Traumatic brain injury in individuals at clinical high risk for psychosis

Recent research suggests that a traumatic brain injury (TBI) can significantly increase the risk of later development of psychosis. However, it is unknown whether people at clinical high risk (CHR) of psychosis have experienced TBI at higher rates, compared to otherwise healthy individuals. This study evaluated the prevalence of mild TBI, whether it was related to past trauma and the relationship of mild TBI to later transition to psychosis

Resting state functional magnetic resonance imaging after pediatric mild TBI: Association of whole brain functional connectivity with diagnosis and post-concussive symptoms

Accurate diagnosis and prognosis is important after pediatric mild traumatic brain injury (TBI), but limited objective measures exist for either purpose. Advanced neuroimaging has garnered increased interest as a means to better understand mild TBI, with the potential to support objective assessment. Broadly, the goal of this dissertation was to examine resting state functional magnetic resonance imaging (RS fMRI) after pediatric mild TBI. Study 1 is a scoping review that aimed to examine the literature on RS fMRI after pediatric and adolescent mild TBI to summarize findings, determine research themes, review methodological approaches, and identify areas for further research. Study 2 is an original research study that aimed to predict group status [i.e., mild TBI versus orthopedic injury (OI)] as well as post-concussive symptoms (PCS) from whole brain functional connectivity (FC) patterns in participants aged 8.00 to 16.99 years (N = 430). Study 1 identified 16 articles with four main research themes: 1) RS fMRI differences between mild TBI and comparison groups; 2) changes in RS fMRI over time; 3) RS fMRI differences in subsamples of mild TBI; and 4) relations of RS fMRI to outcome measures (e.g., symptoms, behaviour, and cognition). Overall, a clear pattern of findings of RS fMRI after mild TBI was difficult to discern, likely due to heterogeneity in study methods and a high proportion of cross-sectional studies with small sample sizes. Study 2 found that significant models of group (mild TBI versus OI) could be built from whole brain RS FC profiles. These FC profiles were characterized primarily by widespread differences in connectivity between networks, largely involving the default mode network, mesolimbic network, executive function/task positive networks, and the cerebellum. However, the observed prediction accuracy did not exceed the proportion of mild TBI cases in the sample. Additionally, no significant models of cognitive or somatic PCS could be built. While these findings provide insight into RS FC profiles that differentiate mild TBI from OI, the models have limited clinical utility, and PCS shortly after injury was not reflected in RS FC. While the results of this dissertation provide an important first step in understanding RS fMRI after pediatric mild TBI, more longitudinal research is needed

Functional Outcomes after Pediatric Mild Traumatic Brain Injury

Although most children recover quickly after a mild traumatic brain injury (TBI), a sizeable minority suffer negative long-term consequences. Thus, the objective of this study was to investigate functional outcomes in children after mild TBI and to examine post-acute post-concussive symptoms (PCS) and neurocognitive test performance as predictors. Children, ages 8 to 16, were recruited (135 with mild TBI and 70 with orthopedic injury). Participants and their parents provided ratings of functioning at baseline, 3 and 6 months post-injury. Although groups differed in functioning shortly after injury, no differences were apparent at 3 or 6 months. Post-acute PCS were significant predictors of parent- and child-reported functioning at 3 and 6 months. Neurocognitive test performance predicted child-reported functioning (but not parent-reported) when considered independently, but did not add incrementally to prediction above PCS. The findings suggest that higher levels of PCS put children at risk for poor functioning after an injury

The Violent Content in Attenuated Psychotic Symptoms.

The relationship between psychosis and violence has typically focused on factors likely to predict who will commit violent acts. One unexplored area is violence in the content of subthreshold positive symptoms. The current aim was to conduct an exploratory analysis of violent content in the attenuated psychotic symptoms (APS) of those at clinical high risk of psychosis (CHR) who met criteria for attenuated psychotic symptom syndrome (APSS). The APS of 442 CHR individuals, determined by the Structured Interview for Prodromal Syndromes, were described in comprehensive vignettes. The content of these symptoms were coded using the Content of Attenuated Positive Symptoms Codebook. Other measures included clinical symptoms, functioning, beliefs and trauma. Individuals with violent content had significantly higher APS, greater negative beliefs about the self and others, and increased bullying. The same findings and higher ratings on anxiety symptoms were present when participants with self-directed violence were compared to participants with no violent content. Individuals reporting violent content differ in their clinical presentation compared to those who do not experience violent content. Adverse life events, like bullying, may impact the presence of violent content in APS symptoms. Future studies should explore violent content in relation to actual behavior

Changes in symptom content from a clinical high-risk state to conversion to psychosis.

AimThere is an interest in the transition to psychosis for those at clinical high risk of developing psychosis. This transition is typically determined by a change in severity of the attenuated symptoms as they reach a psychotic level. However, any concomitant change in the content of such symptoms has not been examined. The current study aimed to examine potential qualitative changes in the symptom content from a clinical high-risk state to a first episode of psychosis.MethodsSixty-seven individuals, who had been identified as meeting the attenuated psychotic syndrome based on the Structured Interview of Psychosis-Risk Syndromes and who later developed a full-blown psychosis were included in the study. Comprehensive clinical vignettes were written and raters were trained using the Content of Attenuated Psychotic Symptoms codebook to code for the presence of specific symptom content found within the attenuated psychotic symptoms of unusual thought content, suspicious ideas, grandiose ideas and perceptual abnormalities.ResultsTwo main changes in symptom content from baseline to conversion were observed. First, content that was vague and lacked intensity progressed to being more specific, concrete and severe. Second, new symptoms appeared whose onset occurred for the first time at conversion.ConclusionA change in symptom content should be monitored by clinicians, as changes in content may be indications of a possible transition to psychosis

Traumatic brain injury in individuals at clinical high risk for psychosis

BACKGROUND: Recent research suggests that a traumatic brain injury (TBI) can significantly increase the risk of later development of psychosis. However, it is unknown whether people at clinical high risk (CHR) of psychosis have experienced TBI at higher rates, compared to otherwise healthy individuals. This study evaluated the prevalence of mild TBI, whether it was related to past trauma and the relationship of mild TBI to later transition to psychosis. METHODS: Seven-hundred forty-seven CHR and 278 healthy controls (HC) were assessed on past history of mild TBI, age at first and last injury, severity of worst injury and number of injuries using the Traumatic Brain Injury Interview. Attenuated psychotic symptoms were assessed with the Scale of Psychosis-risk Symptoms. IQ was estimated using the Wechsler Abbreviated Scale of Intelligence and past trauma and bullying were recorded using the Childhood Trauma and Abuse Scale. RESULTS: CHR participants experienced a mild TBI more often than the HC group. CHR participants who had experienced a mild TBI reported greater total trauma and bullying scores than those who had not, and those who experienced a mild TBI and later made the transition to psychosis were significantly younger at the age at first and most recent injury than those who did not. CONCLUSION: A history of mild TBI is more frequently observed in CHR individuals than in HC. Inclusion or study of CHR youth with more severe TBI may provide additional insights on the relationship between TBI and later transition to psychosis in CHR individuals

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally