Electroconvulsive therapy related anxiety in patients with depression: The influence of cognitive coping styles

INTRODUCTION

Electroconvulsive therapy (ECT) related anxiety (ERA) is a common phenomenon with high individual variability. The way patients cognitively cope with the prospects of receiving ECT could be a mechanism explaining individual differences in ERA. Cognitive coping like monitoring (information seeking, paying attention to consequences) and blunting (seeking distraction and reassurance) has been linked to anxiety in various medical settings, with monitoring leading to more and blunting to less anxiety. How cognitive coping is related to ERA, is unknown.

METHODS

The sample consisted of 71 patients with unipolar or bipolar depression referred for ECT. Cognitive coping was assessed at baseline, while ERA was measured each morning before the ECT session. Using a Linear Mixed Model, the influence of cognitive coping styles on ERA was investigated.

RESULTS

Blunting was associated with lower levels of ERA (p = 0.037) and monitoring tended to be associated with higher levels of ERA (p = 0.057) throughout the ECT course. Patients with a depression with psychotic features scored significantly higher on monitoring, but even after controlling for monitoring they showed a stronger decline in ERA during treatment compared to patients without psychotic features.

CONCLUSION

Cognitive coping style contributes to individual differences in ERA. Blunting is a protective factor, leading to lower levels of ERA throughout the ECT course. On the contrary, patients with a higher monitoring style tend to experience higher levels of ERA. Further insights in these coping mechanisms may help to tailor future treatment to individual patients and reduce ERA before and during ECT treatment.

Knowledge and Attitudes of First- and Final-Year Medical Students about Electroconvulsive Therapy: The Impact of Media

OBJECTIVE

The aim of this study is to evaluate medical students' knowledge about and attitudes towards electroconvulsive therapy (ECT) and to assess the impact of information sources (including those within and outside the curriculum) on knowledge and attitudes by comparing first- and final-year medical students.

METHODS

Two hundred and ninety-five first-year and one hundred forty-nine final-year medical students of the University of Leuven (KU Leuven) in Belgium responded to an anonymous self-administered survey which consisted of questions about sociodemographic background, self-perceived knowledge about medicine, psychiatry and ECT, interest in psychiatry, experience with psychiatric disorders, information sources of ECT, and knowledge about and attitudes towards ECT.

RESULTS

Compared to first-year medical students, final-year students had better knowledge about and more positive attitudes towards ECT, partially explained by differences in information sources. Nevertheless, both student groups showed an average knowledge score below 50%. Whereas freshmen attributed their knowledge to movies or documentaries, senior students gained knowledge mainly at university courses, scientific journals, and attending live ECT sessions. A significant positive correlation was found between knowledge about and positive attitudes towards ECT.

CONCLUSIONS

The knowledge of first- and final-year medical students remains limited, potentially due to limited instruction about ECT in medical courses. The use of media as an information source predicted negative attitudes towards ECT. Therefore, the stigma and misinformation provided in the media need to be addressed in the medical curriculum.

The Effect of Electroconvulsive Therapy on Positive Affect and Hedonism in Patients With Depression: A Prospective Study

OBJECTIVES

The outcome of antidepressant treatments is generally assessed with standardized symptom scales such as the Quick Inventory of Depressive Symptomatology-Clinician Rating (QIDS-C). These scales, however, might not reflect patients' expectations for treatment, including a recovery of positive affect (PA) and hedonism. The Leuven Affect and Pleasure Scale (LAPS) was developed to better reflect patients' expectations for treatment. We used the LAPS to investigate changes in PA and hedonism alongside depressive symptoms during electroconvulsive therapy (ECT) and over 12 weeks after treatment.

METHODS

Fifty-three patients with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, depressive episode, referred for ECT, were included in this prospective study. The LAPS and QIDS-C were administered before and 1 and 12 weeks after the ECT course. LAPS normative levels were obtained in 149 healthy controls.

RESULTS

Pearson correlations revealed only moderate overlap of the QIDS-C with PA and hedonism. Piecewise linear mixed models indicated significant improvements in depressive symptoms (QIDS-C and LAPS negative affect), PA, and hedonism during ECT. In the 12 weeks after ECT treatment, negative affect and QIDS-C further improved, but PA and hedonism plateaued. Exploratory analyses indicated that only fully remitted patients (QIDS-C) attained normative levels on PA and hedonism at 12 weeks after ECT.

CONCLUSIONS

Standardized symptom scales (QIDS-C) may incompletely reflect clinical change in ECT treatment for depression. Although ECT improved depressive symptoms, PA, and hedonism in patients with depression, only fully remitted patients attained normative levels of PA and hedonism, due to plateaus in improvement. These plateaus were not observed for depressive symptoms, which further improved after ECT discontinuation.

Relapse after abrupt discontinuation of maintenance electroconvulsive therapy during the COVID-19 pandemic

OBJECTIVE

Maintenance electroconvulsive therapy (M-ECT) is considered an effective relapse prevention strategy in severe mood and psychotic disorders. How long M-ECT should be continued, and what the outcome is after its discontinuation has not been adequately studied. In our tertiary psychiatric hospital, M-ECT treatments were suspended at the start of the COVID-19 pandemic. We aimed to determine the 6-month relapse rate and time to relapse after abrupt discontinuation of M-ECT and to assess the impact of patient and treatment characteristics on the risk of relapse.

METHODS

Eighty-one patients whose M-ECT was discontinued abruptly were followed up prospectively for 6 months, or until relapse (i.e., hospital admission, restart of ECT, change of pharmacotherapy, or suicide (attempt)). We used multivariable Cox proportional hazards models to assess the impact of patient and treatment characteristics on the risk of relapse.

RESULTS

Thirty-six patients (44.44%) relapsed within 6 months following abrupt discontinuation of M-ECT. A greater number of previous acute ECT courses, a diagnosis of psychotic disorder (compared with major depressive disorder or bipolar disorder), and a shorter interval between M-ECT treatments at the time of discontinuation were significantly associated with increased risk of relapse.

CONCLUSION

Almost half of the patients relapsed, similar to the relapse rate after a successful acute course of ECT. Patients with a shorter interval between M-ECT treatments at the time of discontinuation seem to be at increased risk, as well as patients with a diagnosis of psychotic disorder, compared to patients with mood disorders.

Impact of epicardial adipose tissue increase after ST elevation Myocardial Infarction (STEMI) on IL-13 and left ventricular remodelling

Background

The role of epicardial adipose tissue (EAT) in myocardial diseases is well established, and several evidence suggest that EAT may negatively affect left ventricular (LV) remodelling through an imbalanced production and secretion of pro and anti-inflammatory cytokines. Of these, the IL-13 it is known to play a positive activity on cardiac remodelling. Nowadays, the crosstalk between EAT and the myocardium is still poorly understood and the effects of myocardial ischemia on morphological and functional properties of EAT are almost unknown.

Purpose

In the present study we explored whether an increase of EAT thickness after STEMI might be associated with unfavourable LV remodelling at 3 months (T1). We also evaluated the relationship between changes (Δ) of EAT thickness and systemic levels of Interleukin (IL)-13 which is known to play a favourable activity on LV remodelling after STEMI.

Methods

We enrolled 66 patients with first STEMI, undergoing primary percutaneous angioplasty. At baseline and at 3 months we performed a complete echocardiogram, including EAT maximal thickness assessment, and determined circulating levels of IL-13.

Results

At 3 months after STEMI, the population was stratified into two groups according to different EAT remodelling after cardiac event: Group 1, patients with an increased EAT thickness (Δ EAT>1; 30 patients) and Group 2, patients with unchanged or decreased EAT thickness (Δ EAT<1). The two groups did not differ for age, gender and atherosclerotic risk factors. Group 1 had a worse LV remodelling at 3 months with higher LV diastolic and systolic volumes, lower LV ejection fraction (p=0.003; p=0.013; p=0.013 respectively) and worse diastolic function (E/e'; p=0.011). Of interest, EAT thickness increase was paralleled by circulating IL-13 reduction (p=0.022).

Conclusion

Myocardial injury can result in EAT increase which is associated to worse LV remodelling probably through the loss of the protective role of IL-13.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This research has been funded by the University of Naples “Federico II” and “Compagnia di San Paolo e l'Istituto Banco di Napoli” within the competitive grant STAR 2018; Valentina Parisi is the principal investigator

Kidney transplantation combined with other organs in Bologna: an update

BACKGROUND

We retrospectively reviewed our experience in combined liver-kidney (L-KT) and heart-kidney (H-KT) transplantations.

PATIENTS AND METHODS

Between January 1997 and April 2007, we performed 25 L-KT and 5 H-KT. Patient mean age was 51+/-8 years in L-KT and 43+/-11 years in H-KT. The main cause of liver failure was chronic viral hepatitis (14 cases). Etiology of heart failure was dilated cardiomyopathy and hypertrophic cardiomyopathy (4 and 1 patients, respectively). The main causes of renal failure in L-KT were chronic glomerulonephritis (n=8) and polycystic disease (n=7). Etiology of renal failure in H-KT was interstitial nephropathy (n=2), vascular nephropathy (n=2), and chronic glomerulonephritis (n=1).

RESULTS

Mean follow-up was 32+/-26 months in L-KT and 24+/-17 months in H-KT. Immunosuppression was cyclosporine-based (n=4) or tacrolimus-based (n=21) in L-KT and cyclosporine-based in H-KT. Acute rejection rate was 8% for both liver and kidney in L-KT; 80% (mild) for heart and 40% for kidney in H-KT. In the L-KT group, there was no primary graft nonfunction (PGNF). Two patients experienced liver delayed graft function (DGF); 1 patient required postoperative dialysis. One-year graft and patient survivals were both 84% and overall graft and patient survival was 76%. In the H-KT group, 3 patients needed postoperative dialysis and 1 required a cardiac assistance device for 48 hours; overall graft and patient survival was 100% with good cardiac and renal functions.

CONCLUSION

Our experience confirmed that H-KT and L-KT are safe procedures, offering good long-term results.

Kidney transplantation combined with other organs: experience of Bologna s. Orsola hospital

AIM

We report a series of patients who underwent combined heart-kidney transplantation (CHKT) and combines liver-kidney transplantation (CLKT) at a single center.

METHODS

From January 1997 to October 2004, 13 CLKT and 2 CHKT were performed. The CLKT indications were as follows: polycystic disease (2), kidney polycystic disease associated with Caroli (1) and cirrhosis-hepatitis C virus (HCVs) (1), chronic glomerulonephritis with cirrhosis-HCV (4), and other diseases (5). From December 2003 to October 2004, 2 patients underwent CHKT for idiopathic cardiomyopathy plus glomerulonephritis and ischemic cardiomyopathy associated with vascular nephritis.

RESULTS

In the CLKT group, 1 patient had acute rejection involving both liver and kidney grafts, whereas 1 patient had liver rejection and another 1 had kidney rejection alone. Of the 13 patients, 10 are alive with a mean survival of 583 days (range, 36-2688 days); 2 patients died within 1 month of transplantation (both with polycystic disease) due to ARDS and MOF. Another patient died 6 years and 9 months after CLKT of metastasis from a de novo tumor. In the CHKT group, no patient suffered heart-kidney rejection. They are all alive at 333 and 116 days, with heart and kidney allografts functioning well.

CONCLUSION

In the CLKT group, the worst results were for patients with polycystic disease, in whom a more rigorous selection is necessary because of greater technical difficulties. For the remaining patients we had acceptable complications and excellent long-term results. In selected cases, CHKT can provide long-term graft function and patient survival. Our experience indicates that end-stage kidney failure combined with liver or heart failure does not necessarily preclude dual-organ transplantation.

Surgery Using Median Sternotomy for Diffuse Aneurysmal Disease of the Thoracic Aorta

We present our experience using an anterior approach for the replacement of an extensive aneurysm of the thoracic aorta. In recent years we have performed surgery on 20 patients by means of a median sternotomy for aneurysms of the ascending aorta, aortic arch, or descending thoracic aorta. In all but 1 of the patients, a procedure in the ascending aorta was also performed. In some patients a small anterior left thoracotomy at the 4th intercostal space was required to allow the replacement of the aorta as for the diaphragm. Antegrade selective cerebral perfusion (ASCP) according to Kazui's technique was used as a brain protection method. All procedures were performed successfully and the aneurysm was completely resected. No neurologic complications or other major complications occurred. We believe that the anterior approach for extensive thoracic aorta replacement is feasible, allows the use of ASCP, and has shown encouraging results.

Port-access cardiac surgery: clinical experience with first 50 cases

BACKGROUND

Minimally invasive cardiac surgery constitutes an expanding field for the treatment of many cardiac diseases. We analyze our experience with the first 50 patients operated upon using the port-access system.

METHODS

From October 1999 to October 2000, 50 patients underwent cardiac operations with the port-access technique, for the correction of mitral and tricuspid disease, atrial septal defect closure, and removal of cardiac tumors. The mean age was 56.5 years. In 23 patients the mitral valve was repaired, in 14 cases a prosthetic replacement was performed, in 2 patients a paravalvular leak was resutured, 1 patient had a cardiac myxoma removed, and 1 patient had a correction of tricuspid regurgitation. In 9 cases an atrial septal defect closure was performed.

RESULTS

One redo patient, with severe tricuspid regurgitation, needed conversion to sternotomy; in all the other cases the results of surgery were good and there were no surgical limitations. The mean cross-clamping time and bypass time were 53 +/- 19 and 77 +/- 27 min respectively. The mean in-hospital stay was 6 days. Re-exploration for bleeding was required in 7 patients (14%). Three patients (6%) presented with a postoperative neurological lesion; 2 recovered completely within 48 hours whereas 1 patient had permanent hemiplegia at discharge. There was one hospital death (an 81-year-old patient died of multiorgan failure on the thirteenth postoperative day).

CONCLUSIONS

Minimally invasive port-access surgery is a reliable alternative to conventional surgery for the treatment of mitral and tricuspid disease, the removal of cardiac tumors, and the correction of atrial septal defects. It reduces trauma to the patient, provides a better cosmetic result and also allows for a faster recovery. Careful patient selection is important to avoid complications. Redo patients can be successfully treated and the risks of re-sternotomy avoided.

Leiomyosarcoma of the pulmonary vein: case report with immunohistochemical and ultrastructural findings

We report a case of neoplasia of pulmonary vein in a 45-year-old woman who presented with increasing dyspnea. As a consequence, the neoplasia filled the entire left atrium and appeared to be attached to the left superior pulmonary vein on surgical excision. Histologically, it was composed of a proliferation of sarcomatous cells, with a high mitotic rate and diffuse immunohistochemical positivity for smooth muscle actin, consistent with a leiomyosarcoma. The microscopic, immunohistochemical, and ultrastructural findings are discussed.

[The surgical treatment of a rare primary cardiac tumor: hemangioma. A report of 2 cases]

Primary benign tumors of the heart are particularly rare; cardiac hemangioma is one of the most rare primary benign cardiac tumors. Natural history, symptoms and prognosis of the disease depend on the potential complications due to the location and diffusion of the mass. We report on 2 cases of cardiac hemangioma, diagnosed occasionally in the first patient or due to gastroenteric symptoms in the second patient. The diagnosis was obtained by 2-D-echo and magnetic resonance imaging. In both cases the hemangioma was located on the right ventricle. Both patients underwent tumor resection in hypothermic cardiopulmonary bypass. In one case, a graft to the right coronary artery was associated; in the other case, the right ventricular outflow tract was reconstructed with an infundibular patch. Histology showed mixed hemangioma in one case and cavernous hemangioma in the other. The postoperative course was uneventful. At a follow-up of 8 years and 1 year, respectively, both patients are classified as NYHA 1 and both 2-D-echo and magnetic resonance imaging did not show any residual tumoral mass. This experience demonstrates that, depending on their location, benign neoplastic masses may be radically resected with acceptable operatory risks and excellent long-term results.