Virtual reality cognitive-behavioural therapy versus cognitive-behavioural therapy for paranoid delusions: a study protocol for a single-blind multi-Centre randomised controlled superiority trial.

BACKGROUND: Seventy per cent of patients with psychotic disorders has paranoid delusions. Paranoid delusions are associated with significant distress, hospital admission and social isolation. Cognitive-behavioural therapy for psychosis (CBTp) is the primary psychological treatment, but the median effect size is only small to medium. Virtual reality (VR) has a great potential to improve the effectiveness of CBTp. In a previous study, we found that VR based CBT (VRcbt) for paranoid delusions is superior to waiting list. As a next step, a direct comparison with CBTp is needed. The present study aims to investigate whether VRcbt is more effective and cost-effective than regular CBTp in treating paranoid delusions and improving daily life social functioning of patients with psychotic disorders. METHODS: A total of 106 patients with DSM-5 diagnosis of psychotic disorder and at least moderate level of paranoid ideations will be recruited for this multicentre randomized controlled trial (RCT). Patients will be randomized to either VRcbt or standard CBTp for paranoid delusions. VRcbt consists of maximum 16 sessions in virtual social situations that trigger paranoid ideations and distress, delivered in an 8-12 week time frame. Standard CBTp also consists of maximum 16 sessions including exposure and behavioural experiments, delivered in an 8-12 week time frame. The two groups will be compared at baseline, post-treatment and six months follow-up. Primary outcome is the level of paranoid ideations in daily life social situations, measured with ecological momentary assessments (EMA) at semi-random moments ten times a day during seven days, before and after treatment. Every session, participants and therapists will rate the level of paranoid ideation and global clinical impression. DISCUSSION: Comparison of VRcbt and CBTp will provide information about the relative (cost-) effectiveness of VRcbt for this population. VRcbt may become a preferred psychological treatment for paranoid delusions and social anxiety in patients with psychotic disorder. TRIAL REGISTRATION: Netherlands Trial Register, NL7758. Registered on 23 May 2019.

[Young adult with psychotic disorders have problems relating to sexuality, intimacy and relationships. An explanatory study based on focus group]. / Jongeren met een psychotische kwetsbaarheid over seksualiteit, intimiteit en relaties.

BACKGROUND: Research has shown that young adults with psychotic disorders frequently have problems relating to sexuality, intimacy and relationships. Such problems are often neglected in clinical practice. AIM: To perform a study that explores, on the basis of focus groups, how issues such as sexuality, intimacy and relationships can be addressed as part of the treatment of adolescents suffering from a psychotic disorder. METHOD: We created eight focus groups consisting of clients attending the department of psychotic disorders and caregivers who worked there. The meetings of each focus group were fully transcribed and analysed by means of Nvivo. RESULTS: Clients indicated they wanted to address the topics of sexuality, intimacy and relationships in a group setting. They expressed the wish to have mixed gender groups and decided that in the group discussions the main focus should be on the exchange of personal experiences. CONCLUSION: In our view, it is desirable that psychiatry should pay more attention to the subject of sexuality. By giving adolescents suffering from psychotic disorders the opportunity to discuss their experiences, problems and feelings of insecurity in a group setting and in a low-threshold environment, psychiatrists can greatly improve the quality of care that they provide for their patients.

Long-term effects of metformin on endothelial function in type 2 diabetes: a randomized controlled trial.

OBJECTIVES: We investigated whether metformin can improve endothelial function and decrease inflammatory activity, and thereby decrease the risk of atherothrombotic disease. SUBJECTS AND DESIGN: A randomized, placebo-controlled trial with a follow-up period of 4.3 years set in the outpatient clinics of three nonacademic hospitals (Hoogeveen, Meppel and Coevorden Hospitals, the Netherlands). A total of 390 patients with type 2 diabetes treated with insulin were included. Either metformin 850 mg or placebo (one to three times daily) was added to insulin therapy. Urinary albumin excretion and plasma levels of von Willebrand factor (vWf), soluble vascular adhesion molecule-1 (sVCAM-1), soluble E-selectin (sE-selectin), tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor-1 (PAI-1), C-reactive protein (CRP) and soluble intercellular adhesion molecule-1 (sICAM-1) were measured at baseline and after 4, 17, 30, 43 and 52 months. RESULTS: Metformin significantly reduced levels of vWF, sVCAM-1, t-PA, PAI-1, CRP and sICAM-1, which, except for CRP, remained significant after adjustment for baseline differences in age, sex, smoking and severity of previous cardiovascular (CV) disease. No effects on urinary albumin excretion or sE-selectin were observed. The improvements in vWf and sVCAM-1 statistically explained about 34% of the reduction in the risk of CV morbidity and mortality associated with metformin treatment in this study. CONCLUSIONS: Metformin is associated with improvement in some (vWF and sVCAM-1) but not all markers of endothelial function, which may explain why it is associated with a decreased risk of CV disease in type 2 diabetes.

Melnick-Needles syndrome: indication for an autosomal recessive form.

We describe three patients with bone changes and the facial characteristics of the Melnick-Needles syndrome (MNS). Associated anomalies (once bilateral glaucoma, twice congenital heart defect) were the reason for referral. The MNS literature also suggests a high frequency of associated anomalies, especially cardiopulmonary malformations. The distribution of the affected relatives, consanguinity of one pair of parents, and absence of similar symptoms in parents and other relatives makes autosomal recessive inheritance of the trait in this family a definite possibility. This is of great importance in genetic counseling, particularly of sporadic cases.

A double-blind crossover trial of diflunisal and naproxen in osteoarthritis.

Fifty patients with osteoarthritis were studied in a double-blind, crossover trial of diflunisal (1000 mg daily) and naproxen (750 mg daily). In the 45 patients who completed the study, no significant difference was noted between the drugs in most of the parameters studied, including evening pain intensity and effectiveness rating by patient and investigator. There was a trend towards greater patient preference for diflunisal, although this trend did not reach statistical significance. Naproxen produced significantly fewer side-effects, although side-effects with both drugs were mild.

Retinal dystrophy in long chain 3-hydroxy-acyl-coA dehydrogenase deficiency.

BACKGROUND: Long chain 3-hydroxyacyl-CoA-dehydrogenase (LCHAD) is one of the enzymes involved in the breakdown of fatty acids. A deficiency of this enzyme is associated with life threatening episodes of hypoketotic hypoglycaemia during prolonged fasting. Neuropathy and retinopigmentary changes were mentioned in only a few cases. METHODS: The case histories of two girls, aged 8 and 15 years, with LCHAD deficiency are reported. RESULTS: Both children with LCHAD deficiency exhibited extensive macular pigmentary depositions and a 'salt and pepper' scattering of pigment in their retinas. The patients have decreasing visual acuity. CONCLUSION: The early recognition of LCHAD deficiency can increase the life expectancy in these patients through avoiding catabolism and through appropriate diets. Patients tend to be free of symptoms between attacks, however. Testing for the disorder, therefore, should be included in the diagnostic process for children with retinal dystrophy, in particular when other clinical symptoms are known to have occurred.

[Continuous 2-layer suture of the femoral hernia. Initial clinical results with 31 patients]. / Fortlaufender zweireihiger Nahtverschluss der Schenkelbruchpforte. Erste klinische Ergebnisse an 31 Patienten.

In a retrospective study the two-lined continuous suture for the repair of femoral hernia was examined. From 1.12. 1985 till 31.5. 1988 the femoral defect was closed by a continuous two-lined suture 33 times in 31 patients. In almost 50% (16 cases) the hernia was incarcerated, in total 10 surgeons took part. Postoperatively occurred one wound infection and one serom. During a postoperative observation time of 1-28 months up to now no recurrence has been seen. Thus the two-lined continuous suture of femoral hernia seems to use a sure, simple and practical operation technique, that can be used very well in the every-day-practice, also in case of incarcerated hernia.

Polymyalgia rheumatica and giant cell arteritis. Avoiding management traps.

BACKGROUND: Polymyalgia rheumatica (PMR) needs to be considered in the patient over 55 years of age who presents with stiffness and pain. It appears to exist in a continuum with giant cell arteritis (GCA), and the differential diagnosis is large. It may affect one in 200 patients in this age group. Corticosteroid toxicity is a major problem, either because of inappropriate dosage or prolonged disease. OBJECTIVE: To provide an up to date understanding of the concepts of this group of disorders in order to allow rapid recognition, better management, and to minimise toxicity of the necessary treatment. The most important of these are the appropriate dose of corticosteroid and instituting preventive therapy for potential complications such as osteoporosis. DISCUSSION: As there is no specific test for PMR, the diagnosis is still made on clinical grounds from the presentation, symptoms and signs, and the presence of serological markers of inflammation. Because these are all nonspecific, alternative diagnoses must be actively excluded. Certain newer investigations, such as high resolution ultrasound of the temporal arteries may be very helpful in directing temporal artery (TA) biopsies. When the response to treatment does not follow the usual course (and this may be prolonged: 18 months to five years or more), then re-evaluation is imperative.

Effects of short-term treatment with metformin on markers of endothelial function and inflammatory activity in type 2 diabetes mellitus: a randomized, placebo-controlled trial.

OBJECTIVES: The UK Prospective Diabetes Study (UKPDS) showed that treatment with metformin decreases macrovascular morbidity and mortality independent of glycaemic control. We hypothesized that metformin may achieve this by improving endothelial function and chronic, low-grade inflammation. Data on this issue are scarce and we therefore tested, in the setting of a randomized, placebo-controlled trial, whether metformin can affect endothelial function and low-grade inflammation. DESIGN: The Hyperinsulinaemia the Outcome of its Metabolic Effects (HOME) trial is a double-blind trial, in which all patients were randomized to receive either metformin or placebo in addition to insulin therapy. At the beginning and the end of a 16-week treatment period fasting blood samples were drawn and a physical examination was carried out. SETTING: The trial was conducted in the outpatient clinics of three nonacademic hospitals (Hoogeveen, Meppel and Coevorden; the Netherlands). SUBJECTS: Patients were included if they were between 30 and 80 years of age; had received a diagnosis of diabetes after the age of 25; had never had an episode of ketoacidosis; and their blood glucose-lowering treatment previously consisted of oral agents but now only consisted of either insulin (n = 345) or insulin and metformin (n = 45). We excluded pregnant women and women trying to become pregnant, patients with a Cockroft-Gault-estimated creatinine clearance <50 mL min(-1), or low plasma cholinesterase (reference value <3.5 units L(-1)), patients with congestive heart failure (New York Heart Association class III/IV), or patients with other serious medical or psychiatric disease. A total of 745 eligible patients were approached; 390 gave informed consent and were randomized (196 metformin, 194 placebo). About 353 patients completed 16 weeks of treatment (171 metformin, 182 placebo). MAIN OUTCOME MEASURES: The HOME trial was designed to study the metabolic and cardiovascular effects of metformin during a follow-up of 4 years. Presented here are the results of an interim analysis after 16 weeks of treatment. RESULTS: When compared with placebo, metformin treatment was associated with an increase in urinary albumin excretion of 21% (-1 to +48; P = 0.06); a decrease in plasma von Willebrand factor of 6% (-10 to -2; P = 0.0007); a decrease in soluble vascular cell adhesion molecule-1 of 4% (-7 to -2; P = 0.0002); a decrease in soluble E-selectin of 6% (-10 to -2; P = 0.008); a decrease in tissue-type plasminogen activator of 16% (-20 to -12; P < 0.0001); and a decrease in plasminogen activator inhibitor-1 of 20% (-27 to -10; P = 0.0001). These changes could not be explained by metformin-associated changes in glycaemic control, body weight or insulin dose. Markers of inflammation, i.e. C-reactive protein and soluble intercellular adhesion molecule-1, did not change with metformin treatment. CONCLUSIONS: In patients with type 2 diabetes treated with insulin, metformin treatment was associated with improvement of endothelial function, which was largely unrelated to changes in glycaemic control, but not with improvement of chronic, low-grade inflammation.

Shoulder joint rupture and pseudothrombosis in rheumatoid arthritis.

A patient with rheumatoid arthritis developed sudden unilateral oedema of the right arm resembling vascular obstruction and was shown to have a ruptured shoulder joint.

The effect of the long-term ingestion of konjac-glucomannan on glucose tolerance and immunoreactive insulin values of baboons.

It is uncertain whether the beneficial effects of the high-fibre, high-carbohydrate diets generally recommended for improved glucose control in diabetic patients are in fact due to the fibre. In this study the effect of the long-term ingestion of the dietary fibre, konjac - glucomannan (K-GM), on glucose tolerance and immunoreactive insulin (IRI) concentrations was investigated in normal baboons and compared with the short-term effect of the concurrent feeding of K-GM and glucose. Eighteen young baboons were divided in a control and a K-GM group. Glucose tolerance tests ( GTTs ) performed at baseline showed that the two groups were strictly comparable. The K-GM group then received the same diet as the control group plus 5% K-GM. After a period of 12 - 14 weeks on the diets, the K-GM baboons had significantly higher fasting blood glucose and serum IRI values. The results of GTTs showed, however, that long-term feeding of K-GM improved glucose tolerance significantly and decreased the area under the IRI response. These long-term effects were more pronounced than the short-term effects. It is concluded that the long-term ingestion of K-GM per se has beneficial effects on glucose homeostasis in normal baboons and that the possible mechanisms by which these effects are established warrant further investigation.

An accurate temperature correction model for thermocouple hygrometers.

Numerous water relation studies have used thermocouple hygrometers routinely. However, the accurate temperature correction of hygrometer calibration curve slopes seems to have been largely neglected in both psychrometric and dewpoint techniques.In the case of thermocouple psychrometers, two temperature correction models are proposed, each based on measurement of the thermojunction radius and calculation of the theoretical voltage sensitivity to changes in water potential. The first model relies on calibration at a single temperature and the second at two temperatures. Both these models were more accurate than the temperature correction models currently in use for four psychrometers calibrated over a range of temperatures (15-38 degrees C). The model based on calibration at two temperatures is superior to that based on only one calibration.The model proposed for dewpoint hygrometers is similar to that for psychrometers. It is based on the theoretical voltage sensitivity to changes in water potential. Comparison with empirical data from three dewpoint hygrometers calibrated at four different temperatures indicates that these instruments need only be calibrated at, e.g. 25 degrees C, if the calibration slopes are corrected for temperature.

Salivary scanning in rheumatoid arthritis with sicca syndrome.

Forty-nine patients were studied prospectively by salivary scanning to assess the value of this investigation in possible Sjögren's syndrome (SS). Twenty-three had rheumatoid arthritis (RA) with sicca symptoms and a positive Schirmer's test. Fifteen had RA with no sicca symptoms and a negative Schirmer's test. Eleven had osteoarthrosis (OA) with no sicca symptoms and a negative Schirmer's test. Scanning differentiated only poorly between the three groups. We conclude that it has only limited application in the diagnosis of SS associated with RA.

Pseudomonas folliculitis associated with the use of health-spa whirlpools.

The occurrence of pustular folliculitis in eight people after the use of health-spa whirlpools is described for the first time in Australia. The lesions were discovered ad identified during the peak season in two resorts in the Snowy Mountains area near Jindabyne, New South Wales. Pseudomonas aeruginosa, identified as serotype 0:6, was isolated from pus swabs of the lesions, water in the spa pools and pool filters.

Intra-abdominal versus intramuscular application of two ampicillin preparations in cows.

Plasma ampicillin concentrations were determined in a cross-over trial involving five cows after single intramuscular or intra-abdominal administration of sodium ampicillin (10 mg/kg) and ampicillin anhydrate (40 mg/kg). After injection of sodium-ampicillin, high plasma concentrations were reached within 10 min; Cmax following intramuscular injection was 9.1 micrograms/ml and after intra-abdominal injection 7.5 micrograms/ml. Urine concentrations of ampicillin were low after 24 h (1-1.5 micrograms/ml). No significant changes in blood leucocyte numbers, plasma zinc, iron or fibrinogen levels occurred. After injection of ampicillin anhydrate 1 h elapsed before maximum plasma levels were obtained; Cmax was 5.4 micrograms/ml after intramuscular and 6.7 micrograms/ml after intra-abdominal administration. Urine concentrations were very high (238-303 micrograms/ml) after 24 h and stayed above 1 microgram/ml for 6 days. After administration of ampicillin anhydrate a significant increase in blood neutrophils (P less than 0.01) and a significant increase in plasma fibrinogen was measured after intramuscular and intra-abdominal injection (P less than 0.05). A significant decrease in plasma zinc concentration after intra-abdominal injection occurred (P less than 0.05). In abdominal surgery in cows in which contamination cannot be prevented, and practical objections inhibit preoperative administration, intramuscular or intra-abdominal administration during surgery of sodium ampicillin seems justified. Ampicillin anhydrate should not be used intra-abdominally.