First Use of Clozapine Point of Care Testing in Acute Inpatient Psychiatry: Preliminary Report.

Clozapine is the antipsychotic of choice in treatment-resistant schizophrenia. Serum clozapine concentration testing is essential to monitor adherence, adjust dosing, and ensure treatment safety. However, patients who are acutely unwell are frequently reluctant to undergo blood testing requiring venipuncture. Also, conventional laboratory-based measurement of clozapine plasma levels can take days, thus contributing to the suboptimal use of clozapine when it is most needed. We pioneered clozapine whole-blood point of care (POC) testing in the acute inpatient setting in the treatment of a group of actively psychotic patients receiving clozapine during the outbreak of the COVID-19 pandemic. POC clozapine testing using automated homogenous immunoassay requires only finger prick blood sampling and is more acceptable to patients. As it produces results in minutes, clozapine POC testing serves to promptly ascertain adherence with treatment and inform therapeutic dosing. POC testing offered a more practical, less invasive, and quicker alternative to conventional methods of monitoring clozapine levels. Near immediate availability of clozapine levels expedited clinical decisions and helped ensure safe clozapine prescribing to our severely psychotic patients in a time of crisis. By facilitating patients' early safe discharge from the hospital, clozapine POC testing also reduced length of hospitalization.

Does Nicotine Prevent Cytokine Storms in COVID-19?

COVID-19 has a benign outcome in most cases, yet it can also be fatal and no specific treatment is available as of yet. Older age and several medical comorbidities are risk factors for COVID-19 complications. We report on an elderly man with a longstanding history of bipolar affective disorder associated with heavy smoking, alcohol abuse and multiple comorbidities, including severe chronic obstructive pulmonary disease and recurrent pulmonary sepsis, who contracted COVID-19 during his inpatient treatment of a manic episode, and who fully recovered from COVID-19 without any need for respiratory support. We discuss how his excessive use of nicotine replacement therapy may have contributed to his emerging unscathed from COVID-19. Nicotine, an α7-nACh receptor agonist, may boost the cholinergic anti-inflammatory pathway and hinder the uncontrolled overproduction of pro-inflammatory cytokines triggered by the SARS-CoV-2 virus, which is understood to be the main pathway to poor outcomes and death in severe COVID-19.

COVID-19 and acute inpatient psychiatry: the shape of things to come.

Psychiatric services that provide acute inpatient care have to respond to the challenges brought about by the COVID-19 pandemic to consistently deliver high standards of treatment to patients and ensure the safety of staff. This can only be achieved by fostering a culture that rewards initiative and empowers inpatient teams to implement and comply with changes which everyone understands and benefits from. The experience of an inner London acute psychiatric unit has shown the value of combining proactive leadership, multidisciplinary decision making and good communication in adapting services to an everchanging environment. Practical solutions have emerged that have improved service delivery and patient care, and which will likely outlast the COVID-19 pandemic. These include changes to team work and routine, streamlining patient care with a focus on goal directed admissions, developing a healthier work environment and adopting novel technology in patient care and multidisciplinary collaboration.KEY POINTSPsychiatric inpatient units have to manage the COVID-19 crisis alongside the risk of acutely disturbed behaviour, while ensuring high standards of care and patient throughput.To respond to the COVID-19 crisis, inpatient units have to foster a culture that rewards initiative and empowers teams to implement and comply with changes that everyone understands and benefits from.Adaptive strategies should include good communication, a healthy work environment, flexible rules, dynamic infection control and adopting novel technology for clinical care and multidisciplinary work.Proactive leadership, multidisciplinary teamwork, transparency and a shared ethos of responsibility are the main tools to build effective inpatient teams.

Clozapine in the Time of COVID-19.

Clozapine is the most effective antipsychotic for treatment resistant schizophrenia but adverse reactions to clozapine include neutropenia. The current COVID-19 pandemic may raise specific concerns for clinicians prescribing clozapine for patients who need it. We report on two actively psychotic patients with treatment resistant schizophrenia who required admission to our inner-London acute psychiatric unit during the COVID-19 pandemic and who were treated with clozapine. One was a young patient who developed COVID-19 symptoms and tested positive for the SARS-CoV-2 virus while receiving clozapine and the other was an aging man who tested negative for the SARS-CoV-2 virus but had contact with COVID-19 during initiation of clozapine treatment. Both responded to clozapine treatment and were safely discharged from hospital without any complication. These cases suggest that, in the absence of complications, exposure to COVID-19 per se and the onset of mild symptoms in those infected may not warrant withdrawal or postponement of clozapine treatment when this is indicated.