[Euthanasia: opinions and experiences of Flemish psychiatrists working at a university]. / Euthanasie: opvattingen en ervaringen van universitair werkzame Vlaamse psychiaters.

BACKGROUND: Little is known about the attitude of Belgian psychiatrists and psychiatrists in training towards euthanasia for psychiatric reasons. AIM: To analyse opinions about and experiences with euthanasia in physicians from a university psychiatric hospital. METHOD: A mail with a questionnaire was sent to the 111 psychiatrists and psychiatrists in training from University Psychiatric Centre KU Leuven to assess their profile, opinions towards euthanasia in different cases and own experiences with requests for euthanasia in the last five years. RESULTS: The response rate was 45%. The majority of psychiatrists were accepting towards euthanasia, also in the case of psychiatric disorders (64%) or a combination of non-terminal somatic and psychosocial illness (60%). Religious psychiatrists were less accepting towards euthanasia than non-religious colleagues. Older psychiatrists (more than 20 years of working experience) were more open towards euthanasia than their younger colleagues, but less so than psychiatrists in training. Encounters with euthanasia were limited. CONCLUSION: The common attitude towards euthanasia in doctors from a tertiary psychiatric centre is accepting. More research in a broader population is recommended.

Asian monsoons in a late Eocene greenhouse world.

The strong present-day Asian monsoons are thought to have originated between 25 and 22 million years (Myr) ago, driven by Tibetan-Himalayan uplift. However, the existence of older Asian monsoons and their response to enhanced greenhouse conditions such as those in the Eocene period (55-34 Myr ago) are unknown because of the paucity of well-dated records. Here we show late Eocene climate records revealing marked monsoon-like patterns in rainfall and wind south and north of the Tibetan-Himalayan orogen. This is indicated by low oxygen isotope values with strong seasonality in gastropod shells and mammal teeth from Myanmar, and by aeolian dust deposition in northwest China. Our climate simulations support modern-like Eocene monsoonal rainfall and show that a reinforced hydrological cycle responding to enhanced greenhouse conditions counterbalanced the negative effect of lower Tibetan relief on precipitation. These strong monsoons later weakened with the global shift to icehouse conditions 34 Myr ago.

[Functional neurologic and neuropsychologic outcome after near-hanging]. / Functionele neurologische en neuropsychologische uitkomst na bijna-verhanging.

BACKGROUND: Although hanging is a frequently used suicide method, little is known about the prognosis of patients that survived hanging (near-hanging).
AIM: To describe a case report and present a literature-review on the functional neurologic outcome after near-hanging (with separate analyses for the presence of cardiac arrest and use of neuro-protection), and possible residual neuropsychological symptoms.
RESULTS: Only 12,4% (bi 4,6-29,4) of patients after near-hanging with cardiac arrest had a good functional outcome, compared to 90,6% (bi 85,7-94,0) of those without cardiac arrest. Neuroprotection through targeted temperature management has no significant influence on the outcome, neither in the presence nor absence of cardiac arrest. Near-hanging victims with a good functional outcome have, at most, mild residual neuropsychological symptoms. These can manifest throughout all cognitive domains, although learning and memory are most frequently and severely affected. DISCUSSION A significant subgroup of patients after near-hanging without cardiac arrest recovers towards a good level of functioning. A range of residual neuropsychological symptoms remain apparent, which are challenges for diagnostics and suicide prevention.

[Takotsubo cardiomyopathy and catatonia in a patient with psychotic depression]. / Takotsubo-cardiomyopathie en katatonie bij een patiënte met psychotische depressie.

Takotsubo cardiomyopathy (tcmp) is an acute, reversible disruption of the left ventricular systolic function. In many respects the clinical presentation closely resembles acute coronary syndromes (myocardial infarction). tcmp is a syndrome with a pathophysiology that is not fully understood and which seems to be closely associated with psychiatric disorders or psychological problems. We present a case in which a patient with several risk factors developed a tcmp and a depression with psychotic features, followed by catatonia. We describe the syndrome, make some pathophysiological hypotheses and point to possible connections with psychiatric disorders and psychological factors.

[Electroconvulsion therapy for neuroleptic malignant syndrome]. / Elektroconvulsietherapie in de behandeling van maligne antipsychoticasyndroom.

A 64-year-old man, diagnosed with recurrent depression, developed a neuroleptic malignant syndrome (nms) during treatment with olanzapine and mirtazapine. Psychotropic drugs were discontinued. Supportive therapy in an intensive care setting was initiated and electroconvulsive therapy (ect) was administered, after which the patient recovered. This case report discusses the place of ect in the treatment of nms.

[An increase of compulsory admissions in Belgium and the Netherlands: an epidemiological exploration ]. / Stijging van het aantal gedwongen opnames in België en Nederland: een epidemiologische analyse.

BACKGROUND: Although compulsory admission (CA) is highly relevant to society, epidemiological data for European countries are scarce and of limited reliability and comparability. In several European countries the incidence of CA seems to be increasing. AIM: To estimate the incidence and evolution of CA in Belgium and the Netherlands by pooling and analysing available epidemiological data. METHOD: We reviewed the literature systematically, paying particular attention to relevant epidemiological data (in published articles and in grey literature). All data were (re)calculated into yearly incidence rates of CA per 100,000 inhabitants. RESULTS: The incidence of CA increased by 42% in Belgium (1999-2008) and by 25% in the Netherlands (2002-2009), culminating in incidence rates of 47/100,000/y (Belgium, 2008) and 80/100.000/y (Netherlands, 2009). Between-country differences can be attributed partly to differences in the legal systems. More detailed results, regional differences, and problems with the comparison of epidemiological data on CA are discussed. CONCLUSIONS: Our data point to a significant increase of the incidence of CA in both Belgium and the Netherlands. To improve the comparability and quality of the data on CA, European countries will need to strive for greater uniformity and standardisation in the way these data are registered.

Impact of gavage dosing procedure and gastric content on adverse respiratory effects and mortality in rat toxicity studies.

Unscheduled mortality preceded by adverse respiratory clinical signs in rats dosed by oral gavage may not only be caused by technical gavage error or systemic toxicity but may also be caused by gastro-esophageal reflux and subsequent aspiration of high concentrations of drug formulation. In a 3 week oral gavage rat toxicity study for an early drug development compound, preterminal deaths (approximately 20% of animals) at high doses (≥1000 mg kg(-1) ) and concentrations (≥60 mg ml(-1) ) were preceded by recurrent dyspnea, rales or excessive salivation, without evidence of accidental intrapulmonary gavage error. Histological evaluation revealed extensive necrosis and inflammatory changes in the upper respiratory tract, especially in the nasal turbinates and/or nasopharynx. The presence of food particles in inflammatory exudates suggested a retrograde aspiration of stomach content with test formulation via the nasopharyngeal duct into the posterior region of the nose. In contrast, no mortality or adverse respiratory effects were observed in rats following 2 week intravenous administration at comparable exposures or oral gavage administration at lower concentrations (≤20 mg ml(-1) ). In a pharmacology study, the compound caused a dose-dependent increase in gastric content (partly due to inhibition of gastric emptying), providing a pharmacological basis for the suspected gavage-mediated gastroesophageal reflux. Reducing the dose volume and dosing fasted animals substantially reduced or eliminated the respiratory effects and mortality at the high test article concentrations, demonstrating that the adverse effects are related to the gavage method.

[Does psychotherapy alter the brain? A non-reductionist neurophilosophical perspective]. / Wat doet psychotherapie met het brein? Een niet-reductionistische 'neurofilosofische' visie.

BACKGROUND: Psychiatry and 'philosophy of mind' are both concerned with the study of the relationship between body/brain ('physical' domain) and mind ('mental' domain), but often there is little interaction between both disciplines. In contemporary psychiatry, neurobiological research predominates, and it is often assumed that the results of this type of research are only compatible with reductionist physicalist positions in the 'philosophy of mind', rendering further philosophical reflection obsolete. AIM: To demonstrate the continuing relevance of the 'philosophy of mind' for the self-image of modern psychiatry as a clinical and scientific discipline. METHOD: We illustrate this view by investigating whether a non-reductionist physicalist position, which postulates that the 'mental' supervenes on the 'physical' without being reducible to it, is compatible with the results of research on alterations in the brain during psychotherapy. RESULTS: A non-reductionist physicalist position is compatible with recent functional brain imaging research, since the latter shows that psychiatric disorders (disorders of the 'mind') are associated with functional neurophysiological changes (alterations in the brain) that are influenced in different ways by pharmacotherapy and psychotherapy. CONCLUSION: Modern neurobiological research in psychiatry is not only compatible with reductionist physicalist positions in the 'philosophy of mind', as is often assumed, but also with a non-reductionist physicalist position in which the 'mental' is granted greater autonomy vis-à-vis the physical.

[Mentally ill and dangerous: civil commitment or internment? The Belgian judicial framework]. / Geestesziek en gevaarlijk: gedwongen opname of internering? Het Belgische wettelijke kader.

There are two important Belgian laws referring to psychiatric disturbances that may prove dangerous. The Civil Code includes the law relating to the protection of the mentally ill person, dated 26th June 1990, better known as the law of civil commitment of the mentally ill. Since April, 2007, the Penal Code has contained a new law on the internment of people with a psychiatric disorder; this new law replaces the old law of the 1st July, 1964, meant to protect the society. Although the two laws apply to different fields, in clinical practice there are sometimes 'grey areas' where it is not immediately evident which legal framework is applicable. Starting from a case study in which the civil judge ordered the civil commitment of a detainee, we explore these 'grey areas' and compare the two legal frameworks. We base our study on the new law on internment, clarify it and sketch the legal history of internment in Belgium.

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.

[Does evidence-b(i)ased psychiatry have its limitations?]. / Grenzen aan evidence-b(i)ased psychiatrie?

Evidence-based medicine (EBM) is an algorithm that integrates information technology and the results of outcome research into clinical work. EBM, if well understood, is a valuable and critical bottom-up method that promotes a dialectical process by which the practitioner is able to arrive at an informed treatment choice; the method starts from the individual patient and involves discussion with the patient and critical reading of the relevant literature. However, there is a risk that EBM will become an ideology unless we are aware of its assumptions and epistemology. It is not valuefree, but is driven by an implicit objectivist view of man. EBM attaches greater value to biomedical sciences that to the humanities, to empiricism than to hermeneutics and to quantitative research than to qualitative research. EBM focuses on internal validity, but is in danger of neglecting factors such as qualitative changes that are difficult to measure, ecological validity and effectiveness and may hinder the generalisation of research results to clinical practice. The limitations of EBM are even more poignant in psychiatry, because psychiatry is highly sensitive to context and values. EBM is a blessing if we use it critically and remain aware of its limitations and underlying philosophy and if we supplement it with strategies such as value-based medicine (VBM). EBM, however, does not teach us what is useful or valuable, whereas VBM helps us to explain and weigh up the values that are at stake.

[Civil commitment of mentally ill patients: developments in Flanders]. / Gedwongen psychiatrische opname: ontwikkelingen in Vlaanderen.

The Belgian law of 1990 concerning the protection of the mentally ill was the principal achievement of the last 25 years in the field of civil commitment of mentally ill patients in Flanders. Since that time there have been very few alterations in the criteria determining civil commitment. Very little legislation has been passed on this subject. The pragmatic and casuistic way in which the law is applied hinders any discussion of the principles on which these criteria are based. In spite of the large increase in the number of civil commitments, so far the law has remained unchanged.

[Neurosarcoidosis as a cause of manic psychosis]. / Neurosarcoïdose als oorzaak van manische psychose.

A case report and a systematic review of the literature show that neurosarcoidosis can present initially as a manic episode with psychotic features. The diagnosis of neurosarcoidosis is based on a combination of clinical features, and radiological and histopathological findings. Contrast-enhanced MRI and lumbar puncture are the most sensitive investigations for detecting neurosarcoidosis. Corticosteroids are the treatment of choice. Very few data are available concerning the efficacy of psychotropic drugs for the treatment of psychiatric symptoms caused by neurosarcoidosis.

[When is psychosis dangerous? Ethical, professional en juridical considerations concerning psychosis and coercion in Belgium]. / Wanneer is een psychose gevaarlijk? Ethische, professionele en juridische afwegingen inzake psychose en gedwongen opname in België

BACKGROUND: In Belgium a patient can only be compulsorily admitted to a psychiatric hospital if he is a danger to himself or others (law concerning coercion in Belgium, 26/06/1990). AIM: To explore the relationship between psychosis and danger, and to analyse the various interpretations of the 'dangerousness' criterion in the context of psychotic disorders and the underlying ethical positions. METHOD: We studied the literature by means of PubMed, PsycINFO, manuals and references and used the search terms: 'coercion', 'commitment of mentally ill', 'dangerous behaviour', and 'psychotic disorders'. results The correlation between psychosis and danger is limited but is strengthened by comorbid substance abuse and non-compliance. The clinical assessment of danger does not have a firm scientific basis. The underlying ethical position determines when danger is regarded as being serious enough to justify coercion. CONCLUSION: Danger is a problematical criterion for coercion. We propose a model that weighs up the likelihood of danger against the expected pros and contrasts of coercion and the extent to which the disorder can be treated. The fluid nature of the 'dangerousness' criterion and the principle of proportionality call for a more varied arsenal of coercive measures which are less drastic than compulsory admission.

Carcinogenicity studies of astemizole in mice and rats.

The histamine H1 antagonist astemizole (Hismanal) was tested for carcinogenicity in Swiss mice and Wistar rats. Astemizole was administered with the food to mice for 18 and to rats for 24 consecutive months. The doses given--approximately 5, 20, and 80 mg/kg body weight.day--were equivalent to 25, 100, and 400 times, respectively, the recommended human dose of 10 mg/day. Survival of both mice and rats was comparable between groups. Peto's age-adjusted, dose-related trend analysis for the tumor-bearing rats did not reveal a statistically significant difference for males or females. There was no evidence that astemizole led to an increased incidence of spontaneously or unusually occurring neoplastic lesions in either mice or rats. Special attention was given to the effect of astemizole on the progression of spontaneously occurring mammary gland adenomas and fibroadenomas. Peto's analysis applied to the number of female rats bearing these benign mammary gland tumors disclosed no statistically significant dose-related trend. There was no positive trend for the onset of this tumor type, and the median size of the tumor over time per rat was also not statistically significantly different in a comparison of the control group with each of the dosed groups. The findings from these carcinogenicity studies suggest that astemizole is not tumorigenic and that it does not promote tumor growth.

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.

Visceral hypersensitivity in functional disorders of the upper gastrointestinal tract.

Visceral hypersensitivity is now recognised as a major pathophysiological mechanism in functional gastrointestinal disorders of the upper gastrointestinal tract. In patients with non-cardiac chest pain and functional dyspepsia, a high prevalence of visceral hypersensitivity has been indeed observed. In these patients, luminal physiological stimuli can be perceived as unpleasant or even painful. Although the fine mechanisms underlying such "aberrant perceptions" are yet not fully clarified, it is thought that an altered activation of the gut-wall receptors, an altered conduction of sensory inputs at the level of neural pathways, or an impaired processing of the sensations at the level of brain, may occur along the brain-gut axis. So far, drugs able to reduce hypersensitivity, that target each of the constituents of the stimuli-perception chain, have the therapeutic potential to reduce visceral hypersensitivity and, thus, to improve the symptoms. In this context, the availability of new agonists/antagonists to neurotransmitters offers a new exciting tool for the treatment of functional disorders of the upper gastrointestinal tract.