Ketamine as an alternative to ECT in catatonia in elderly women with bipolar disorder: A case report.

The following paper described two cases of patients with catatonic depression in bipolar disorder (BD) referred to our electroconvulsive therapy (ECT) service. Both were deemed not medically fit for ECT, and were, instead, treated with intravenous (IV) ketamine. Both responded with a resolution of symptoms, returning to baseline level of functioning. During the COVID-19 pandemic, given the risks associated with providing ECT (an aerosol generating procedure) and, in the context of limited resources, ketamine therapy for catatonia is a potentially beneficial alternative or supportive treatment to ECT that merits additional research.

Uncovering the Benefits of the Ketamine-Dexmedetomidine Combination for Procedural Sedation during the Italian COVID-19 Pandemic.

This retrospective observational study evaluated the safety and efficacy of the ketamine and dexmedetomidine combination (keta-dex) compared to ketamine or dexmedetomidine alone for sedation of patients with acute respiratory distress due to COVID-19 pneumonia who require non-invasive ventilation. The following factors were assessed: tolerance to the ventilation, sedation level on the Richmond Agitation-Sedation Scale (RASS), hemodynamic and saturation profile, adverse effects, and discontinuation or mortality during ventilation. The study included 66 patients who underwent sedation for non-invasive ventilation using keta-dex (KETA-DEX group, n = 22), ketamine (KET group, n = 22), or dexmedetomidine (DEX group, n = 22). The DEX group showed a slower sedation rate and a significant reduction in blood pressure compared to the KETA-DEX group (p < 0.05). An increase in blood pressure was recorded more frequently in the KET group. No reduction in oxygen saturation and no deaths were observed in any of the groups. None of the patients discontinued ventilation due to intolerance. The mean duration of sedation was 28.12 h. No cases of delirium were observed in any of the groups. Overall, keta-dex was associated with faster sedation rates and better hemodynamic profiles compared to dexmedetomidine alone. Keta-dex is effective and safe for sedation of uncooperative patients undergoing non-invasive ventilation.

Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

New antidepressants: monoamines and beyond

The monoamine hypothesis of depression has dominated treatment for decades, but for some with treatment-resistant depression, alternative approaches are needed. This article discusses some of the other mechanisms involved in depression and how novel treatments could address these.Copyright © 2023 Wiley Interface Ltd.

Micro-dose, macro-impact: Leveraging psychedelics in frontline healthcare workers during the COVID-19 pandemic

Background and aims: The COVID-19 pandemic exacerbated pre-existing high-levels of physician stress and burnout1. In order to help treat frontline colleagues who were diagnosed with acute stress disorder, we chose a non-psychedelic, ketamine micro-dose treatment strategy for symptom management. Methods: We provided care virtually, and all patients were prescribed sublingual ketamine once daily. Each patient was evaluated using the NIH-PROMIS CAT assessments for stress, depression, anxiety, and PTSD via a remote, HIPAA compliant patient self-reporting platform. Progress was tracked and assessed against a baseline value obtained prior to the start of treatment. Patient progress was evaluated at a 4-6-week interval. Patients did not report any significant side effects to the treatment regimen. Results: 100% (25/25) of patients experienced improved anxiety, 92% (23/25) experienced improved stress, 96% (24/25) experienced improved PTSD, and 91% (20/22) experienced improved depression. Conclusions: While we cannot draw definitive conclusions from the association demonstrated by this data, we believe these results demonstrate that further research into the efficacy of daily, short-term ketamine micro-doses for treatment of acute stress disorder is warranted. © 2022 The Author(s).

Anesthetic management of toxic epidermal necrolysis: a report of two cases

Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.

Toxicity patterns associated with chronic ketamine exposure

Introduction: Synthesized in 1962, ketamine is used as a sedative, antidepressant and for the management of complex chronic pain. More recently, besides its therapeutic use, ketamine has been increasingly used as a recreational drug among young adults. As a result, an increasing number of reports have described side effects associated with its chronic exposure. This review aims to present the current evidence on the toxicity associated with chronic ketamine exposure. Method(s): Considering the limited literature on the topic, Pubmed and Embase were searched and all types of articles were considered, including systematic reviews, retrospective studies, case series and animal studies. Evidence: Chronic ketamine exposure is associated with urological toxicity manifesting mainly by lower urinary tract symptoms with features of ulcerative cystitis. More severe forms with upper urinary tract involvement can require multiple line treatments, including surgery. There are reports of gastrointestinal toxicity with abdominal pain, liver function test derangement and cholangiopathy. More recently, reports have described the association between prolonged ketamine sedation during covid-19 outbreak and cholangiopathies. Development of tolerance, brain and psychiatric changes have been described. These can manifest in cognitive impairment and psychiatric disorders, with schizophrenia-like symptoms. Possible cardiovascular alterations have been described in few reports. Whereas supportive treatment can offer transient relief, ketamine cessation remains the cornerstone of the treatment. Conclusion(s): There is evidence of toxicity associated with chronic ketamine exposure on the different systems studied in this review. Nevertheless, due to the limitation of the studies more prospective studies would be required to clarify those findings.Copyright © 2023 Societe Francaise de Toxicologie Analytique

Ketamine-Assisted Group Psychotherapy for Frontline Healthcare Workers with COVID-19-Related Burnout and PTSD: A Case Series of Effectiveness/Safety for 10 Participants.

This study reports on 10 frontline healthcare workers, employed during the COVID-19 pandemic and experiencing symptoms of burnout and PTSD, treated with group ketamine-assisted psychotherapy (KAP) in a private outpatient clinic setting. Participants attended 6 sessions once weekly. These included 1 preparation session, 3 ketamine sessions (2 sublingual, 1 intramuscular), 2 integration sessions. Measures of PTSD (PCL-5), depression (PHQ-9), and anxiety (GAD-7) were administered at baseline and post-treatment. During ketamine sessions, the Emotional Breakthrough Inventory (EBI) and the 30-item Mystical Experience Questionnaire (MEQ-30) were recorded. Participant feedback was gathered 1-month post-treatment. We observed improvements in participants' average PCL-5 (59% reduction), PHQ-9 (58% reduction), and GAD-7 (36% reduction) scores from pre- to post-treatment. At post-treatment, 100% of participants screened negative for PTSD, 90% had minimal/mild depression or clinically significant improvement, and 60% had minimal/mild anxiety or clinically significant improvement. MEQ and EBI scores had large variations among participants at each ketamine session. Ketamine was well tolerated, and no significant adverse events were reported. Participant feedback corroborated findings of improvements observed in mental health symptoms. We found immediate improvements treating 10 frontline healthcare workers experiencing burnout, PTSD, depression, and anxiety using weekly group KAP and integration.

Trends in drug use among nightclub and festival attendees in New York City, 2017-2022.

BACKGROUND: Drug use is prevalent among people who attend electronic dance music (EDM) parties at nightclubs or festivals. This population can serve as a sentinel population to monitor trends in use of party drugs and new psychoactive substances (NPS) that may diffuse through larger segments of the population. METHODS: We surveyed adults entering randomly selected EDM parties at nightclubs and dance festivals in New York City about their drug use in 2017 (n=954), 2018 (n=1,029), 2019 (n=606), 2021 (n=229), and 2022 (n=419). We estimated trends in past-year and past-month use of 22 drugs or drug classes based on self-report from 2017-2022 and examined whether there were shifts pre- vs. post-COVID (2017-2019 vs. 2021-2022). RESULTS: Between 2017 and 2022, there were increases in past-year and past-month use of shrooms (psilocybin), ketamine, poppers (amyl/butyl nitrites), synthetic cathinones ("bath salts"), and novel psychedelics (lysergamides and DOx series), increases in past-year cannabis use, and increases in past-month use of 2C series drugs. Between 2017 and 2022, there were decreases in past-year heroin use and decreases in past-month cocaine use, novel stimulant use, and nonmedical benzodiazepine use. The odds of use of shrooms, poppers, and 2C series drugs significantly increased after COVID, and the odds of use of cocaine, ecstasy, heroin, methamphetamine, novel stimulants, and prescription opioids (nonmedical use) decreased post-COVID. CONCLUSIONS: We estimate shifts in prevalence of various drugs among this sentinel population, which can inform ongoing surveillance efforts and public health response in this and the general populations.

Profile of liver cholestatic biomarkers following prolonged ketamine administration in patients with COVID-19.

BACKGROUND: To investigate the possible influence of prolonged ketamine (K) or esketamine (ESK) infusion on the profile of liver cholestatic biomarkers in patients with COVID-19 infection. METHODS: A retrospective analysis was performed on 135 patients with COVID-19 related ARDS who received prolonged K or ESK infusion. They were compared to 15 COVID-19 ICU patients who did not receive K/ESK while being mechanically ventilated and 108 COVID-19 patients who did not receive mechanical ventilation nor K/ESK. The profile of the liver function tests was analysed in the groups. RESULTS: Peak values of ALP, GGT and bilirubin were higher in the K/ESK group, but not for AST and ALT. Peak values of ALP were significantly higher among patients who underwent mechanical ventilation and who received K/ESK, compared with mechanically ventilated patients who did not receive K/ESK. There was a correlation between these peak values and the cumulative dose and duration of K/ESK therapy. CONCLUSIONS: Based on the observations of biliary anomalies in chronic ketamine abusers, prolonged exposure to ketamine sedation during mechanical ventilation may also be involved, in addition to viral infection causing secondary sclerosing cholangitis. The safety of prolonged ketamine sedation on the biliary tract requires further investigations.

Successful use of ketamine to treat severe depression with suicidality post-COVID-19 - A case report.

Every second patient who suffers from COVID-19 experiences is at risk for depression. The treatment of severe depression with suicidal risk is challenging in patients with COVID-19 given the restrictions in access to and safety concerns with the use of electroconvulsive therapy during the COVID pandemic. Although ketamine is effective in treating depression, especially in presence of acute suicidality, to date, there are no reports on ketamine use to treat severe depression in the context of COVID-19. In this case report, we describe the success of ketamine to treat a person with severe depression and suicidality following COVID-19 infection.

The Aversive Lens: Stress effects on the prefrontal-cingulate cortical pathways that regulate emotion.

ARNSTEN, A.F.T., M.K.P. Joyce and A.C. Roberts. The Aversive Lens: Stress effects on the prefrontal-cingulate cortical pathways that regulate emotion. NEUROSCI BIOBEHAV REV XXX-XXX, 2022. The symptoms of major-depressive-disorder include psychic pain and anhedonia, i.e. seeing the world through an "aversive lens". The neurobiology underlying this shift in worldview is emerging. Here these data are reviewed, focusing on how activation of subgenual cingulate (BA25) induces an "aversive lens", and how higher prefrontal cortical (PFC) areas (BA46/10/32) provide top-down regulation of BA25 but are weakened by excessive dopamine and norepinephrine release during stress exposure, and dendritic spine loss with chronic stress exposure. These changes may generate an attractor state, which maintains the brain under the control of BA25, requiring medication or neuromodulatory treatments to return connectivity to a more flexible state. In line with this hypothesis, effective anti-depressant treatments reduce the activity of BA25 and restore top-down regulation by higher circuits, e.g. as seen with SSRI medications, ketamine, deep brain stimulation of BA25, or rTMS to strengthen dorsolateral PFC. This research has special relevance in an era of chronic stress caused by the COVID19 pandemic, political unrest and threat of climate change.

The Use of Ketamine Sedation for the Treatment of Nail Bed Repairs in the Paediatric Emergency Department

Aim: To determine if ketamine sedation is a safe and cost-effective way of treating paediatric patients presenting with nail bed injuries to the emergency department. Method:Aretrospective cohort study was carried out over a nine-month period in children between ages 18 months and 16 years old, presenting to the paediatric emergency department (PED) at Chelsea and Westminster Hospital, London, with nail bed injuries requiring repair by the plastic surgery team. The primary outcome measures are complications at the time of sedation and at outpatient follow up including surgical site infection at seven days. A secondary outcome measure of parental satisfaction was collected at four months. A cost analysis comparison against procedures completed under general anaesthetic was also undertaken. Results: During the 9-month period, 10 nail bed repairs were performed under ketamine sedation in the PED. There were no serious adverse events recorded. No cases required further procedures and there were no cases of surgical site infections at 7 days. Parents reported favourable outcomes, with an average overall satisfaction score of 9.4 (where 10 is complete satisfaction). At follow up, there was one recorded complication which was successfully treated, with all patients being discharged from follow up within 3 months. Conclusion: This small study has shown ketamine procedural sedation in the paediatric population to be a safe and cost-effective method for the treatment of nail bed injuries in children presenting to PED. We believe that this management strategy, brought to the fore during the COVID-19 pandemic, should be considered as standard across all PEDs.

Paediatric Mediastinal Masses: Case Series: Intensivist Perspective

Introduction: Mediastinal masses in the paediatric population pose a challenge for diagnosis and acute management especially when they present with compression of mediastinal structures. Objectives: To study clinical, radiological, and pathological characteristics, treatment, complications, and outcome of patients with mediastinal masses admitted to IPCU with emphasis on respiratory support provided. Materials and methods: Retrospective analysis of medical records of patients admitted with mediastinal masses between 1st July 2020 and 31st October 2021 in PICU at B.J.Wadia Hospital for Children. Results: 10 patients (6 months to 16 years) were included. The common presenting symptoms were breathlessness (90%), orthopnea (44%), cough (40%), fever (40%), and weight loss (20%). One patient had superior vena cava syndrome, 50% had hepato-splenomegaly/lymphadenopathy. One patient was diagnosed outside as a yolk sac tumour and referred. Three patients were wrongly treated as TB before they were referred. The average duration of symptoms before presenting to the hospital was 82.7 days. Airway compression was seen on a CT scan in 6/10 patients. Mechanical ventilation was required in 6 patients and non-invasive ventilation in three. The mean duration of mechanical ventilation was 13.1 days. All the patients required PEEP >7 cm H2O, propped up position, and intermittent desaturations requiring an increase in ventilator settings for a short duration of time or use of paralytics/sedation boluses. Difficult intubation was encountered in 2 patients of whom a smaller size tube was used in 1 patient. Bronchoscopy, LMA insertion was not required in any. Tissue for diagnosis was obtained by CT-guided or USG-guided LN biopsy. 80% needed a mediastinal mass biopsy. During the biopsy, procedural sedation was done using drugs propofol or ketamine which was well tolerated. CT-guided retroperitoneal lymph node biopsy was inconclusive in 1 patient and eventually required open inguinal lymph node biopsy. Final diagnoses included: T cell ALL in 2 patients, AML, classical Hodgkin's lymphoma, neuroblastoma, alveolar rhabdomyosarcoma, yolk sac tumour, teratoma, tuberculosis, in single cases. Definitive diagnosis could not be confirmed in 1 child though blood EBV PCR came positive (viral copies >105 copies/mL) after the child expired. The mean time from symptom onset to diagnosis was 90 days. The mean time from presentation to diagnosis was 7.2 days. The mean duration of IPCU stay was 15.8 days. Patient with yolk sac tumour was COVID-19 positive who later developed peripheral digit gangrene. 7 patients received chemotherapy, 1 patient received AKT and one underwent surgical resection of tumour. Complications encountered were AKI (10%), TLS requiring hemodialysis (10%), and chylothorax (10%). Mortality was 50% of whom 2 did not respond to chemotherapy and 3 had intercurrent events. 5 children were discharged from the unit. Conclusion: At our centre, mediastinal masses are frequently malignant in origin. Though TB is common in our country, not all mediastinal masses are TB. All the effort should be made to obtain microbiological/tissue diagnosis before initiating the treatment. Intubating and ventilating a mediastinal mass is a challenging task and those who require intubation have a poor prognosis. Late diagnosis and associated poor prognosis are glaring, prompting for early intervention to improve outcome.

Safety and efficacy of ketamine-augmented electroconvulsive therapy in third trimester pregnancy complicated by COVID-19.

Major depressive disorder during pregnancy can be detrimental to the fetus and patient. Treatments can include electroconvulsive therapy (ECT) for severe cases. The use of ketamine in ECT can provide symptomatic relief as well as induce anesthesia. Here, we describe the case of a 35-year-old gravid woman with a long-standing history of major depressive disorder who presented with treatment-resistant depression with suicidal ideation after an alteration in her antidepressant medication. After psychiatric evaluation, she was deemed to be a good candidate for ECT augmented with ketamine for symptomatic relief. This was complicated by an positive but asymptomatic COVID-19 status. Despite these factors, the patient experienced significant relief after an eight-treatment course of ECT, with a reduction of her PHQ-9 score from 22/27 to 4/27 points.

New-Onset Refractory Status Epilepticus After Pfizer-BioNTech COVID-19 Vaccination

Objective: NA Background: Previous case reports have described 3 cases of autoimmune encephalitis and 1 case of new-onset refractory status epilepticus (NORSE) following COVID-19 viral vector vaccinations. However, no cases have been documented in association with COVID-19 mRNA vaccinations. We describe a case of NORSE after vaccination with Pfizer-BioNTech COVID-19 vaccine. Design/Methods: Case report. Results: A 56 year old healthy man presented with three days of fever, fatigue, and aphasia beginning 2 weeks after he received his first dose of the Pfizer-BioNTech COVID-19 vaccine. Video EEG showed temporally predominant seizures occurring independently bilaterally (right greater than left). Clinical seizures were characterized by head turn to the left and right hand movements. He then developed sustained right frontotemporal spike and slow wave activity consistent with non-convulsive status epilepticus. CSF demonstrated mild lymphocytic pleocytosis with WBC 16 cells/mm3, protein 24, glucose 76, and an opening pressure of 47. CSF bacterial and viral encephalitis panels, HSV, lyme, West Nile virus, and VDRL were all negative. Oligoclonal bands, paraneoplastic panel, and encephalopathy panel were negative. Systemic malignancy workup was negative. Initial MRI brain was unremarkable, but 1 week after symptom onset he developed bilateral hippocampal edema. The patient was empirically treated with broad spectrum antibiotics and antivirals which were later discontinued. Due to presumed diagnosis of autoimmune encephalitis, he was treated with high dose steroids, plasmapheresis, IVIG, and rituximab. He was treated with progressively escalating anti-seizure medications including midazolam, propofol, and ketamine continuous infusions and eventually stabilized on levetiracetam, lacosamide, phenobarbital, clobazam, zonisamide, oxcarbazepine, and perampanel. At the time of discharge, mental status had improved and aphasia resolved. Conclusions: To our knowledge, this is the first case of NORSE reported after Pfizer COVID-19 vaccination. While no test exists to definitively establish causality, these findings warrant further investigation of the possible association between COVID-19 vaccination and autoimmune encephalitis.

Psychoactive Drugs in the Management of Post Traumatic Stress Disorder: A Promising New Horizon.

Post-traumatic stress disorder (PTSD) is an anxiety disorder that often presents after exposure to a traumatic, life-threatening event. Experiencing a traumatic event is not rare, with inciting incidents ranging from being burglarized to politically motivated genocide. While traditional psychopharmacology and psychotherapy are the mainstays of the treatment of PTSD currently, psychoactive drugs (otherwise known as psychedelics) are being explored for their novel role in the treatment of PTSD patients. Psychoactive drugs such as MDMA, ketamine, and psilocybin have been shown to specifically target and decrease fear and anxiety pathways in the brain. These unique properties hold the potential to be utilized in addressing symptoms of trauma in those with refractory or treatment-resistant PTSD. Historically, federal and state laws have restricted research into how psychoactive drugs can be used to treat mental illness due to the widespread belief that these drugs present more harm than benefit. However, the current shift in public opinion on psychedelics has propelled research to look into the benefits of these drugs for patients with mental illness. This article aims to discuss the mechanisms of how MDMA, ketamine, and psilocybin work in the PTSD brain, as well as their beneficial role in treatment.