[ECMO Therapy in a Case of Severe ARDS Related to COVID-19]. / ECMO als Therapie des schweren Lungenversagens bei COVID-19.

We report the case of a 60-year old female patient with advanced severe lung injury as a consequence of COVID-19-pneumonia. The patient was initially treated with highflow oxygen via nasal cannula (HFNC) and CPAP for two days but had to be intubated and mechanically ventilated. After failure of mechanical ventilation because of persistant severe hypoxemia treatment was switched to ECMO which was applicated for 24 days. Prognostic parameters indicated a favourable trend after day 14. After discontinuation of ECMO and 11 days of intermittent assisted ventilation via tracheostoma and low dose oxygen (1 l/min), the patient could be transferred to rehabilitation. The last chest radiograph prior to transferral revealed a nearly complete resolution of bilateral pulmonary infiltrates. Our case demonstrates that severe COVID-19-associated lung injury can be reversible even after prolonged ECMO.

Implementing shared decision-making on acute psychiatric wards: a cluster-randomized trial with inpatients suffering from schizophrenia (SDM-PLUS).

AIMS: Although shared decision-making (SDM) has the potential to improve health outcomes, psychiatrists often exclude patients with more severe mental illnesses or more acute conditions from participation in treatment decisions. This study examines whether SDM is facilitated by an approach which is specifically adapted to the needs of acutely ill patients (SDM-PLUS). METHODS: The study is a multi-centre, cluster-randomised, non-blinded, controlled trial of SDM-PLUS in 12 acute psychiatric wards of five psychiatric hospitals addressing inpatients with schizophrenia or schizoaffective disorder. All patients fulfilling the inclusion criteria were consecutively recruited for the trial at the time of their admission to the ward. Treatment teams of intervention wards were trained in the SDM-PLUS approach through participation in two half-day workshops. Patients on intervention wards received group training in SDM. Staff (and patients) of the control wards acted under 'treatment as usual' conditions. The primary outcome parameter was the patients' perceived involvement in decision-making at 3 weeks after study enrolment, analysed using a random-effects linear regression model. RESULTS: In total, 161 participants each were recruited in the intervention and control group. SDM-PLUS led to higher perceived involvement in decision-making (primary outcome, analysed patients n = 257, mean group difference 16.5, 95% CI 9.0-24.0, p = 0.002, adjusted for baseline differences: ß 17.3, 95% CI 10.8-23.6, p = 0.0004). In addition, intervention group patients exhibited better therapeutic alliance, treatment satisfaction and self-rated medication compliance during inpatient stay. There were, however, no significant improvements in adherence and rehospitalisation rates in the 6- and 12-month follow-up. CONCLUSIONS: Despite limitations in patient recruitment, the SDM-PLUS trial has shown that the adoption of behavioural approaches (e.g. motivational interviewing) for SDM may yield a successful application to mental health. The authors recommend strategies to ensure effects are not lost at the interface between in- and outpatient treatment.Trial registration: The trial was registered at Deutsches Register Klinischer Studien (DRKS00010880).

What are depressive symptoms in acutely ill patients with schizophrenia spectrum disorder?

BACKGROUND: Aim was to examine depressive symptoms in acutely ill schizophrenia patients on a single symptom basis and to evaluate their relationship with positive, negative and general psychopathological symptoms. METHODS: Two hundred and seventy-eight patients suffering from a schizophrenia spectrum disorder were analysed within a naturalistic study by the German Research Network on Schizophrenia. Using the Calgary Depression Scale for Schizophrenia (CDSS) depressive symptoms were examined and the Positive and Negative Syndrome Scale (PANSS) was applied to assess positive, negative and general symptoms. Correlation and factor analyses were calculated to detect the underlying structure and relationship of the patient's symptoms. RESULTS: The most prevalent depressive symptoms identified were depressed mood (80%), observed depression (62%) and hopelessness (54%). Thirty-nine percent of the patients suffered from depressive symptoms when applying the recommended cut-off of a CDSS total score of >6 points at admission. Negligible correlations were found between depressive and positive symptoms as well as most PANSS negative and global symptoms despite items on depression, guilt and social withdrawal. The factor analysis revealed that the factor loading with the PANSS negative items accounted for most of the data variance followed by a factor with positive symptoms and three depression-associated factors. LIMITATIONS: The naturalistic study design does not allow a sufficient control of study results for the effect of different pharmacological treatments possibly influencing the appearance of depressive symptoms. CONCLUSION: Results suggest that depressive symptoms measured with the CDSS are a discrete symptom domain with only partial overlap with positive or negative symptoms.

Area characteristics and admission rates of people with schizophrenia and affective disorders in a German rural catchment area.

BACKGROUND: Studies in urban areas identified environmental risk factors for mental illness, but little research on this topic has been performed in rural areas. METHODS: Hospital admission rates were computed for 174 rural municipalities in the catchment area of the state psychiatric hospital in Günzburg in years 2006 to 2009 and combined with structural and socio-economic data. Relationships of overall and diagnosis-specific admission rates with municipality characteristics were analysed by means of negative binomial regression models. RESULTS: Admission rates of patients with a diagnosis of schizophrenia and affective disorder combined decrease with increasing population growth, population density, average income and green areas, while admission rates are positively correlated with commuter balance, income inequality, unemployment rates and traffic areas. Admission rates for schizophrenia are negatively related to population growth, average income and agricultural areas, but positively related to mobility index, income inequality and unemployment rate. Admission rates for affective disorders are negatively related to population growth, population density, average income and green areas, while higher admission rates are correlated with commuter balance, high income inequality, unemployment rate and traffic-related areas. CONCLUSIONS: Effects of wealth, economic inequality, population density and structural area characteristics influence psychiatric admission rates also in rural areas.

Insight in schizophrenia-course and predictors during the acute treatment phase of patients suffering from a schizophrenia spectrum disorder.

BACKGROUND: To analyse insight of illness during the course of inpatient treatment, and to identify influencing factors and predictors of insight. METHODS: Insight into illness was examined in 399 patients using the item G12 of the Positive and Negative Syndrome Scale ("lack of insight and judgement"). Ratings of the PANSS, HAMD, UKU, GAF, SOFAS, SWN-K and Kemp's compliance scale were performed and examined regarding their potential association with insight. The item G12 was kept as an ordinal variable to compare insight between subgroups of patients. RESULTS: Almost 70% of patients had deficits in their insight into illness at admission. A significant improvement of impairments of insight during the treatment (p<0.0001) was observed. At admission more severe positive and negative symptoms, worse functioning and worse adherence were significantly associated with poorer insight. Less depressive symptoms (p=0.0004), less suicidality (p=0.0218), suffering from multiple illness-episodes (p<0.0001) and worse adherence (p=0.0012) at admission were identified to be significant predictors of poor insight at discharge. CONCLUSION: The revealed predictors might function as treatment targets in order to improve insight and with it outcome of schizophrenia.

Does oral antipsychotic pre-treatment influence outcome of a switch to long-acting injectable risperidone in patients with schizophrenia?

INTRODUCTION: The objective of this open-label study was to evaluate treatment benefits of risperidone long-acting injectable (RLAI) in patients with schizophrenia following direct transition from oral risperidone (RIS) compared with transition from other oral second generation antipsychotics. METHODS: Stable in- or outpatients (n=206) receiving RIS or OQAZ (olanzapine, quetiapine, amisulpride, ziprasidone) were transitioned to RLAI for 12 weeks. The primary outcome was the between-group treatment difference in change in PANSS total score from baseline to endpoint. Secondary outcomes included health-related quality-of-life and therapeutic alliance. RESULTS: Mean between-group difference in the change in PANSS total score from baseline to endpoint was -6.1 (CI: -17.6, 5.4), suggesting greater improvement in OQAZ than RIS patients. Due to the pre-specified non-inferiority margin of 5.1, it could not be concluded that OQAZ pre-treatment results in an at least non-inferior PANSS reduction versus RIS pre-treatment. Patient satisfaction with medication and change in quality-of-life subscores showed advantages for OQAZ patients. DISCUSSION: Compared to RIS pre-treatment, clinically stable patients with schizophrenia who are pre-treated with OQAZ might draw a stronger clinical benefit from direct transition to RLAI.

Outcome of suicidal patients with schizophrenia: results from a naturalistic study.

OBJECTIVE: Purpose was to assess suicidality before and at the time of admission in patients with schizophrenia and compare outcome differences. METHOD: Biweekly PANSS (Positive and Negative Syndrome Scale), HAMD (Hamilton Depression Rating Scale) and UKU (Udvalg for Klinske Undersogelser Side Effect Rating Scale) ratings were evaluated in 339 in-patients with schizophrenic spectrum disorders. Response was defined as an initial 20% PANSS total score reduction at discharge, remission was defined according to the proposed consensus criteria by the Remission in Schizophrenia Working Group. RESULTS: Suicidal patients (22%) scored significantly higher on the PANSS negative subscore, PANSS insight item and HAMD total score at admission and at discharge. They developed significantly more side effects. No differences were found concerning response and remission between the two patient subgroups. CONCLUSION: Despite receiving significantly more antidepressants the suicidal patients suffered from significantly more depressive symptoms up to discharge, yet without differing regarding response and remission.

Early improvement as a predictor of remission and response in schizophrenia: Results from a naturalistic study.

OBJECTIVE: To examine the predictive validity of early improvement in a naturalistic sample of inpatients and to identify the criterion that best defines early improvement. METHODS: Two hundred and forty-seven inpatients who fulfilled ICD-10 criteria for schizophrenia were assessed with the Positive And Negative Syndrome Scale (PANSS) at admission and at biweekly intervals until discharge from hospital. Remission was defined according to the recently proposed consensus criteria, response as a reduction of at least 40% in the PANNS total score from admission to discharge. RESULTS: Receiver operating characteristic (ROC) analyses showed that early improvement (reduction of the PANSS total score within the first 2 weeks of treatment) predicts remission (AUC=0.659) and response (AUC=0.737) at discharge. A 20% reduction in the PANSS total score within the first 2 weeks was the most accurate cut-off for the prediction of remission (total accuracy: 65%; sensitivity: 53%; specificity: 76%), and a 30% reduction the most accurate cut-off for the prediction of response (total accuracy: 76%; sensitivity: 47%; specificity: 90%). CONCLUSION: The findings of clinical drug trials that early improvement is a predictor of subsequent treatment response were replicated in a naturalistic sample. Further studies should examine whether patients without early improvement benefit from an early change of antipsychotic medication.

[Combining antidepressants: a useful strategy for therapy resistant depression?]. / Kombination von Antidepressiva--eine sinnvolle Behandlungsstrategie bei therapieresistenten Depressionen?

Various pharmacological strategies have been developed to treat such refractory depression, of which combination therapies with antidepressants are one of the most important. This article reviews both benefits and risks of all known antidepressant combination strategies. The relevant literature was identified by means of a computerized MEDLINE research on the years 1990-2006 and scanning of review articles. The use of antidepressant combinations to overcome refractory depression is a common strategy in practice. Many antidepressants can be usefully combined especially if they engage separate mechanisms of action--like SSRIs with Reboxetine, Bupropion, Mirtazapine and Tricyclics--or on the other hand--Tricyclics with MAO-Inhibitiors. Combination strategies are effective treatment options, however they do have potential safety risks due to pharmacokinetic and pharmacodynamic interactions. Combinations including MAOIs can cause serotonin syndrome, and some SSRIs like Fluoxetine may elevate tricyclic plasma levels with the consequence of an increased risk of toxicity. The distinct knowledge of available antidepressant combination strategies may help to increase response--as well as remission rates in therapy resistant depression. However, further research is urgently needed to determine relative efficacy.

Long-term treatment with flupentixol results of a post-marketing surveillance study.

Schizophrenia is one of the most expensive illnesses. Antipsychotics are an essential component of the acute and preventative treatment of this illness, and long-term treatment is necessary to decrease the risk of psychotic relapse. The efficacy and tolerability of flupentixol was evaluated in a post-marketing surveillance study (PMS) in schizophrenic patients receiving long-term treatment in routine clinical practice. Psychiatrists in office practice treated patients for approximately 10 weeks, with a subsequent follow-up period of up to 18 months. We here report on the follow-up period in 128 patients. The benefit for schizophrenic patients increased with the treatment duration of flupentixol as documented by the Clinical Global Impression (CGI). Subjective quality of life improved during the first study period, and this remained stable in the follow-up period. No increase in body weight was observed during the study. The relapse rate was much lower than in other studies. Anticholinergic medication was necessary for 22.7% of the patients at any time. More than 70% of the psychiatrists involved evaluated the treatment as very good or good. The results of this study suggest that flupentixol is a potent and safe antipsychotic for the long-term treatment of schizophrenia in routine clinical practice.

Escitalopram in clinical practice: results of an open-label trial in outpatients with depression in a naturalistic setting in Germany.

INTRODUCTION: An open, multi-center, study was designed to address the efficacy and tolerability profile of treatment with escitalopram under naturalistic conditions in outpatients with depression. METHODS: A total of 11,760 patients were treated with escitalopram and followed for 8 weeks. Rating scales included the Clinical Global Impression-Severity (CGI-S), the Clinical Global Impression-Improvement (CGI-I), and a short version of the Montgomery-Asberg Depression Rating Scale (svMADRS) for assessment of various clinical parameters. RESULTS: During the course of the study, patients showed a clear pattern of improvement in their general state of health (CGI-S) and a decrease in the severity of their depression. The majority (82.8%) of patients initially received 10 mg/day escitalopram. By the end of the trial period, 32.5% of the patients were treated with 20 mg/day escitalopram compared to 64.0% receiving 10 mg/day escitalopram. After 2 weeks, 40.7% of patients were much or very much improved (CGI-I < or =2), increasing to 82.5% at the last assessment. There were no significant differences in response to treatment between women and men, with regard to treatment by specialists versus GPs, or with regard to age (< or =65 versus >65 years of age). Adverse reactions were similar to those found in controlled trials, and no new reactions were noted. The most common adverse reactions were nausea, anxiety, and vertigo. CONCLUSIONS: This observational study corroborates the high therapeutic efficacy of escitalopram treatment, while confirming the tolerability profile, in a naturalistic treatment setting.