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The Covid-19 outbreak has taken a substantial toll on the mental and physical wellbeing of healthcare workers (HCWs), impacting healthcare systems at a global scale. One year into the pandemic, the need to establish the prevalence of sleep dysfunction and psychological distress in the face of COVID-19, identify risk and protective factors and explore effective countermeasures remains of critical importance. Despite implicit limitations relating to the quality of available studies, a plethora of evidence to-date suggests that a considerable proportion of HCWs experience significant sleep disturbances (estimated to afflict every two in five HCWs) as well as mood symptoms (with more than one in five reporting high levels of depression or anxiety). Younger age, female gender, frontline status, fear or risk of infection, occupation, current or past mental health concerns, and a lower level of social support were all associated with a greater risk of disturbed sleep and adverse psychological outcomes. Furthermore, we discuss the link between sleep deprivation, susceptibility to viral infections and psychosocial wellbeing, in relevance to COVID-19 and summarize the existing evidence regarding the presence and predictors of traumatic stress/PTSD and burnout in HCWs. Finally, we highlight the role of resilience and tailored interventions in order to mitigate vulnerability and prevent long-term physical and psychological implications. Indeed, promoting psychological resilience through an enhanced social support network has proven crucial for HCWs in coping under these strenuous circumstances. Future research should aim to provide high quality information on the long-term consequences and the effectiveness of applied interventions.

Arturas Kalniunas,1 Ipsita Chakrabarti,1 Rakhee Mandalia,1 Jasna Munjiza,2,3 Sofia Pappa1,2 1West London NHS Trust, London, UK; 2Division of Psychiatry, Imperial College London, London, UK; 3Central and North West London NHS Foundation Trust, London, UKCorrespondence: Sofia PappaRecovery Team East, Avenue House, 43-47 Avenue Road, London, W3 8NJ, UKEmail sofia.pappa@westlondon.nhs.uk; s.pappa@imperial.ac.ukObjective: We aim to systematically review evidence for a relationship between antipsychotic-induced akathisia and suicidal behaviour, in order to guide further clinical decision making in this area.Methods: Several electronic databases (Embase, Medline, Cochrane and PsychINFO) were systemically searched for articles published up to February 2021, using search terms related to akathisia, antipsychotics and suicidal behaviour. Two reviewers independently evaluated all the relevant studies using predetermined criteria and assessed the risk of bias for each included study. The systematic review was conducted in line with PRISMA methodology and reporting.Results: Following de-duplication, screening and application of exclusion criteria, four eligible studies were identified. All of the available studies were in English and included adult patients. Nevertheless, there was significant variability regarding methodology and overall quality was deemed low due to small sample sizes. There was insufficient data to perform statistical analyses of the results. Of the four studies, two found a weak correlation between antipsychotic-related akathisia and suicidal behaviour, a finding that was not supported by the remaining two studies.Conclusion: The search yielded very few studies for inclusion. On the basis of the existing evidence, akathisia cannot be reliably linked to the presence of suicidal behaviour in patients treated with antipsychotic medication. However, proactive screening for emerging suicidal behaviour in this vulnerable patient group is advisable. Our findings highlight the pressing need for further research in this area.Keywords: antipsychotic medication, akathisia, restlessness, suicidal behaviour

Aims: The Covid-19 pandemic has had a substantial impact on the mental health of the general public and high-risk groups across the globe. Southeast Asia, one of the first regions to be affected by the outbreak, is of particular interest given its proximity and close links to China, experience with recent epidemics (i.e. SARS), and the variable course of the outbreak in the region thus far. The aim of this study was to systemically review and assess the prevalence of anxiety, depression and insomnia symptoms in the general adult population, frontline and general healthcare workers (HCWs), and adult students in Southeast Asia during the course of the first year of the Covid-19 pandemic. Methods: Several literature databases (PubMed, Embase, PsycINFO, Web of Science, and medRxiv) were systemically searched for articles published up to February 2021. Two reviewers independently evaluated all the relevant studies using pre-determined criteria and assessed the risk of bias for each included study. The prevalence rates of mental health symptoms were estimated using a random-effect meta-analysis model. Results: In total, 32 samples from 25 studies with 20,352 participants were included. Anxiety symptoms was assessed in all 25 studies and depressive symptoms in 15 studies with pooled prevalence rates of 22% and 16% respectively. Only two studies evaluated insomnia, whose prevalence was estimated to be 19%. The overall prevalence of mental health disorders was similar amongst frontline HCWs (18%), general HCWs (17%), and students (20%) whilst being noticeably higher in the general population (27%). Conclusions: The results indicate that a considerable proportion of participants report the presence of anxiety, depression and insomnia symptoms. However, the pooled prevalence rates in Southeast Asia are significantly lower than those reported in other meta-analyses from other areas such as China and Europe. This meta-analysis may provide valuable evidence for more targeted identification of mental health needs and guide future research of long-term outcomes. Keywords: meta-analysis; Covid-19; mental health; pandemic; general population; healthcare workers; students; anxiety; depression; insomnia

Background Serious mental illnesses (SMI) such as schizophrenia and bipolar disorder first develop between ages 14 and 25. Once diagnosed, young peoples’ health can deteriorate, and it is therefore vital to detect this early to prevent severe outcomes including hospitalisations and deaths by suicide. The main study aim is to describe and discuss observational studies that examine signs of deterioration in young patients with SMI. Methods A systematic review guided by the published protocol was conducted. Cumulative Index to Nursing and allied Health Literature (CINAHL), MEDLINE, Embase, PsycINFO, Health Management Information Consortium (HMIC) and Web of Science were searched against pre-defined criteria until 1 March 2021. Observational studies were extracted according to design, country, participant, indicator, outcome and main finding categories. Quality was assessed independently using the Newcastle Ottawa Scale (NOS). Results Of the 15,788 publications identified, 5 studies were included and subjected to narrative synthesis. Two indicators of mental health deterioration were identified: cognitive functioning (decline, worsening and poor school/academic performance) and expressed emotion status. Indicators revealed mixed views on predicting deterioration. Worsening cognitive functioning and expressed emotion status significantly predicted medication non-adherence and relapse respectively. However, a decline in cognitive functioning (poor academic performance) was not found to significantly correlate to deaths by suicide. Study quality was mostly poor and associations between indicators and varied outcomes were weak. The heterogeneous nature of the data made comparisons difficult and did not allow for further statistical analysis. Conclusion To our knowledge, this is the first review of observational studies to identify indicators of deterioration in young patients with SMI. Worsening cognitive functioning and expressed emotion status could indicate non-adherence and relapse in young patients with SMI but larger sample sizes in good quality studies are needed. The dearth of observational studies means further research is required to ascertain other indicators of deterioration before serious outcomes occur. Funding This work was supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre via an NIHR programme grant. The authors are also grateful for support from the NIHR under the Applied Health Research programme for North West London and the NIHR Imperial Biomedical Research Centre. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service (NHS), the NIHR or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Trial registration This systematic review has been registered on PROSPERO (registration number: CRD42017075755).

During the COVID-19 pandemic, the need to establish the prevalence of sleep dysfunction and psychological distress, identify predisposing and protective factors, and explore effective management strategies remains an important priority. Evidence to date suggests that a considerable proportion of COVID-19 patients experience significant sleep disturbances (estimated to afflict up to 50–75%) as well as psychological distress such as depression, anxiety, and traumatic stress. Duration of hospitalization, pre-existing mental health concerns, lower absolute lymphocyte count, and increased neutrophil-to-lymphocyte ratio have been all associated with a greater risk of sleep dysfunction in infected and hospitalized patients. Furthermore, in this review, we discuss the link between sleep deprivation, susceptibility to viral infections, and psychosocial wellbeing in relevance to COVID-19 and summarize the existing evidence regarding the presence and role of sleep apnea in infected individuals. Finally, we highlight the importance of suitable interventions in order to prevent and manage sleep dysfunction and avoid long-term physical and psychological implications. Future research should aim to provide high-quality information including in high risk, underserved, or difficult to reach populations and on the long-term consequences and effectiveness of applied interventions.

Asthma exacerbations are a common cause of ED visits and can be life-threatening for patients with asthma. Identification of these patients characteristics could help improve their management and reduce exacerbations rate. We called for a 3-month follow-up visit patients that visited ED and were initially diagnosed with asthma exacerbation. Patients with a definite diagnosis of asthma were finally assessed in terms of the following parameters (Table 1a). 100 patients were enrolled, with 34% being newly diagnosed with asthma. The majority of them had mild asthma, outreaching 72.6% in GINA stages I and II. 13.7% were classified in stage III and 13.7% in stages IV/V. Prior to ED visit treatment included ICS/LABA(32.3%), SABA as needed(24.2%), ICS/LABA plus LAMA(19.4%), ICS/LABA as needed(9.7%) and 8.1% did not receive any treatment. 62.3% were adherent at prescribed treatment. Active smoking was self-reported by 40.4% and passive smoking outreached 31% in non-smokers. Following HAD’s score evaluation 31.2% showed anxiety and 12.5% showed depression (cutoffs>11). See all characteristics on Table 1b. Conclusively, 1/3 of patients visiting ED with asthma exacerbation, were newly diagnosed with asthma. Most of patients were classified in stages I and II and a significant proportion used SABA monotherapy prior to visit. Smoking, poor adherence, psychopathology and commorbidities were highly prevalent characteristics among participants.

Background To understand the implications of switching from paliperidone palmitate 1-monthly (PP1M) to paliperidone palmitate 3-monthly (PP3M) treatment of schizophrenia from the perspective of four key stakeholders: patients, physicians, nurses and carers. Methods This was a cross-sectional, retrospective, non-interventional study comprising a one-time questionnaire (PINC-Q) for adult patients (aged ≥18 years) with schizophrenia (International Classification of Diseases; ICD-10) and their physician, nurse and carer. Questionnaires were developed in association with patient and carer advocacy groups (GAMIAN and EUFAMI) and following an advisory board formed of psychiatrists and nurses. The degree of alignment between stakeholders was also examined. Results Responses were received from a total of 224 evaluable patients. For most patients (88.4%), responses were received from at least two other stakeholders. Patients were moderately ill with mild-to-moderate lack of insight and had received PP1M for a mean (standard deviation [SD]) of 23.9 (21.28) months before switching to PP3M (duration mean [SD] 12.8 [3.72] months). The most frequently reported reasons to switch from PP1M to PP3M were ‘to live life as normally as possible’ and ‘patient convenience’. Over 79% of responses within each stakeholder group stated that PP3M helped the patients, with increased patient activity and social involvement, improved frequency and quality of physician–patient and nurse–patient communication and decreased perceived stigma. Conclusions The results of this study add to the increasing body of evidence supporting the benefits of PP3M in a population of patients with schizophrenia representative of real-world clinical practice.

Introduction Sexual dysfunction is one of the most frequently occurring side-effects of antipsychotic medication, impacting both quality of life and adherence to treatment. Despite this, limited evidence-based guidance on treatment options is available. Aim To synthesize and analyze the evidence on management of antipsychotic-related sexual dysfunction, specifically taking note of the more recently developed antipsychotics that have been incorporated in studies over the past decade. Methods EMBASE, Medline, and PsychINFO databases were searched using search terms related to sexual or erectile dysfunction, treatments, and antipsychotics. 2 reviewers independently assessed papers for the inclusion criteria for randomized controlled trials (RCTs) of treatments for antipsychotic-related sexual dysfunction, including adjunctive medications and a switch of antipsychotic. Studies were excluded if participants did not have recorded sexual dysfunction at baseline. Main Outcome Measure The primary outcome measure was any change in sexual function. Results 6 RCTs were identified, all of which investigated different interventions; hence, it was not possible to synthesize the data quantitatively. Results were overall limited by small sample size, brief treatment duration, and the potential for bias. 2 studies, one assessing adjunctive sildenafil and the other adjunctive aripiprazole, reported a reduction in antipsychotic-related sexual dysfunction. Clinical Implications Due to the lack of high-quality data, no clinical recommendations can be made. Strengths & Limitations A comprehensive search strategy was used with an extensive number of relevant search terms including “erectile dysfunction” and newer antipsychotics such as aripiprazole. In light of evidence that prolactin is not a reliable marker for sexual dysfunction, this review focused its inclusion criteria on participants presenting with sexual dysfunction rather than with hyperprolactinemia, which should give its recommendations more validity. However, only 6 RCTs were identified, and results were overall limited by small sample size, brief treatment duration, and the potential for bias. Conclusion Our findings highlight the paucity of high-quality research in this area, and conjecture that it may be difficult to recruit participants with antipsychotic-related sexual dysfunction. Future research may be necessary to unlock and address these difficulties. Furthermore, fully powered future studies should focus on the management of sexual dysfunction rather than the surrogate marker of hyperprolactinemia.

Introduction Lurasidone is an atypical antipsychotic that was approved in Europe in 2014 for the treatment of schizophrenia in adults aged ≥ 18 years. Clinical experience with lurasidone in Europe is currently limited, and there is therefore a need to provide practical guidance on using lurasidone for the treatment of adults with schizophrenia. Methods A panel of European psychiatrists with extensive experience of prescribing lurasidone was convened to provide recommendations on using lurasidone to treat adults with schizophrenia. Results Extensive evidence from clinical trials and the panel’s clinical experience suggest that lurasidone is as effective as other atypical agents, with the possible exception of clozapine. Lurasidone is associated with a lower propensity for metabolic side effects (in particular, weight gain) and hyperprolactinaemia than most other atypical antipsychotics and has a relatively benign neurocognitive side effect profile. Patients switching to lurasidone from another antipsychotic may experience weight reduction and/or improvements in the ability to focus/concentrate. Most side effects with lurasidone (such as somnolence) are transitory, easily managed and/or ameliorated by dose adjustment. Akathisia and extrapyramidal symptoms may occur in a minority of patients, but these can be managed effectively with dose adjustment, adjunctive therapy and/or psychosocial intervention. Conclusions Given the crucial importance of addressing the physical as well as mental healthcare needs of patients, lurasidone is a rational therapeutic choice for adults with schizophrenia, both in the acute setting and over the long term. Funding Sunovion Pharmaceuticals Europe Ltd. Electronic supplementary material The online version of this article (10.1007/s40120-019-0138-z) contains supplementary material, which is available to authorized users.

The COVID-19 pandemic has the potential to adversely affect the mental health of healthcare workers (HCWs). The public healthcare system in Greece was already facing serious challenges at the outset of the outbreak following years of austerity and an escalating refugee crisis. This multi-center, cross-sectional study aims to assess the levels and associated risk factors of anxiety, depression, traumatic stress and burnout of frontline staff in Greece. A total of 464 self-selected HCWs in six reference hospitals completed a questionnaire comprising sociodemographic and work-related information and validated psychometric scales. The proportion of HCWs with symptoms of moderate/severe depression, anxiety and traumatic stress were 30%, 25% and 33%, respectively. Burnout levels were particularly high with 65% of respondents scoring moderate/severe in emotional exhaustion, 92% severe in depersonalization and 51% low/moderate in personal accomplishment. Predictive factors of adverse psychological outcomes included fear, perceived stress, risk of infection, lack of protective equipment and low social support. The psychological burden associated with COVID-19 in healthcare professionals in Greece is considerable, with more than half experiencing at least mild mental health difficulties. Findings signal the need for immediate organizational and individually tailored interventions to enhance resilience and support wellbeing under pandemic conditions.

Early Intervention in psychosis (EIP) teams are the gold standard treatment for first-episode psychosis (FEP). EIP is time-limited and clinicians are required to make difficult aftercare decisions that require weighing up individuals’ wishes for treatment, risk of relapse, and health service capacity. Reliable decision-making tools could assist with appropriate resource allocation and better care. We aimed to develop and externally validate a readmission risk tool for application at the point of EIP discharge. All persons from EIP caseloads in two NHS Trusts were eligible for the study. We excluded those who moved out of the area or were only seen for assessment. We developed a model to predict the risk of hospital admission within a year of ending EIP treatment in one Trust and externally validated it in another. There were n = 831 participants in the development dataset and n = 1393 in the external validation dataset, with 79 (9.5%) and 162 (11.6%) admissions to inpatient hospital, respectively. Discrimination was AUC = 0.76 (95% CI 0.75; 0.77) in the development dataset and AUC = 0.70 (95% CI 0.66; 0.75) in the external dataset. Calibration plots in external validation suggested an underestimation of risk in the lower predicted probabilities and slight overestimation at predicted probabilities in the 0.1–0.2 range (calibration slope = 0.86, 95% CI 0.68; 1.05). Recalibration improved performance at lower predicted probabilities but underestimated risk at the highest range of predicted probabilities (calibration slope = 1.00, 95% CI 0.79; 1.21). We showed that a tool for predicting admission risk using routine data has good performance and could assist clinical decision-making. Refinement of the model, testing its implementation and further external validation are needed.

Background Early intervention in psychosis services (EIS) support individuals experiencing a first episode of psychosis. Support required will vary in response to the remittance and reoccurrence of symptoms, including relapses. Characterising individuals who will need more intensive support can inform care planning. This study explores service utilisation profiles and their trajectories of service use in a sample of individuals referred to EIS. Method We analysed service utilisation during the 3 years following referral to EIS (n = 2363) in West London between 2011 and 2020. Mental health service utilisation data were submitted to model-based clustering. Latent growth models were then estimated for identified profiles. Profiles were compared regarding clinical and demographic characteristics and onward pathways of care. Results Analyses revealed 5 profiles of individuals attending EIS based on their service utilisation over 3 years. 55.5% of the sample were members of a low utilisation and less clinically severe profile. The distinct service use patterns of these profiles were associated with Health of the Nations Outcome Scale scores at treatment initiation (at total, subscale, and individual item level), along with age and gender. These patterns of use were also associated with onward care and ethnicity. Conclusions Profiles and trajectories of service utilisation call for development of integrated care pathways and use of more personalised interventions. Services should consider patient symptoms and characteristics when making clinical decisions informing the provision of care. The profiles represent typical patterns of service use, and identifying factors associated with these subgroups might help optimise EIS support.

Background: The pragmatic management of psychotic disorders is more complex than that delivered in a controlled trial environment. Therefore, this study aims to evaluate the real-world effectiveness of aripiprazole long-acting injectable (ALAI) and compare it with another commonly used long-acting anti-psychotic, once-monthly paliperidone palmitate (PP1M). Methods: This naturalistic, independent 4-year mirror image study compared the mean number and length of hospital admissions 2 years before and 2 years after treatment initiation with ALAI. Retention rates, discontinuation reasons and level of adherence were also recorded. Furthermore, indirect comparisons were made between treatment outcomes on ALAI and PP1M. Results: A total of 109 eligible patients with a severe mental illness (65% with schizophrenia and 35% with other diagnosis) commenced on ALAI and 173 patients (69% with schizophrenia and 31% with other diagnoses) initiated on PP1M were included. Of these, 37% on ALAI and 34% on PP1M stopped treatment at 2 years; retention rates were most favourable for the schizophrenia group on PP1M. Patients were more likely to discontinue due to lack of effectiveness on ALAI and due to tolerability issues on PP1M. Those who continued for 2 years on ALAI ( n = 69), demonstrated an overall decrease of 84% in the mean number and 88% in the mean length of hospital admissions compared with the 2 years before initiation. Although patients on ALAI appeared to have a significantly higher bed occupancy the 2-year period before initiation than patients on PP1M, the reductions in hospitalizations were comparable across both cohorts after 2 years of treatment. Conclusions: The introduction of ALAI had a substantial impact on long-term clinical outcomes in this naturalistic cohort; more than half of patients continued treatment and had no admission during 2 years of follow up. There were no significant differences in hospitalisation rates between patients on ALAI and PP1M at 2 years.

COPD in developed countries is mainly attributed to tobacco smoking. Sustained smoking accelerates the progression of COPD with grave consequences on healthcare costs, disability and morbidity. Separate studies on smoking cessation (SC) in COPD pts and psychiatric comorbidities reveal a highly addicted and difficult to quit sub category. However, the possible interaction between COPD and mental health conditions and its potential impact on quitting behavior ofCOPD pts has not been sufficiently researched. We examined the records of 2.542.732 patients which are part of the Whole SystemsIntegrated Care dataset (WSIC) in North West London, one of the mostcomprehensive data sets in the UK, containing linked coded data from primary care,secondary care, community, mental health and social care across a population of over 2.5million. We evaluated the co-occurrence of sleep disorders, schizophrenia, depression and anxiety and its effects on continuing smoking. An estimated 32.389(1.3%) pts of the total cohort had COPD.Of these, 4.437(13.7%) pts belonged to stage I, 7.786(24%) to II, 3.548(11%) to III and 1.377(4.3%) to stage IV. Furthermore, 2.791(8.6 %) of COPD pts were also suffering from depression, 3.186(9.8%) from anxiety, 508(1.6%) from schizophrenia and 1.556(4.8%) from sleep disorders. Of note, 21.022(64.9%) of COPD diagnosed patients were still smoking. This rate was even higher for pts with mental health difficulties as 2.106(75.5%) pts with depression, 2.296(72%) with anxiety, 433(85.2%) with schizophrenia and 1.147(73.7%) withsleep disorders continued to smoke. Anxiety, depression and schizophrenia as barriers to quitting should be taken into account so as to offer tailored SC programs to COPD pts following diagnosis.

Smoking worsens all asthma parameters. Smokers with psychiatric comorbidities show high nicotine addiction and difficulty to quit. However, the possible interaction between asthma and mental health conditions and its potential impact on quitting behavior on smokers with such commorbidity has not gained research interest. We examined 2.542.732 patients record which are part of the Whole Systems Integrated Care database (WSIC) in North West London. This is a comprehensive data set in the UK, containing linked coded data from primary care, secondary care, community, mental health and social care across a population of over 2.5 million. We evaluated asthma patient characteristics that are not well studied such as the co-occurrence of sleep disorders, schizophrenia, depression and anxiety and its effects on continuing smoking. 76.224 (3%) pts had asthma. Of these, 6.003 (7.88%) were also suffering from depression, 8.679 (11.4%) from anxiety, 753 (1%) from schizophrenia and 2.764(3.6%) from sleep disorders;revealing asthma the most frequent comorbity (CVD,DM,COPD) of mental health pts. Of note pts with mental health difficulties continued to smoke. Namely 2.787 (46.4%) pts with depression, 3.325(38.3%) with anxiety, 414 (55%) with schizophrenia and 1.091 (39.5%) with sleep disorders were asthmatic smokers. We found that the triple of smoking,asthma and mental health disorders spikes NHS resources consumptions (hospital & social care, A&E and GP visits). Tailored smoking cessation programs should be offered to asthmatic smokers. The contribution of anxiety, depression and schizophrenia as barriers to quitting, adherence to treatment and exacerbation prevention should be taken into account and form part of the management plan.

Smoking is associated with impaired fasting glucose levels and increased insulin resistance.Post-cessation weight gain (PSWG) highly concerns diabetic patients since it leads to poor control of diabetic parameters, discourages them to quit and can be a cause of relapse. Identification of this population9s characteristics could help improve smoking cessation rates. We recruited smokers with DM (type 1 and 2), who agreed to take varenicline and attend an intense smoking cessation program once a week given by multidisciplinary team. 41 (14 women, 27 men) diabetic smokers accepted to follow the program. The participants were very addicted (FTND 9/11, 30cigs/day), motivated (8,1/10) but lacking confidence (5,1/10). Characteristics shown on Fig 1a. After 3 months 25 participants quit smoking (61%), 7 reduced more than half the cigarettes smoked daily, while 9 participants quit the program. Interestingly, patients who quit the program showed higher levels of psychopathology compared to those who continued. Changes of body weight and rest metabolism rate (RMR) were not significant after smoking cessation (RMR measurements for DM 2 only, N=21) (Fig 1b). HDL was significantly increased. Findings were partly attributed to an increase of physical activity level reported after strong recommendations (Fig 1c). Diabetics succeeded in quitting (61%), ameliorated lipidemic profile, without a statistically significant PSWG by improving physical activity.

Introduction: Asthma attacks constitute a major cause of Emergency Room (ER) visits and a potential danger to patients9 life. Additionally, asthma exacerbations pose a severe economic burden for public health. Consequently, identifying the specific characteristics of this patient subgroup may lead to better patient management and subsequently less asthma attacks occurrence. Methods: Patients treated for an asthma exacerbation at the ER during four months (2019) were assessed for a definite asthma diagnosis at the outpatient clinic. The study included patients that the diagnosis of asthma was confirmed. Parameters reported at Figure 1a. Results: A total of 70 patients were enrolled, with 36,2% of them having an asthma diagnosis for the first time. Reexamination, carried out at least 3 months after the attack, revealed that the majority of patients had mild asthma. Specifically, 73,5% had stage I or II, 9,4% stage III and only 17% stage IV or V. Hospital admission occurred in 13,3% of patients (of which 50% stage I-II, 13% stage III and 37% of stage IV-V). Among patients with a previous diagnosis of asthma, prescribed medication included ICS-LABA (16,8%), ICS-LABA & LAMA (10%), SABA monotherapy (26,6%) whereas 30% did not receive any medication. 25,5% were exposed to passive smoking. Specific characteristics available at Figure 1b. Conclusion: The vast majority of patients with asthma attacks visiting ER were either not diagnosed for asthma or if they were diagnosed, they abused SABA and lacked proper medication. Most of them belong to stage II. Smoking, psychopathology, poor therapy adherence, lack of action plan and a new diagnosis where the most common characteristics.

The novel coronavirus disease (COVID-19) was declared a pandemic οn March 11, 2020. Healthcare workers (HCWs), though vital for the functioning of the health systems during this global pandemic crisis, are unequivocally exposed to increased risk of infection through direct contact with patients. The European Respiratory Society, in a signed joint statement at the end of March, urged the European Union and national governments to prioritise health and safety of the frontline fight against COVID-19 [1]. In COVID-19 Situation Report 82, the World Health Organization (WHO) subject stressed the under-representativeness and paucity of publications and national situation reports that provide information on the number of infected HCWs. In this report, 52 countries had reported a total of 22 073 HCWs that had contracted COVID-19 [2]. Considering the current paucity of consolidated data on this, we attempted to quantify the number of reported HCW infections and case fatalities from COVID-19 in different areas and countries., Provision of PPE, placing experienced HCWs mostly in organisational positions, increasing testing, minimising exposure by adjusting shift schedules, and providing food and sleep facilities could be some restorative measures to protect HCWs from #COVID19 https://bit.ly/2zcVARW

Background: Previous studies showed a linear correlation between partial compliance with an oral antipsychotic medication and hospitalisation risk among patients with schizophrenia. Long-acting injections (LAIs) may significantly improve adherence and reduce relapse in patients with psychosis. The aim of this study was to evaluate the relationship between the level of compliance with 1-monthly paliperidone palmitate (PP1M) and hospitalisation rates. Methods: This was a naturalistic, mirror-image study examining retention, compliance and hospitalisation rates 3 years pre- and 3 years post-PP1M initiation. Compliance was divided in three groups: full (no missed dose/year), good (6–11injections/year), poor (Results: A total of 173 patients suffering from a severe mental illness (70% with a diagnosis of schizophrenia and 30% with other diagnoses) were included; 77% of patients continued PP1M for 1 year, 66% for 2 years and 55% for 3 years. Of the 95 patients who remained on PP1 throughout the 3 years of follow up, 81% showed full, 13% good, and only 6% poor compliance. In the patients who were fully compliant, the mean number of hospital admissions decreased from 1.34 to 0.43, and the mean number of bed days from 82 to 19 days per patient 3 years before and 3 years after PP1M initiation ( p Conclusion: There was a direct association between partial compliance and re-hospitalisation; fully compliant patients maintained the best outcomes in terms of reduced bed use following PPM1 initiation.

Background Sexual dysfunction is one of the most frequently occurring side-effects of antipsychotic medication, impacting both quality of life and adherence to treatment. Despite this, limited evidence-based guidance on treatment options is available. The aim of this systematic review was to synthesize and analyze the evidence on the management of antipsychotic-related sexual dysfunction, specifically taking note of the more recently developed antipsychotics that have been incorporated Methods EMBASE, Medline, and PsychINFO databases were searched using search terms related to sexual or erectile dysfunction, treatments, and antipsychotics. 2 reviewers independently assessed papers for the inclusion criteria for randomized controlled trials (RCTs) of treatments for antipsychotic-related sexual dysfunction, including adjunctive medications and a switch of antipsychotic. Studies were excluded if participants did not have recorded sexual dysfunction at baseline. Results The primary outcome measure was any change in sexual function. Results 6 RCTs were identified, all of which investigated different interventions; hence, it was not possible to synthesize the data quantitatively. Results were overall limited by small sample size, brief treatment duration, and the potential for bias. 2 studies, one assessing adjunctive sildenafil and the other adjunctive aripiprazole, reported a reduction in antipsychotic-related sexual dysfunction. Discussion Due to the lack of high-quality data, no clinical recommendations can be made. Our findings highlight the paucity of high-quality research in this area, and conjecture that it may be difficult to recruit participants with antipsychotic-related sexual dysfunction. Future research may be necessary to unlock and address these difficulties. Furthermore, fully powered future studies should focus on the management of sexual dysfunction rather than the surrogate marker of hyperprolactinemia.

There is a growing need for real world data on long-term clinical and health resource utilization outcomes. The main purpose of this study was to establish the effects of 1-monthly Paliperidone Palmitate (PP1M) on treatment continuation and hospital stay in routine clinical practice. This is a naturalistic, 6-year mirror-image study examining retention and hospitalization rates 3 years pre-PP1M and 3 years post-PP1M initiation. One hundred seventy-three patients were included; 120 (70%) had a primary diagnosis of schizophrenia and 53 (30%) other diagnosis. In total, 77% of patients continued PP1M for one year, 66% for two years and 55% for three years. For the patients who continued with PP1M for 3 years (n = 95), the mean number of hospital admissions decreased significantly from 1.44 to 0.53 and the mean number of bed days from 93 to 29 bed days 3 years before and 3 years after PP1M initiation (P < 0.001). The group of patients with schizophrenia who continued for 3 years (n = 79) demonstrated similar outcomes. The introduction of PP1M had a significant impact on long-term clinical outcomes. More than half of patients were still continuing on PP1M at 3 years after initiation and had no admission during 3 years follow-up.

BACKGROUND: Previous studies showed a direct correlation between partial compliance with an oral antipsychotic medication and hospitalization risk among patients with schizophrenia across a continuum of compliance behavior. Long Acting Injections (LAIs) may enhance compliance and reduce relapse. The aim of this study was to evaluate the relationship between compliance with LAI 1-monthly Paliperidone Palmitate (PP1M) and risk of discontinuation and hospitalization. METHODS: This was a naturalistic, 6-year mirror-image study examining retention, compliance & hospitalization rates 3 years pre and 3 years post PP1M initiation. Compliance was divided in four groups: full (no missed dose/year), good (>6 injections/year), poor (

This article describes a rare case of giant cell tumor of the tendon sheath (GCTTS) that was developed over the substance of chimeric-free latissimus dorsi and ­serratus ­anterior muscle flaps performed for lower limb reconstruction. To our knowledge, development of GCTTS over a free flap is first described in the literature. A 71-year-old ­woman was presented with a large protuberant ulcerated tumor mass that was developed over the substance of chimeric free muscle flaps at the foot and ankle. We performed an extensive tumor resection, and the pathology report confirmed the presence of a primary giant cell tumor. The patient was advised to have a below-knee amputation. However, the patient refused the amputation, and 4 months later, she was presented with a metastatic mass proximally at the upper thigh. We believe that the GCTTS was associated with the chronic inflammation of the soft tissue and bones along with the recurrent episodes of infection, mainly due to proteus mirabilis and proteus syndrome (PS). PS may lead to the development of malformations and overgrowth of different tissues in unusual locations. In cases resistant to antibiotics, the radical surgical debridement should be considered as the most effective treatment.

The burden of the COVID-19 pandemic on health systems and the physical and mental health of healthcare workers (HCWs) has been substantial. This cross-sectional study aims to assess the effects of COVID-19 on the psychological wellbeing of mental health workers who provide care to a vulnerable patient population that have been particularly affected during this crisis. A total of 387 HCWs from across a large urban mental health service completed a self-administered questionnaire consisting of socio-demographic, lifestyle and work-based information and validated psychometric scales. Depression and anxiety were measured using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7), respectively, sleep problems with the Athens Insomnia Scale (AIS), burnout with the Maslach Burnout Inventory (MBI), and resilience with the Resilience Scale-14 (RS-14). Multivariable logistic regression analysis was performed to determine potential mediating factors. Prevalence of burnout was notable, with 52% recording moderate/severe in Emotional Exhaustion, 19.5% moderate/severe in Depersonalisation, and 55.5% low/moderate Personal Accomplishment. Over half of all respondents (52%) experienced sleep problems, the presence of depressive symptoms was a significant predictor of insomnia. An increase in potentially harmful lifestyle changes, such as smoking, alcohol consumption and overeating was also observed. However, high Resilience was reported by 70% of the samples and the importance of this is highlighted. Female gender was associated with increased levels of depression and emotional exhaustion while those with a history of mental health conditions were most at risk of affective symptoms, insomnia, and burnout. Overall, our study revealed considerable levels of psychological distress and maladaptive coping strategies but also resilience and satisfaction with organizational support provided. Findings can inform tailored interventions in order to mitigate vulnerability and prevent long-term psychological sequelae.

Food allergens are a well acknowledged issue in food industry and are regulated by legislation. The presence of allergens can either origin from the raw material or due to contamination during production. Allergen information on packaging is mandatory although it cannot be accurate in the case of contamination therefore warnings are used. The purpose of the study is the development and validation of a SYBR Green Real Time Polymerase Chain Reaction method using specific primer pairs based on Jug r 1, Jug r 3, and Jug r 4 allergen-coding sequences to improve the sensitivity of Real Time Polymerase Chain Reaction techniques for detection of walnut and almond traces in commercial food products and its comparison with ELISA methodology in terms of detection ability. A total of 100 samples were collected from local markets and were analyzed by Real Time Polymerase Chain Reaction (RT-PCR) and ELISA methods. The results indicated that 16 samples (16%) were found positive in walnut traces and 18 samples (18%) were found positive in almond traces by Real Time Polymerase Chain Reaction of which Elisa identified 14 samples (14%) positive in walnut traces and 15 samples (15%) positive in almond traces. Among them, 4 samples (25%) that contained walnut traces and 6 samples (33.3%) that contained almond traces had no allergen declaration on their label. The improved accuracy of Real Time Polymerase Chain Reaction underlines the importance of this method for allergen detection and quantification in the food industry

Background Although the impact of childhood chronic neurological diseases (CND) on patients’ psychological well-being has been increasingly addressed, little attention has been given to the influence of these conditions on family members and family functioning. The purpose of the present study was to investigate the family characteristics of Greek children suffering from CND. Methods A total of 52 parents of children with CND were studied by using the Family Environmental Scale (FES), the Family Burden Scale, the General Health Questionnaire (GHQ-28) and a questionnaire on the knowledge of their children's illness, their coping strategies and their satisfaction with our services. During the same period, 30 parents of hospitalized children for common paediatric illnesses completed the FES. In both groups social and demographic features were registered. Appropriate statistical processes were applied to compare the above-mentioned family groups and to study the differences between the families of children with epilepsy (n = 37) and the families of children with other CND (n = 15). Results Parents of children with CND discuss their problems less freely, talk less openly around home, score highly on FES subscale of Conflict and, pay more attention to ethical and religious issues and values. Furthermore, the families of children with other CND were more burdened regarding the financial state and the health status of other family members in comparison with families of children with epilepsy. In addition, families of children with epilepsy were more involved in social and recreational activities, appeared to be more knowledgeable on the availability of help in critical conditions and were more satisfied with rendered medical services, in comparison with families of children with other CND. Conclusion These preliminary findings provide important information concerning the special characteristics of Greek families of children suffering from CND, which may prove especially helpful in organizing specific support services.

Levetiracetam (LEV), a novel antiepileptic drug, has demonstrated antidyskinetic effect in preclinical animal models of Parkinson's disease (PD) and in one open label study in PD patients with levodopa-induced dyskinesia. The acute antidyskinetic effects of LEV in patients with tardive dyskinesia were evaluated in an open label study. Eight patients received oral LEV (1,000 mg/day) for 1 month and blinded evaluations were performed at baseline and at the end of the treatment period. A significant reduction of the abnormal movements was recorded while psychiatric symptoms did not worsen and the adverse event profile was benign. LEV may be efficacious for the treatment of tardive dyskinesia and deserves further clinical testing. Mov Disord

OBJECTIVE: The objective of the study was to demonstrate whether the N-methyl-D-aspartate antagonist, amantadine, can safely ameliorate tardive dyskinesia (TD) without deteriorating the mental state of the patients. METHODS: Twenty-two TD patients, with a mean age 52 years, participated in the study. A double-blind, placebo-controlled, crossover design was used. Patients were randomly assigned to receive either amantadine or placebo for 2 weeks followed by a washout period of 4 days. Subsequently,the groups were crossed over, and the procedure repeated. Participants received amantadine (100 mg) or placebo. Tardive dyskinesia was assessed by means of the Abnormal Involuntary Movements Scale(AIMS). The primary efficacy end point was changes in AIMS score, at baseline and at the end of the 2-week treatment period.Results: After amantadine treatment, patients exhibited a reduced average score of total AIMS (from 13.5 before treatment to 10.5 after treatment,P = 0.000), of facial and oral AIMS (from 5.5 before treatment to 4.2 after treatment, P = 0.002), of extremity AIMS (from 4.18 before treatment to 2.8 after treatment, P = 0.000), and of severity AIMS (from 2.04 before treatment to 1.54 after treatment, P = 0.002). With amantadine,the average total AIMS reduction was 21.81%. On the contrary with placebo treatment, no reduction was noted.In addition, amantadine administration exhibited a positive effect,which was statistically significant for incapacitation and Clinical Global Impression score. Amantadine did not alter any of the cognitive measures used in this study, as Mini-Mental State Examination, distress, and Brief Psychiatric Rating Scale. CONCLUSIONS: Amantadine may be an effective and safe treatment for TD. The severity of TD movements in patients receiving amantadine improved significantly more than in those receiving placebo, as measured by the AIMS score. Clin Neuropharmacol

Mov Disord

Although psychiatric disturbances and personality features are possibly involved in inflammatory bowel disease, little attention has been given to the potential role of defense mechanisms in the formation, course, or prognosis of the disease. The purpose of the present study was to determine whether certain defense styles and ego mechanisms of defense are associated with inflammatory bowel disease, including both ulcerative colitis and Crohn’s disease. Seventy-six consecutive unselected outpatients participated in the study. The sample consisted of 39 patients with Crohn’s disease, 33 with ulcerative colitis, and 4 with an intermediate form of inflammatory bowel disease. The Symptom Distress Checklist (SCL-90-R), Defense Style Questionnaire (DSQ), and Hostility and Direction of Hostility Questionnaire (HDHQ) were used. Crohn’s disease patients presented a more immature defensive profile than ulcerative colitis patients, using a “maladaptive action” style, as well as “consumption” and “pseudo-altruism” defense mechanisms more often. These differences were statistically significant and they were independent of age, sex, educational level, disease extension, and pharmacologic treatment. A significant positive correlation was also found between disease activity and defensive profiles in both ulcerative colitis and Crohn’s disease patients. In contrast, there was no statistically significant difference between ulcerative colitis and Crohn’s disease patients in terms of psychiatric symptoms. Crohn’s disease patients presented a different and more immature defensive profile than patients with ulcerative colitis. In addition, the more psychologically mature inflammatory bowel disease patients had lower rates of relapses and surgical operations, providing evidence that these aspects of personality are likely to influence the patients’ adaptation to the disease.