Search

ZusammenfassungWir berichten über den Fall einer 60-jährigen Patientin mit fortgeschrittenem schwerem Lungenversagen bei COVID-19-assoziierter Pneumonie. Die Patientin erhielt zuerst 2 Tage eine (Highflow-)Sauerstoff-Therapie (HFNC) und CPAP, anschließend musste sie intubiert und invasiv beatmet werden. Nach dem Scheitern einer invasiven Beatmung mit schwerster Hypoxämie erfolgte der Anschluss an eine vv-ECMO. Diese wurde über 24 Tage durchgeführt. Die prognostischen Parameter zeigten ab Tag 14 eine günstige Tendenz. Nach Beendigung der ECMO und insgesamt 11 Tagen stundenweiser assistierter Beatmung über Tracheostoma und Sauerstoff (1 l/min) konnte die Patientin in die Rehabilitationsbehandlung verlegt werden. Die letzte Röntgenthoraxaufnahme zeigte eine nahezu vollständige Rückbildung der initialen ausgedehnten beidseitigen Verschattungen. Unser Fall zeigt, dass auch nach einer prolongierten ECMO-Therapie eine Ausheilung der schweren COVID-assoziierten Lungenschäden möglich ist.

ZusammenfassungDepressive Störungen sind in den aktuellen Diagnosesystemen ICD-10 und DSM-IV bzw. DSM-V primär nach klinischen Kriterien wie Schweregrad und Verlauf eingeteilt. Neben dieser kategorealen Diagnostik werden in diesem Artikel auch Aspekte der syndromalen Diagnostik dargestellt. Im Weiteren finden sich Hinweise auf das diagnostische Vorgehen bei Verdacht auf depressive Störungen und auf die wichtigsten somatischen und psychiatrischen Differenzialdiagnosen (Angsterkrankungen, Belastungsstörungen, schizoaffektive Psychosen, Schizophrenie, Burnout).

In Germany, the economic situation of psychiatric hospitals has markedly changed during the last years. Whilst the number of patients has steadily increased, many clinics considerably reduced the number of therapeutic staff due to an increasing lack of financial support. The German psychiatry personnel regulations act defines the number of therapeutic staff required for an adequate psychiatric treatment, but the requirements of this regulations act nowadays are widely missed in most of the German psychiatric hospitals. This severely affects the therapeutic work on psychiatric wards. This study analyses tasks and activities of medical doctors on psychiatric wards and compares the hours spent with various types of activities with the amount of time that should be spent according to the personnel regulations act. Results show that doctors spend much more time with documentation and administrative work than originally intended by the personnel regulations act. They compensate this mainly by a reduction of time spent in direct contact with the patients. In this context, the number of psychotherapy sessions as well as sessions with the patients' relatives has been considerably reduced, whereas the time spent for emergency intervention and basic treatment still corresponds to the calculations according to the personnel regulations act. All in all, the results show that a reduction of therapeutic staff in psychiatric hospitals directly leads to a change in treatment settings with a focus on less individual treatment options.

Despite the availability of a wide range of effective antidepressant drugs, nearly 30% of depressed patients fail to respond to antidepressant treatment. Various pharmacological strategies have been developed to treat such refractory depression, of which augmentation therapies are one of the most important. This article reviews both benefits and risks of all known augmentation therapies. Among these treatment strategies the efficacy of lithium augmentation is very well documented by a large number of controlled studies - lithium augmentation can therefore be recommended in depression refractory to antidepressant treatment. The efficacy of triiodothyronine (T3) augmentation and the combination of different antidepressants - like a TCA-MAOI combination - is described in a large number of case reports and uncontrolled studies; the number of placebo controlled double blind studies, confirming the efficacy of these treatment strategies, is however relatively small. T3 augmentation and combined antidepressant treatment may therefore be considered in the treatment of refractory depression; in contrast to lithium augmentation these combination therapies are however only second-line strategies. Other augmentation therapies (TCA + stimulants, TCA + reserpine, TCA + yohimbine, TCA + fenfluramine, SSRI + buspirone) are very interesting clinical research strategies, but don't have too much importance in clinical practice at the moment.

A 28-year-old patient with a 5-year history of bipolar disorder developed signs of encephalopathy 2 weeks after the addition of valproic acid to his treatment regimen of doxepine, risperidone, and biperidene. The clinical signs were drowsiness, ataxic gait, asterixis, and a generalized epileptic seizure. Discontinuation of valproic acid gradually resulted in complete remission of these symptoms. Valproate encephalopathy has been described mainly in patients receiving anticonvulsant polytherapy. This complication might become more prevalent in psychiatric pharmacotherapy due to the increasing use of valproic acid.

In the last 15 years the central effects of adenosine and its importance for neurology and psychiatry have increasingly become an object of investigation. Physiology and metabolism of adenosine have been examined by different research groups. The effects of adenosine in the central nervous system and the various mechanisms of these effects have been described by electrophysiologic methods. The inhibition of the release of several neurotransmitters through adenosine has already been described 10 years ago. In this review studies on binding sites for adenosine receptor ligands are discussed thoroughly. The properties and the highly specific distribution of the distinct receptor subtypes are described. For the functioning of the adenosinergic system the different interactions with other centrally active substances such as benzodiazepines, barbiturates, neuroleptics, anti-depressants, opiates, alcohol and carbamazepine have turned out to be of interest. The results of neuropsychiatric investigations on methylxanthines, which are antagonists at the adenosine receptor, are widely considered. Finally the discussion on the importance of the adenosinergic system in different neurological and psychiatric diseases is summed up. The particular significance of adenosine in the modulation of dopaminergic functions is emphasised.

Oxaprotiline (C 49/802 BA), a further development and structural analogue of maprotiline, is characterized by a very potent and extremely specific inhibitory effect on the re-uptake of norepinephrine. In an open early phase II study oxaprotiline was investigated in 10 inpatients with endogenous depression with regard to its antidepressive efficacy and occurrence of adverse effects. Oxaprotiline was given in a dosage up to 225 mg over a period of 28 days. 9 out of 10 patients completed the study, and, of these, 5 were found to be either very much improved or much improved. Standardized rating scales (HAMD, Bf-S, EWL-K) indicated significant improvement after 4 weeks of treatment. Except dry mouth, generally mild, there were no remarkable side effects; there was no influence of oxaprotiline on heart, cardiovascular and routine laboratory parameters. The results of this study indicate that oxaprotiline is an effective antidepressant without significant adverse effects.

A comparison of the effect on growth hormone (GH) stimulation in men (n = 6) of desimipramine (DMI), a tricyclic antidepressant, and of the benzodiazepine derivatives diazepam and metaclazepam with that of a placebo, showed that only DMI caused a significant (p less than 0.01) GH stimulation. After DMI, all six subjects showed a GH stimulation greater than 7.5 ng/ml, whereas after diazepam or metaclazepam, only three of the six subjects showed GH stimulation greater than 7.5 ng/ml, and the other three showed only a very small change, or no change at all in GH secretion. Higher GH stimulation occurred after diazepam (10 mg i.v.) than after diazepam (10 mg p.o.). No dose-dependent difference in GH stimulation after metaclazepam (10 and 30 mg p.o.) was apparent. No side effects appeared after administration of DMI during the test period (180 min); however, after administration of the benzodiazepine derivatives, sedative effects were clearly noted. DMI thus causes reliable GH stimulation in healthy male subjects, whereas GH stimulation could only be measured in some of the subjects after diazepam and metaclazepam.

– In 70 inpatients with major depressive disorder postdexamethasone cortisol and prolactin, but not baseline cortisol and prolactin, was found to correlate significantly with various state variables of depression. Postdexamethasone prolactin appeared to be a more specific state variable of depression compared with postdexamethasone cortisol. While prolactin was decreased following dexamethasone in controls and nonendogenous depressed patients, in endogenous depressed patients prolactin was increased by 30%. Due to this inverse prolactin response to dexamethasone, the sensitivity of this test should be considerably increased by using a higher dexamethasone dosage. The DST failed to be a diagnostic marker for any subgroup of depression.

It is assumed that established antidepressants exert their clinical efficacy by potentiation or decrease of central noradrenergic and serotonergic neurotransmission. However, recent experimental work suggests that antihistaminic and/or cholinolytic effects may also be involved. This double-blind controlled study compared amitriptyline (catecholamine potentiating, antihistaminic, cholinolytic) with promethazine (antihistaminic, cholinolytic) in 50 severely depressed inpatients over a 30-day treatment period. Analysis of the Hamilton depression rating scale revealed significant clinical superiority of amitriptyline over promethazine in such major depressive symptoms as depressed mood, suicidal ideation, psychic anxiety, and sleep disturbances. No significant difference was evident as far as autonomous side effects were concerned. Similar results were found by analysis of the AMP rating system. It is concluded that antihistaminic or cholinolytic effects per se do not explain the antidepressants' efficacy. However, potentiation of noradrenergic neurotransmission by cholinolytic activity might be the major antidepressive mechanism.

International audience; Importance: Knowledge about the metabolic states of patients with amyotrophic lateral sclerosis (ALS) may provide a therapeutic approach.Objective: To investigate the association between the onset and prognosis of ALS and serum retinol-binding protein 4 (RBP4) concentration as a biomarker for insulin resistance and vitamin A metabolism.Design, setting, and participants: Case-control design for risk factors of ALS; cohort design for prognostic factors within ALS cases. Between October 1, 2010, and June 30, 2014, a population-based case-control study with randomly selected controls was established based on the ALS Registry Swabia in southern Germany, with a target population of 8.4 million inhabitants. Response rates were 64.8% among the cases and 18.7% among the controls. The dates of analysis were April 2016 to May 2017.Main outcomes and measures: Serum samples were measured for RBP4. Information on covariates was assessed by an interview-based standardized questionnaire. Main outcomes and measures were adjusted odds ratios for risk of ALS associated with serum RBP4 concentration, as well as time to death associated with RBP4 concentration at baseline in ALS cases only. Conditional logistic regression was applied to calculate multivariable odds ratios for risk of ALS. Survival models were used in cases only to appraise their prognostic value.Results: Data from 289 patients with ALS (mean [SD] age, 65.7 [10.5] years; 172 [59.5%] male) and 504 controls (mean [SD] age, 66.3 [9.8] years; 299 [59.3%] male) were included in the case-control study. Compared with controls, ALS cases were characterized by lower body mass index, less educational attainment, smoking, light occupational work intensity, and self-reported diabetes. The median serum RBP4 concentration was lower in ALS cases than in controls (54.0 vs 59.5 mg/L). In the multivariable model, increasing RBP4 concentration was associated with reduced odds for ALS (top vs bottom quartile odds ratio, 0.36; 95% CI, 0.22-0.59; P for trend