Chemsex refers to the use of drugs, typically stimulants and/or psychoactive substances, in a sexual context, often in the context of casual or group sex encounters. Currently, the practice of chemsex focuses on men who have sex with men (MSM). On the other hand, Pre-exposure prophylaxis (PrEP) is a biomedical method that has proven effective in preventing HIV transmission, particularly among individuals at a heightened risk, including those who engage in chemsex. MSM account for two thirds of new HIV cases in the US. It is estimated that in 70% of cases seroconversion occurs through “condomless anal sex” (CAS). According to the CDC, one in six MSM will be infected with HIV during their lifetime. The consumption of methamphetamine (MA) has been identified as the main driver of the practice of CAS, alteration of rectal immunological function and faster seroconversion. One in three new HIV infections have been associated with MA consumption. (Grov C et al. JAIDS 2020; 85 272-279).

The primary goal of this study is to describe the prevalence of chemsex engagement among PrEP users, delineate user characteristics and requirements, gain deeper insights into this phenomenon within the Barcelona region, and formulate customized strategies accordingly.

This study conducts a literature review to explore the current correlation between engaging in chemsex and the utilization of PrEP. We identified research articles published between January 2020 and December 2022, that discussed the utilization of chemsex drugs prior to or during sexual activities. The findings were synthesised using a narrative approach and conceptualised using a behavioural analysis framework.

According to a recent cross-sectional study performed at Hospital Clínic de Barcelona, SUD among patients who are being followed-up in the outpatient clinic of PrEP was higher (89%) compared with other European regions such as England (38.5%) or Amsterdam (41%). Moreover, according to data collected in the EMIS 2017 survey, Barcelona is the city with the highest prevalence of chemsex in Spain. (De La Mora L et al. AIDS Beh. 2022; 26: 4055-4062).

The frequency of chemsex practice among individuals using PrEP in Barcelona surpasses what has been observed in other groups. Nearly 25% of the participants express worries and a requirement for assistance regarding the management of drug use, matters associated with their sexuality, and sexually transmitted infections (STIs). MSM who suffers from substance use disorder may experience difficulty achieving effective daily oral PrEP adherence prevention levels that may serve as early indicators of increased risk of disengagement from PrEP care and discontinuation the PrEP. These results highlight the importance of adopting aninterdisciplinary approach that incorporates education about substances and the implementation of risk mitigation strategies within the context of riskier sexual behaviors.

None Declared

In Spain and other European countries, patients coming to the emergency room (ER) are usually classified as “organic” or “psychiatric” on arrival, but this may be complicated when psychiatric history is present as the focus can be misplaced (Leeman. IJPM 1975;6(4):544-40; Alam et al. Psychiatr. Clin. North Am. 2017;40(3):425–33).

To describe three cases seen in the psychiatric emergency room (PER) in which triage errors occurred and to review whether it is widespread for psychiatric patients with organic pathology or in need of medical care to be wrongly triaged.

We retrospectively reviewed three cases seen in the PER of Hospital Clínic in July 2023 in which triage errors happened. Triage error was considered when patients triaged directly to the PER presented symptoms that either needed medical treatment or required medical clearance before being considered purely psychiatric.

Case 1: A 27-year-old woman with history of depressive syndrome was triaged for a speech disturbance that had occurred fifteen minutes after intercourse. After being evaluated, she was referred to neurology where she was diagnosed with an acute ischaemic stroke in left middle cerebral artery territory, requiring thrombectomy and posterior admission to neurology.

Case 2: A 50-year-old man with history of alcohol use disorder was brought to the PER after saying that “he was seeing people doing magic” at home. When evaluated, significant distal tremor, tachycardia and hypertension were observed, being compatible with withdrawal symptoms, so he was transferred to the ER. There he was monitored and treated, finally requiring admission to internal medicine due to persistent symptoms.

Case 3: A 26-year-old man with history of substance use disorder was triaged for loss of consciousness and “spasms”. After evaluation, he was transferred to the ER, where organic screening was carried out, being oriented as a probable tonic-clonic seizure and discharged with outpatient follow-up.

The cases presented are instances in which somatic diseases in patients pre-labelled with psychiatric histories were wrongly assumed to be recurrences of their psychiatric disorders. In all cases, they needed to be re-examined by the corresponding medical specialty and required diagnostic tests, in two cases hospital admission was needed. Emergency physicians and emergency psychiatrists often disagree on how to medically clear patients (Alam et al. Psychiatr. Clin. North Am. 2017;40(3):425–33; Janiak et al. JEM. 2012;43(5):866–70), some authors have even proposed protocols for doing this in a more systematic way (Shah et al. JEM. 2012;43(5):871–5). To avoid a delay in diagnosis and treatment and the consequences that may result from it, establishing guidelines for proper triage of patients with psychiatric history should be considered.

None Declared

The Acute Organic Change of Character (AOCC) is an organic mental disorder subtype in which perception, thought, mood and personality impairment predominate. It consists in a change in the individual’s general behaviour or attitude, which is shown to be closely associated with or caused by an underlying organic process, and which is rapidly resolved when the organic noxious agent is eliminated (Pintor et al. Journal of Psychiatry and Psychiatric Disorders 4 (2020): 354-358).

To describe the importance of taking AOCC diagnosis into consideration and the role of liaison psychiatrists in AOCC management by presenting two AOCC cases admitted to the Hospital Clinic of Barcelona.

We retrospectively reviewed two AOCC cases in patients followed by our hospital’s liaison psychiatry unit during the summer of 2023. We also searched for previous case reports of AOCC using a PubMed query.

Case 1: A 50-year-old male who suffered a polytrauma with diffuse axonal injury (DAI). His relatives and the referring medical team observed a change in his behaviour consisting in irritability, suspicion, hostility and impatience. No cognitive impairment nor fluctuation in the described symptoms were observed. At the time of discharge character changes were still present due to DAI slow and unpredictable clinical course. Symptomatic treatment with risperidone 6mg/day and quetiapine 100mg/day was administered achieving a satisfactory clinical response.

Case 2: A 47-year-old woman with type 2 diabetes who suffered an infectious cellulitis that spread causing sepsis. The patient began to appear disruptive with verbose and tangential speech during her admission. No cognitive impairment nor fluctuation in the described symptoms were observed. Symptomatic treatment with risperidone 10mg/day and olanzapine 5mg/day was administered achieving a satisfactory clinical response. At the time of discharge character changes described before were almost resolved.

The clinical presentation of both cases suggested organic mental disorders in which a change in general behaviour predominates. Liaison psychiatrists play a key role in AOCC management by recognizing the clinical pattern, helping if needed with psychopharmacological treatment and ensuring a good understanding of the disorder both by the referring medical team and the patient’s relatives. To our knowledge, it would be of great importance to achieve a better understanding of this clinical condition which to date we consider to be underdiagnosed.

None Declared

With the rapid changes of attitude, investigation and legislation around cannabis and its subproducts in the Western world, there is a need to profoundly examine the consequences of its use in the general population and, specifically, in people affected by mental disorders. There is a clear relationship between cannabis use and psychosis, but there is also growing evidence of its relationship with manic episodes (Sideli et al, 2019).

A systematic review published by the CANMAT Task Force in 2022 examined again the relationship between cannabis use and bipolar disorder (BD), establishing association with worsened course and functioning of BD in frequent users (Tourjman et al., 2023). On the other hand, some recent papers have highlighted the role of the endocannabinoid system (ECS) in BD, suggesting even possible beneficial effects, mainly through the CB2 receptor (Arjmand et al, 2019).

To describe the impact of cannabis in the psychiatric readmission in BD and to approach the differences in course in cannabis users with regards to non-users.

We conducted a prospective cohort study including the patients admitted to our acute psychiatric unit with the diagnosis of manic or mixed episode during the period between 2015 and 2019 (including patients with one of both final diagnosis: BD or schizoaffective disorder). We established a follow-up of 3 years from the date of admission in which hospital readmissions are examined.

The study, which included 309 patients, concluded that cannabis users were admitted and had the first episode at a younger age (p=0.005), a higher percentage of them did not have a previous diagnosis (p=0.026) nor a previous history of mental health issues (p=0.019) and it was more likely to be their first admission (p=0.011) and to suffer psychotic symptoms (p=0.002).

As of treatment, the results were statistically significant regarding the fact that a lower proportion of patients had received previous psychiatric treatment (p=0.004) and previous electroconvulsive therapy (p=0.003). There was a higher chance of them being non-adherent with medication (p<0.001) and to be administered extended-release antipsychotic treatment during admission (p<0.001).

The study did not find a statistically significant relationship with cannabis use and a higher rate of readmission in the 3 years of follow-up.

Although a higher relapse rate could not be proven in our study, other previously identified factors related to a worse illness course (Sajatovic et al., 2009) did show a significant association with cannabis use, which could lead to one suggesting that our results are compatible with the actual evidence and that cannabis products are detrimental to people who suffer from BD and schizoaffective disorder.

None Declared

The coronavirus infectious disease 2019 (COVID-19) pandemic has had a deleterious impact in many areas. Given this, efforts have focused on developing effective vaccines and vaccination campaigns have been carried out prioritizing population at risk. This should include mental health patients since they are at higher risk of developing complications or ending up in a critical status. Since it may be sometimes difficult for these patients to access vaccination, hospitalization may be a window of opportunity to evaluate and offer vaccination.

This study aims to retrospectively assess vaccination status and offer during admission of psychiatry inpatients at Hospital Clínic of Barcelona during a 6-month period, in order to determine if there are differences regarding vaccination rates compared to general population and between main diagnostic categories.

We retrospectively evaluated all admitted patients to the acute psychiatry ward. The main collected variables included age, gender, main psychiatric diagnosis, presence of organic comorbidities, vaccination status at admission and vaccination offer during admission. We used descriptive statistics to extract most of the information. A binary logistic regression was also conducted to evaluate whether the main diagnosis, age and gender had some influence upon vaccination status at admission.

Between January 1st and June 30th of 2022, 216 patients were admitted to the psychiatry ward. A total of 42% were female, with a mean age for the whole sample of 42.8 years (SD 14.7). More than half were current smokers (55%), and 46% of the patients had at least one significant organic comorbidity. The percentages of main diagnosis were as follows: addiction 21.3%; bipolar disorder 18.5%; schizophrenia 18.1%; non-specified psychosis 14.4%; depression 7.4%; cognitive impairment 0.9%; personality disorders 6.9%.

Vaccination status was available for 187 patients (86.6%). Of these, 78 patients were fully vaccinated, 68 had an incomplete vaccination status and 41 patients had not received any dose. No differences on the vaccination status were seen based on the psychiatric diagnosis. Among patients with incomplete or no vaccination, 19 patients (17.4%) were offered a vaccination dose. A total of 11 patients accepted and received it (57.9%). In the logistic regression model, the only significant variable predicting an increase in the likelihood of being fully vaccinated was age, with every year of age increasing the probability of full vaccination by 6%.

Our data suggest that routine screening of vaccination status during psychiatric admission and improved strategies for vaccination offer and acceptance should become a priority in psychiatric wards. Given the impact of the pandemics, and the likelihood of new waves or even new pandemics, more research on vaccination strategies among mental health patients is warranted.

None Declared

Brain reserve, cognitive reserve, and education are thought to protect against late-life cognitive decline, but these variables have not been directly compared to one another in the same model, using future cognitive and functional decline as outcomes. We sought to determine whether the influence of these protective factors on executive function (EF) and daily function decline was dependent upon Alzheimer’s disease (AD) pathology severity, as measured by the total tau to beta-amyloid (T-τ/Aβ1-42) ratio in cerebrospinal fluid (CSF).

Participants were 1201 older adult volunteers in the Alzheimer’s Disease Neuroimaging Initiative (ADNI) study. Brain reserve was defined using a composite index of structural brain volumes (total brain matter, hippocampus, and white matter hyperintensity). Cognitive reserve was defined as the variance in episodic memory performance not explained by brain integrity and demographics.

At higher levels of T-τ/Aβ1-42, brain and cognitive reserve predicted slower decline in EF. Only brain reserve attenuated decline at lower levels of T-τ/Aβ1-42. Education had no independent association with cognitive decline.

These results point to a hierarchy of protection against aging- and disease-associated cognitive decline. When pathology is low, only structural brain integrity predicts rate of future EF decline. The ability of cognitive reserve to predict future EF decline becomes stronger as CSF biomarker evidence of AD increases. Although education is typically thought of as a proxy for cognitive reserve, it did not show any protective effects on cognition after accounting for brain integrity and the residual cognitive reserve index.

Alcohol hangover is the most commonly experienced next day consequence of heavy drinking. The symptoms experienced during this post-intoxication state develop when blood alcohol concentration (BAC) returns to zero. The feeling of general misery can persist up to 24 h and can significantly affect planned activities and cognitive functioning.

To examine the effects of alcohol hangover on driving performance.

In N=47 healthy volunteers, driving performance was tested the morning following heavy drinking (alcohol hangover) and on a control day (no alcohol). Subjects performed a standardized 100-km highway driving test in the STISIM driving simulator. Primary outcome measure was the Standard Deviation of Lateral Position (SDLP), i.e. the weaving of the car. In addition, self-reported driving quality and driving style measures were scored.

Driving performance was significantly worse during alcohol hangover (ΔSDLP = +1.85 cm; p=0.005). Driving impairment during alcohol hangover was supported by subjective measures. During alcohol hangover, driving quality was rated as significantly worse (p=0.0001), less safe, less considerate, less predictable, and less responsible (p=0.001). Subject reported being significantly more tensed during hangover and more effort was needed to perform the driving test (p=0.001).

Driving is significantly impaired during alcohol hangover. The magnitude of driving impairment is higher than that observed after administering alcohol to achieve a BAC of 0.05% (ΔSDLP = +1.7 cm), i.e. the legal limit for driving in many countries.

A meta-analysis was conducted to determine the effect sizes of placebo effect in 21 controlled studies on rTMS in the treatment of AVH in schizophrenia. MRI was also acquired in patients treated by rTMS to evaluate the scalp to cortex distances (SDCs) and the gray matter densities (GMDs) at the target of stimulation. Finally, we evaluated the efficacy of high (20 Hz) frequency stimulation in a controlled placebo study.

Weak or no placebo effect in the control groups led to reveal a superiority of active rTMS over sham rTMS in the treatment of AVH. Clinical efficacy of rTMS was also correlated with the SCD or the GMD at the region of the target stimulation. Finally, we also demonstrated that more responders were observed after 2 weeks in the active group treated by 20 Hz than in the placebo group.

We clearly demonstrated that several factors such as high frequency, the placebo effect, anatomical cortical variations can impact on the efficacy of rTMS. These results fundamentally inform the design and the method of further controlled studies, particularly with respect to studies of rTMS in the treatment of AVH.

The authors have not supplied their declaration of competing interest.