Key Points Question Is there evidence for a potential relationship between inflammation and brain structure, and is this relevant for schizophrenia and other neuropsychiatric disorders? Findings In this mendelian randomization study including 20 688 participants in the UK Biobank, genetically predicted levels of interleukin 6 were associated with gray matter volume and cortical thickness primarily in the middle temporal gyrus and superior frontal region. The middle temporal gyrus overexpressed a number of genes relevant to interleukin 6 pathway proteins and neuropsychiatric disorder ontologies, including schizophrenia and autism spectrum disorder. Meaning This study found that inflammation may be associated with brain structure and may be an early predeterminant of neuropsychiatric conditions, which has important implications for identification of risk and novel treatments.

Background Treatment resistance causes significant burden in psychosis. Clozapine is the only evidence-based pharmacologic intervention available for people with treatment-resistant schizophrenia; current guidelines recommend commencement after two unsuccessful trials of standard antipsychotics. Aims This paper aims to explore the prevalence of treatment resistance and pathways to commencement of clozapine in UK early intervention in psychosis (EIP) services. Method Data were taken from the National Evaluation of the Development and Impact of Early Intervention Services study (N = 1027) and included demographics, medication history and psychosis symptoms measured by the Positive and Negative Syndrome Scale (PANSS) at baseline, 6 months and 12 months. Prescribing patterns and pathways to clozapine were examined. We adopted a strict criterion for treatment resistance, defined as persistent elevated positive symptoms (a PANSS positive score ≥16, equating to at least two items of at least moderate severity), across three time points. Results A total of 143 (18.1%) participants met the definition of treatment resistance of having continuous positive symptoms over 12 months, despite treatment in EIP services. Sixty-one (7.7%) participants were treatment resistant and eligible for clozapine, having had two trials of standard antipsychotics; however, only 25 (2.4%) were prescribed clozapine over the 12-month study period. Treatment-resistant participants were more likely to be prescribed additional antipsychotic medication and polypharmacy, instead of clozapine. Conclusions Prevalent treatment resistance was observed in UK EIP services, but prescription of polypharmacy was much more common than clozapine. Significant delays in the commencement of clozapine may reflect a missed opportunity to promote recovery in this critical period.

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The cyclic tetrapeptides cyclo(‐Leu‐Sar‐Gly‐), cyclo(‐Val‐Sar‐Sar‐Gly‐), and cylco(‐Meleu‐Gly‐D‐Alasar‐) have been synthesized from the component amino acids (BOP‐Cl coupling), using the pentafluorophenyl esters for the cyclization step (42, 13, and 30% yield, respectively). Multiple deprotonation (LDA in THF/LiBr/DMPU) and addition of highly reactive electrophiles (CF3CO2D, MeI, CH2O, CH2CHCH2Br, PhCH2Br) produce cyclic tetrapeptides with additional substituents introduced diastereoselectively (70 to > 98% ds) in yields ranging from 20 to 90%. The C‐alkylatd products are all derived from a sarcosine‐enolate moiety adjacent to another N‐methylamino acid. The structures of the resulting products are determined by NMR spectroscopy (DNOE and ROESY techniques) and by hydrolysis to the parent amino acids, suitable derivatization, and analysis by chromatography on a chiral GC column. It was shown in two cases that the overall yield of cyclization/alkylation to give a disubstitued cyclic tetrapeptide is higher than that of a synthesis of the same product from the corresponding amino‐acid building blocks. Surprising temperature and salt effects on the yields and selectivities of the reactions of the cyclic tetrapeptide enolates are presented, and possible mechanistic interpretations are discussed.