Facts and myths about use of esketamine for treatment-resistant depression: a narrative clinical review.

Introduction and aims: Treatment-resistant depression (TRD) occurs when at least two different antidepressants, taken at the right dosage, for adequate period of time and with continuity, fail to give positive clinical effects. Esketamine, the S-enantiomer of ketamine, was recently approved for TRD treatment from U.S. Food and Drug Administration and European Medicine Agency. Despite proved clinical efficacy, many misconceptions by clinicians and patients accompany this medication. We aimed to review the most common "false myths" regarding TRD and esketemine, counterarguing with evidence-based facts. Methods: The keywords "esketamine", "treatment resistance depression", "depression", "myth", "mythology", "pharmacological treatment", and "misunderstanding" were entered in the main databases and combined through Boolean operators. Results: Misconceptions regarding the TRD prevalence, clinical features and predictors have been found. With respect of esketamine, criteria to start treatment, dissociative symptoms, potential addiction and aspects of administration and monitoring, were found to be affected by false beliefs by clinicians and patients. Discussion and conclusion: TRD represents a challenging condition, requiring precise diagnosis in order to achieve patient's full recovery. Esketamine has been proved as an effective medication to treat TRD, although it requires precautions. Evidence can inform clinical practice, in order to offer this innovative treatment to all patients with TRD.

Is There a Burnout Epidemic among Medical Students? Results from a Systematic Review.

Background and Objectives: Medical students represent the ideal target group for promoting mental health and mental wellbeing, being exposed to specific risk factors, such as the content of medical training, the exposure to sickness and death, and a stressful academic routine. Medical students report high levels of cynicism and emotional exhaustion, which represent two of the essential features of burnout syndrome. In this systematic review, studies assessing the levels of burnout among medical students through validated tools worldwide were analyzed. Materials and Methods: A systematic review has been performed in order to identify studies: (1) focusing on samples of medical students; (2) evaluating burnout syndrome using validated tools; (3) providing prevalence data on burnout; and (4) written in English. Results: Out of the 5547 papers initially obtained, 64 were finally included in the analysis. The sample sizes ranged from 51 to 2682 participants. Almost all studies had a cross-sectional design; the Maslach Burnout Inventory and its related versions were the most frequently used assessment tools. The prevalence of burnout, which was stratified based on gender and academic stage, ranged from 5.6 to 88%. Burnout was mostly predicted by thoughts of stopping medical education, negative life events, lack of support, dissatisfaction, and poor motivation. Conclusions: The prevalence of burnout syndrome in medical students is quite heterogeneous, reaching a peak of 88% in some countries. However, several predictors have been identified, including negative life events or poor motivation. These findings highlight the need to develop preventive interventions targeting the future generation of medical doctors, in order to improve their coping strategies and resilience styles.

The predictive role of proinflammatory and neuroendocrine factors in the acute phases of bipolar disorder: study protocol of a longitudinal controlled trial.

INTRODUCTION AND AIMS: Bipolar disorder (BD) is a severe and recurring mental illness associated with a significant personal and social burden. It has been recently hypothesized that increased levels of pro-inflammatory cytokines and cortisol, which is also associated with a reduced expression of the brain-derived neurotrophic factor (BDNF), may influence affective recurrences in BD. Our study aims to: 1) assess changes in the levels of peripheral cytokines, BDNF and salivary cortisol during acute and euthymic phases of bipolar disorder, compared to that of a sample oh healthy controls; 2) evaluate whether these changes represent a biosignature for the different phases of the illness. MATERIALS AND METHODS: Patients aged 18-65 years old, with a diagnosis of BD I or II types, will be enrolled during an acute episode, according to DSM-5 criteria, together with age- and gender-matched healthy controls. Blood and salivary samples will be collected at baseline and after 3 and 6 months. Validated assessment instruments will be administered to all participants for the evaluation of symptom severity, global functioning, suicidal risk, stress levels and physical comorbidities. EXPECTED RESULTS: We expect changes in inflammatory and neuroendocrine indices to be predictive of the onset of an acute phase of bipolar disorder and that overall levels of cytokines, cortisol and BDNF are overall significantly different between BD patients and healthy controls. CONCLUSIONS: The longitudinal design of the study will allow to assess whether the presence of acute affective symptoms in BD patients correlates with significantly higher levels of cytokines and salivary cortisol and with reduced BDNF levels compared to euthymic phases. Moreover, the comparison with healthy control subjects will allow to understand if inflammatory mediators as well as the hypothalamic-pituitary-adrenal (HPA) axis are chronically elevated in BD patients and are independent from mood swings.

What influences psychological functioning in patients with mood disorders? The role of clinical, sociodemographic, and temperamental characteristics in a naturalistic study.

BACKGROUND: The present study aims to assess clinical and psychological correlates of psychological functioning in patients with mood disorders, in a naturalistic setting. In particular, we aimed to describe which sociodemographic, clinical, and temperamental dispositions are more frequently associated with poor psychological functioning, and to describe the association between cognitive and psychological functioning in euthymic patients with major depression and bipolar disorder. METHODS: Inclusion criteria were as follows: (1) diagnosis of major depression, or bipolar disorder type I or II; (2) age between 18 and 65 years; and (3) being in a stable phase of the disorder. Patients' psychiatric symptoms, quality of life, affective temperaments, and impulsivity were investigated with validated assessment instruments. RESULTS: 166 patients have been recruited, mainly female (55.4%), whose mean age was 47.1 ± 14.2 years. 42.6% of individuals reported a diagnosis of major depression. According to regression analyses, poor cognitive performance (p < 0.05), reduced perceived quality of life (p < .0001), lifetime suicide attempts (p < 0.01), and increased trait-related impulsivity (p <0 .001) strongly correlated with poor psychological functioning. Moreover, cyclothymic and irritable dispositions were also associated with poor social functioning (p < 0.01), whereas hyperthymic affective disposition was associated to a better psychological performance (p < 0.01). CONCLUSIONS: Our results support the evidence that patients with mood disorders should be assessed for psychological functioning and affective dispositions, to identify patients at higher risk to develop worse long-term outcomes and to develop targeted interventions.

Physical comorbidities in patients with severe mental disorders: a brief narrative review on current challenges and practical implications for professionals.

A paradox of the modern world is represented by the increasing rate of comorbidities, although the life expectancy is increasing worldwide, the number of disease-free years is not improving consequently. Physical comorbidities are often overlooked in people with severe mental disorders, although this problem needs to be adequately managed since it is associated with a worse quality of life and a poorer personal and social functioning. In this paper, we aim to: 1) carry out a narrative review of the recent literature in order to provide an update on the prevalence and incidence of the most frequent comorbid physical disorders in people with severe mental disorders; 2) highlight the most important difficulties in managing comorbidities in people with severe mental disorders in ordinary clinical care; 3) discuss possible solutions to overcome those difficulties, particularly through the role of education and scientific associations.

The Psychiatric Consequences of Long-COVID: A Scoping Review.

The COVID-19 pandemic has represented a new form of traumatic event, affecting the general population worldwide and causing severe disruption of daily routine. A new urgent concern is related to the burden associated with COVID-19 symptoms that persist beyond the onset of infection, the so-called long-COVID syndrome. The present paper aims to: (1) describe the most frequent psychiatric symptoms reported by patients affected by long-COVID syndrome; (2) evaluate methodological discrepancies among the available studies; (3) inform clinicians and policy-makers on the possible strategies to be promoted in order to manage the psychiatric consequences of long-COVID syndrome. Twenty-one papers have been included in the present review, mostly with a cross-sectional or cohort design. Significant heterogeneity of long-COVID syndrome definitions was found. The presence of psychiatric symptoms was evaluated with very different assessment tools. The most common psychiatric symptoms of the long-COVID syndrome included fatigue, cognitive disturbances/impairment, depression, and anxiety symptoms. The rate of fatigue varied from 93.2-82.3% to 11.5%, cognitive impairment/cognitive dysfunction from 61.4% to 23.5% and depressive-anxiety symptoms from 23.5%to 9.5%.

Vitamin D Deficiency and Risk Factors Related to Acute Psychiatric Relapses in Patients with Severe Mental Disorders: A Preliminary Study.

Previous studies have indicated that vitamin (Vit) D deficiency is frequent in psychiatric patients, regardless of diagnostic category. We aimed to assess whether acute psychiatric relapses in inpatients was associated with Vit D deficiency compared to stabilized outpatients. The cohort (152 total patients, 75 males and 77 females) had a mean age of 47.3 ± 14.4 years at admission and was grouped according to psychiatric diagnosis. Psychopathological symptom severity was assessed by the Brief Psychiatric Rating Scale (BPRS), a multidimensional symptom inventory. Total calcium serum levels were measured using standard laboratory methods, while plasma levels of 25-OH-Vit D and parathyroid hormone (PTH) were measured by automated chemiluminescence immunoassays. The psychiatric inpatient subgroup showed a significant difference in serum levels of 25-OH-Vit D and PTH (p < 0.001). Correlation analysis between serum levels of 25-OH-Vit D and BPRS total and subitem scores indicated a significantly negative relationship. In addition, linear regression analysis evidenced that the inpatient condition might predict low PTH and 25-OH-Vit D serum levels. Hospitalized psychiatric patients are at increased risk for Vit D deficiency regardless of their diagnostic categories. The mechanism underlying the association between acute psychiatric relapses and Vit D deficiency remains unclear. Therefore, screening for Vit D deficiency should pertain to the health assessment of patients with major psychiatric disorders.

Does antenatal depression predict post-partum depression and obstetric complications? Results from a longitudinal, long-term, real-world study.

Background: Main aims of the present paper are to: (1) assess the prevalence of antenatal depression (AD) and identify its predictors; (2) analyse the impact of AD on obstetric outcomes and on the incidence of post-partum depression. Methods: All pregnant women referring to the Gynecology and Obstetrics inpatients unit of the University of Campania "Luigi Vanvitelli" were invited to participate. Upon acceptance, women completed the Italian version of the Edinburgh Postnatal Depression Scale and an ad-hoc questionnaire on the women's sociodemographic, gynecological and peripartum characteristics as well as their psychiatric history. Women were assessed at each trimester of pregnancy, immediately after the childbirth and after one, three, 6 and 11 months. Results: 268 pregnant women were recruited, with a mean of 32.2 (±5.81) years. Ninety-seven women (36.2%) reported the presence of depressive symptoms during pregnancy. Predictors of AD were personal history of depression, a family history for depressive disorders and problematic relationships with the partner. The presence of AD was associated to a reduced gestational age at the time of delivery, a lower APGAR score at 1 and 5 min, labor induction and admission of the new-born into neonatal intensive care unit. Mothers with antenatal depression are less likely to natural breastfeed. Lastly, antenatal depression was a risk factor for higher EPDS scores at follow-ups. Conclusions: Our results support the idea that women should be screened during pregnancy and post-partum for the presence of depressive and anxiety symptoms. Health professionals should be adequately trained to detect psychiatric symptoms during pregnancy.

Characteristics and outcomes of laparoscopic surgery in patients with large hiatal hernia. A single center study.

INTRODUCTION: Giant hiatal hernia is characterized by the presence of more than 1/3 of the stomach in the chest, through the diaphragmatic hiatus, with or without other intra-abdominal organs. It is a rare pathology, representing the 5-10% of all hiatal hernias. The advent of laparoscopic surgery led to new surgical techniques, which include the simple reduction with the excision of the hernial sac and the execution of a posterior hiatoplasty, with or without mesh, and the execution of a Collis-Nissen gatroplasty in case of short esophagus. PRESENTATION OF CASES: We followed 24 cases of giant hiatal hernia with more than 1/3 stomach located in the chest, analyzing the results reached by the miniinvasive procedure, and the long-term pathophysiologic results of the disease. DISCUSSION: Laparoscopic hiatal hernia repair results in less postoperative pain compared with the open approach. The smaller incisions of minimally-invasive surgery are less likely to be complicated by incisional hernias and wound infection. Postoperative respiratory complications are reduced. CONCLUSION: Results from multiple studies are similar, with shorter hospital stay and less morbidity resulting from the minimally invasive approach.

Uniportal bilateral video-assisted sequential thoracoscopic extended thymectomy.

Standard video-assisted thoracoscopic surgery has been reported as a minimally invasive approach alternative to sternotomy for management of myasthenia gravis (MG) associated with thymoma or thymic hyperplasia. Uniportal video-thoracoscopy is an evolution of standard multi-portal video-thoracoscopy for management of several thoracic diseases but its role for resecting mediastinal tumor remains under-evaluated. Herein, we describe our experience with bilateral uniportal thoracoscopic sequential extended thymectomy with case and video illustrations.

Interlobar fixation using TachoSil(®): a novel technique.

BACKGROUND: We evaluated the use of TachoSil(®) for anchoring middle lobe to lower lobe after upper right lobectomy. METHODS: The fixation of middle lobe to lower lobe was required in 39/213 consecutive upper lobectomies. In 19/39 (49%) cases, it was performed with suturing and/or stapler (standard group) and in 20 cases (TachoSil group) with Tachosil(®) alone. RESULTS: The operative time, complications, length of chest drain and hospital stay were similar between two groups. However, standard compared to TachoSil(®) group presented a higher incidence of atelectasis (5% vs. 0%, P=0.4) and air leaks (5% vs. 0%, P=0.4) but it did not reach significant difference. Our technique was safe, easy, and quick. CONCLUSIONS: Upon contact with pleura, the clotting factors of TachoSil(®) dissolved and formed a fibrin network which glued the collagen sponge to the pleura surface. It allowed to fix the middle lobe to lower lobe without restricting lung re-expansion and/or injuring the parenchyma.

Gallstone ileus without bilioenteric fistula years after bypass surgery for Crohn's disease. Case report and clues to etiology of a neglected cause of obstruction.

INTRODUCTION: Gallstone ileus is a very rare cause of bowel obstruction. Patients suffering from Crohn's disease are at increased risk of developing gallstone disease, especially when terminal ileum is involved. Gallstone ileus can occur, but etiology remains controversial. We report on a case of such a rare condition, illustrating etiology and treatments. PRESENTATION OF CASE: A patient with long-standing Crohn's disease, who had undergone ileotransverse bypass for ileocaecal involvement 40 years before, presented with cramp-like abdominal pain. Imaging was consistent with a gallstone ileus with no evidence of bilioenteric fistulae. DISCUSSION: At surgery, we found gallstones stuck at the site of ileotransverse anastomosis. No bilioenteric fistulae were found. Due to disease progression, many enteric fistulae were found, requiring a massive bowel resection. The diverted segment may have been responsible of gallstone formation, and etiology is discussed. Recovery after surgery was uneventful, but the patient required continued nutritional support. CONCLUSION: Physicians dealing with Crohn's disease patients with bypassed segments should keep in mind, the increased risk of gallstone formation, in order to not overlook gallstone ileus. Early suspect and diagnosis may allow for less aggressive approaches. A diverted segment should always be removed, and long-term follow-up encouraged.