[Epidemiology and treatment of aggression in patients with psychotic disorders]. / Epidemiologie en behandeling van agressie bij patiënten met een psychotische stoornis.

BACKGROUND: Aggression is a major problem within psychiatry. During the recent years, a lot of research has been done, but many clinical decisions are still not evidence-based. AIM: This article describes three studies of the thesis 'Aggression in Psychiatry'. The overarching goal was to contribute to the current knowledge on aggression with clinically relevant results. The three studies described in this article are focused on psychotic disorders. METHOD: The first study is a survival analysis with data from a 6-year follow-up study. The second study is focused on associations between aggression and clinical factors and the effect of antipsychotics on aggression in first episode psychosis patients. The third study is a meta-analysis focused on the effectiveness of typical versus atypical antipsychotics on aggression. RESULTS: The yearly incidence of aggression in patients with psychotic disorders is around 2%. Patients with symptoms such as impulsivity, but also childhood trauma are at risk for aggression. Amisulpride appears effective against aggression during the first weeks of treatment. In patients with more persistent aggression, clozapine is most effective. CONCLUSION: Aggression is complex and heterogeneous. More research is needed, but with the findings of these three studies, we contribute to the current knowledge of aggression and treatment options.

[The new curriculum for the University Training Course in Psychiatry in South Limburg and for the Mental Health Services in Eindhoven]. / Het vernieuwde cursorische onderwijs van de universitaire opleiding psychiatrie Zuid-Limburg en GGZ Eindhoven.

BACKGROUND: The curriculum for the Academic Training Course in Psychiatry in South- Limburg (UOP-ZL) needed to be modernised. There were widely differing views about the purpose and function of psychiatry and about the structure of the curriculum. Trainees failed to attend regularly because of their daily duties. AIM: Following discussion about the need for modernisation of the course in Psychiatry (HOOP), the UOP-ZL curriculum was thoroughly revised and updated. METHOD: Further development of HOOP, a careful study of the teaching material and discussion among members of UOP-ZL and the Mental Health Service in Eindhoven, led to the development of more unified views about psychiatry and produced the ingredients for a revised curriculum for training in psychiatry. RESULTS: In the early stages of their course, trainees are introduced to some basic principles; these include understanding the mechanisms for dimensions of affect, motivation, salience and cognition from a biological, cognitive and ecological perspective, and perceiving the relationship between these factors and normal and abnormal behaviour. The course is a mix of problem based learning and interactive classroom teaching and is delivered by clinical and scientific experts. Every two weeks the trainees in each year-group are given a whole day 'free' (i.e. free of normal duties) when they are required to attend classed and lectures. CONCLUSION: The two main results of the new curriculum are: diagnosis-related teaching has been replaced by an approach based on explanatory mechanisms for dimensional psychopathology and dysfunction, and the tuition provided is both problem-based and interactive and is given by expert teachers.

Retrograde bridging nail in periprosthetic femoral fracture treatment which allows direct weight bearing.

The bridging nail is a retrograde intramedullary femoral nail designed to stabilize periprosthetic femoral fractures. It offers a minimal invasive surgical approach in combination with early mobilization. The goal of this study was to evaluate the osteosynthesis under full weight-bearing conditions. Three groups of five composite fibreglass femora were prepared with a cemented hip stem. Group 1 underwent cyclic axial loading with 1500 N during 150 000 cycles. After completion, linear loading to failure was conducted. Groups 2 and 3 were submitted to linear increased torsional loading with and without an axial load respectively. Failure was defined as rotational movement of the connection (slippage). In the axial cyclic loading configuration, one specimen failed after 122 000 cycles. Four specimens passed 150 000 cycles and failed after linearly increasing the axial loading of 1940-2600 N (mean, 2408 N +/- 313 standard deviation (SD)). Slippage was first detected at a torque varying between 2.5 and 8.2 Nm (mean, 5.1 Nm +/- 2.1 SD) in group 2 and between 10.0 and 15.4 Nm (mean, 13.0 N m +/- 2.3 SD) in group 3. In conclusion the bridging nail offers a stable connection with the stem of a hip arthroplasty which can resist high repetitive loads, representative of direct full axial weight bearing. The biomechanical results support the clinical experience of a stable osteosynthesis enabling early post-operative mobilization.

Pre-operative injections of epoetin-alpha versus post-operative retransfusion of autologous shed blood in total hip and knee replacement: a prospective randomised clinical trial.

This prospective randomised clinical trial evaluated the effect of alternatives for allogeneic blood transfusions after total hip replacement and total knee replacement in patients with pre-operative haemoglobin levels between 10.0 g/dl and 13.0 g/dl. A total of 100 patients were randomly allocated to the Eprex (pre-operative injections of epoetin) or Bellovac groups (post-operative retransfusion of shed blood). Allogeneic blood transfusions were administered according to hospital policy. In the Eprex group, 4% of the patients (two patients) received at least one allogeneic blood transfusion. In the Bellovac group, where a mean 216 ml (0 to 700) shed blood was retransfused, 28% (14 patients) required the allogeneic transfusion (p = 0.002). When comparing Eprex with Bellovac in total hip replacement, the percentages were 7% (two of 30 patients) and 30% (nine of 30 patients) (p = 0.047) respectively, whereas in total knee replacement, the percentages were 0% (0 of 20 patients) and 25% (five of 20 patients) respectively (p = 0.042). Pre-operative epoetin injections are more effective but more costly in reducing the need for allogeneic blood transfusions in mildly anaemic patients than post-operative retransfusion of autologous blood.

Retransfusion of filtered shed blood in everyday orthopaedic practice.

The efficiency of post-operative cell saving after major joint arthroplasty has been demonstrated in prospective studies focusing on blood management. In everyday practice, however, it is likely that transfusion policy is followed less rigorously because of a slackening in attention to blood management, with a reduced efficiency of post-operative cell saving. The primary research question of this retrospective study was whether the number of allogeneic blood transfusions administered to patients treated with a retransfusion system was similar to the results found in a preceding prospective study. A total of 438 patients treated with the Bellovac ABT retransfusion system were analysed in which the majority was operated on a total hip arthroplasty (THA) and total knee arthroplasty (TKA). The amount of retransfused shed blood, the perioperative haemoglobin levels and the number of allogeneic blood transfusions were registered. The average amount of retransfusion was 152 mL in THA and 410 mL in TKA, whereas the allogeneic blood transfusion rate was 8.4 and 5.1% in both groups, respectively. The average percentage of allogeneic blood transfusions administered in this study (i.e. 7%) proved to be marginally higher than the percentage found in a preceding prospective study (i.e. 6%) because of slackening of attention for transfusion policy in everyday practice. Limited bone resection procedures such as resurfacing THA or unicompartmental knee arthroplasty were associated with very limited shed blood and low risk of allogeneic blood transfusion, indicating the doubtful cost efficiency of using a retransfusion system in these patients. It can be concluded that the efficiency of the retransfusion system in everyday practice was similar to the efficiency shown in a preceding prospective study focusing on blood management. However, continual training of the clinical team is crucial.

[Do we really still need psychiatric case registers?]. / Hebben we psychiatrische casusregisters nog wel nodig?

SUMMARY: A question frequently raised in the Netherlands is whether regional case registers have added value compared to national information systems. Research in regional case registers, however, has shown that they have added value based on longitudinal data-gathering, specialised knowledge of the region concerned and data-processing. Regional case registers reflect developments in the total range of services available (cure and care, including clinics to treat alcoholism and drug addiction). Case register research can also aim at developing outcome measures and creating links between mental health care and other health care areas.

Experience in the first four years of rapid recovery; is it safe?

The average length of hospital stay after Total Hip Replacement (THR) has been decreasing over time. Recently, many hospitals have commenced rapid recovery programs such as Joint Care. In Joint Care the patients are usually discharged on the fifth post-operative day with relatively fresh surgical wounds. The aim of this study is to evaluate the Joint Care program after THR. Between February 2000 and February 2004, the Joint Care program was used in 611 patients after THR. The average age of the patients was 66.3 yrs (SD 9.3; range 24-86 yrs) and 68% (n= 415) of them were female. All clinical and outpatient charts as well as nursery records were evaluated. The follow up was from 6 months to 4 years (average: 2.5 years). At the planned fifth post-operative day, 92% (n = 562) of patients were discharged from hospital (SD 1.7 days; range 6-25 days). 3.8% (n= 23) of the remaining cases faced wound problems--prolonged wound drainage in 2.3% (n = 14) and potential superficial infection in 1.5% (n = 9) - causing a delay in their discharge. The readmission rate was 6.4% (n = 39) due to hip dislocation (3.4%; n = 21), re-evaluation of wound (1.5%; n= 9), deep infection (1.2%; n = 7)) and cardiac events (0.3%; n = 2). All the infection cases were treated effectively with debridement and antibiotics and no revision for any reason was reported. The Joint Care program seems to be effective after THR. Post-operative hip dislocation was the main reason for post-operative readmission. However, no clear signs that the intensive rehabilitation program caused more complications compared to previous regimens were evident. The above results encourage the application of rapid recovery programs in Orthopaedic surgery and joint replacement.

Puberty and the onset of psychosis.

According to the neurodevelopmental hypothesis of schizophrenia, maturational events in the brain at puberty interact with congenital defects to produce psychotic symptoms. As girls reach puberty at a younger age than boys, we predicted that (i) females would show earlier onset of psychotic illness arising around puberty, and (ii) onset of psychosis in females would be related to menarche. Analysis of epidemiological data regarding admission to psychiatric units in (a) England over the period 1973-1986, (b) France over the period 1975-1980, as well as examination of 97 psychotic adolescents referred to an adolescent unit over a 14 year period, supported both these propositions.