI: 0.79-0.96) in heart failure care and measurement for albuminuria (RR 0.96, 95% CI: 0.93-0.99), eye examination at least every second year (RR 0.97, 95% CI: 0.94-0.99) and feet examination (RR 0.96, 95% CI: 0.93-0.99) in diabetes care. Diabetic patients with schizophrenia also had lower chance of receiving antihypertensive (RR 0.84, 95% CI: 0.73-0.96) and ACE/ATII inhibitors (RR 0.72, 95% CI: 0.55-0.94). In COPD care, patients with schizophrenia had lower chance of receiving LAMA/LABA medication (RR 0.92, 95% CI: 0.87-0.98), however, higher chance of treatment with non-invasive inhalation (RR 1.85, 95% CI: 1.61-2.12).
Quality of care for three medical comorbidities was suboptimal for patients with schizophrenia.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The dynamics of bubbles inertially collapsing in water near solid objects have been the subject of numerous studies in the context of cavitation erosion. While non-spherical bubble collapse, re-entrant jet dynamics and emitted shock waves have received significant interest, less is known about the temperatures thereby produced and their possible connection to damage. In this article, we use highly resolved numerical simulations of a single bubble inertially collapsing near a rigid surface to measure the temperatures produced in the fluid and estimate those in the solid, as well as to identify the responsible mechanisms. In particular, we find that elevated temperatures along the wall can be produced by one of two mechanisms, depending on the initial stand-off distance of the bubble from the wall and the driving pressure: for bubbles initially far from the wall, the shock generated by the bubble collapse is the source of the high temperature, while bubbles starting initially closer migrate towards the wall and eventually come into contact with it. A scaling is introduced to describe the maximum fluid temperature along the wall as a function of the initial stand-off distance and driving pressure. To predict the temperature of the solid, we develop a semianalytical heat transfer model, which supports recent experimental observations that elevated temperatures achieved during collapse could play a role in cavitation damage to soft heat-sensitive materials.
Our understanding of the complex relationship between schizophrenia symptomatology and etiological factors can be improved by studying brain-based correlates of schizophrenia. Research showed that impairments in value processing and executive functioning, which have been associated with prefrontal brain areas [particularly the medial orbitofrontal cortex (MOFC)], are linked to negative symptoms. Here we tested the hypothesis that MOFC thickness is associated with negative symptom severity.
This study included 1985 individuals with schizophrenia from 17 research groups around the world contributing to the ENIGMA Schizophrenia Working Group. Cortical thickness values were obtained from T1-weighted structural brain scans using FreeSurfer. A meta-analysis across sites was conducted over effect sizes from a model predicting cortical thickness by negative symptom score (harmonized Scale for the Assessment of Negative Symptoms or Positive and Negative Syndrome Scale scores).
Meta-analytical results showed that left, but not right, MOFC thickness was significantly associated with negative symptom severity (βstd = −0.075; p = 0.019) after accounting for age, gender, and site. This effect remained significant (p = 0.036) in a model including overall illness severity. Covarying for duration of illness, age of onset, antipsychotic medication or handedness weakened the association of negative symptoms with left MOFC thickness. As part of a secondary analysis including 10 other prefrontal regions further associations in the left lateral orbitofrontal gyrus and pars opercularis emerged.
Using an unusually large cohort and a meta-analytical approach, our findings point towards a link between prefrontal thinning and negative symptom severity in schizophrenia. This finding provides further insight into the relationship between structural brain abnormalities and negative symptoms in schizophrenia.
Excessive alcohol use is associated with brain damage but less is known about brain effects from moderate alcohol use. Previous findings indicate that patients with severe mental illness, particularly schizophrenia, are vulnerable to alcohol-related brain damage. We investigated the association between levels of alcohol consumption and cortical and subcortical brain structures in schizophrenia and bipolar disorder patients and healthy controls, and investigated for group differences for this association.
1.5 T structural magnetic resonance images were acquired of 609 alcohol-using participants (165 schizophrenia patients, 172 bipolar disorder patients, 272 healthy controls), mean (s.d.) age 34.2 (9.9) years, 52% men. Past year alcohol use was assessed with the Alcohol Use Disorder Identification Test – Consumption part (AUDIT-C). General linear models were used to investigate associations between AUDIT-C score and cortical thickness, surface area, and total brain and subcortical volumes.
Increasing AUDIT-C score was linearly associated with thinner cortex in medial and dorsolateral frontal and parieto-occipital regions, and with larger left lateral ventricle volume. There was no significant interaction between AUDIT-C score and diagnostic group. The findings remained significant after controlling for substance use disorders, antipsychotic medication and illness severity.
The results show a dose-dependent relationship between alcohol use and thinner cortex and ventricular expansion. The findings are present also at lower levels of alcohol consumption and do not differ between schizophrenia or bipolar disorder patients compared to healthy controls. Our results do not support previous findings of increased vulnerability for alcohol-related brain damage in severe mental illness.
Schizophrenia and bipolar disorder share genetic risk factors and one possible illness mechanism is abnormal myelination. T1-weighted magnetic resonance imaging (MRI) tissue intensities are sensitive to myelin content. Therefore, the contrast between grey- and white-matter intensities may reflect myelination along the cortical surface.
MRI images were obtained from patients with schizophrenia (n = 214), bipolar disorder (n = 185), and healthy controls (n = 278) and processed in FreeSurfer. The grey/white-matter contrast was computed at each vertex as the difference between average grey-matter intensity (sampled 0–60% into the cortical ribbon) and average white-matter intensity (sampled 0–1.5 mm into subcortical white matter), normalized by their average. Group differences were tested using linear models covarying for age and sex.
Patients with schizophrenia had increased contrast compared to controls bilaterally in the post- and precentral gyri, the transverse temporal gyri and posterior insulae, and in parieto-occipital regions. In bipolar disorder, increased contrast was primarily localized in the left precentral gyrus. There were no significant differences between schizophrenia and bipolar disorder. Findings of increased contrast remained after adjusting for cortical area, thickness, and gyrification. We found no association with antipsychotic medication dose.
Increased contrast was found in highly myelinated low-level sensory and motor regions in schizophrenia, and to a lesser extent in bipolar disorder. We propose that these findings indicate reduced intracortical myelin. In accordance with the corollary discharge hypothesis, this could cause disinhibition of sensory input, resulting in distorted perceptual processing leading to the characteristic positive symptoms of schizophrenia.
We have developed a sheep model to facilitate studies of the fetal programming effects of mismatched perinatal and postnatal nutrition. During the last trimester of gestation, twenty-one twin-bearing ewes were fed a normal diet fulfilling norms for energy and protein (NORM) or 50 % of a normal diet (LOW). From day 3 postpartum to 6 months (around puberty) of age, one twin lamb was fed a conventional (CONV) diet and the other a high-carbohydrate–high-fat (HCHF) diet, resulting in four groups of offspring: NORM-CONV; NORM-HCHF; LOW-CONV; LOW-HCHF. At 6 months of age, half of the lambs (all males and three females) were slaughtered for further examination and the other half (females only) were transferred to a moderate sheep diet until slaughtered at 24 months of age (adulthood). Maternal undernutrition during late gestation reduced the birth weight of LOW offspring (P< 0·05), and its long-term effects were increased adrenal size in male lambs and adult females (P< 0·05), increased neonatal appetite for fat-(P= 0·004) rather than carbohydrate-rich feeds (P< 0·001) and reduced deposition of subcutaneous fat in both sexes (P< 0·05). Furthermore, LOW-HCHF female lambs had markedly higher visceral:subcutaneous fat ratios compared with the other groups (P< 0·001). Postnatal overfeeding (HCHF) resulted in obesity (>30 % fat in soft tissue) and widespread ectopic lipid deposition. In conclusion, our sheep model revealed strong pre- and postnatal impacts on growth, food preferences and fat deposition patterns. The present findings support a role for subcutaneous adipose tissue in the development of visceral adiposity, which in humans is known to precede the development of the metabolic syndrome in human adults.
Some dietary fats are a risk factor for Alzheimer's disease (AD) but the mechanisms for this association are presently unknown. In the present study we showed in wild-type mice that chronic ingestion of SFA results in blood–brain barrier (BBB) dysfunction and significant delivery into the brain of plasma proteins, including apo B lipoproteins that are endogenously enriched in amyloid-β (Aβ). Conversely, the plasma concentration of S100B was used as a marker of brain-to-blood leakage and was found to be increased two-fold because of SFA feeding. Consistent with a deterioration in BBB integrity in SFA-fed mice was a diminished cerebrovascular expression of occludin, an endothelial tight junction protein. In contrast to SFA-fed mice, chronic ingestion of MUFA or PUFA had no detrimental effect on BBB integrity. Utilising highly sensitive three-dimensional immunomicroscopy, we also showed that the cerebral distribution and co-localisation of Aβ with apo B lipoproteins in SFA-fed mice are similar to those found in amyloid precursor protein/presenilin-1 (APP/PS1) amyloid transgenic mice, an established murine model of AD. Moreover, there was a strong positive association of plasma-derived apo B lipoproteins with cerebral Aβ deposits. Collectively, the findings of the present study provide a plausible explanation of how dietary fats may influence AD risk. Ingestion of SFA could enhance peripheral delivery to the brain of circulating lipoprotein–Aβ and exacerbate the amyloidogenic cascade.
Snowpack changes during the melt season are often not incorporated in modelling studies of the surface mass balance of the Greenland ice sheet. Densification of snow accelerates when meltwater is present, due to percolation and subsequent refreezing, and needs to be incorporated in ice-sheet models for ablation calculations. In this study, simple parameterizations to calculate surface melt, snow densification and meltwater retention are included as surface boundary conditions in a large-scale ice-sheet model of Greenland. Coupling the snow densification and meltwater-retention processes achieves a separation of volume and mass changes of the surface layer, in order to determine the surface melt contribution to runoff. Experiments for present-day conditions show that snow depth at the onset of melt, mean annual near-surface air temperature and the mean density of the annual snow layer are key factors controlling the quantity and spatial distribution of meltwater runoff above the equilibrium line on the Greenland ice sheet.
Near-surface air temperature (2 m) over the Greenland ice sheet (GrIS) is parameterized using data from automatic weather stations located on land and on the ice sheet. The parameterization is expressed in terms of mean annual temperatures and mean July temperatures, both depending linearly on altitude, latitude and longitude. The temperature parameterization is compared to a previous study and is shown to be in better agreement with observations. The temperature parameterization is tested in a positive degree-day model to simulate the present (1996–2006) mean melt area extent of the GrIS. The model accounts for firn warming, rainfall and refreezing of meltwater, with different degree-day factors for ice and snow under warm and cold climate conditions. The simulated melt area extent is found to have reasonable agreement with satellite-derived observations.
Limited and inconsistent data exist on simple, readily available predictors of long-term mortality of critically ill chronic obstructive pulmonary disease patients requiring invasive mechanical ventilation. We therefore examined the influence of arterial blood gas derangement and burden of comorbidities on 90-day and 1-yr mortality of chronic obstructive pulmonary disease patients treated with invasive mechanical ventilation.
We identified all chronic obstructive pulmonary disease patients (n = 230) treated with invasive mechanical ventilation between 1994 and 2004 at a Danish primary-level hospital. Data on arterial blood gas specimens and comorbidity were obtained from medical records and Hospital Discharge Registries. We used Cox’s regression analysis to estimate mortality ratios according to arterial blood gas values and level of comorbidity.
Ninety-day and 1-yr mortality among chronic obstructive pulmonary disease patients requiring invasive mechanical ventilation was 30.8% and 40.5%, respectively. All 90-day and 1-yr mortality ratios according to arterial blood gas values were close to one and one was included in all 95% CI. Among patients with a high level of comorbidity 90-day mortality ratio was 1.3 (95% CI: 0.6–2.7) when compared with patients without comorbidity. The corresponding 1-yr mortality ratio was 1.4 (95% CI: 0.7–2.9).
Chronic obstructive pulmonary disease patients treated with invasive mechanical ventilation have substantial long-term mortality. Neither the levels of arterial blood gas values measured immediately before invasive mechanical ventilation was initiated nor the burden of comorbidity were strong determinants of long-term mortality among these patients.
For the deep ice-core drilling community, the 2005/06 Antarctic season was an exciting and fruitful one. In three different Antarctic locations, Dome Fuji, EPICA DML and Vostok, deep drillings approached bedrock (the ice–water interface in the case of Vostok), emulating what had previously been achieved at NorthGRIP, Greenland, (summer 2003 and 2004) and at EPICA Dome C2, Antarctica (season 2004/05). For the first time in ice-core drilling history, three different types of drill (KEMS, JARE and EPICA) simultaneously reached the depth of ‘warm ice’ under high pressure. After excellent progress at each site, the drilling rate dropped and the drilling teams had to deal with refrozen ice on cutters and drill heads. Drills have different limits and perform differently. In this comparative study, we examine depth, pressure, temperature, pump flow and cutting speed. Finally, we compare a few parameters of ten different deep drills.
The North Greenland Icecore Project (NorthGRIP) was initiated in 1995 as a joint international programme involving Denmark, Germany, Japan, Belgium, Sweden, Iceland, the U.S.A., France and Switzerland. the main goal was to obtain undisturbed high-resolution information about the Eemian climatic period (115–130 kyr BP). the records from the Greenland Icecore Project (GRIP) and Greenland Ice Sheet Project 2 (GISP2) in central Greenland are different and disturbed down in the ice covering this period. Internal radio-echo sounding layers show that NorthGRIP, placed 325 km north-northwest of GRIP at the Summit of the Greenland ice sheet, is located on a gently sloping ice ridge with very flat bedrock and internal layers found so high that an undisturbed Eemian record is possible. Internal layers much farther above bedrock than their apparent counter parts at GRIP suggest that conditions are favourable for recovery of an undisturbed Eemian record. So far, a 1351 mdeep ice core (NorthGRIP1) and a 3001 mdeep ice core (NorthGRIP 2) have been recovered. the ice thickness is expected to be 3080 m, and the ice temperature at 3001 m is –5.6°C, so we expect basal melting at the bedrock. Most of the Eemian ice will be melted away, leaving only the last part and the transition between the Eem and the Last Glacial Period. At 3001 m the age of the ice is 110 kyr BP and the annual layers are of the order 1 cm.With modern methods the annual layers can be resolved, resulting in detailed information on the decline of the warm Eemian period into the Last Glacial Period.