Primary and Secondary Negative Symptoms in Schizophrenia

The negative symptoms of schizophrenia include volitional (motivational) impairment manifesting as avolition, anhedonia, social withdrawal, and emotional disorders such as alogia and affective flattening. Negative symptoms worsen patients' quality of life and functioning. From the diagnostic point of view, it is important to differentiate between primary negative symptoms, which are regarded as an integral dimension of schizophrenia, and secondary negative symptoms occurring as a result of positive symptoms, comorbid depression, side effects of antipsychotics, substance abuse, or social isolation. If secondary negative symptoms overlap with primary negative symptoms, it can create a false clinical impression of worsening deficit symptoms and disease progression, which leads to the choice of incorrect therapeutic strategy with excessive dopamine blocker loading. Different longitudinal trajectories of primary and secondary negative symptoms in different schizophrenia stages are proposed as an important additional discriminating factor. This review and position paper focuses primarily on clinical aspects of negative symptoms in schizophrenia, their definition, phenomenology, factor structure, and classification. It covers the historical and modern concepts of the paradigm of positive and negative symptoms in schizophrenia, as well as a detailed comparison of the assessment tools and psychometric tests used for the evaluation of negative symptoms.

Oral Candida Infection in Psoriatic Patients Treated with IL17A Inhibitors: Report of 3 Cases and a Comprehensive Review of the Literature

An intact and fully functional immune system plays a crucial role in the prevention of several infectious diseases. Interleukin (IL)17 is significantly involved in oral mucosa immunity against several antigens and microorganisms, including Candida albicans (CA). Herein, we present three cases of oral candidiasis (OC) related to the use of an IL17A inhibitor for psoriasis. Three psoriatic individuals presented for evaluation of widespread symptomatic oral lesions temporally correlated with the onset of IL17A inhibitors (secukinumab in two patients and brodalumab in one patient). Clinical examination revealed either partially removable white plaques in an erythematous background (case #1) or diffuse erythematous lesions (cases #2 and 3) involving several areas of the oral mucosa. Cytology smear, accompanied by histopathologic examination in case #1, confirmed the clinical impression of OC in all three cases. All patients received antifungal therapy with satisfactory clinical response. No discontinuation of the antipsoriatic regimen was recommended, but all patients were advised to remain under monitoring for possible OC relapses. During the last few years, new systemic biologic agents targeting IL17 have been used for the management of variable immune-mediated diseases. Few clinical trials and scarce case reports have shown that these medications place individuals at high risk of developing candidiasis. We propose that patients treated with these medications should be at close monitoring for the development of OC and, if it occurs, receive appropriate management.

The Impact of Seasonality on Prosthetic Arteriovenous Vascular Access Graft Thrombosis

Highlights Abstract Introduction: Arteriovenous prosthetic grafts are susceptible to recurrent thrombotic occlusions mainly due to venous outflow disease secondary to neointimal hyperplasia. Maintenance of vascular access for dialysis is a perpetual challenge for both patients and health care systems. In regions with hotter climates, there is a clinical impression that episodes of prosthetic arteriovenous vascular access graft thrombosis are more frequent during hot dry summers secondary to dehydration and increased blood viscosity. Seasonality of thrombotic events has been observed in multiple vascular beds. However, a seasonal pattern or any association of arteriovenous graft thrombosis with temperature and relative humidity levels has never been fully demonstrated. Methods: Data were collected prospectively from January 2014 until December 2020 but analyzed retrospectively. In this 7-year timeframe, 289 episodes of arteriovenous graft thrombosis were identified from 142 grafts fashioned. Results: No monthly variation (P = 0.35) or seasonal variation (P = 0.91) was identified. No statistically significant correlation between episodes of thrombosis and mean monthly temperature and mean relative humidity was noted. Conclusion: No evidence was identified to support this theory. However, multiple issues with assessments of events must be conceded. Graft thrombosis is multifactorial in nature, and venous outflow disease contributes toward a significant number of these events. Within our local cohort, a low primary patency rate was identified, which further contributes to graft interventions. Relatively small numbers were recruited, and therefore, potential correlations could have been missed.

Implementing Collaborative Care Management of Behavioral Health for Patients with Inflammatory Bowel Disease

Background Individuals with inflammatory bowel disease (IBD) are up to twice as likely to suffer from anxiety and/or depression. Collaborative care management (CoCM) is an evidenced-based approach to treating behavioral health disorders that has proven effective for a range of conditions in primary care and some specialty settings. This model involves a team-based approach, with care delivered by a care manager (case reviews and behavioral therapy), psychiatrist (case reviews and psychopharmacological recommendations), and medical provider (ongoing care including psychopharmacological prescriptions). We assessed the feasibility and effectiveness of CoCM in reducing anxiety and depressive symptoms in patients with IBD. Methods Patients with psychological distress identified by clinical impression and/or the results of the Patient Health Questionaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were referred to the CoCM program. Data from our 9-month CoCM pilot were collected to assess depression and anxiety response and remission rates. We obtained provider surveys to assess provider acceptability with delivering care in this model. Results Though the coronavirus SARS-CoV2 (COVID-19) pandemic interrupted screening, 39 patients enrolled and 19 active participants completed the program. Overall, 47.4% had either a response or remission in depression, while 36.8% had response or remission in anxiety. The gastroenterologists highly agreed that the program was a beneficial resource for their patients and felt comfortable implementing the recommendations. Discussion CoCM is a potentially feasible and well accepted care delivery model for treatment of depression and anxiety in patients with IBD in a specialty gastroenterology clinic setting

Isolated duodenal ischemia of unknown etiology: a case report

Background Acute abdomen is among the most common presentations observed in clinical practice. The present study describes a patient with isolated duodenal ischemia as an extremely rare etiology of acute abdomen. Case presentation A 79-year-old male with acute abdominal pain, nausea, and vomiting presented to the emergency department of our hospital. He was diagnosed with myelodysplastic syndrome 7 years ago, for which he took thalidomide and erythropoietin as the main medications. The prominent findings of the physical examination were hypotension, tachycardia, fever, mild hypoxemia, and epigastric and right upper quadrant tenderness of the abdomen. Except for mildly increased creatinine and lipase, other laboratory findings were in concordance with myelodysplastic syndrome. Due to the patient’s oliguria, the computed tomography (CT) scan was performed without contrast, which, together with the ultrasonography, raised the clinical impression of acute pancreatitis. The patient’s hypotension was refractive to supportive treatment, resulting in progressive deterioration of the clinical condition. A later contrast-enhanced CT scan suggested microvascular ischemia of the duodenum. An emergent Whipple’s procedure was planned initially, which was later switched to a damage control surgery due to the patient’s cardiac arrest during the surgery. Despite all the supportive therapy provided at the intensive care unit, the patient expired of a cardiac arrest which occurred two hours after the termination of the surgery. Conclusions The high rate of mortality in duodenal necrosis necessitates emergent diagnosis and proper management. When other common etiologies are ruled out, clinicians should consider duodenal pathology as a potential cause of acute abdomen.

Implementation of the Treat-to-Target Concept in Evaluation of Psoriatic Arthritis Patients

Background: The treat-to-target approach was recently adopted for psoriatic arthritis (PsA) management. Objective: To assess the implementation of the “treat-to-target” (T2T) concept in daily management of PsA by use of composite scores of disease activity versus clinical judgement alone. Methods: A total of 117 PsA patients from a longitudinal PsA cohort were enrolled consecutively in the study during each patient’s first clinic visit during 2016–2017. Clinic notes from the treating rheumatologist were reviewed by an independent rheumatologist, noting clinical impression of disease activity, treatment changes based on clinical judgement, and rationale. Treatment changes were then compared to the use of formal disease activity parameters in Minimal Disease Activity (MDA) and Disease Activity Index for Psoriatic Arthritis (DAPSA) composite measures. All associations were assessed using the chi-square test or the Mann–Whitney test, as appropriate. Results: The 117 PsA patient cohort consisted of 65.5% women, mean age 58.4 ± 13.6 years. Clinical judgement of treating rheumatologist concorded with MDA and DAPSA in 76 (65.5%) and 74 (64.9%) patients, respectively. Agreement between clinical judgement and composite measure criteria did not correlate with patient age, sex, alcohol/tobacco use, or treatment regimens chosen. Disagreement between physician assessment and MDA occurred in 40 (34.5%) cases: in 30 cases, the MDA status was overestimated due to disregard of patient reported outcomes (PRO), while underestimation of MDA status occurred in 25% of cases with treatment changes made in patients with a single active joint or enthesis. Underestimation of disease activity using DAPSA occurred in 22 cases and could be attributed to disregarding tender joint count, patient pain visual analogue scale and C-reactive protein level. Conclusion: In our cohort, agreement between clinical impression and formal composite measure utilization for implementation of T2T strategy occurred in 65% of patients. Discordance resulted from physicians’ overlooking PRO and emphasizing objective findings when using clinical judgement alone.

Indolent Enhancing Spinal Lesions Mimicking Spinal Metastasis in Pediatric Patients With Malignant Primary Brain Tumors

BackgroundSpinal metastasis from malignant primary brain tumor (MPBT) in pediatric is rare, often appearing as enhancing lesions on MRI. However, some indolent enhancing spinal lesions (IESL) resulting from previous treatment mimic metastasis on MRI, leading to unnecessary investigation and treatment. MethodsIn 2005-2020, we retrospectively enrolled 12 pediatric/young patients with clinical impression of spinal metastasis, and pathological diagnosis of their spinal lesions. Three patients had MPBT with IESL, and 9 patients had malignant tumors with metastases. The histopathologic diagnosis of IESL was unremarkable marrow change. We evaluated their MRI, CT, and bone scan findings.Results Image findings of IESL vs spinal metastasis were 1) shape: round/ovoid (3/3, 100%) vs irregular (9/9, 100%) (P= .005); 2) target-shaped enhancement: (3/3, 100%) vs (0/9, 0%) (P= .005); 3) pathologic fracture of vertebral body: (1/3, 33.3%) vs (9/9, 100%) (P= .045); 4) expansile vertebral shape (0/3, 0%) vs (9/9, 100%) (P= .005); 5) obliteration of basivertebral vein: (0/3, 0%) vs (9/9, 100%) (P= .005); 6) osteoblastic change on CT: (3/3, 100%) vs (2/9, 22.2%) (P= .034).ConclusionsIESL in pediatrics with MPBT can be differentiated from metastasis by their image characteristics. We suggest close follow-up rather than aggressive investigation and treatment for IESL.

A Case Report of Silent Cervical Spondylosis with Neck Pain

Background: Cervical Spondylosis, commonly known as Cervical Osteoarthritis, is a kind of degenerative osteoarthritis of the joints between the spinal vertebrae's and the neural foramina. It's a condition characterized by changes in the cervical bones, discs, and joints as a result of regular aging wear and tear. Spondylosis of the cervical spine is most common in 40s and 50s. Case Presentation: A 65 years old male came to physiotherapy department with complaints of pain in left upper limb and neck and weakness in his left upper back muscles and unilateral since 2 months. Clinical impression showed cervical non radiculopathy. X-ray of cervical spine revealed osteophytosis and narrowed inter- vertebral space, seen in C6 and C7 cervical vertebral bodies with straightening of cervical spine. Cervical Distraction and compression test was positive. Conclusion: A well planned physical therapy intervention has shown significant improvement in cases with cervical spondylosis in relieving the symptoms and improving quality of life.

Sclerosing Epithelioid Fibrosarcoma; A Case report and review of literature

Introduction/Objective Sclerosing Epithelioid Fibrosarcoma (SEF) is an unusual, rare clinically aggressive form of soft tissue sarcoma. It is characterized by a slow evolution, with local recurrences and late metastases that are mainly pulmonary and pleural in about 80% of cases. SEF has distinctive morphology and occurs most commonly in deep soft tissue of adult extremities. Lesions involving the head and neck region are uncommon and rare intraosseously in oral cavity. Methods/Case Report Herein we report a case of a 52-year-old male who presented with a symptomatic radiolucent lesion at apex #18, with clinical impression of periapical granuloma. The patient did present with pain associated with lower left quadrant #18 area, for several days to pressure and hot temperature. A periapical radiograph revealed a large ill-defined radiolucent area at apex of resorbing roots #18. The patient’s medical history was significant with history of cancer diagnosis of sclerosing epithelioid fibrosarcoma of skull treated by chemotherapy and radiation. Microscopic examination of the specimen revealed a multi-fragmented specimen consisting of numerous fragments and islands of highly cellular, basophilic bone and osteoid surrounded by loose fibrous stroma which contains large lobules and islands of round to oval cells, with distinct cell borders and faintly granular eosinophilic cytoplasm. Separate islands of tumor cells surround large islands of necrosis with the background stroma appearing as hyalinized and eosinophilic with the basaloid cells demonstrating smudge and crush artifact. Peripherally, spindled cells are noted and faint areas of eosinophilic osteoid within the eosinophilic background stroma. Lesional cells are MUC4 strong, diffusely positive and strongly positive for INI-1. CD43, CD20, PAX-5, CD3, Desmin, CD34, S100, CD99, AE1/3 and SMA are interpreted to be negative. A diagnosis of metastatic sclerosing epithelioid fibrosarcoma was made, with correlation with the primary lesion was recommended. Results (if a Case Study enter NA) N/A Conclusion The clinical and histological findings of our case correlate with the diagnostic criteria of sclerosing epithelioid fibrosarcoma. Despite its microscopic features can create diagnostic difficulties, in that SEF can resemble a variety of benign and pseudosarcomatous as well as malignant lesions, our case diagnosis was confirmed by morphology and MUC4 diffuse strong reactivity and negativity for other markers.

Accuracy of Roche SARS-CoV-2 Rapid Antigen Test in Nasopharyngeal Swab: Clinical Impression Matters

Background: In COVID-19 pandemic, the diagnosis and treatment must be as early as possible to save the life of each patient. Moreover, screening of asymptomatic carriers, close contacts or healthy subjects must not be delay to prevent transmission to publics. For confirmation of diagnosis of SARS-CoV-2 infection, nasopharyngeal swab must be tested either by real-time Reverse Transcription Polymerase Chain Reaction (RT-PCR) tests or Rapid Antigen Test (RAT). RAT is faster, easier and cheaper; thus, it is suitable for health service in developing country. Objectives: The aim of this study was to assess the diagnostic accuracy of Roche SARS-CoV-2 Rapid Antigen Test (RAT) in diagnosing SARS-CoV-2 infection. Methods: Hospital based exploratory study was done in out-patient department and fever clinic, and molecular laboratory of No. (1) Defence Services General Hospital. Nasopharyngeal swabs were taken, and the Roche SARS- CoV-2 RAT was conducted in parallel with RT-PCR test (reference standard). Results: Among the 932 patients/subjects recruited, RT-PCR was positive in 468 individuals, corresponding to a prevalence of 50.2%. The RAT was positive in 363 patients (60.4%), false positive in 120 patients; it was negative in 569 individuals (39.6%), false negative in 225 patients. The overall sensitivity of the RAT was 51.9% (95% Confidence Interval [CI] 47.29-56.53) and, the specificity was 74.1% (95% CI 69.9-78.07); positive predictive value was 66.9% and negative predictive value was 60.5%. The sensitivity varied with Ct value; 78% in clinical samples with Ct values < 20, 57.5% in those with Ct values between 21 and 25, 41.8% in samples with Ct values between 26 and 30, and, 36.4% in samples with Ct value > 30. Conclusion: The accuracy of the SARS-CoV-2 Roche RAT in diagnosing SARS-CoV-2 infections was inferior to RT-PCR and manufacturer’s data. The sensitivity was with low Cycle threshold values < 20 which were inversely related to the viral load. RAT test should be used in association with clinical impression of physicians. In hospital setting especially in emergency department, the role of RAT should be reconsidered in those patients presenting with anosmia and some cases of dyspnoea, late symptoms in the course of disease, as the RAT results would be false negative. Other errors may arise if the operator for RAT has to handle more than recommended tests per hour especially in the peak of epidemics.