[Euthanasia: opinions and experiences of Flemish psychiatrists working at a university]

BACKGROUND

Little is known about the attitude of Belgian psychiatrists and psychiatrists in training towards euthanasia for psychiatric reasons.

AIM

To analyse opinions about and experiences with euthanasia in physicians from a university psychiatric hospital.

METHOD

A mail with a questionnaire was sent to the 111 psychiatrists and psychiatrists in training from University Psychiatric Centre KU Leuven to assess their profile, opinions towards euthanasia in different cases and own experiences with requests for euthanasia in the last five years.

RESULTS

The response rate was 45%. The majority of psychiatrists were accepting towards euthanasia, also in the case of psychiatric disorders (64%) or a combination of non-terminal somatic and psychosocial illness (60%). Religious psychiatrists were less accepting towards euthanasia than non-religious colleagues. Older psychiatrists (more than 20 years of working experience) were more open towards euthanasia than their younger colleagues, but less so than psychiatrists in training. Encounters with euthanasia were limited.

CONCLUSION

The common attitude towards euthanasia in doctors from a tertiary psychiatric centre is accepting. More research in a broader population is recommended.

[Functional neurologic and neuropsychologic outcome after near-hanging]

Although hanging is a frequently used suicide method, little is known about the prognosis of patients that survived hanging (near-hanging).<br/> AIM: To describe a case report and present a literature-review on the functional neurologic outcome after near-hanging (with separate analyses for the presence of cardiac arrest and use of neuro-protection), and possible residual neuropsychological symptoms.<br/> RESULTS: Only 12,4% (bi 4,6-29,4) of patients after near-hanging with cardiac arrest had a good functional outcome, compared to 90,6% (bi 85,7-94,0) of those without cardiac arrest. Neuroprotection through targeted temperature management has no significant influence on the outcome, neither in the presence nor absence of cardiac arrest. Near-hanging victims with a good functional outcome have, at most, mild residual neuropsychological symptoms. These can manifest throughout all cognitive domains, although learning and memory are most frequently and severely affected. DISCUSSION A significant subgroup of patients after near-hanging without cardiac arrest recovers towards a good level of functioning. A range of residual neuropsychological symptoms remain apparent, which are challenges for diagnostics and suicide prevention.

[Takotsubo cardiomyopathy and catatonia in a patient with psychotic depression]

Takotsubo cardiomyopathy (tcmp) is an acute, reversible disruption of the left ventricular systolic function. In many respects the clinical presentation closely resembles acute coronary syndromes (myocardial infarction). tcmp is a syndrome with a pathophysiology that is not fully understood and which seems to be closely associated with psychiatric disorders or psychological problems. We present a case in which a patient with several risk factors developed a tcmp and a depression with psychotic features, followed by catatonia. We describe the syndrome, make some pathophysiological hypotheses and point to possible connections with psychiatric disorders and psychological factors.

[Electroconvulsion therapy for neuroleptic malignant syndrome]

A 64-year-old man, diagnosed with recurrent depression, developed a neuroleptic malignant syndrome (nms) during treatment with olanzapine and mirtazapine. Psychotropic drugs were discontinued. Supportive therapy in an intensive care setting was initiated and electroconvulsive therapy (ect) was administered, after which the patient recovered. This case report discusses the place of ect in the treatment of nms.

[An increase of compulsory admissions in Belgium and the Netherlands: an epidemiological exploration ]

BACKGROUND

Although compulsory admission (CA) is highly relevant to society, epidemiological data for European countries are scarce and of limited reliability and comparability. In several European countries the incidence of CA seems to be increasing.

AIM

To estimate the incidence and evolution of CA in Belgium and the Netherlands by pooling and analysing available epidemiological data.

METHOD

We reviewed the literature systematically, paying particular attention to relevant epidemiological data (in published articles and in grey literature). All data were (re)calculated into yearly incidence rates of CA per 100,000 inhabitants.

RESULTS

The incidence of CA increased by 42% in Belgium (1999-2008) and by 25% in the Netherlands (2002-2009), culminating in incidence rates of 47/100,000/y (Belgium, 2008) and 80/100.000/y (Netherlands, 2009). Between-country differences can be attributed partly to differences in the legal systems. More detailed results, regional differences, and problems with the comparison of epidemiological data on CA are discussed.

CONCLUSIONS

Our data point to a significant increase of the incidence of CA in both Belgium and the Netherlands. To improve the comparability and quality of the data on CA, European countries will need to strive for greater uniformity and standardisation in the way these data are registered.

Associations between gastric sensorimotor function, depression, somatization, and symptom-based subgroups in functional gastroduodenal disorders: are all symptoms equal?

BACKGROUND

Previous work indicated that psychosocial factors (depression and somatization) are more strongly associated with symptom severity and weight loss in functional dyspepsia (FD) than gastric sensorimotor function. However, there is conflicting evidence regarding the association of these etiopathogenetic factors with Rome III symptom-based subgroups in FD [epigastric pain syndrome (EPS), postprandial distress syndrome (PDS)]. We aimed to test whether gastric sensitivity and emptying, depression, and somatization are differentially associated with empirically derived functional gastroduodenal disorders (FGD) symptom factors in one comprehensive model.

METHODS

In 259 tertiary care FD patients, we studied gastric sensorimotor function with barostat and gastric emptying breath test. Depression, somatization, and FGD symptoms were measured using self-report questionnaires. Confirmatory factor analysis (CFA) on 7 FGD symptoms was used to determine the fit of a latent variable structure based on Rome III symptom-based subgroups. Structural equation modeling (SEM) was used to test the putative relationships of the symptom factors with gastric sensorimotor function, depression, and somatization.

KEY RESULTS

The results of the CFA show a good fit [C(min) /DF = 1.54, CFI(comparative fit index) = 0.97] for the three-factor solution based on Rome III subgroups. The SEM also fitted the data well (C(min) /DF = 1.24, CFI = 0.98) and demonstrated that gastric sensitivity and depression are associated with PDS and nausea and vomiting. Gastric emptying is uniquely associated with EPS and somatization is strongly associated with all three symptom factors.

CONCLUSIONS & INFERENCES

Confirmatory factor analysis confirms the existence of three FGD symptom factors, corresponding to Rome III symptom-based subgroups. The SEM results suggest that different psychobiological mechanisms may play a role in these subgroups.

Do we have an alternative for the Rome III gastroduodenal symptom-based subgroups in functional gastroduodenal disorders? A cluster analysis approach

BACKGROUND

Functional dyspepsia (FD) is a heterogeneous biopsychosocial disorder. The Rome III consensus proposed a subdivision into epigastric pain syndrome and postprandial distress syndrome, based on gastroduodenal symptom pattern only; nausea/vomiting- and belching disorders were classified as separate functional gastroduodenal disorders (FGD). We aimed to investigate an alternative subdivision of FGD, taking into account gastric sensorimotor function, anxiety & depression and 'somatization', besides gastroduodenal symptoms.

METHODS

Gastroduodenal symptom data were available for 857 consecutive FGD patients (Rome II criteria). In a subsample (n=259), additional data were obtained on gastric sensitivity, anxiety, depression and 'somatization'. Two separate cluster analyses were performed. In analysis 1, clustering was based on individual gastroduodenal symptom scores. In analysis 2, gastric sensitivity, anxiety & depression and 'somatization', besides total gastroduodenal symptoms score, were used for clustering.

KEY RESULTS

Analysis 1 identified four clusters, largely supporting the Rome III classification, with early satiation, pain and nausea/vomiting clusters, besides a limited severity cluster (R(2) = 0.32). Analysis 2 suggested a five-cluster solution (R(2) = 0.48). Anxiety, depression and 'somatization' were the most important variables separating the clusters. 'Primary somatization' (with low psychiatric symptom levels) as well as 'secondary somatization' (with high anxiety & depression scores) subgroups were identified, besides three other subgroups characterized by psychiatric/gastroduodenal symptoms, mild anxiety symptoms and limited overall severity, respectively.

CONCLUSIONS & INFERENCES

We propose an alternative to the current subgrouping in FGD that is exclusively based on gastroduodenal symptoms. This may have consequences for future classification of FGD, as well as broader relevance towards the debate on subgrouping 'functional somatic syndromes'.

Factors associated with co-morbid irritable bowel syndrome and chronic fatigue-like symptoms in functional dyspepsia

BACKGROUND

It is unclear which factors explain the high co-morbidity between functional dyspepsia (FD) and other functional somatic syndromes. The aim of this study is to investigate the association between gastric sensorimotor function, psychosocial factors and 'somatization' on the one hand, and co-morbid irritable bowel syndrome (IBS) and chronic fatigue (CF)-like symptoms on the other, in FD.

METHODS

In 259 tertiary care FD patients, we studied gastric sensorimotor function with barostat (sensitivity, accommodation). We measured psychosocial factors (abuse history, alexithymia, trait anxiety, depression, panic disorder) and 'somatization' using self-report questionnaires, and presence of IBS and CF-like symptoms. Hierarchical multiple logistic regression was used to determine which of these factors were independently associated with co-morbid IBS and CF-like symptoms, including testing of potential mediator effects.

KEY RESULTS

Co-morbid IBS or CF-like symptoms respectively were found in 142 (56.8%) and 102 (39.4%) patients; both co-morbidities were not significantly associated (P=0.27). Gastric accommodation (β=0.003, P=0.04) and 'somatization' (β=0.17, P= 0.0003) were independent risk factors for IBS (c=0.74, P<0.0001); the effect of adult abuse (β=0.72, P=0.20) was mediated by 'somatization'. Depression (β=0.16, P=0.008) and 'somatization' (β=0.18, P=0.004) were overlapping risk factors for CF-like symptoms (c=0.83, P<0.0001); the effects of alexithymia and lifetime abuse were mediated by depression and 'somatization', respectively.

CONCLUSIONS & INFERENCES

'Somatization' is a common risk factor for co-morbid IBS and CF-like symptoms in FD and mediates the effect of abuse. Gastric sensorimotor function and depression are specific risk factors for co-morbid IBS and CF-like symptoms, respectively.

Risk factors for impaired health-related quality of life in functional dyspepsia

BACKGROUND

The influence of patient characteristics on HRQoL in functional dyspepsia is poorly understood.

AIM

To determine the contribution of gastric sensorimotor function, psychosocial factors & 'somatization' to HRQoL in functional dyspepsia.

METHODS

In 259 tertiary care functional dyspepsia patients, we studied gastric sensorimotor function with barostat. We measured psychosocial factors and 'somatization' using self-report questionnaires. HRQoL was assessed using the SF-36 physical and mental composite scores (PCS, MCS). Bivariate associations between gastric sensorimotor function, psychosocial factors and 'somatization' on the one hand and PCS and MCS on the other were estimated. Variables significantly associated with PCS or MCS in bivariate analysis were entered into hierarchical multiple linear regression models.

RESULTS

Mean PCS was 40.1 ± 9.5; mean MCS was 45.1 ± 10.8. 'Somatization' (P < 0.0001) and chronic fatigue (P = 0.002) were significantly associated with impaired PCS (R² = 0.52, P < 0.0001). The effects of abuse history and depression were 'mediated' by 'somatization'. Trait anxiety (P = 0.02), alexithymia (P = 0.06), depression (P = 0.06), positive affect (P < 0.0001), negative affect (P = 0.002) and generalised anxiety disorder (P = 0.01) were significantly associated with impaired MCS (R² = 0.67, P < 0.0001).

CONCLUSIONS

'Somatization' is the most important risk factor for impaired physical HRQoL in functional dyspepsia; it 'mediates' the effect of abuse history and depression. Mental HRQoL is mainly explained by psychosocial factors.

Impact of gavage dosing procedure and gastric content on adverse respiratory effects and mortality in rat toxicity studies

Unscheduled mortality preceded by adverse respiratory clinical signs in rats dosed by oral gavage may not only be caused by technical gavage error or systemic toxicity but may also be caused by gastro-esophageal reflux and subsequent aspiration of high concentrations of drug formulation. In a 3 week oral gavage rat toxicity study for an early drug development compound, preterminal deaths (approximately 20% of animals) at high doses (≥1000 mg kg(-1) ) and concentrations (≥60 mg ml(-1) ) were preceded by recurrent dyspnea, rales or excessive salivation, without evidence of accidental intrapulmonary gavage error. Histological evaluation revealed extensive necrosis and inflammatory changes in the upper respiratory tract, especially in the nasal turbinates and/or nasopharynx. The presence of food particles in inflammatory exudates suggested a retrograde aspiration of stomach content with test formulation via the nasopharyngeal duct into the posterior region of the nose. In contrast, no mortality or adverse respiratory effects were observed in rats following 2 week intravenous administration at comparable exposures or oral gavage administration at lower concentrations (≤20 mg ml(-1) ). In a pharmacology study, the compound caused a dose-dependent increase in gastric content (partly due to inhibition of gastric emptying), providing a pharmacological basis for the suspected gavage-mediated gastroesophageal reflux. Reducing the dose volume and dosing fasted animals substantially reduced or eliminated the respiratory effects and mortality at the high test article concentrations, demonstrating that the adverse effects are related to the gavage method.

[Does psychotherapy alter the brain? A non-reductionist neurophilosophical perspective]

BACKGROUND

Psychiatry and 'philosophy of mind' are both concerned with the study of the relationship between body/brain ('physical' domain) and mind ('mental' domain), but often there is little interaction between both disciplines. In contemporary psychiatry, neurobiological research predominates, and it is often assumed that the results of this type of research are only compatible with reductionist physicalist positions in the 'philosophy of mind', rendering further philosophical reflection obsolete.

AIM

To demonstrate the continuing relevance of the 'philosophy of mind' for the self-image of modern psychiatry as a clinical and scientific discipline.

METHOD

We illustrate this view by investigating whether a non-reductionist physicalist position, which postulates that the 'mental' supervenes on the 'physical' without being reducible to it, is compatible with the results of research on alterations in the brain during psychotherapy.

RESULTS

A non-reductionist physicalist position is compatible with recent functional brain imaging research, since the latter shows that psychiatric disorders (disorders of the 'mind') are associated with functional neurophysiological changes (alterations in the brain) that are influenced in different ways by pharmacotherapy and psychotherapy.

CONCLUSION

Modern neurobiological research in psychiatry is not only compatible with reductionist physicalist positions in the 'philosophy of mind', as is often assumed, but also with a non-reductionist physicalist position in which the 'mental' is granted greater autonomy vis-à-vis the physical.

Cross Reactivity between the Roche Elecsys® Progesterone Assay and Exemestane

Background:Oral aromatase inhibitors (AI) and to a lesser extend tamoxifen can promote recovery of ovarian function in postmenopausal breast cancer patients. Biochemical monitoring of ovarian function is important as folliculogenesis may lead to pregnancy, vaginal bleeding and loss of efficacy of the oral AI. Biochemical monitoring of oestradiol in exemestane users is problematic because exemestane metabolites cross react in most immunoassays for oestradiol. Following our finding of luteal phase progesterone levels in serum of some postmenopausal women with vaginal bleeding on exemestane, we assessed potential cross reactivity between exemestane and its 4-OH metabolite in the Roche Elecsys® progesterone assay. We also studied the frequency of such progesterone activity in serum from consecutive exemestane users and correlated values with FSH.Methods:Progesterone concentrations were measured with the Elecsys® assay in blanco serum, blanco serum with pure exemestane and blanco serum with the pure 17-OH-exemestane metabolite. Several concentrations of the purifided 17-OH-exemestane metabolite in DSMO solvent were then prepared using the Elecsys Diluent MultiAssay and progesterone concentration was measured in these samples using the Elecsys® assay. Cross sectional blood samples from 94 exemestane users were measured for progesterone activity with this assay and also for FSH using the Roche Modular E170® (F. Hoffmann-La Roche Ltd, Basel, Switserland).Results:Using this progesterone assay, 41% of exemestane users had luteal phase progesterone levels (&gt;1.7 ng/mL). There is cross reactivity with exemestane but more importantly with the 17-OH metabolite (table). The level of progesterone and cross reactivity for 2 known concentrations of the 17-OH-metabolite are also shown in this table. There is a correlation between progesterone picked up by the Elecsys® assay and FSH which increased with progesterone activity.Elecsys® assay RocheProgesterone (ng/mL)Blanco serum0.030Blanco serum + exemestane0.313Blanco serum + 17-OH-exemestane0.781Blanco serum + 2500 ng-ML 17-OH-exemestane16.20.65 %*Blanco serum + 5000 ng ng/mL 17-OH-exemestane32.50.65%/*(*): percentage of cross reactivityConclusion:Progesterone levels in exemestane users measured with the Elecsys® assay from Roche were often overestimated due to cross reactivity with exemestane and its main metabolite. This progesterone assay can not be used to define menopause or distinguish postmenopausal from menstrual bleeding in exemestane users. Higher FSH levels with higher progesterone activity in this assay suggest a link between circulating exemestane/metabolites and the quantitative downregulation of postmenopausal estrogens by this AI, but serial rather than cross sectional measurements are required to confirm this.We acknowledge Pfizer for providing us with pure exemestane and 17-OH-metabolite.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5147.

Cortical deactivations during gastric fundus distension in health: visceral pain-specific response or attenuation of 'default mode' brain function? A H2 15O-PET study

Gastric distension activates a cerebral network including brainstem, thalamus, insula, perigenual anterior cingulate, cerebellum, ventrolateral prefrontal cortex and potentially somatosensory regions. Cortical deactivations during gastric distension have hardly been reported. To describe brain areas of decreased activity during gastric fundus distension compared to baseline, using data from our previously published study (Gastroenterology, 128, 2005 and 564). H(2) (15)O-brain positron emission tomography was performed in 11 healthy volunteers during five conditions (random order): (C(1)) no distension (baseline); isobaric distension to individual thresholds for (C(2)) first, (C(3)) marked, (C(4)) unpleasant sensation and (C(5)) sham distension. Subtraction analyses were performed (in SPM2) to determine deactivated areas during distension compared to baseline, with a threshold of P(uncorrected_voxel_level) < 0.001 and P(corrected_cluster_level) < 0.05. Baseline-maximal distension (C(1)-C(4)) yielded significant deactivations in: (i) bilateral occipital, lateral parietal and temporal cortex as well as medial parietal lobe (posterior cingulate and precuneus) and medial temporal lobe (hippocampus and amygdala), (ii) right dorsolateral and dorso- and ventromedial PFC, (iii) left subgenual ACC and bilateral caudate head. Intragastric pressure and epigastric sensation score correlated negatively with brain activity in similar regions. The right hippocampus/amygdala deactivation was specific to sham. Gastric fundus distension in health is associated with extensive cortical deactivations, besides the activations described before. Whether this represents task-independent suspension of 'default mode' activity (as described in various cognitive tasks) or an visceral pain/interoception-specific process remains to be elucidated.

[Mentally ill and dangerous: civil commitment or internment? The Belgian judicial framework]

There are two important Belgian laws referring to psychiatric disturbances that may prove dangerous. The Civil Code includes the law relating to the protection of the mentally ill person, dated 26th June 1990, better known as the law of civil commitment of the mentally ill. Since April, 2007, the Penal Code has contained a new law on the internment of people with a psychiatric disorder; this new law replaces the old law of the 1st July, 1964, meant to protect the society. Although the two laws apply to different fields, in clinical practice there are sometimes 'grey areas' where it is not immediately evident which legal framework is applicable. Starting from a case study in which the civil judge ordered the civil commitment of a detainee, we explore these 'grey areas' and compare the two legal frameworks. We base our study on the new law on internment, clarify it and sketch the legal history of internment in Belgium.

Influence of abuse history on gastric sensorimotor function in functional dyspepsia

Patients with functional gastrointestinal disorders have elevated rates of sexual or physical abuse, which may be associated with altered rectal sensorimotor function in irritable bowel syndrome. The aim was to study the association between abuse history and gastric sensorimotor function in functional dyspepsia (FD). We studied gastric sensorimotor function with barostat (sensitivity, compliance and accommodation) and gastric emptying test in 233 consecutive FD patients from a tertiary care centre (162 women, mean age 41.6 +/- 0.9). Patients filled out self-report questionnaires on history of sexual and physical abuse during childhood or adulthood. Eighty-four patients (out of 198, 42.4%) reported an overall history of abuse [sexual and physical in respectively 30.0% (60/200) and 20.3% (42/207)]. FD patients reporting general as well as severe childhood sexual abuse have significantly lower discomfort thresholds during gastric distension [respectively 10.5 +/- 0.4 vs 7.5 +/- 1.0 mmHg above minimal distending pressure (MDP), P = 0.014 and 10.5 +/- 0.4 vs 6.6 +/- 1.2 mmHg above MDP, P = 0.007]. The corresponding intra-balloon volume was also significantly lower (respectively 579 +/- 21 vs 422 +/- 59 mL, P = 0.013 and 579 +/- 19 vs 423 +/- 79 mL, P = 0.033). Gastric accommodation was significantly more pronounced in patients reporting rape during adulthood (91 +/- 12 vs 130 +/- 40 mL, P = 0.016). Abuse history was not associated with differences in gastric emptying. A history of abuse is associated with alterations in gastric sensorimotor function in FD. Particularly sexual abuse, rather than physical abuse, may influence gastric sensitivity and motor function.