[Should the psychiatrist of the future become a multi-specialist or a super-specialist?] / Wordt de psychiater van de toekomst een multispecialist of een superspecialist?

BACKGROUND: The subject of psychiatry is not easy to define and is characterised by considerable complexity of dysfunctional human behaviour. What does this mean for the training of psychiatrists? Is further differentiation with a strong specialisation from the start of the training process the only option to develop the discipline?
AIM: To formulate a strategic direction for the future training of psychiatrists in the Netherlands and Belgium.
METHOD: Personal reflection by two senior psychiatrists from the Netherlands and Belgium.
RESULTS: The profile of the psychiatrist of the future is that of a multi-specialist. It is desirable to keep the training programme broad and to develop sufficient competencies for young colleagues to enjoy throughout their careers: in addition to the clinical competencies in diagnostics and treatment, it concerns cooperation, communication, leadership (organisation), and professionalism. Psychotherapeutic skills are essential. Specialisation after the formal education is almost inevitable. Of the current focus areas (geriatric psychiatry, child and adolescent psychiatry and adult psychiatry), especially adult psychiatry should be further differentiated. The professional associations should facilitate the transfer from one sub-area to another sub-area without extensive administrative work. The enthusiasm of medical students for psychiatry should be actively stimulated, based on a new professional profile.
CONCLUSION: Throughout the entire program (4 years in the Netherlands, 5 years in Belgium) learning general competencies (truncus communis) must be advocated. These competencies must form the basis for a deepening or specialisation after the training. This should ensure that psychiatrists can move relatively smoothly from one sub-area to another. The psychiatrist as a multi-specialist.

[The future of psychiatry and the psychiatrist of the future]. / De toekomst van de psychiatrie en de psychiater van de toekomst.

BACKGROUND: The training curriculum of the psychiatrist needs to be reviewed. To determine the model of the future psychiatrist, the question of how the future psychiatry will look needs to be answered first.
AIM: Assessment of relevant developments in psychiatry and the organisation of psychiatric care with the aim to propose a profile of the future psychiatrist.
METHOD: The recent history of psychiatry as a starting point for a vision of the future.
RESULTS: 1. Psychiatry must use an integrative anthropological theory, in order to be able to understand psychopathology in its essence. 2. Content-driven moral leadership is necessary to prevent psychiatry being tempted by hypes. 3. The tacit social contract between the medical profession and society is under pressure; both parties distrust each other and psychiatrists must regain trust and renew the contract. 4. Psychiatric care must remain affordable, which means a review of the current organisation of care; psychiatry will become network psychiatry. 5. Psychiatrists will work in a network of care providers and the patient will be in control. The psychiatrist will have a flexible role, ranging from managerial to supportive and advisory. Keeping psychotherapeutic skills up-to-date is an essential requirement. 6. Future training should focus on the sustainable employability of the psychiatrist as a human being, on knowledge of history of psychiatry and its socio-economic context, and policy and engagement; and on the skill of conceptual thinking (philosophy).
CONCLUSION: The profession of psychiatry needs a new job profile. The process of development and elaboration should contain the following core elements: broad education, conceptual skills, sensitivity for activism, social involvement, and expertise in treatment of patients with complex problems in diverse settings.

[Differences in non-native resident psychiatrists and native residents psychiatrists in completion of the psychiatry residency training programmes]. / Verschil in uitval tussen allochtone en autochtone artsen in opleiding tot psychiater; enquête onder opleiders.

BACKGROUND: A relatively small number of psychiatrists in the Netherlands have a non-Dutch origin. We suspect that resident psychiatrists who do not have Dutch as their first language are less likely than native Dutch speakers to complete the psychiatry residency training programmes.
AIM: To find out how often and for what reasons resident psychiatrists do not complete the psychiatry residency training programmes.
METHOD: All course coordinators in the Netherlands were asked to participate in a survey to provide information about the residents who had started but had abandoned the psychiatry residency training programmes between the years 2008 and 2015. They were also asked about factors that had influenced residents to abandon the course.
RESULTS: We were able to obtain data on 37% of the trainees. The data revealed that the number of non-native resident psychiatrists who failed to complete the training course was almost four times higher than the number of native trainee psychiatrists who dropped out before the end of the course. According to the coordinators, possible reasons for this discrepancy are lack of proficiency in Dutch, communication problems and cultural differences.
CONCLUSION: The results of our survey could possibly be used to adjust the training programmes.

Endometrial scratching in women with implantation failure after a first IVF/ICSI cycle; does it lead to a higher live birth rate? The SCRaTCH study: a randomized controlled trial (NTR 5342).

BACKGROUND: Success rates of assisted reproductive techniques (ART) are approximately 30%, with the most important limiting factor being embryo implantation. Mechanical endometrial injury, also called 'scratching', has been proposed to positively affect the chance of implantation after embryo transfer, but the currently available evidence is not yet conclusive. The primary aim of this study is to determine the effect of endometrial scratching prior to a second fresh in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycle on live birth rates in women with a failed first IVF/ICSI cycle. METHOD: Multicenter randomized controlled trial in Dutch academic and non-academic hospitals. A total of 900 women will be included of whom half will undergo an endometrial scratch in the luteal phase of the cycle prior to controlled ovarian hyperstimulation using an endometrial biopsy catheter. The primary endpoint is the live birth rate after the 2nd fresh IVF/ICSI cycle. Secondary endpoints are costs, cumulative live birth rate (after the full 2nd IVF/ICSI cycle and over 12 months of follow-up); clinical and ongoing pregnancy rate; multiple pregnancy rate; miscarriage rate and endometrial tissue parameters associated with implantation failure. DISCUSSION: Multiple studies have been performed to investigate the effect of endometrial scratching on live birth rates in women undergoing IVF/ICSI cycles. Due to heterogeneity in both the method and population being scratched, it remains unclear which group of women will benefit from the procedure. The SCRaTCH trial proposed here aims to investigate the effect of endometrial scratching prior to controlled ovarian hyperstimulation in a large group of women undergoing a second IVF/ICSI cycle. TRIAL REGISTRATION: NTR 5342 , registered July 31st, 2015. PROTOCOL VERSION: Version 4.10, January 4th, 2017.

Exposure assessment of cattle via roughages to plants producing compounds of concern.

Food producing animals are exposed to biologically active plant compounds through feed and roughages, presenting a potential risk to the animal but also consumers of food of animal origin. To evaluate to which plant compounds of concern dairy cows in the Netherlands are exposed, a ranking filter model was developed, combining information on abundance of plant species in vegetation plots in the Netherlands (183,905 plots of three different vegetation types) with plant-compound combinations (700), and with consumption data of fresh grass, grass silage and corn silage by cattle. The most abundant plant genera are those producing cyanogenic glycosides, coumarins and benzofuranocoumarins, being predominantly fodder plants (alfalfa, clover and some grasses) considered to be safe. Highest exposures were estimated for plant genera producing piperidine alkaloids (horsetail), furanocoumarins (parsley and relatives), pyrrolizidine alkaloids (Symphytum, Senecio, Leucanthemum, Eupatorium) and essential oils. The current results allow to prioritise future scientific research on these compounds.

Antioxidants as a treatment for acute pancreatitis: A meta-analysis.

OBJECTIVE: To assess the efficacy of antioxidants in acute (AP) pancreatitis. METHODS: We searched PubMed, Embase and the Cochrane library for all randomized controlled trials (RCT) involving administration of antioxidants in the therapy of AP until February 2012. AP studies were pooled to analyze the effect of antioxidants on hospital stay, mortality, and complications. Subgroup analyses were performed on the use of the antioxidant glutamine. RESULTS: In total, eleven RCTs were included. Among patients with AP, antioxidant therapy resulted in a borderline significant reduction in hospital stay (mean difference -1.74; 95%CI -3.56 to 0.08), a significant decrease in complications (RR 0.66; 95%CI 0.46-0.95) and a non-significant decrease in mortality rate (RR 0.66; 95%CI 0.30-1.46). Subgroup analyses showed that glutamine significantly reduced complications (RR 0.51; 95%CI 0.34-0.78) and mortality rate (RR 0.33; 95%CI 0.13-0.85). CONCLUSION: The present meta-analysis shows a possible benefit of glutamine supplementation in patients with acute pancreatitis. However, large randomized trials are needed to confirm these observations.

Sperm aneuploidy in infertile male patients: a systematic review of the literature.

Males with abnormal karyotypes and subgroups of fertile and infertile males with normal karyotypes may be at risk of producing unbalanced or aneuploid spermatozoa. Biological, clinical, environmental and other factors may also cause additional sperm aneuploidy. However, increased risk of sperm aneuploidy is directly related to chromosomally abnormal embryo production and hence to poor reproductive potential. This systemic literature review focuses on the identification of these males because this is an essential step in the context of assisted reproduction. This research may allow for a more personalised and, hence, more accurate estimation of the risk involved in each case, which in turn will aid genetic counselling for affected couples and help with informed decision-making.

[Short-term dialectical behaviour therapy for borderline personality disorder]. / Kortdurende klinische dialectische gedragstherapie voor de borderlinepersoonlijkheidsstoornis: ontwerp van programma en resultaten pilotstudie.

BACKGROUND: Outpatient dialectical behaviour therapy (DBT) reduces severe suicidal and self-injurious behaviour in patients with borderline personality disorder. The Jelgersma center for personality disorders has developed an intensive inpatient dbt programme that lasts for 14 weeks and is designed to achieve a faster reduction in these borderline symptoms. AIM: To examine the effect of the Jelgersma programme by means of a pilot study in order to prepare a randomised clinical trial in which a short intensive course of DBT will be compared with standard outpatient DBT. METHOD: We compared the starting data and the final data for 39 female patients with borderline problems (DBT). We participated in 3½-month-long inpatient DBT programme. The collected data referred to (para)suicidal behaviour, drop-out, severity of borderline problems and the quality of life. RESULTS: The severity of borderline problems, particularly in the field of interpersonal problems, was significantly reduced. There was no significant reduction in (para) suicidal behaviours. The drop-out percentage was higher than in comparable studies. CONCLUSION: Short-term inpatient DBT had a positive effect on borderline problems. (Para)suicidal behaviour, however, was not reduced significantly. The randomised trial that began in 2012 should reveal whether the use of short-term inpatient DBT can lead to a faster decline of suicidal and self-injurious behaviour than does standard outpatient DBT.

Cryopreservation of human sperm: efficacy and use of a new nitrogen-free controlled rate freezer versus liquid nitrogen vapour freezing.

Preservation of spermatozoa is an important aspect of assisted reproductive medicine. The aim of this study was to investigate the efficacy and use of a recently developed liquid nitrogen and cryogen-free controlled rate freezer and this compared with the classical liquid nitrogen vapour freezing method for the cryopreservation of human spermatozoa. Ten patients entering the IVF programme donated semen samples for the study. Samples were analysed according to the World Health Organization guidelines. No significant difference in total sperm motility after freeze-thawing between the new technique and classical technique was demonstrated. The advantage of the new freezing technique is that it uses no liquid nitrogen during the freezing process, hence being safer to use and clean room compatible. Investment costs are higher for the apparatus but running costs are only 1% in comparison with classical liquid nitrogen freezing. In conclusion, post-thaw motility of samples frozen with the classical liquid nitrogen vapour technique was comparable with samples frozen with the new nitrogen-free freezing technique. This latter technique can thus be a very useful asset to the sperm cryopreservation laboratory.

Correlation between male age, WHO sperm parameters, DNA fragmentation, chromatin packaging and outcome in assisted reproduction technology.

In the human, male ageing results in reproductive hormonal and cellular changes that can influence semen quality (volume, motility, concentration and morphology) and ultimately result in a reduced fertilising capacity and a longer 'time to pregnancy' for ageing men as well as an increased risk for miscarriage. This prospective cohort study of 278 patients undergoing a first in vitro fertilisation or intracytoplasmic sperm injection treatment was undertaken to examine whether patient's age was reflected in sperm motility, concentration, morphology as well as in DNA fragmentation (DFI) and immature chromatin (unprocessed nuclear proteins and/or poorly condensed chromatin) as measured by the sperm chromatin structure assay. This study also investigated the possible influence of male age (after correcting for female age) on their fertilising capacity, on obtaining a pregnancy and a healthy baby at home. Logistic regression analysis did not reveal any male age-related influences on sperm parameters like concentration, motility or morphology. No significant male age-related increase in DFI or immature chromatin was demonstrable for these patients. Elevated male age, after correcting for female age, was not related to lower fertilisation rates or significant decreases in the chance for a healthy baby at home.

Statistical flaws in design and analysis of fertility treatment -studies on cryopreservation raise doubts on the conclusions.

Decisions about pharmacotherapy are being taken by medical doctors and authorities based on comparative studies on the use of medications. In studies on fertility treatments in particular, the methodological quality is of utmost -importance in the application of evidence-based medicine and systematic reviews. Nevertheless, flaws and omissions appear quite regularly in these types of studies. Current study aims to present an overview of some of the typical statistical flaws, illustrated by a number of example studies which have been published in peer reviewed journals. Based on an investigation of eleven studies at random selected on fertility treatments with cryopreservation, it appeared that the methodological quality of these studies often did not fulfil the -required statistical criteria. The following statistical flaws were identified: flaws in study design, patient selection, and units of analysis or in the definition of the primary endpoints. Other errors could be found in p-value and power calculations or in critical p-value definitions. Proper -interpretation of the results and/or use of these study results in a meta analysis should therefore be conducted with care.

Cross-border reproductive care in Belgium.

BACKGROUND: Cross-border reproductive care indicates the cross-border movements made by patients to obtain infertility treatment they cannot obtain at home. The problem at present is that empirical data on the extent of the phenomenon are lacking. This article presents the data on infertility patients going to Belgium for treatment. METHODS: A survey was conducted among the centres for reproductive medicine that are allowed to handle oocytes and create embryos (B-centres). Data were collected on the nationality of patients and the type of treatment for which they attended during the period 2000-2007. RESULTS: Sixteen of 18 centres responded to the questionnaire. The flow of foreign patients has stabilized since 2006 at approximately 2100 patients per year. The majority of foreign nationals seeking treatment in Belgium were French women for sperm donation. The next highest group was patients entering the country to obtain ICSI with ejaculated sperm. CONCLUSIONS: There are clear indications that numerous movements are motivated by the wish to evade legal restrictions in one's home country, either because the technology is prohibited or because the patients have characteristics, which exclude them from treatment in their own countries.

Decoupling the cortical power spectrum reveals real-time representation of individual finger movements in humans.

During active movement the electric potentials measured from the surface of the motor cortex exhibit consistent modulation, revealing two distinguishable processes in the power spectrum. At frequencies <40 Hz, narrow-band power decreases occur with movement over widely distributed cortical areas, while at higher frequencies there are spatially more focal power increases. These high-frequency changes have commonly been assumed to reflect synchronous rhythms, analogous to lower-frequency phenomena, but it has recently been proposed that they reflect a broad-band spectral change across the entire spectrum, which could be obscured by synchronous rhythms at low frequencies. In 10 human subjects performing a finger movement task, we demonstrate that a principal component type of decomposition can naively separate low-frequency narrow-band rhythms from an asynchronous, broad-spectral, change at all frequencies between 5 and 200 Hz. This broad-spectral change exhibited spatially discrete representation for individual fingers and reproduced the temporal movement trajectories of different individual fingers.

In search for the general population's semen profile: the study of sperm parameters in partners of women with chronic anovulation.

BACKGROUND: Human fertility is linked to sperm quality and therefore the establishment of reference values for normality is mandatory. AIMS: The first aim was to establish a reference profile of men in the general population by examining the semen of partners of women with chronic anovulation. The second aim was to determine the prevalence of sperm abnormalities in this patient group. METHODS: Sperm samples of 304 partners of patients with chronic anovulation were analysed prospectively. Semen samples were examined according to WHO guidelines, for sperm morphology Tygerberg strict criteria were used. We compared the results of this study with the cut-off values for normality we obtained in a previous study performed in our centre. RESULTS: The mean value was 3.1 ml for volume, 64.7 mill / ml for concentration, 51.9% for progressive motility (grade a + b motility) and 7.4% for sperm morphology. Single parameter and double parameter abnormalities were observed in 42.7% and 8.2% of cases respectively. A normal sperm sample for all three parameters was noted in 46% of cases. Oligo-Astheno-Teratozoospermia was present in 3.0% of cases while azoospermia was found in two patients (0.7%). CONCLUSION: We believe that the study of sperm parameters in partners of patients with chronic anovulation can be used to study the prevalence of sperm abnormalities in the general population. Our data show that semen abnormalities are not uncommon in partners of women with chronic anovulation, highlighting the importance of a semen examination in every infertility work-up, even in case of obvious female pathology.

Early interactions between neuronal adaptation and voluntary control determine perceptual choices in bistable vision.

At the onset of bistable stimuli, the brain needs to choose which of the competing perceptual interpretations will first reach awareness. Stimulus manipulations and cognitive control both influence this choice process, but the underlying mechanisms and interactions remain poorly understood. Using intermittent presentation of bistable visual stimuli, we demonstrate that short interruptions cause perceptual reversals upon the next presentation, whereas longer interstimulus intervals stabilize the percept. Top-down voluntary control biases this process but does not override the timing dependencies. Extending a recently introduced low-level neural model, we demonstrate that percept-choice dynamics in bistable vision can be fully understood with interactions in early neural processing stages. Our model includes adaptive neural processing preceding a rivalry resolution stage with cross-inhibition, adaptation, and an interaction of the adaptation levels with a neural baseline. Most importantly, our findings suggest that top-down attentional control over bistable stimuli interacts with low-level mechanisms at early levels of sensory processing before perceptual conflicts are resolved and perceptual choices about bistable stimuli are made.

Percept-choice sequences driven by interrupted ambiguous stimuli: a low-level neural model.

Existing neural explanations of spontaneous percept switching under steady viewing of an ambiguous stimulus do not fit the fact that stimulus interruptions cause the same percept to reappear across many ON/OFF cycles. We present a simple neural model that explains the observed behavior and predicts several more complicated percept sequences, without invoking any "high-level" decision making or memory. Percept choice at stimulus onset, which differs fundamentally from standard percept switching, depends crucially on a hitherto neglected interaction between local "shunting" adaptation and a near-threshold neural baseline. Stimulus ON/OFF timing then controls the generation of repeating, alternating, or more complex choice sequences. Our model also explains "priming" versus "habituation" effects on percept choice, reinterprets recent neurophysiological data, and predicts the emergence of hysteresis at the level of percept sequences, with occasional noise-induced sequence "hopping."

Effect of a columnar defect on the shape of slow-combustion fronts.

We report experimental results for the behavior of slow-combustion fronts in the presence of a columnar defect with enhanced or reduced driving, and compare them with those of mean-field theory. We also compare them with simulation results for an analogous problem of driven flow of particles with hard-core repulsion (ASEP) and a single defect bond with a different hopping probability. The difference in the shape of the front profiles for enhanced vs reduced driving in the defect clearly demonstrates the existence of a Kardar-Parisi-Zhang-type nonlinear term in the effective evolution equation for the slow-combustion fronts. We also find that slow-combustion fronts display a faceted form for large enough enhanced driving, and that there is a corresponding increase then in the average front speed. This increase in the average front speed disappears at a nonzero enhanced driving in agreement with the simulated behavior of the ASEP model.

Anomalous roughness, localization, and globally constrained random walks.

The scaling properties of a random walker subject to the global constraint that it needs to visit each site an even number of times are determined. Such walks are realized in the equilibrium state of one-dimensional surfaces that are subject to dissociative-dimer-type surface dynamics. Moreover, they can be mapped onto unconstrained random walks on a random surface, and the latter corresponds to a non-Hermitian random free fermion model that describes electron localization near a band edge. We show analytically that the dynamic exponent of this random walk is z=d+2 in spatial dimension d. This explains the anomalous roughness, with exponent alpha=1/3, in one-dimensional equilibrium surfaces with dissociative-dimer-type dynamics.