[Idiopathic normal pressure hydrocephalus]. / Idiopathische normaledrukhydrocefalie.

Idiopathic normal pressure hydrocephalus (INPH) is a syndrome that can be characterised by the following triad of symptoms: gait disturbances, cognitive impairment and urinary incontinence. The suspected diagnosis can be confirmed by cerebral ventriculomegaly and by a positive result of cerebrospinal fluid drainage. The frequent occurrence of comorbidity and a unflinching firm belief in the significance of the triad of clinical symptoms can hinder a correct diagnosis, leading to a delay in treatment and a poor prognosis. To illustrate this thesis we describe a 77-year-old patient with INPH and severe neuropsychiatric comorbidity.

Management of burn wounds of the head and neck region.

Management of burn wounds of the head and neck region. Management of the severely burned patient is ery often a challenge, not only due to major disturbances in anatomy and physiological processes, but also because the relatively low incidence of this pathology in both civilian and military practice results in care providers'lack of experience. The purpose of this educational document is to provide doctors confronted with these formidable trauma patients with basic management guidelines as well as some practical tips. In summary, and most importantly, these patients should be reated as any other multitrauma patient. First aid is essential and can be provided by non-medical staff. Initial medical nanagement should focus on the usual, familiar trauma algorithms of ABCDEF from the emergency management of evere burns (EMSB) manual' or the ABCDEs of the manual of advanced trauma life support (ATLS)2 or advanced burn life support (ABLS). Medical care should proceed through the following steps - Step one: establish a reliable intravenous nfusion; step two: protect the airway; step three: establish and maintain a haemodynamic state compatible with sufficient organ perfusion in order to reduce aggravation of the burn wounds and increase overall survival likelihood; step four: provide analgesia with adequate sedation and provide anaesthesia for escharotomy, fasciotomy or other surgical injuries; step five: maintain normothermia; step six: feed the patient by starting enteral nutrition as early as possible; step seven: prevent infection using antiseptic wound management, systemic antibiotics and tetanus prophylaxis. All of these intricate steps require continuous reassessment and adjustment, but the existence of other wounds (blast injuries, penetrating and blunt trauma) even further complicates the management of burn casualties.

[Early use of memantine in the treatment of Lewy body dementia]. / Vroegtijdig gebruik van memantine bij dementie met lewylichaampjes.

Early use of memantine in the treatment of Lewy body dementia (LBD) is a common type of major neurocognitive disorder (NCD), which is difficult to treat. The use of memantine can be an early treatment strategy. This is illustrated by a case of an 80-year-old patient whose cognition, motor skills and perception disorders reacted favourably to treatment with memantine. The beneficial effect, however, was soon lost after the treatment was discontinued, but reappeared after the medication was reintroduced.

[Therapy for elderly family members and couples: concerning the viability of relationships in later life, the role reversal and 'finishing' amicably]. / Familie- en paartherapie bij ouderen: over leefbaarheid, rolomkering en finishing well.

BACKGROUND: Research shows that in most countries the number of elderly persons is increasing and that close relationships in late life are playing a more important role. Therefore, it is surprising that there have been so few publications about family therapy for the elderly. AIM: To formulate some guidelines for psychotherapy for family members in their later years and to make suggestions regarding further research. METHOD: We summarise the existing literature and focus on important themes about working with the elderly, supplementing major issues with our own clinical experience. RESULTS: Family therapy with the elderly differs from therapy for younger adults in some respects; for instance, the emphasis in the case of the elderly is more on strengthening the viability of a long/standing relationship. The reversal of roles that often accompanies the ageing process and leads to increasing dependency is another factor that affects the elderly more than the younger adults. If the last stage of life is to finish calmly and amicably, therapists need to tackle any tensions or injustices that patients have experienced in the course of their relationships. CONCLUSION: Psychotherapy for the elderly needs to provide clients with constant opportunities for reflection and should initiate discussions about partners' experiences of tensions and injustices in their earlier relationship. However, the increasing number of elderly persons means that more empirical research needs to be done into systematic psychotherapy.

[Neurocognitive disorders in DSM-5: a critical review]. / Neurocognitieve stoornissen in de DSM-5: een kritische bespreking.

BACKGROUND: The APA published the DSM-5 in May, 2013. When compared to dsm-iv, the latest edition incorporates many changes, some relating to neurocognitive disorders. AIM: To review critically the new DSM-5 alterations and adjustments relating to neurocognitive disorders. METHOD: We compared the relevant chapters in DSM-IV-TR and DSM-5 and we searched the literature for articles involving discussions about cognitive disorders in DSM-5. RESULTS: With regard to differential diagnosis of neurocognitive disorders, DSM-5 has more in common with current clinical practice than does the DSM-IV. DSM-5 names ten etiological subtypes for which the diagnostic criteria are based on recent scientific research. However, some researchers and clinicians have reservations about using the term 'major neurocognitive disorder' instead of 'dementia', and are reluctant to make a distinction between 'mild' and 'major' cognitive disorders. CONCLUSION: The alterations and adjustments that appear in DSM-5 in relation to neurocognitive disorders may well mean progress for clinicians and researchers but they will inevitably require greater investment.

[The use of clozapine and levodopa for the treatment of persistent visual hallucinations and parkinsonism in Lewy body dementia]. / Clozapine en levodopa als behandeling van persisterende visuele hallucinaties en motorische symptomen bij dementie met lewylichaampjes.

Visual hallucinations (VH) are sometimes difficult to treat in patients with Lewy body dementia (LBD). We describe the concurrent use of clozapine and levodopa for the treatment of persistent VH and parkinsonism in a patient with LBD and severely increased sensitivity to antipsychotics.

Determinants of symptoms in functional dyspepsia: gastric sensorimotor function, psychosocial factors or somatisation?

BACKGROUND: Gastric sensorimotor dysfunction, psychosocial factors and somatisation are all implicated in symptom generation in functional dyspepsia (FD). AIM: To determine the relative contribution of each of these factors to overall dyspeptic symptom severity and weight loss in FD. METHODS: In 201 consecutive tertiary care patients with FD (mean age 40.1 (SD 12.6) years), gastric sensorimotor function was studied using barostat (sensitivity, compliance and accommodation). Psychosocial factors (depression and anxiety disorders, positive and negative affect, perceived stress, alexithymia and history of abuse), somatisation and co-morbid irritable bowel syndrome (IBS) and chronic fatigue symptoms were assessed using self-report questionnaires. Variables were correlated with dyspepsia symptom severity (DSS) and weight loss. Hierarchical multiple linear regression was used to identify determinants of DSS and weight loss. RESULTS: Multiple linear regression identified the following determinants of DSS: gastric sensitivity (beta = 0.77, p = 0.25), depression (beta = 0.12, p = 0.06) and somatisation (beta = 0.48, p<0.0001) (controlling for age and occupation, R(2) = 0.29, p<0.0001). The effect of depression on DSS is partially mediated by somatisation. Gastric sensitivity (beta = 2.87, p = 0.08), history of childhood sexual abuse (beta = 9.37, p = 0.0006), depression (beta = 0.19, p = 0.24) and somatisation (beta = 0.67, p = 0.01) are independent determinants of weight loss (controlling for gender and occupation, R(2) = 0.42, p<0.0001). The effect of depression on weight loss is fully mediated by somatisation. CONCLUSION: Symptom severity and weight loss in FD are determined by psychosocial factors (depression, abuse history) and somatisation, and only to a lesser extent by gastric sensorimotor function. The importance of psychosocial factors and somatisation compared to gastric sensorimotor function is most pronounced in hypersensitive patients.

The impact of major depressive disorder on the short- and long-term outcome of Crohn's disease treatment with infliximab.

BACKGROUND: Major depressive disorder is the most common psychiatric diagnosis in Crohn's disease. In other chronic diseases, evidence suggests that depression influences the course of the disease. Strong evidence of such a mediating role of major depressive disorder in Crohn's disease has never been found. AIM: To assess the relationship between major depressive disorder and outcome of treatment of luminal Crohn's disease with infliximab. METHODS: In this prospective study, 100 consecutive unselected patients underwent assessment of psychosocial, demographical disease-related biological and clinical parameters at baseline and at 4 weeks after infliximab. Major depressive disorder was diagnosed using the Patient Health Questionnaire. Subsequently, the patients were followed up clinically until the next flare or during 9 months. RESULTS: The Crohn's disease responded in 75% of the patients, and remission was achieved in 60%. The presence of major depressive disorder at baseline predicted a lower remission rate (OR = 0.166, 95% CI = 0.049-0.567, P = 0.004). At follow-up, 88% of the patients needed retreatment. At univariate regression analysis, major depressive disorder significantly decreased time to retreatment (P = 0.001). Multivariate Cox regression confirmed major depressive disorder as an independent determinant of active disease both at baseline and at re-evaluation (hazard ratio = 2.271, 95% CI: 1.36-3.79, P = 0.002). CONCLUSION: Major depressive disorder is a risk factor for failure to achieve remission with infliximab and for earlier retreatment in patients with active luminal Crohn's disease. Assessment and management of major depressive disorder should be part of the clinical approach to patients with Crohn's disease.

Dyspeptic patients with visceral hypersensitivity: sensitisation of pain specific or multimodal pathways?

BACKGROUND AND AIMS: Patients with functional dyspepsia who have hypersensitivity to gastric distension have more prevalent pain, suggesting the presence of hyperalgesia. It is unclear whether this reflects activation of pain specific afferent pathways or multimodal afferent pathways that also mediate non-painful sensations. In the former case, hyperalgesia should occur when intensity of non-painful sensations is still low. The aim of the study was to analyse whether the symptom profile during gastric dissentions in functional dyspepsia patients with hyperalgesia reflects sensitisation of pain specific or multimodal pathways. METHODS: Forty eight consecutive dyspeptic patients (35 female) underwent gastric sensitivity testing with a barostat balloon using a double random staircase protocol. At the end of every distending step, patients scored perception of upper abdominal sensations on a graphic 0-6 rating scale and completed visual analogue scales (VAS 0-100 mm) for pain, nausea, satiety, and fullness. The end point was a rating scale of 5 or more. RESULTS: Hypersensitivity was present in 20 patients (40%); gastric compliance did not differ between normo- and hypersensitive patients. At maximal distension (score 5 or more), hypersensitive patients had significantly lower distending pressures and intra-balloon volumes, but similar VAS scores for pain, nausea, satiety, and fullness compared with normosensitive patients. In both normosensitive and hypersensitive patients, elevation of pain VAS scores with increasing distending pressures paralleled the elevation in VAS scores for nausea, satiety, and fullness. CONCLUSIONS: Hypersensitive dyspeptic patients reach the same intensity of painful and non-painful sensations as normosensitive patients but at lower distending pressures. Hyperalgesia occurs in hypersensitive dyspeptic patients at distending pressures that also induce intense non-painful sensations. These findings argue against isolated upregulation of pain specific afferents in functional dyspepsia patients with visceral hypersensitivity.