The Observable Movement Quality scale for patients with low back pain (OMQ-LBP): validity and reliability in a primary care setting of physical therapy.

BACKGROUND: The Observable Movement Quality scale for patients with low back pain (OMQ-LBP) is a newly developed measurement instrument for use in primary care settings of physical and exercise therapists to assess movement quality (MQ) of patients with low back pain (LBP). OBJECTIVE: This study aims to determine validity, reliability and feasibility of the OMQ-LBP. The OMQ-LBP consists of a standardized movement circuit (performed twice) consisting of five daily activities problematic for LBP patients, which are scored with an 11-item observation list. METHODS: Construct validity was determined by testing seven hypotheses on associations between constructs (n = 85 patients with LBP) and four hypotheses on known group differences (n = 85 patients with LBP and n = 63 healthy controls; n = 35 matched participant-patients having VAS-pain ≥ 20 mm during and/or after both circuits and healthy controls). Internal consistency was analyzed with Cronbach's alpha (n = 85 patients with LBP). For inter- and intra-rater reliability Intraclass Correlation Coefficient (ICC) values were examined (n = 14 therapists: seven primary care physical therapists and seven exercise therapists). Additionally, content validity and feasibility were determined using thematic analysis of a brief interview with participants, patients (n = 38) and therapists (n = 14). RESULTS: After Bonferroni correction 2/7 associations between constructs and 2/4 significant group differences were confirmed. Cronbach's alpha was 0,79. The ICC-values of interrater reliability of the OMQ-LBP total score and the duration score were 0.56 and 0.99 and intra-rater reliability 0.82 and 0,93, respectively. Thematic analysis revealed five themes. Three themes elucidate that both patients and therapists perceived the content of the OMQ-LBP as valid. The fourth theme exhibits that OMQ-LBP provides a clear and unambiguous language for MQ in patients with LBP. Theme 5 depicts that the OMQ-LBP seems feasible, but video recording is time-consuming. CONCLUSIONS: The OMQ-LBP is a promising standardized observational assessment of MQ during the five most problematic daily activities in patients with LBP. It is expected that uniform and objective description and evaluation of MQ add value to clinical reasoning and facilitate uniform communication with patients and colleagues.

[Shared decision-making using outcome information: qualitative research among patients]. / Samen beslissen met ROM als informatiebron: kwalitatief onderzoek onder cliënten.

BACKGROUND: In the period 2019-2022, eight mental health care organizations have been working on the development and implementation of shared decision-making (SDM) using routine outcome monitoring (ROM) as a source of information. AIM: To obtain insight in needs and experiences of patients among SDM using ROM, and to investigate which implementation approach this requires. METHOD: Explorative, qualitative research consisting of semi-structured interviews and focusgroups with patients (n = 101) treated by mental health care organizations across the Netherlands. RESULTS: Patients reported SDM as important. Generic aspects (listening, trust, complete information and equal input) and customization (connecting to the need for help, and for every decision meta-communication about the roles of patients, relatives and clinicians and the way of giving information) were equally important. Patients valued ROM as source of information during SDM, providing that questionnaires are not too long, are related to the problems and results are discussed. CONCLUSION: SDM using ROM is as yet not widely implemented in mental health care. This requires continuous stimulation and evaluation. Implementation requires (re)training clinicians and supporting patients by relatives, peer experts and psycho-education. Patients appreciate ROM as an aid in SDM; access to their own ROM is helpful here.

Conversion of unresponsiveness to immune checkpoint inhibition by fecal microbiota transplantation in patients with metastatic melanoma: study protocol for a randomized phase Ib/IIa trial.

BACKGROUND: The gut microbiome plays an important role in immune modulation. Specifically, presence or absence of certain gut bacterial taxa has been associated with better antitumor immune responses. Furthermore, in trials using fecal microbiota transplantation (FMT) to treat melanoma patients unresponsive to immune checkpoint inhibitors (ICI), complete responses (CR), partial responses (PR), and durable stable disease (SD) have been observed. However, the underlying mechanism determining which patients will or will not respond and what the optimal FMT composition is, has not been fully elucidated, and a discrepancy in microbial taxa associated with clinical response has been observed between studies. Furthermore, it is unknown whether a change in the microbiome itself, irrespective of its origin, or FMT from ICI responding donors, is required for reversion of ICI-unresponsiveness. To address this, we will transfer microbiota of either ICI responder or nonresponder metastatic melanoma patients via FMT. METHODS: In this randomized, double-blinded phase Ib/IIa trial, 24 anti-PD1-refractory patients with advanced stage cutaneous melanoma will receive an FMT from either an ICI responding or nonresponding donor, while continuing anti-PD-1 treatment. Donors will be selected from patients with metastatic melanoma treated with anti-PD-1 therapy. Two patients with a good response (≥ 30% decrease according to RECIST 1.1 within the past 24 months) and two patients with progression (≥ 20% increase according to RECIST 1.1 within the past 3 months) will be selected as ICI responding or nonresponding donors, respectively. The primary endpoint is clinical benefit (SD, PR or CR) at 12 weeks, confirmed on a CT scan at 16 weeks. The secondary endpoint is safety, defined as the occurrence of grade ≥ 3 toxicity. Exploratory endpoints are progression-free survival and changes in the gut microbiome, metabolome, and immune cells. DISCUSSION: Transplanting fecal microbiota to restore the patients' perturbed microbiome has proven successful in several indications. However, less is known about the potential role of FMT to improve antitumor immune response. In this trial, we aim to investigate whether administration of FMT can reverse resistance to anti-PD-1 treatment in patients with advanced stage melanoma, and whether the ICI-responsiveness of the feces donor is associated with its effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05251389 (registered 22-Feb-2022). Protocol V4.0 (08-02-2022).

Age-related differences in self-reported disgust toward core disgust, sex-related, and food stimuli.

INTRODUCTION: While disgust is functional in preventing contagion from pathogens, it also plays a role in various psychopathologies. Disgust responses toward dirt, bodily secretions, certain types of food, and sexual stimuli typically emerge during (early) childhood. However, there is a lack of research on how disgust develops. This cross-sectional study investigated whether there are age-related differences in subjective, self-reported disgust between early and late adolescence and whether there are differences for distinctive types of disgust (core-disgust, sex-related, food-related). METHODS: Using an online survey, 240 Dutch children (116 female, 124 male) aged 9 through 16 years rated the extent to which they found the different types of stimuli disgusting or not on a VAS scale. RESULTS AND CONCLUSIONS: The results showed that only the disgust responses to sex-related stimuli decreased with age, whereas disgust toward the other categories did not show any age-related differences. Overall girls reported somewhat higher disgust ratings than boys for sex-related stimuli, but not for the other categories. The present study offers important new angles for future research, which might further disentangle the mechanisms through which the changes occur.

Treatment-related fertility impairment in long-term female childhood, adolescent and young adult cancer survivors: investigating dose-effect relationships in a European case-control study (PanCareLIFE).

STUDY QUESTION: Which chemotherapeutic agents and body site-specific radiation fields are dose-dependently associated with an increased risk of fertility impairment in long-term female childhood, adolescent and young adulthood (CAYA) cancer survivors? SUMMARY ANSWER: Busulfan, lower abdominal radiotherapy (RT) and total body irradiation (TBI) seem to be associated with fertility impairment at any dose, whereas gonadotoxicity of melphalan and procarbazine is suggested at medium/high (>140 mg/m2) or high dose (>5600 mg/m2) therapy, respectively. WHAT IS KNOWN ALREADY: Several treatment-related fertility deficits, as assessed by both self-reported outcomes and hormonal markers are known to occur following treatment of CAYA cancer. However, knowledge regarding precise dose-related estimates of these treatment-related risks are scarce. STUDY DESIGN, SIZE, DURATION: The current case-control study was nested within the PanCareLIFE cohort study. In total, 1332 CAYA survivors from 8 countries, 9 institutions and 11 cohorts, participated in and contributed data to the study. PARTICIPANTS/MATERIALS, SETTING, METHODS: All participants were female 5-year CAYA cancer survivors. In total, 450 cases (fertility impaired survivors) and 882 matched controls (not fertility impaired survivors) were included. Fertility impairment was defined using both questionnaire data (primary or secondary amenorrhea; use of artificial reproductive techniques; unfulfilled wish to conceive) and hormonal data (FSH and anti-Müllerian hormone (AMH)). Multivariable logistic regression models were used to investigate the effect of (i) alkylating agent exposure, and (ii) dose categories for individual chemotherapeutic agents and for RT-exposed body sites. MAIN RESULTS AND THE ROLE OF CHANCE: A positive dose-effect relationship between cyclophosphamide equivalent dose (CED) score and fertility impairment was found, with survivors with a CED score > 7121 mg/m2 being at a significantly increased risk of fertility impairment (odds ratio (95% CI) = 2.6 (1.9-3.6) P < 0.001). Moreover, cumulative dose variables of the following treatments were significantly associated with fertility impairment: busulfan, carmustine, cyclophosphamide, melphalan, procarbazine, lower abdominal RT and TBI. Busulfan, lower abdominal RT and TBI seem to be associated with fertility impairment at any dose, whereas gonadotoxicity of melphalan and procarbazine is suggested at medium/high (>140 mg/m2) or high dose (>5600 mg/m2) therapy, respectively. LIMITATIONS, REASONS FOR CAUTION: Our study may have been subject to selection bias since data from about half of the original base cohorts were available for the current study. This could impact the generalizability of our study results. WIDER IMPLICATIONS OF THE FINDINGS: We identified survivors at high risk for fertility impairment and, consequently, for a reduced or even absent reproductive life span. Both girls and young women who are about to start anti-cancer treatment, as well as adult female survivors, should be counselled about future parenthood and referred to a reproductive specialist for fertility preservation, if desired. STUDY FUNDING/COMPETING INTEREST(S): This study has received funding from the European Union's Seventh Framework Programme for research, technological development and demonstration under grant agreement no. 602030. There are no competing interests. TRIAL REGISTRATION NUMBER: n/a.

The D*Phase-study: study protocol for a pragmatic two-phased, randomised controlled (non-inferiority) trial that addresses treatment non-response and compares cognitive behavioural therapy and short-term psychodynamic supportive psychotherapy for major depression.

BACKGROUND: Several evidence-based psychotherapeutic treatment options are available for depression, but the treatment results could be improved. The D*Phase study directly compares short-term psychodynamic supportive psychotherapy (SPSP) and cognitive behavioural therapy (CBT) for Major Depressive Disorder (MDD). The objectives are 1. to investigate if, from a group level perspective, SPSP is not inferior to CBT in the treatment of major depressive disorder, 2. to build a model that may help predict the optimal type of treatment for a specific individual; and 3. to determine whether a change of therapist or a change of therapist and treatment method are effective strategies to deal with non-response. Furthermore (4.), the effect of the therapeutic alliance, treatment integrity and therapist allegiance on treatment outcome will be investigated. METHOD: In this pragmatic randomised controlled trial, 308 patients with a primary diagnosis of MDD are being recruited from a specialised mental health care institution in the Netherlands. In the first phase, patients are randomised 1:1 to either SPSP or CBT. In case of treatment non-response, a second phase follows in which non-responders from treatment phase one are randomised 1:1:1 to one of three groups: continuing the initial treatment with the same therapist, continuing the initial treatment with another therapist or continuing the other type of treatment with another therapist. In both treatment phases, patients are offered sixteen twice-weekly psychotherapy sessions. The primary outcome is an improvement in depressive symptoms. Process variables, working alliance and depressive symptoms, are frequently measured. Comprehensive assessments take place before the start of the first phase (at baseline), in week one, two and four during the treatment, and directly after the treatment (week eight). DISCUSSION: While the naturalistic setting of the study involves several challenges, we expect, by focusing on a large and diverse number of research variables, to generate important knowledge that may help enhance the effect of psychotherapeutic treatment for MDD. TRIAL REGISTRATION: The study was registered on 26 August 2016 with the Netherlands Trial Register, part of the Dutch Cochrane Centre (NL5753), https://www.trialregister.nl/trial/5753.

Validity of the Rotterdam Elderly Pain Observation Scale for institutionalised cognitively impaired Dutch adults.

BACKGROUND: The Rotterdam Elderly Pain Observation Scale (REPOS) has not yet been validated for institutionalised cognitively impaired adults. To fill this gap of knowledge, we tested psychometric properties of the REPOS when used for pain assessment in this population. METHODS: In this multicentre observational study, residents were filmed during a possibly painful moment and at rest. Healthcare professionals were asked to rate residents' pain by means of a Numeric Rating Scale (NRS)-proxy. Two researchers assessed pain with the REPOS and the Chronic Pain Scale for Non Verbal Adults with Intellectual Disabilities (CPS-NAID) from video-recordings. RESULTS: In total, 168 observations from 84 residents were assessed. Inter-observer reliability between the two researchers was good, with Cohen's kappa 0.72 [95% confidence interval (CI) 0.64 to 0.79]. Correlation between the REPOS and CPS-NAID for a possibly painful moment was 0.73 (95% CI 0.65 to 0.79). Sensitivity (85%) and specificity (61%) for the detection of pain were calculated with REPOS ≥ 3 and NRS ≥ 4 as a reference value. Item response theory analysis shows that the item grimace displayed perfect discrimination between residents with and without pain. CONCLUSION: The REPOS is a reliable and valid instrument to assess pain in cognitively impaired individuals.

Reproductive intentions and use of reproductive health care among female survivors of childhood cancer.

STUDY QUESTION: Do female childhood cancer survivors (CCSs) express a decreased desire to have children and do they use reproductive health care more often compared to women without a history of cancer? SUMMARY ANSWER: Overall, no difference was found in the desire to have children between CCSs and controls, whereas CCSs consult a fertility specialist more often, at a younger age, and sooner after their first attempt at conceiving. WHAT IS KNOWN ALREADY: Female CCSs may face a shorter than anticipated reproductive window as a result of their cancer treatment. Little is known about their desire to have children and use of reproductive health care, especially in relation to their former cancer treatment. STUDY DESIGN, SIZE, DURATION: This study is part of the DCOG LATER-VEVO study, a nationwide retrospective cohort study on female fertility in Dutch CCSs. In total, 1749 CCSs and 1673 controls were invited for the study. Data collection took place between January 2008 and May 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data on the desire to have children and use of reproductive health care were collected by questionnaire. The control group consisted of sisters from CCSs and females from the general population. In total, 1106 (63%) CCSs and 818 (49%) controls completed the questionnaire. MAIN RESULTS AND THE ROLE OF CHANCE: Overall, no difference was found in the desire to have children between CCSs and controls (86% and 89%, respectively). However, survivors of a CNS tumour were less likely to desire children and CCSs without biological children at time of study were more likely to report that their desire to have children was unfulfilled because of medical reasons (9%), compared to controls (1%). In total, 12% of CCSs ever consulted a fertility specialist compared to 10% of controls (OR = 1.7, 95% CI: 1.3-2.4). Mean (SD) age at time of their first visit was 27.7 (4.4) years for CCSs and 29.9 (3.9) years for controls (P < 0.01). In total, 43% of CCSs consulted a fertility specialist within 12 months after they had started trying to achieve a pregnancy, compared to 27% of controls. Risk factors for consulting a fertility specialist included a previous diagnosis of renal tumour, leukaemia, lymphoma or a CNS tumour, and treatment with alkylating chemotherapy, gonadotoxic radiotherapy or both. In total, 70% of CCSs reported a female factor as cause of subfertility compared to 34% of controls (OR = 4.5, 95% CI: 2.3-8.7) and in this specific group, CCSs seemed more likely to use fertility treatment (OR = 2.9, 95% CI: 1.0-8.2). LIMITATIONS, REASONS FOR CAUTION: Because of the low number of CCSs who used fertility treatment, we were not able to look at specific diagnoses and treatment types associated with using fertility treatment. Nevertheless, we were able to identify diagnostic- and treatment-related risk factors for consulting a fertility specialist. Details regarding consultations with a fertility specialist and fertility treatment were based on self-report and may therefore be subject to recall bias. WIDER IMPLICATIONS OF THE FINDINGS: Decisions about parenthood affect all CCSs. It's important to evaluate reproductive intentions and function timely after cancer treatment, so CCSs can be adequately counselled regarding family planning and fertility treatment. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by the Dutch Cancer Society (Grant no. VU 2006-3622) and the Children Cancer Free Foundation (Project no. 20). TRIAL REGISTRATION NUMBER: NTR2922.

Meta-analysis evaluating music interventions for anxiety and pain in surgery.

BACKGROUND: This study aimed to evaluate anxiety and pain following perioperative music interventions compared with control conditions in adult patients. METHODS: Eleven electronic databases were searched for full-text publications of RCTs investigating the effect of music interventions on anxiety and pain during invasive surgery published between 1 January 1980 and 20 October 2016. Results and data were double-screened and extracted independently. Random-effects meta-analysis was used to calculate effect sizes as standardized mean differences (MDs). Heterogeneity was investigated in subgroup analyses and metaregression analyses. The review was registered in the PROSPERO database as CRD42016024921. RESULTS: Ninety-two RCTs (7385 patients) were included in the systematic review, of which 81 were included in the meta-analysis. Music interventions significantly decreased anxiety (MD -0·69, 95 per cent c.i. -0·88 to -0·50; P < 0·001) and pain (MD -0·50, -0·66 to -0·34; P < 0·001) compared with controls, equivalent to a decrease of 21 mm for anxiety and 10 mm for pain on a 100-mm visual analogue scale. Changes in outcome corrected for baseline were even larger: MD -1·41 (-1·89 to -0·94; P < 0·001) for anxiety and -0·54 (-0·93 to -0·15; P = 0·006) for pain. Music interventions provided during general anaesthesia significantly decreased pain compared with that in controls (MD -0·41, -0·64 to -0·18; P < 0·001). Metaregression analysis found no significant association between the effect of music interventions and age, sex, choice and timing of music, and type of anaesthesia. Risk of bias in the studies was moderate to high. CONCLUSION: Music interventions significantly reduce anxiety and pain in adult surgical patients.

Is there an increased risk of cervical neoplasia in atopic dermatitis patients treated with oral immunosuppressive drugs?

BACKGROUND: Oral immunosuppressive drugs are frequently prescribed in young women with atopic dermatitis (AD). Immunocompromised patients may have a higher risk of developing high-risk HPV infections, cervical intra-epithelial neoplasia (CIN) and cervical carcinoma. Most literature on patients using oral immunosuppressive drugs is available in organ transplant patients. Literature on the risk of developing cervical carcinoma in AD patients treated with oral immunosuppressive drugs is lacking. At this moment, there is no clear guideline/consensus on this topic, but in daily practice, questions arise concerning whether this risk is increased and whether more intensive screening in women using immunosuppressive drugs should take place. OBJECTIVE: To investigate the occurrence of cervical carcinoma in women with AD treated with oral immunosuppressive drugs. METHODS: In this retrospective cohort study in two university medical centres in the Netherlands, all female adult AD patients receiving oral immunosuppressive drugs (cyclosporine A, azathioprine, methotrexate, mycophenolate mofetil, enteric-coated mycophenolate sodium and extended release tacrolimus) for more than 2 months between 1989 and 1 January 2014 were included. Patient files in the national histopathology register were screened for PAP3a, CIN I, CIN II, CIN III and cervical carcinoma. RESULTS: A total of 257 female AD patients with one or more treatment episodes from 1989 until 1 January 2014 were identified and included in this study. In 189 patients (73.5%), results of cervical examination were reported in the national histopathology database. Median total duration of treatment in these 189 women was 407.0 days (IQR 243.0-940.0). No cervical carcinoma during or following immunosuppressive therapy was found in our patient group. CONCLUSIONS: No intensified screening programme for cervical neoplasia seems necessary for women with AD using oral immunosuppressive drugs.

Sense and simplicity in HADDOCK scoring: Lessons from CASP-CAPRI round 1.

Our information-driven docking approach HADDOCK is a consistent top predictor and scorer since the start of its participation in the CAPRI community-wide experiment. This sustained performance is due, in part, to its ability to integrate experimental data and/or bioinformatics information into the modelling process, and also to the overall robustness of the scoring function used to assess and rank the predictions. In the CASP-CAPRI Round 1 scoring experiment we successfully selected acceptable/medium quality models for 18/14 of the 25 targets - a top-ranking performance among all scorers. Considering that for only 20 targets acceptable models were generated by the community, our effective success rate reaches as high as 90% (18/20). This was achieved using the standard HADDOCK scoring function, which, thirteen years after its original publication, still consists of a simple linear combination of intermolecular van der Waals and Coulomb electrostatics energies and an empirically derived desolvation energy term. Despite its simplicity, this scoring function makes sense from a physico-chemical perspective, encoding key aspects of biomolecular recognition. In addition to its success in the scoring experiment, the HADDOCK server takes the first place in the server prediction category, with 16 successful predictions. Much like our scoring protocol, because of the limited time per target, the predictions relied mainly on either an ab initio center-of-mass and symmetry restrained protocol, or on a template-based approach whenever applicable. These results underline the success of our simple but sensible prediction and scoring scheme. Proteins 2017; 85:417-423. © 2016 Wiley Periodicals, Inc.

Allo-HLA Cross-Reactivities of Cytomegalovirus-, Influenza-, and Varicella Zoster Virus-Specific Memory T Cells Are Shared by Different Healthy Individuals.

Virus-specific T cells can recognize allogeneic HLA (allo-HLA) through TCR cross-reactivity. The allospecificity often differs by individual (private cross-reactivity) but also can be shared by multiple individuals (public cross-reactivity); however, only a few examples of the latter have been described. Because these could facilitate alloreactivity prediction in transplantation, we aimed to identify novel public cross-reactivities of human virus-specific CD8+ T cells directed against allo-HLA by assessing their reactivity in mixed-lymphocyte reactions. Further characterization was done by studying TCR usage with primer-based DNA sequencing, cytokine production with ELISAs, and cytotoxicity with 51 chromium-release assays. We identified three novel public allo-HLA cross-reactivities of human virus-specific CD8+ T cells. CMV B35/IPS CD8+ T cells cross-reacted with HLA-B51 and/or HLA-B58/B57 (23% of tetramer-positive individuals), FLU A2/GIL (influenza IMP[58-66] HLA-A*02:01/GILGFVFTL) CD8+ T cells with HLA-B38 (90% of tetramer-positive individuals), and VZV A2/ALW (varicella zoster virus IE62[593-601] HLA-A*02:01/ALWALPHAA) CD8+ T cells with HLA-B55 (two unrelated individuals). Cross-reactivity was tested against different cell types including endothelial and epithelial cells. All cross-reactive T cells expressed a memory phenotype, emphasizing the importance for transplantation. We conclude that public allo-HLA cross-reactivity of virus-specific memory T cells is not uncommon and may create novel opportunities for alloreactivity prediction and risk estimation in transplantation.

Early Conversion to Prednisolone/Everolimus as an Alternative Weaning Regimen Associates With Beneficial Renal Transplant Histology and Function: The Randomized-Controlled MECANO Trial.

In renal transplantation, use of calcineurin inhibitors (CNIs) is associated with nephrotoxicity and immunosuppression with malignancies and infections. This trial aimed to minimize CNI exposure and total immunosuppression while maintaining efficacy. We performed a randomized controlled, open-label multicenter trial with early cyclosporine A (CsA) elimination. Patients started with basiliximab, prednisolone (P), mycophenolate sodium (MPS), and CsA. At 6 months, immunosuppression was tapered to P/CsA, P/MPS, or P/everolimus (EVL). Primary outcomes were renal fibrosis and inflammation. Secondary outcomes were estimated glomerular filtration rate (eGFR) and incidence of rejection at 24 months. The P/MPS arm was prematurely halted. The trial continued with P/CsA (N = 89) and P/EVL (N = 96). Interstitial fibrosis and inflammation were significantly decreased and the eGFR was significantly higher in the P/EVL arm. Cumulative rejection rates were 13% (P/EVL) and 19% (P/CsA), (p = 0.08). A post hoc analysis of HLA and donor-specific antibodies at 1 year after transplantation revealed no differences. An individualized immunosuppressive strategy of early CNI elimination to dual therapy with everolimus was associated with decreased allograft fibrosis, preserved allograft function, and good efficacy, but also with more serious adverse events and discontinuation. This can be a valuable alternative regimen in patients suffering from CNI toxicity.

Outcome of conservative and surgical treatment of pyogenic spondylodiscitis: a systematic literature review.

BACKGROUND: Spondylodiscitis is a spinal infection affecting primarily the intervertebral disk and the adjacent vertebral bodies. Currently many aspects of the treatment of pyogenic spondylodiscitis are still a matter of debate. PURPOSE: The aim of this study was to review the currently available literature systematically to determine the outcome of patients with pyogenic spondylodiscitis for conservative and surgical treatment strategies. METHODS: A systematic electronic search of MEDLINE, EMBASE, Cochrane Collaboration, and Web of Science regarding the treatment of pyogenic spondylodiscitis was performed. Included articles were assessed on risk of bias according the Cochrane Handbook for Systematic Reviews of Interventions, and the quality of evidence and strength of recommendation was evaluated according the GRADE approach. RESULTS: 25 studies were included. Five studies had a high or moderate quality of evidence. One RCT suggest that 6 weeks of antibiotic treatment of pyogenic spondylodiscitis results in a similar outcome when compared to longer treatment duration. However, microorganism-specific studies suggest that at least 8 weeks of treatment is required for S. aureus and 8 weeks of Daptomycin for MRSA. The articles that described the outcome of surgical treatment strategies show that a large variety of surgical techniques can successfully treat spondylodiscitis. No additional long-term beneficial effect of surgical treatment could be shown in the studies comparing surgical versus antibiotic only treatment. CONCLUSION: There is a strong level of recommendation for 6 weeks of antibiotic treatment in pyogenic spondylodiscitis although this has only been shown by one recent RCT. If surgical treatment is indicated, it has been suggested by two prospective studies with strong level of recommendation that an isolated anterior approach could result in a better clinical outcome.

Effectiveness of the implementation of guidelines for anxiety disorders in specialized mental health care.

OBJECTIVE: To examine the effect of implementing anxiety disorders guidelines on guideline adherence and patient outcomes in specialized mental health care. METHOD: A treatment setting in which guidelines were implemented (intervention condition) was compared with one in which guidelines were only disseminated (control condition). RESULTS: Of 61.7% of 81 intervention-condition patients received treatment according to the guidelines vs. 40.6% of 69 control-condition patients (P = 0.01). At 1-year follow-up, intervention-condition patients showed a greater decrease in anxiety symptoms (d = 0.48, P < 0.05); higher percentages of response (52.6% vs. 33.8%; P = 0.025) and remission (33.3% vs.16.9%; P = 0.026); and a greater decrease in the rate of phobic avoidance (d = 0.34, P < 0.05). At 2-year follow-up, control-condition patients had experienced a longer period of treatment, which had eroded most of these differences, except for phobic avoidance. CONCLUSION: Systematic guideline implementation results in earlier gains and shorter treatment times.

Extensive thoracolumbosacral vertebral osteomyelitis after Lemierre syndrome.

PURPOSE: To present a unique case of multilevel vertebral osteomyelitis after Lemierre syndrome. METHODS: A previously healthy 27-year-old man presented in the Emergency Department in septic shock because of Lemierre syndrome for which he was subsequently treated with intravenous benzylpenicillin for 2 months. Two and a half months later, the patient was readmitted with severe back pain without neurological deficits or fever. Imaging revealed an extensive vertebral osteomyelitis of the complete thoracic, lumbar and sacral spine. RESULTS: Although the blood cultures obtained at the initial admission for Lemierre syndrome revealed Fusobacterium species and Streptococcus milleri, the cultures from the spinal biopsies remained negative. Histology of the spinal biopsies showed a purulent sclerosing osteomyelitis. The patient was successfully treated with intravenous piperacillin and tazobactam. Despite persisting back pain, no recurrence of infection was seen at 3 years of follow-up. CONCLUSION: Lemierre syndrome and an extensive thoracolumbosacral vertebral osteomyelitis are rare but serious infections. Clinicians must maintain a high index of suspicion for infectious metastases leading to vertebral osteomyelitis when a patient presents with back pain after an episode of life-threatening septicaemia caused by Lemierre syndrome.

Childhood drowning in South Africa: local data should inform prevention strategies.

STUDY OBJECTIVE: Drowning is an important cause of childhood injury, however, little is known about drowning in Africa. The aim of this study is to investigate submersion incidents in Cape Town, South Africa and provide specific prognostic factors as well as to develop age-appropriate prevention strategies. METHODS: A retrospective chart review performed at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Patients admitted because of 'drowning' or 'near-drowning' between January 2007 and April 2013 were included. RESULTS: 75 children were included. 63 (84 %) survived without complications, 8 (10.7 %) died and 4 (5.3 %) had permanent neurological sequelae. The median age was 2.2 years (range 0.1-12.4). 46 (60.5 %) incidents happened in or around the home, only 14 (18.7 %) were witnessed. 42 (56 %) took place in a pool (29 private, 13 public). Significant predictors of the outcome were: estimated submersion time, duration of apnea, unresponsive and dilated pupils, intubation and use of inotropes. On arrival at the ER we found these significant predictors of the outcome: CPR, a GCS <5, hypothermia, bradycardia, asystole, as well as the PIM2-calculated mortality risk for patients admitted to the ICU. CONCLUSION: The majority of incidents were unwitnessed and occurred in or around the home. Prevention programs should be focused on adult supervision for younger children and creating awareness on the dangers of drowning in the home environment. While bathing in baths or buckets, children should never be left alone and parents should be made aware of the dangers. In our study, the majority of incidents occurred in swimming pools and limiting access to these could prevent many incidents of drowning among older children. Although children of all language groups are at risk for drowning, English- or Afrikaans-speaking children were particularly at risk for drowning in private pools while Xhosa-speaking children mostly drowned in baths or buckets. We also report multiple prognostic factors for the outcome, but none of them were absolute predictive of the outcome, indicating that each victim of submersion deserves full resuscitative treatment.

[Resolution of a treatment impasse by combining two Dutch laws regarding a patient with paranoid thoughts and a testicular cancer]. / Behandelimpasse bij een patiënt met paranoïde denkbeelden en een testis--carcinoom doorbroken door gecombi-neerde inzet WGBO én Wet Bopz.

Doctors dealing with patients who simultaneously have both psychiatric and somatic disorders often find themselves 'trapped' between two Dutch laws, the WBGO (the Law on the Medical Contract) and the Bopz (Law on Compulsory Admission to Psychiatric Hospitals). In order to illustrate a typical situation we present a case-study concerning a 50-year-old male with a probable seminoma testis and paranoid thoughts arising from an autistic disorder. The patient had refused the investigations and treatment that were considered necessary. His compulsory attendance at the Court of Law and the adoption, by the doctors, of a multidisciplinary approach led to a successful outcome and patient satisfaction. We hope that the new Involuntary Mental Health Care Act (WvGGZ) will bridge the current gap between WGBO and the Bopz.