SARS-CoV-2 Risk Management in Clinical Psychiatry: A Few Considerations on How to Deal With an Unrivaled Threat.

The pandemic spread of the corona virus SARS-CoV-2 has even-handedly shattered national and international health systems and economies almost in an instant. As numbers of infections and COVID-19-related deaths rise from day to day, fears and uncertainties on how to deal with this unknown threat are extremely present both for individuals and societies as a whole. In this manuscript, we aim to exemplarily describe the bullet points concerning (a) the internal risk management, (b) the organizational and structural changes, and (c) the communicational strategies applied in a Psychiatric University Hospital in the Southern part of Germany. The authors are well aware about the fact that almost none of these considerations may be considered as evidence-based at the moment. However, the authors trust that these reflections and experiences may be useful as an orientation for similar risk constellations in other afflicted countries due to the temporal delay of the pandemic course.

Management of a measles outbreak in a reception facility for asylum seekers in Regensburg, Germany.

In July/August 2018, a measles outbreak occurred in a reception facility for asylum seekers in Regensburg, Bavaria, Germany. A five-year-old child and an 18-year-old man from Moldova were affected. At the time of the report, 491 people were accommodated at the facility. The outbreak was limited to the two cases mentioned by the consistent use of infection control measures. Decisive factors for successfully combating this outbreak were, in particular, the close cooperation of the local public health authority (Gesundheitsamt) with the district government officials, the institution's management, and the general practitioners on site. The measures taken included the early information of all parties involved, the timely and repeated implementation of containment vaccinations, a consequent segregation of contagion and/or disease suspects and the critical consideration of each individual case in connection with the separate risk-adapted segregation of particularly vulnerable cohorts.

Transcranial magnetic stimulation for the treatment of depression: feasibility and results under naturalistic conditions: a retrospective analysis.

An increasing number of controlled studies strongly support an antidepressant effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) over the left dorsolateral prefrontal cortex. However, these data come from highly selected study populations. Whether rTMS is a feasible therapeutic tool for the treatment of depression under naturalistic condition has not yet been addressed. Here, we report results from 232 depressive patients [aged 20-76 years, baseline Hamilton Depression Rating Score (HDRS-21) 24.0 ± 7.3] treated with rTMS add-on to continued psychopharmacological treatment in a naturalistic clinical setting. Two thousand stimuli of 20-Hz rTMS were applied daily over the left dorsolateral prefrontal cortex with an intensity of 110% of motor threshold. Treatment duration was individually planned and varied between 10 and 20 sessions. In average, patients received 13 ± 6.1 rTMS sessions. In 90% of the cases, treatment was terminated regularly. No severe side effects were observed. Only four patients stopped rTMS treatment because of side effects. Ratings with the HDRS-21 before and after treatment were available in 130 patients. The average improvement of the HDRS-21 in this subsample was 9.0 ± 9.2 points. Fifty-three patients had an improvement of 50% or more. These results document that rTMS is feasible, safe and well tolerated under naturalistic conditions.

Transcranial magnetic stimulation for the treatment of tinnitus: a new coil positioning method and first results.

Auditory phantom perceptions are associated with hyperactivity of the central auditory system. Neuronavigation guided repetitive transcranial magnetic stimulation (rTMS) of the area of increased activity was demonstrated to reduce tinnitus perception. The study aimed at developing an easy applicable standard procedure for transcranial magnetic stimulation of the primary auditory cortex and to investigate this coil positioning strategy for the treatment of chronic tinnitus in clinical practice. The left gyrus of Heschl was targeted in 25 healthy subjects using a frameless stereotactical system. Based on individual scalp coordinates of the coil, a positioning strategy with reference to the 10--20-EEG system was developed. Using this coil positioning approach we started an open treatment trial. 28 patients with chronic tinnitus received 10 sessions of rTMS (intensity 110% of motor threshold, 1 Hz, 2000 Stimuli/day). Being within a range of about 20 mm diameter, the scalp coordinates for stimulating the primary auditory cortex allowed to determine a standard procedure for coil positioning. Clinical validation of this coil positioning method resulted in a significant improvement of tinnitus complaints (p<0.001). The newly developed coil positioning strategy may have the potential to offer a more easy-to-use stimulation approach for treating chronic tinnitus as compared with highly sophisticated, imaging guided treatment methods.

Altered motor cortex excitability in tinnitus patients: a hint at crossmodal plasticity.

Idiopathic tinnitus is a frequent and often debilitating auditory phantom perception of largely unknown pathological conditions. In electrophysiological and functional neuroimaging studies, affected subjects have shown excessive spontaneous activity in the central auditory system. To further investigate the underlying central nervous component, we assessed motor cortex excitability in 19 patients with chronic tinnitus by means of transcranial magnetic stimulation (TMS). When results were compared with data from 19 healthy controls matched for age and sex, we found significantly enhanced intracortical facilitation in tinnitus patients. These findings parallel excitability changes after limb amputation and experimental deafferentation. Our results give further support to crossmodal interactions involving neuroplastic changes in some forms of tinnitus and may help to better understand mechanisms of maladaptive cortical reorganisation involved in phantom perceptions.

[GABA-B-associated neuropsychiatric disorders]. / GABA-B-assoziierte neuropsychiatrische Erkrankungen.

OBJECTIVE: Disturbed GABA-B mediated inhibitory cortical processes are discussed to be involved both in schizophrenia as well as in chronic tinnitus. Transcranial magnetic stimulation (TMS) provides an intriguing in vivo method to investigate GABA-B associated aspects of cortical inhibition, thus allowing to detect disease-related cortical inhibitory processes. METHOD: Parameters of cortical excitability were measured by TMS in drug-naive first-episode schizophrenic patients and in patients suffering from chronic tinnitus. RESULTS: The cortical silent period as measured by TMS indicated a dysfunctional GABA-B mediated cortical inhibition in both groups of patients. CONCLUSIONS: TMS offers new insights into the pathophysiology of neuropsychiatric disorders. Parameters of this technique point to changes in GABA-B associated inhibitory processes within thalamocortial circuits both in schizophrenia and chronic tinnitus. These data are in line with current models of disturbed thalamic gating in phantom perceptions like auditory hallucinations, chronic tinnitus and central pain.

[Low frequency repetitive transcranial magnetic stimulation (rTMS) for the treatment of chronic tinnitus--are there long-term effects?]. / Behandlung von chronischem Tinnitus mit niedrigfrequenter repetitiver transkranieller Magnetstimulation (rTMS)--gibt es Langzeiteffekte?

OBJECTIVE: Clinical, neurophysiological and neuroimaging data suggest that chronic tinnitus resembles neuropsychiatric syndromes characterised by focal brain activation. Low frequency repetitive transcranial magnetic stimulation (rTMS) has been proposed as an efficient method in treating brain hyperexcitability disorders. METHODS: Patients suffering from chronic tinnitus underwent a [ (18)F]deoxyglucose-PET (positron emission tomography). Fusioning of the individual PET scan with the structural MRI-scan (magnetic resonance imaging, T1, MPRAGE) revealed an increased metabolic activation in the primary auditory cortex as target point for rTMS. A neuronavigational system enabled the positioning of the figure of eight coil in relation to the target area. rTMS (110 % motor threshold; 1 Hz; 2000 stimuli/day over 5 days) was performed using a placebo controlled cross-over design. RESULTS: Following active rTMS there was a moderate improvement of tinnitus perception. Treatment effects lasted up to six months in some patients. CONCLUSIONS: Neuronavigated rTMS offers new possibilities in the understanding and treatment of chronic tinnitus.