Increased sodium intake and decreased sodium excretion in ICU-acquired hypernatremia: A prospective cohort study.

PURPOSE: To provide more in-depth insight in the development of early ICU-acquired hypernatremia in critically ill patients based on detailed, longitudinal and quantitative data. MATERIALS AND METHODS: A comparative analysis was performed using prospectively collected data of ICU patients. All patients requiring ICU admission for more than 48 h between April and December 2018 were included. For this study, urine samples were collected daily and analyzed for electrolytes and osmolality. Additionally, plasma osmolality analyses were performed. Further data collection consisted of routine laboratory results, detailed fluid balances and medication use. RESULTS: A total of 183 patient were included for analysis, of whom 38% developed ICU-acquired hypernatremia. Whereas the hypernatremic group was similar to the non-hypernatremic group at baseline and during the first days, hypernatremic patients had a significantly higher sodium intake on day 2 to 5, a lower urine sodium concentration on day 3 and 4 and a worse kidney function (plasma creatinine 251 versus 71.9 µmol/L on day 5). Additionally, hypernatremic patients had higher APACHE IV scores (67 versus 49, p < 0.05) and higher ICU (23 versus 12%, p = 0.07) and 90-day mortality (33 versus 14%, p < 0.01). CONCLUSIONS: Longitudinal analysis shows that the development of early ICU-acquired hypernatremia is preceded by increased sodium intake, decreased renal function and decreased sodium excretion.

[Intoxicated women: A study into gender differences in substance abuse in forensic psychiatric patients]. / Vrouwen onder invloed: een studie naar genderverschillen in middelengebruik bij forensisch psychiatrische patiënten.

BACKGROUND: Substance abuse is an important risk factor for (violent) offending, but is mostly studied in male populations. More knowledge about women is needed.
AIM: To gain insight into possible gender differences in substance abuse and offending in forensic psychiatric patients.
METHOD: Files were analysed of 275 women and 275 men who have been admitted between 1984 and 2014 to one of four Dutch forensic psychiatric facilities and related to incidents of violence during treatment or recidivism after discharge (for 78 women).
RESULTS: Although substance abuse was common in women (57%), it was significantly more prevalent in men (68%). Men were more often diagnosed with substance dependency and more often committed the index-offense whilst intoxicated. Predictive accuracy for violent incidents during treatment was better for men. Both women and men with substance abuse had significantly more historical risk factors compared to those without substance abuse. A history of substance abuse was not a significant predictor for recidivism after discharge in women.
CONCLUSION: There are gender differences in substance abuse and the relationship with offending was stronger for men. These differences may have implications for substance use treatment in forensic mental health services.

Cerebral autoregulatory performance and the cerebrovascular response to head-of-bed positioning in acute ischaemic stroke.

BACKGROUND AND PURPOSE: Cerebrovascular responses to head-of-bed positioning in patients with acute ischaemic stroke are heterogeneous, questioning the applicability of general recommendations on head positioning. Cerebral autoregulation is impaired to various extents after acute stroke, although it is unknown whether this affects cerebral perfusion during posture change. We aimed to elucidate whether the cerebrovascular response to head position manipulation depends on autoregulatory performance in patients with ischaemic stroke. METHODS: The responses of bilateral transcranial Doppler ultrasound-determined cerebral blood flow velocity (CBFV) and local cerebral blood volume (CBV), assessed by near-infrared spectroscopy of total hemoglobin tissue concentration ([total Hb]), to head-of-bed lowering from 30° to 0° were determined in 39 patients with acute ischaemic stroke and 17 reference subjects from two centers. Cerebrovascular autoregulatory performance was expressed as the phase difference of the arterial pressure-to-CBFV transfer function. RESULTS: Following head-of-bed lowering, CBV increased in the reference subjects only ([total Hb]: + 2.1 ± 2.0 vs. + 0.4 ± 2.6 µM; P < 0.05), whereas CBFV did not change in either group. CBV increased upon head-of-bed lowering in the hemispheres of patients with autoregulatory performance <50th percentile compared with a decrease in the hemispheres of patients with better autoregulatory performance ([total Hb]: +1.0 ± 1.3 vs. -0.5 ± 1.0 µM; P < 0.05). The CBV response was inversely related to autoregulatory performance (r = -0.68; P < 0.001) in the patients, whereas no such relation was observed for CBFV. CONCLUSION: This study is the first to provide evidence that cerebral autoregulatory performance in patients with acute ischaemic stroke affects the cerebrovascular response to changes in the position of the head.

European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology.

BACKGROUND AND PURPOSE: Current guidelines on cerebral venous thrombosis (CVT) diagnosis and management were issued by the European Federation of Neurological Societies in 2010. We aimed to update the previous European Federation of Neurological Societies guidelines using a clearer and evidence-based methodology. METHOD: We followed the Grading of Recommendations, Assessment, Development and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews and writing recommendations based on the quality of available scientific evidence. RESULTS: We suggest using magnetic resonance or computed tomographic angiography for confirming the diagnosis of CVT and not routinely screening patients with CVT for thrombophilia or cancer. We recommend parenteral anticoagulation in acute CVT and decompressive surgery to prevent death due to brain herniation. We suggest preferentially using low-molecular-weight heparin in the acute phase and not direct oral anticoagulants. We suggest not using steroids and acetazolamide to reduce death or dependency. We suggest using antiepileptics in patients with an early seizure and supratentorial lesions to prevent further early seizures. We could not make recommendations concerning duration of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest that, in women who have suffered a previous CVT, contraceptives containing oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but use of prophylactic low-molecular-weight heparin should be considered throughout pregnancy and puerperium. CONCLUSIONS: Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of CVT.

Plant-mediated interactions between two herbivores differentially affect a subsequently arriving third herbivore in populations of wild cabbage.

Plants are part of biodiverse communities and frequently suffer from attack by multiple herbivorous insects. Plant responses to these herbivores are specific for insect feeding guilds: aphids and caterpillars induce different plant phenotypes. Moreover, plants respond differentially to single or dual herbivory, which may cascade into a chain of interactions in terms of resistance to other community members. Whether differential responses to single or dual herbivory have consequences for plant resistance to yet a third herbivore is unknown. We assessed the effects of single or dual herbivory by Brevicoryne brassicae aphids and/or Plutella xylostella caterpillars on resistance of plants from three natural populations of wild cabbage to feeding by caterpillars of Mamestra brassicae. We measured plant gene expression and phytohormone concentrations to illustrate mechanisms involved in induced responses. Performance of both B. brassicae and P. xylostella was reduced when feeding simultaneously with the other herbivore, compared to feeding alone. Gene expression and phytohormone concentrations in plants exposed to dual herbivory were different from those found in plants exposed to herbivory by either insect alone. Plants previously induced by both P. xylostella and B. brassicae negatively affected growth of the subsequently arriving M. brassicae. Furthermore, induced responses varied between wild cabbage populations. Feeding by multiple herbivores differentially activates plant defences, which has plant-mediated negative consequences for a subsequently arriving herbivore. Plant population-specific responses suggest that plant populations adapt to the specific communities of insect herbivores. Our study contributes to the understanding of plant defence plasticity in response to multiple insect attacks.

[Violent women: a multicentre study of the characteristics of female forensic psychiatric patients]. / Gewelddadige vrouwen: een multi-centeronderzoek naar kenmerken van vrouwelijke forensisch psychiatrische patiënten.

BACKGROUND: Violence perpetrated by women has attracted more and more attention in the past few years. However, there is lack of background information about women admitted to forensic psychiatric hospitals and about risk factors for recidivism. AIM: To conduct a multicenter study which will give more insight into female psychiatric patients and which will probably have implications for psychodiagnostics, risk assessment and treatment in (forensic) psychiatric settings. METHOD: We coded the files of 297 women who, between 1984 and 2013, had been admitted to one of four Dutch forensic psychiatric facilities by reason of violent delinquent behaviour. We used an extensive coding list and several risk assessment tools including the recently developed Female Additional Manual (fam) for women. RESULTS: The general picture that emerged was one of severely traumatised women with complex pathology and a high level of comorbidity. Many of the women had experienced previous treatment failures and had caused many incidents during treatment. CONCLUSION: Female forensic psychiatric patients are a complex group that deserves more specific attention. Attention for traumas from the past, intensive supervision in relationships and training for staff in dealing with, for instance, manipulative behaviour are the most important implications from this study.

Advances in the treatment of cerebral venous thrombosis.

OPINION STATEMENT: Patients with recent cerebral venous sinus thrombosis (CVT) should be fully anticoagulated with heparin as soon as the diagnosis is confirmed, even in the presence of cerebral hemorrhagic venous infarcts. Fixed-dose subcutaneous low-molecular-weight heparins (LMWH) in therapeutic dosage have a better safety profile and are probably more effective than dose-adjusted intravenous unfractionated heparin. After the patient is stabilized , oral anticoagulant treatment is started, aimed at an INR value between 2.0 and 3.0 for at least three months after the acute phase. Since about 40 % of patients with CVT have epileptic seizures at onset or during the first days, many require treatment with anti-epileptics. Prophylactic anti-epileptic treatment is an option, but its efficacy has not been investigated. If no new seizures occur after the acute phase, anti-epileptics can be tapered after three to six months. The efficacy of endovascular treatment, with mechanical and/or pharmacologic thrombolysis, has only been published in small case series, and cannot be regarded as proven effective treatment for CVT. Its theoretical advantage of more rapid clearance of thrombi may be offset by severe bleeding complications, and the limited availability and higher cost of the procedure. Patients who deteriorate because of large space-occupying venous infarcts have a high risk of dying from cerebral herniation. In such cases an emergent decompressive hemicraniectomy is often life-saving. Experience from different centers with this procedure shows a good clinical outcome in the majority of these patients. Patients with CVT may develop - and sometimes present with - chronic intracranial hypertension with headache and papilledema. In such patients the priority is prevention of visual function loss; intracranial hypertension should be controlled with acetazolamide, and occasionally with repeated lumbar punctures if vision is threatened. Refractory cases will need a CSF shunting procedure.

Shunting in acute cerebral venous thrombosis: a systematic review.

BACKGROUND AND PURPOSE: The efficacy of cerebrospinal fluid shunting to reduce intracranial hypertension and prevent fatal brain herniation in acute cerebral venous thrombosis (CVT) is unknown. METHOD: From the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) and a systematic literature review, we retrieved acute CVT patients treated only with shunting (external ventricular drain, ventriculoperitoneal or ventriculojugular shunt). Outcome was classified at 6 months and final follow-up by the modified Rankin Scale (mRS). RESULTS: 15 patients were collected (9 from the ISCVT and 6 from the review) who were treated with a shunt (external ventricular drain in 6 patients, a ventriculoperitoneal shunt in 8 patients or an unspecified type of shunt in another one). Eight patients (53.3%) regained independence (mRS 0-2), while 2 patients (13.3%) were left with a severe handicap (mRS 4-6) and 4 (26.7%) died despite treatment. Five patients with parenchymal lesions were shunted within 48 h from admission deterioration, 4 with an external ventricular drain: 2 (40%) recovered to independence, 2 (40%) had a severe handicap and 1 (20%) died. In contrast, all 3 patients with intracranial hypertension and no parenchymal lesions receiving a ventriculoperitoneal shunt later than 48 h regained independence. CONCLUSION AND IMPLICATIONS: A quarter of acute CVT patients treated with a shunt died, and only half regained independence. With the limitation of the small number of subjects, this review suggests that shunting does not appear to be effective in preventing death from brain herniation in acute CVT. We cannot exclude that shunting may benefit patients with sustained intracranial hypertension and no parenchymal lesions.

Safety of lumbar puncture in patients with cerebral venous thrombosis.

BACKGROUND AND PURPOSE: Lumbar puncture (LP) may precipitate cerebral venous thrombosis (CVT), but it is unclear if LP is deleterious in patients with CVT. We aimed to assess the safety of LP in the International Study on Cerebral Veins and Dural Sinus Thrombosis prospective cohort. METHODS: In 624 patients with CVT, we compared the prognosis of patients submitted or not to LP. The primary outcome was 'death or dependency at 6 months', as evaluated by the modified Rankin Scale (mRS; mRS = 3-6, with adjustment for variables associated with poor prognosis); secondary outcomes were: 'worsening after admission'; 'acute death'; and 'complete recovery at 6 months' (mRS = 0-1). We analyzed the same outcomes in subgroups of patients with brain lesions on the admission computer tomography/magnetic resonance imaging. RESULTS: LP was performed in 224 patients (35.9%). There was no difference in frequency of 'death or dependency at 6 months' between patients with or without LP [13.4% vs. 14.4%; odds ratio (OR) = 0.9, 95% confidence interval (CI) 0.6-1.5; P = 0.739]. LP was not associated with 'worsening after hospitalization' [21.5% vs. 23.5%; OR = 0.9, 95% CI 0.6-1.3; P = 0.577], 'acute death' [3.6% vs. 3.3%; OR = 1.1, 95% CI 0.5-2.7; P = 0.844] or 'complete recovery' [79.9% vs. 76.6%; OR = 1.2, 95% CI 0.8-1.7; P = 0.484]. In the subgroups of patients with brain lesions, the prognoses were not different between patients submitted or not to LP. CONCLUSION: LP was not associated with the functional outcome of patients with CVT, suggesting that LP was not harmful in these patients. These results should not be generalized to patients with large brain lesions and risk of herniation where LP is contraindicated.

Long-term satisfaction after neurological second opinions and tertiary referrals.

BACKGROUND AND PURPOSE: The number of second opinions (SO) and tertiary referrals (TR) in neurology is increasing. Previously, we showed that a day-care admission for neurological SO's and TR's often results in a new diagnosis and/or treatment advice and increases patient satisfaction. However, long-term satisfaction for these consultations has never been studied. The main purpose of this study was to investigate long-term satisfaction in these groups of patients. METHODS: A 2-year follow-up study in 300 patients who had attended a day-care clinic for SO and TR. Long-term satisfaction was assessed with a questionnaire using four Visual Analogue Scale (VAS) satisfaction items (ranging 0-10). Patients were asked if they had sought further consultations for the same problem after they had consulted the day-care clinic. A model was constructed to assess predictors for seeking new consultations. RESULTS: Overall satisfaction decreased 2.4 (SD 2.4) points during follow-up to the same level as before the consultation. The decrease was similar in SO and TR patients. Twenty-eight per cent of the patients consulted other health-care workers. Greater satisfaction immediately after the consultation was the only predictor for not seeking additional consultations (OR 0.78, 95% CI 0.61-0.99 for every point increase on VAS). CONCLUSION: Despite a high rate of new diagnoses and advised treatments, long-term satisfaction decreased after 2 years to baseline levels. These results question the long-term efficacy of a day-care clinic to evaluate neurological second opinions and tertiary referrals.

Patient satisfaction in neurological second opinions and tertiary referrals.

Although the number of neurological second opinions (SOs) and tertiary referrals (TRs) is increasing, only little is known about expectations and patient satisfaction in this group of patients. Therefore, the purpose of this study was to explore expectations of patients who get a neurological SO or TR and to assess patient satisfaction in these groups of patients. All new patients attending an academic neurological day-care clinic in a 6-month period were investigated. Demographic characteristics, duration of symptoms, expectations and motivation, new diagnoses and treatment consequences were studied, and patient satisfaction with the previous physician and the day-care clinic physician was assessed. Three hundred consecutive patients (183 SOs and 117 TRs) were evaluated. SO patients were younger (47 years vs. 51 years), and their duration of symptoms was longer (24 vs. 13 months) than TR patients. Most patients expected a new diagnosis or treatment (60%). SO patients were equally as satisfied with the day-care clinic consultation as TR patients (overall satisfaction using a VAS-score ranging 0-10: 7.4 vs. 7.5; p = 0.81), and significantly less satisfied with the referring physician (overall satisfaction: 5.6 vs. 7.0; p < 0.001). SO patients, in particular, were more satisfied with the degree of information and emotional support provided by the consulting neurologist as compared to the referring physician. Receiving a new diagnosis and/or treatment advice did not influence satisfaction. A day-care admission for neurological SO and TR leads to an increase of patient satisfaction, irrespective of making a new diagnosis or initiation of a new treatment.

A randomised controlled trial of antiplatelet therapy in combination with Rt-PA thrombolysis in ischemic stroke: rationale and design of the ARTIS-Trial.

BACKGROUND: Thrombolysis with intravenous rt-PA is currently the only approved acute therapy for ischemic stroke. Re-occlusion after initial recanalization occurs in up to 34% in patients treated with rt-PA, probably caused by platelet activation. In acute myocardial infarction, the combination of thrombolysis and antiplatelet therapy leads to a greater reduction of mortality compared to thrombolysis alone. In patients with acute ischemic stroke, several studies showed that patients already on antiplatelet treatment prior to thrombolysis had an equal or even better outcome compared to patients without prior antiplatelet treatment, despite an increased risk of intracerebral bleeding. Based on the fear of intracerebral haemorrhage, current international guidelines recommend postponing antiplatelet therapy until 24 hours after thrombolysis. Remarkably, prior use of antiplatelet therapy is not a contra-indication for thrombolysis. We hypothesize that antiplatelet therapy in combination with rt-PA thrombolysis will improve outcome by enhancing fibrinolysis and preventing re-occlusion. METHODS/DESIGN: ARTIS is a randomised multi-center controlled trial with blind endpoint assessment. Our objective is to investigate whether immediate addition of aspirin to rt-PA thrombolysis improves functional outcome in ischemic stroke. Patients with acute ischemic stroke eligible for rt-PA thrombolysis are randomised to receive 300 mg aspirin within 1.5 hours after start of thrombolysis or standard care, consisting of antiplatelet therapy after 24 hours. Primary outcome is poor functional health at 3 months follow-up (modified Rankin Scale 3 - 6). DISCUSSION: This is the first clinical trial investigating the combination of rt-PA and acute aspirin by means of a simple and cheap adjustment of current antiplatelet regimen. We expect the net benefit of improved functional outcome will overcome the possible slightly increased risk of intracerebral haemorrhage. TRIAL REGISTRATION: The Netherlands National Trial Register NTR822. The condensed rationale of the ARTIS-Trial has already been published in Cerebrovascular Diseases.

EFNS guideline on the treatment of cerebral venous and sinus thrombosis in adult patients.

BACKGROUND: Cerebral venous and sinus thrombosis (CVST) is a rather rare disease which accounts for <1% of all strokes. Diagnosis is still frequently overlooked or delayed as a result of the wide spectrum of clinical symptoms and the often subacute or lingering onset. Current therapeutic measures which are used in clinical practice include the use of anticoagulants such as dose-adjusted intravenous heparin or body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH), the use of thrombolysis and symptomatic therapy including control of seizures and elevated intracranial pressure. METHODS: We searched MEDLINE (National Library of Medicine), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library to review the strength of evidence to support these interventions and the preparation of recommendations on the therapy of CVST based on the best available evidence. Review articles and book chapters were also included. Recommendations were reached by consensus. Where there was a lack of evidence but consensus was clear we stated our opinion as good practice points. RESULTS AND CONCLUSIONS: Patients with CVST without contraindications for anticoagulation (AC) should be treated either with body weight-adjusted subcutaneous LMWH or with dose-adjusted intravenous heparin (level B recommendation). Concomitant intracranial haemorrhage (ICH) related to CVST is not a contraindication for heparin therapy. The optimal duration of oral anticoagulant therapy after the acute phase is unclear. Oral AC may be given for 3 months if CVST was secondary to a transient risk factor, for 6-12 months in patients with idiopathic CVST and in those with "mild" thrombophilia, such as heterozygous factor V Leiden or prothrombin G20210A mutation and high plasma levels of factor VIII. Indefinite AC should be considered in patients with recurrent episodes of CVST and in those with one episode of CVST and 'severe' thrombophilia, such as antithrombin, protein C or protein S deficiency, homozygous factor V Leiden or prothrombin G20210A mutation, antiphospholipid antibodies and combined abnormalities (good practice point). There is insufficient evidence to support the use of either systemic or local thrombolysis in patients with CVST. If patients deteriorate despite adequate AC and other causes of deterioration have been ruled out, thrombolysis may be a therapeutic option in selected cases, possibly in those without large ICH and threatening herniation (good practice point). There are no controlled data about the risks and benefits of certain therapeutic measures to reduce an elevated intracranial pressure (with brain displacement) in patients with severe CVST. However, in severe cases with impending herniation craniectomy can be used as a life-saving intervention (good practice point).

How to treat cerebral venous and sinus thrombosis.

SUMMARY: Cerebral venous and sinus thrombosis (CVT) is a rare form of thrombosis, with many different clinical manifestations. Better imaging techniques have greatly improved the diagnosis, but as a result of the paucity of controlled trials, choosing the optimal treatment for each patient often remains a challenge. Heparin is generally considered the mainstay of treatment, supported by data from a few small trials. More invasive treatment options are available, such as endovascular thrombolysis and--in more severe cases--decompressive hemicraniectomy. Furthermore, CVT is often accompanied by various neurological complications, such as seizures and intracranial hypertension, which require specific treatment. In this review we summarize the available treatment options for CVT and suggest which therapy should be reserved for which patients.

Antiplatelet therapy in combination with rt-PA thrombolysis in ischemic stroke (ARTIS): rationale and design of a randomized controlled trial.

BACKGROUND: Thrombolysis with recombinant tissue plasminogen activator (rt-PA) is currently the only approved acute therapy for ischemic stroke. After rt-PA-induced recanalization, reocclusion is observed in 20-34%, probably caused by platelet activation. In acute myocardial infarction, the combination of thrombolytic and antiplatelet therapy leads to a better outcome compared to thrombolytic treatment alone. In patients with acute ischemic stroke, several studies showed that those on antiplatelet treatment prior to rt-PA had an equal or even better outcome compared to patients without prior use of antiplatelet therapy, despite an increased risk of bleeding. METHODS: We present the protocol of a multicenter randomized clinical trial (n = 800) investigating the effects of immediate addition of aspirin to rt-PA on poor outcome (modified Rankin score >2) in ischemic stroke patients. CONCLUSION: This study will answer the question whether the combination of rt-PA and antiplatelet therapy improves the functional outcome in ischemic stroke patients.

Asian cerebral venous thrombosis registry: study protocol.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a well known but poorly reported entity. Most of the studies and registries related to CVT are reported from European countries. No large multi-center or multi- national data base or registry has been reported from Asian countries. CVT is not uncommon in Asia especially in south Asian subcontinent including India, Pakistan and Bangladesh. One study reported from India that CVT accounted for half of all strokes in the young and 40% of strokes in women. Review of CVT cases from Asian countries is suggestive of differences in risk factors profile and outcome in these patients as compared with European studies. These findings from multi- center data base in Asian countries will be extremely important in identifying risk factors for CVT in these countries. STUDY DESIGN: This is a prospective observational study. We plan to enroll more than 1000 patients from at least ten Asian countries (about 40-50 centers). Patients will be enrolled prospectively and followed for six months. Primary outcome would be death or dependence as assessed by modified Rankin scale (mRS). Data will be collected on a pre-defined data form. There will not be any laboratory test, investigation or treatment specified by the study. Only results of routinely performed studies and treatments will be recorded. Patient (aged 16 or above) will only be included in study if they have diagnosis of CVT proven by magnetic resonance imaging (MRI), magnetic resonance venography (MRV), computed tomography (CT) venography and cerebral venography according to established criteria. Follow up visits will be performed at 6 months, 12 months, and yearly thereafter, preferably by direct interview and observations by the local investigators. OUTCOME: Primary outcome is death or dependence (mRS >2) at the end of the follow-up period. Secondary outcomes are death and dependence at 6 months. Patients will be enrolled from January 2009 to June 2010.

Second opinions and tertiary referrals in neurology: a prospective observational study.

BACKGROUND AND OBJECTIVE: The number of neurological second opinions (SO) and tertiary referrals (TR) is increasing. The main purpose of this study was to assess whether a day-care admission made a meaningful contribution to standard neurological outpatient care, for a wide range of second opinions and tertiary referrals. METHODS: All new patients attending an academic neurological day-care clinic in a 6-month period were investigated. Before admission, all previous medical correspondence and ancillary investigations were reviewed. On the day of admission, extensive time was available for clinical evaluation and additional ancillary investigations and an attempt was made to come to a final diagnosis. Demographic characteristics, duration of symptoms, patient satisfaction, new diagnoses and treatment consequences were studied. RESULTS: 300 patients (183 SO and 117 TR) were evaluated. In total 103 patients (35 %) received a new diagnosis (26 % SO vs. 48 % TR, p < 0.001) and 69 (67 %) of these had therapeutic implications. A new treatment advice was given to a total of 149 patients (50 %), which was similar in both groups (48 % vs. 53 %). Second opinions were considered medically less relevant than tertiary referrals (39 % vs. 64 %, p < 0.001). The number of new diagnoses differed largely between various diagnosis categories. Especially somatoform disorders and radicular syndromes were often newly diagnosed. CONCLUSION: A high number of second opinion and tertiary referral patients benefits from a day-care admission in a neurological outpatient clinic. Careful selection for referral of patients who will benefit from daycare admission may even enlarge the diagnostic and therapeutic yield.