Electroconvulsive therapy, personal protective equipment and aerosol generating procedures: a review to guide practice during Coronavirus Disease 2019 (COVID-19) pandemic.

OBJECTIVE: To review the literature on the definition of aerosol-generating procedures (AGPs), identify high-risk AGPs, guidelines to use personal protective equipment (PPE) and review evidence to see if electroconvulsive therapy (ECT) is a high-risk AGP requiring the use of PPE. METHODS: Existing guidelines and research data were reviewed to answer the questions. RESULTS: There is consensus about the type of anaesthesia used during ECT, what constitutes AGPs and what PPE should be used. It was not clear if ECT was an AGP, but we argue that it is one based on evidence. CONCLUSION: We conclude that ECT is an AGP and that it requires the appropriate use of PPE after taking in to account local supply and demand.

Clozapine-related myocarditis and cardiomyopathy in an Australian metropolitan psychiatric service.

OBJECTIVES: Myocarditis and cardiomyopathy are rarely reported complications of clozapine treatment. The incidence of clozapine-related myocarditis has been variably reported at between 0.03% and 0.19% of initiations and cardiomyopathy has been reported even less commonly. In our Brisbane-based service, nine of 94 patients initiated on clozapine over the previous 3 years appeared to have experienced myocarditis or cardiomyopathy. The unique co-location of our service with a major cardiothoracic hospital facilitated a review of identified cases to inform decisions regarding clozapine treatment and rechallenge in this service. METHOD: Cases were identified by survey of psychiatric and cardiac medical staff at The Prince Charles Hospital and subjected to re-evaluation by a multidiscipline consensus panel. The panel compared cases to international reports and identified the clinical features that supported a diagnosis of clozapine-related myocarditis or cardiomyopathy. RESULTS: This process resulted in the stratification of the nine cases into the following categories of diagnostic likelihood: three highly probable, three probable, and two possible cases of clozapine-related myocarditis, and one possible case of clozapine-related cardiomyopathy. Successful clozapine rechallenge/continuation was undertaken in two patients and the panel agreed that this was a viable future option for several other patients. CONCLUSIONS: Findings of the panel review supported the initial clinical diagnoses. This confirmed that there was an apparent high incidence of clozapine-related myocarditis within this service, for which there was no clear reason. Mechanisms underlying clozapine-related myocarditis and cardiomyopathy, as well as successful clozapine continuation and rechallenge were considered, but definitive explanations remain unknown. This review highlighted the clinician's role in post-marketing drug surveillance to guide rational management of suspected adverse drug effects.