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Objectives: Malignant catatonia (MC) is a rare, yet potentially life-threatening neuropsychiatric condition. Evidence on its therapy is weak, treatment recommendations are scarce and predominantly unprecise. The aim of this study was to compare the effectiveness of different MC treatment approaches regarding outcome and severity of MC. Methods: We conducted systematic searches for MC case reports in biomedical databases and the psychiatric archive of University Hospital Ulm. Treatments were compared considering MC severity and temporal aspects. Results: A total of 117 cases were included. Treatment had a significant influence on outcome: treatment with both benzodiazepines and electroconvulsive therapy (ECT) entailed the most favourable, purely supportive therapy the least favourable outcome. Earlier application of benzodiazepines was significantly associated with a favourable outcome. A classification of MC severity was developed. Patients with severe MC were significantly more often subject to intensive care treatment and had a 78% higher risk of dying than in moderate MC. Conclusions: This is the first study to introduce a severity classification for MC, and the largest to compare outcomes of MC treatments with clear distinction from neuroleptic malignant syndrome (NMS). Preferable MC treatment should include early initiation of benzodiazepines and ECT. MC severity could serve as a prognostic instrument. [ABSTRACT FROM AUTHOR]

Abstract: Though electroconvulsive therapy (ECT) requires a close cooperation between anesthesiology and psychiatry, literature lacks of approaches that consider both disciplines in parallel. Special problems might be posed by patients with complicated features or ECT-indications other than treatment-refractory depression (TRD). Considering these patients there is a particular paucity of data, especially regarding anesthesiological aspects. Therefore, we sought (1) to discuss special issues of the peri-interventional management of non-TRD-cases from a combined psychiatric–anesthesiological point of view and (2) to assess the efficacy of ECT in the classical indication of TRD as compared to cases undergoing ECT for other indications or under difficult conditions (non-TRD) by means of Clinical Global Impression-Improvement (CGI-I) scale scores. A retrospective chart analysis of patients treated with ECT between the years 2009 and 2011 at the University of Ulm, Department of Psychiatry, was conducted. Special anesthesiological efforts were necessary in cohort non-TRD. There was no difference in the clinical outcome between cohort non-TRD (n=7) and TRD (n=22) with a median CGI-I score of 2 (“much improved”) in both groups. Close cooperation between psychiatry and anesthesiology is indispensable in non-TRD patients. Our results provide preliminary evidence that ECT is equally effective in the standard indication of TRD compared to other indications. [Copyright &y& Elsevier]

Abstract: Tranylcypromine (TCP) is a non-selective and irreversible monoamine oxidase inhibitor and an effective agent in the treatment of major depression. It features a complex pharmacologic profile and overdoses might induce severe intoxications. To identify typical clinical presentations of TCP-intoxications, range of associated TCP-dosages and possible differences between fatal and non-fatal intoxications a systematic review of all previously published cases of TCP-intoxications was conducted. We detected n=20 reports of TCP-intoxications in the literature (fatalities n=10). Mean age was 36.7 years (median 37); the majority of patients were female (60%). Frequent findings in patients with TCP-intoxications were disturbance of consciousness/cognitive dysfunction (90%), cardio-vascular symptoms (55%), hyperthermia (50%), respiratory distress (45%), delirium (45%), muscular rigidity (30%) and renal failure (20%). Suicidal intent was present in n=18 (90%) patients. First clinical symptoms related to TCP-intoxication developed on average in less than 1 day. The average dosage related to TCP-intoxication was 677mg. The highest survived TCP-dosage was 4000mg and the lowest fatal dosage was 170mg. Patients with fatal intoxications were on average older (40.5 vs. 32.8 years) and developed a more rapid onset of symptoms (0.2 vs. 0.8 days). Death occurred after a mean time of 0.6 days; symptom relief in patients with non-fatal intoxications developed on average after 3.2 days. Considering the large dose spectrum between survived and lethal TCP-dosages individual susceptibility factors might play a role regarding the severity of clinical symptoms independently of the ingested dosage. [Copyright &y& Elsevier]

OBJECTIVE • To compare prostate cancer detection rates using the Vienna nomogram versus an8-core prostate biopsy protocol. To compare the complication rates of transrectal prostate biopsy in the two groups. PATIENTS AND METHODS • In a prospective randomized trial, men with a serum PSA ≥ 2.5 ng/ml were stratified according to serum PSA (I = PSA 2.5–10; II = PSA 10.1–30; III =PSA 30.1–50 ng/mL) and were then randomized to group A (number of cores determined according tothe Vienna nomogram) or group B (8-core prostate biopsy). • Statistical analysis was performed using Student’s t-test for parametric data, Mann- Whitney test for nonparametric data and Fisher’s exact test for contingency tables. A two-tailed p-value <0.05 was accepted as statistically significant. RESULTS• In the period July 2006 to July 2009, 303 patients were randomized to group A (n = 152) or group B (n= 151). There wereno significant differences in serum PSA, prostate volume, PSA density or post-biopsycomplications between the groups. • The cancer detection rate was lower ingroup A than in group B for the whole study cohort (35.5% vs 38.4%), for those with PSA < 10 ng/ml (28.1% vs 33%) and for those with prostate volume > 50 ml (22% vs 25.8%). These differences were notstatistically significant (NSS). CONCLUSION • These findings suggest that there is nosignificant advantage in using the Vienna nomogram to determine the number of prostate biopsy cores to be taken, compared to an 8-core biopsy protocol. [ABSTRACT FROM AUTHOR]

Summary: Repetitive transcranial magnetic stimulation (rTMS) has been increasingly evaluated as a therapeutic tool for the treatment of depression, using various stimulation parameters and protocols. Heterogeneous results have been reported with regard to clinical outcome, at least partly due to the variety of procedures for coil placement above the desired site of stimulation. This article reviews the strategies for coil positioning in the treatment of depression. Considering preliminary clinical evidence, neuronavigated rTMS appears desirable to treat depression, compared to the standard targeting procedure (5cm anterior to the motor cortex). Coil positioning strategy might improve in the future by taking into consideration the individual abnormalities revealed by functional neuroimaging data. [Copyright &y& Elsevier]

Background: There is no agreement on the most effective therapy for motor conversion symptoms. Functional electric stimulation has been successfully used to reverse conversion paralysis. We tested the therapeutic potential of high-frequency repetitive transcranial magnetic stimulation (rTMS) in a 20-year-old patient suffering from a conversion paralysis of the right arm.Method: rTMS was applied to the contralateral motor cortex. Stimulations were performed on working days at a frequency of 15 Hz (train length 2 s; inter-train interval 4 s) yielding 4,000 pulses/day.Results: Within 12 weeks, motor function, hyposensibility and muscle bulk were completely restored.Conclusions: The patient recovered completely during rTMS treatment. In addition to possible psychological effects, rTMS may have had a causal therapeutic effect by strengthening corticocortical connections and thereby priming voluntary movements. Further controlled studies are needed. [ABSTRACT FROM AUTHOR]

Background: Depression, as major depressive disorder (MDD) or as bipolar depression, is frequent among pregnant women (Evans et al., 2001) and an efficient treatment is fundamental. If left untreated, there are specific risks such as preterm delivery, low birth weight, and potentially death due to acute suicidality. Treatment of depression during pregnancy supposes a great challenge for pregnant women, their partner and for physicians involved. Despite psychopharmacotherapy and psychotherapy, electroconvulsive therapy (ECT) and other brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) or vagus nerve stimulation (VNS) are current available treatment strategies to treat depressive symptoms. ECT is recommended by the American Psychiatric Association Task Force on ECT as a safe and effective treatment of depression throughout pregnancy. However, ECT during pregnancy often involves concerns by both the patient and the physician due to unsolved questions regarding safety and tolerability as well as efficacy. Method: In order to retrieve insights into the frequency of reports, safety and efficacy of ECT for the treatment of MDD and bipolar depression during pregnancy we performed a systematic review of the existing literature. All publications between 1942 and the 1th December 2012 in the Medline, Embase and Scopus databases, that deal with ECT in MDD and bipolar depression during pregnancy were considered. Results: N=87 cases of ECT during pregnancy (MDD n =78; bipolar depression n =9) published in n =41 articles were detected. Of these 30 were case reports and 11 case series (with reported cases between n =2 and n =16). Furthermore, we evaluated the number of reported cases between the first report in 1942 and 2012 and divided the results in 4 time periods (1942–1959 n =46, 1960–1977 n =0, 1978–1995 n =14, and 1996–2012 n =18) in order to compare reported frequency. The results of our preliminary analysis suggest that ECT is efficacious and well tolerated in mother and offspring in the majority of analysed cases. In terms of safety, the comparison of the 4 time periods revealed that in the last analyzed time period a lower complication rate was observed. Most reported adverse effects were transient confusion, memory loss, headache and very rare premature contractions (mother) and fetal bradyarrhythmias. Further parameters (e.g. outcome of follow-up investigations, applied, narcotics, gestation age at the time of ECT, mean number of ECT sessions, detailed efficacy parameters as measured by psychometric scales, changes of the frequencies of reported ECTs during pregnancy) will be presented at the congress. Conclusions: Considering the results of our systematic review, ECT seems feasible in pregnant patients with MDD or bipolar depression. Our data support ECT to be more safe in the last decades for mother and offspring; however, the registered reported frequency does not support an increasingly use of this method with regard to the mentioned indication. [Copyright &y& Elsevier]

Electroconvulsive therapy (ECT) is predominantly being recommended for treatment of severe mood disorders and of catatonia. We report improvement with ECT in a patient suffering from somatization disorder. The patient, a 55-year-old man, suffered from intractable somatization disorder for more than thirty years. Numerous diagnostic and several futile surgical procedures had been performed in the past. On admission there had been no psychopharmacological therapy for one month. Subsequently treatment trials with duloxetine, mirtazapine, and venlafaxine were performed, but remained ineffective. Pregabalin lead to only slight amelioration of anxiety and no improvement of pain symptoms. After 3 months of unsuccessful clinical treatment, including pharmacotherapy, cognitive behavioral therapy, and regularly scheduled interdisciplinary medical consultations, ECT was first considered. A trial of right unilateral ECT was initiated. After five sessions the course had to be terminated due to severe ECT-related hypertension. During and following the ECT course, the patient reported rapid and significant improvement of somatic symptoms. In order to evaluate the effects of ECT the patient passed an assessment before and after the ECT (Hamilton Depression Rating Scale, Whiteley-Index, Quantification Inventory for Somatoform Syndroms, and an observer-rated version of the Screening for Somatoform Disorders). Assessment scores were in line with our clinical impression. Follow-up examination four months later showed no further change. Though somatic anxiety and hypochondriasis have been described to be negative predictors of successful remission with ECT, in our patient ECT has been particularly effective with regard to somatic symptoms of somatization disorder. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 23-year-old male with bulimia nervosa and major depressive disorder who developed hypogonadism and gynecomastia under duloxetine treatment. The patient complained of swelling and tenderness in the breast after four months of duloxetine medication and bilateral mastectomy. The swellings and tenderness of the breast have subsided after discontinuation of the duloxetine medication.

Presents a letter to the editor concerning the use of ziprasidone in treating Parkinson's disease psychosis.

Aim To evaluate the diagnostic accuracy of methylene blue used as a non-invasive in vivo stain to detect ocular surface squamous neoplasia (OSSN). Methods A test validation study was performed according to Standards for the reporting of diagnostic accuracy studies (STARD) guidelines on 75 consecutive patients who presented with ocular surface lesions suspicious of OSSN. Methylene blue 1% was instilled in vivo following local anaesthetic. Stain results were documented photographically and read by an independent observer. Lesions were excised at the same visit and evaluated histologically by pathologists who were blind to the stain results. Sensitivity, specificity, positive and negative predictive values were determined. Results Thirty-three patients had histologically malignant lesions, of which 32 stained with methylene blue, and 42 patients had benign or premalignant lesions, of which 21 stained with methylene blue. Methylene blue had a sensitivity of 97%, specificity of 50% and positive and negative predictive values of 60% and 96%, respectively. Conclusions The topical application of methylene blue is a simple, inexpensive, non-invasive diagnostic test that can be helpful in excluding malignant ocular surface lesions but cannot replace histology as gold standard for diagnosis of OSSN. [ABSTRACT FROM AUTHOR]

Vancomycin-resistant enterococci (VRE) infections and outbreaks are still infrequent in Spain. A six-month outbreak, which took place in a haematology ward, its control and management are described in this study. A total of 22 patients were colonised and two bloodstream infections occurred during this period. Even though there were two waves of new colonised patients, a multidisciplinary approach, quick interventions and enhanced infection control policies were required in order to control this outbreak. [ABSTRACT FROM AUTHOR]

Introduction: There are limited treatment options for people with schizophrenia with cytochrome P450 2D6 ultrarapid metabolizer status who do not respond to amisulpride.Furthermore, the literature does not provide evidence-based guidelines for this particular constellation.Case Presentation: We report the case of a 50-year-old Caucasian female patient with schizophrenia and cytochrome P450 2D6 ultrarapid metabolizer status who experienced an insufficient antipsychotic effect with amisulpride. She was successfully treated with melperone-augmented haloperidol.Conclusion: This report yields melperone-augmented haloperidol as a possible pharmacological strategy in the described situation. In addition, our observations support the available evidence for the potential of melperone to act as an inhibitor of cytochrome P450 2D6. [ABSTRACT FROM AUTHOR]

Question: Little is known regarding the risks of electroconvulsive therapy (ECT) in patients with clippings of intracerebral aneurysms. Currently, literature merely provides few anecdotal reports (Najiar and Guttmacher, 1998) and manufacturers of such clipping systems (usually made of titanium) refrain from any suggestions concerning the safety during the performance of ECT. Thus, clinicians facing the coincidence of therapy-refractory depression (suggesting performance of ECT) and presence of intracerebral clips have to trade of possible benefits of ECT against theoretical risks in the complete absence of any guidelines or recommendations. Indeed, titanium is principally inert and the application of electric current should therefore not result in significant warming (with the risk of damaging surrounding brain tissue). However, the indication of ECT under these conditions must be confirmed meticulously. Methods: A case report is presented in order to to contribute to the available experience concerning this clinical situation. Results: We present the case of a 55-year old female patient who successfully underwent clipping (Yasargil Titanium Clip, Aesculap®) of the left middle cerebral artery (MCA) due to MCA-aneurysm three years prior. The patient suffered from treatment-refractory major depressive disorder (recurrent type). Taking into account that various pharmacologic treatment attempts failed, ECT was considered. The patient was comprehensively informed about possible risks of the procedure related to the titanium clip. Before ECT CT-angiography was performed showing no re-development of the surgically treated aneurysm or development of new aneurysms. 12 cycles of right-unilateral ECT were performed without any complications despite ECT-related tachycardia. During ECT the patient was treated with esmolol. Subsequently, the patient’s clinical situation significantly improved. Conclusions: Though clear guidelines or suggestions of manufacturers of neurosurgical clips regarding safety during ECT are absent we did not observe any major complications during ECT in a patient with an intracerebral Yasargil titanium clip. However, the material behaviour of titanium during application of electric current remains to be studied systematically in order to rule out problematic warming with the risk of tissue damage. [ABSTRACT FROM AUTHOR]