Baseline imbalance about depressive symptoms may overestimate the effectiveness of mindfulness-based cognitive therapy for anxiety disorders.

We read the article by Ninomiya et al. with great interest and appreciate the author's efforts to analyze the effect of primary mindfulness-based cognitive therapy (MBCT) in patients with anxiety disorder in secondary-care settings, compared with a waiting-list group. However, we have concerns about baseline imbalance of depressive symptoms that may influence the conclusion of the trial. Comorbid major depressive disorder can have caused an underestimation of anxiety symptoms in the waiting-list group and distort effectiveness of MBCT. The wait-list group had more severe depressive symptoms than the intervention group, about 7 points more in the Center for Epidemiologic Studies Depression Scale (CES-D) scores, and that group might have more major depressive disorder. Indeed, the rate of antidepressant use in the wait-list group was 25% higher than the intervention group. It is well known that major depressive disorder is associated with cognitive errors and underestimation of self-report outcomes. Baseline imbalance of depressive symptoms may therefore weaken the conclusion of the study, because all outcome measures were self-report questionnaires. The authors should acknowledge the limitation and provide information about the diagnosis of major depressive disorder.

Mechanical circulatory support in cardiogenic shock from acute myocardial infarction: Impella CP/5.0 versus ECMO

Background: Short-term mechanical circulatory support devices are increasingly used in cardiogenic shock after acute myocardial infarction. As no randomised evidence is available, the choice between high-output Impella or extra-corporeal membrane oxygenation (ECMO) is still a matter of debate. Real-life data are necessary to assess adverse outcomes and to help guide the treatment decision between the different devices. The purpose of this study was to compare characteristics and clinical outcomes of Impella CP/5.0 with ECMO support in patients with cardiogenic shock from myocardial infarction. Methods: A retrospective, two-centre study was performed on all cardiogenic shock from myocardial infarction patients with Impella CP/5.0 or ECMO support, from 2006 until 2018. The primary outcome was 30-day mortality. Potential baseline imbalance between the groups was adjusted using inverse probability treatment weighting, and survival analysis was performed with an adjusted log-rank test. Secondarily, the occurrence of device-related complications (limb ischaemia, access site-related bleeding, access site-related infection) was evaluated. Results: A total of 128 patients were included (Impella, N=90; ECMO, N=38). The 30-day mortality was similar for both groups (53% vs. 49%, P=0.30), also after adjustment for potential baseline imbalance between the groups (weighted log-rank P=0.16). Patients with Impella support had significantly fewer device-related complications than patients treated with ECMO (respectively, 17% vs. 40%, P<0.01). Conclusions: Patients treated with Impella CP/5.0 or ECMO for cardiogenic shock after myocardial infarction did not differ in 30-day mortality. More device-related complications occurred with ECMO compared to Impella support.