[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.

Determinants of symptoms in functional dyspepsia: gastric sensorimotor function, psychosocial factors or somatisation?

BACKGROUND

Gastric sensorimotor dysfunction, psychosocial factors and somatisation are all implicated in symptom generation in functional dyspepsia (FD).

AIM

To determine the relative contribution of each of these factors to overall dyspeptic symptom severity and weight loss in FD.

METHODS

In 201 consecutive tertiary care patients with FD (mean age 40.1 (SD 12.6) years), gastric sensorimotor function was studied using barostat (sensitivity, compliance and accommodation). Psychosocial factors (depression and anxiety disorders, positive and negative affect, perceived stress, alexithymia and history of abuse), somatisation and co-morbid irritable bowel syndrome (IBS) and chronic fatigue symptoms were assessed using self-report questionnaires. Variables were correlated with dyspepsia symptom severity (DSS) and weight loss. Hierarchical multiple linear regression was used to identify determinants of DSS and weight loss.

RESULTS

Multiple linear regression identified the following determinants of DSS: gastric sensitivity (beta = 0.77, p = 0.25), depression (beta = 0.12, p = 0.06) and somatisation (beta = 0.48, p<0.0001) (controlling for age and occupation, R(2) = 0.29, p<0.0001). The effect of depression on DSS is partially mediated by somatisation. Gastric sensitivity (beta = 2.87, p = 0.08), history of childhood sexual abuse (beta = 9.37, p = 0.0006), depression (beta = 0.19, p = 0.24) and somatisation (beta = 0.67, p = 0.01) are independent determinants of weight loss (controlling for gender and occupation, R(2) = 0.42, p<0.0001). The effect of depression on weight loss is fully mediated by somatisation.

CONCLUSION

Symptom severity and weight loss in FD are determined by psychosocial factors (depression, abuse history) and somatisation, and only to a lesser extent by gastric sensorimotor function. The importance of psychosocial factors and somatisation compared to gastric sensorimotor function is most pronounced in hypersensitive patients.

The role of somatosensory cortical regions in the processing of painful gastric fundic distension: an update of brain imaging findings

Painful gastric distension is processed in a network consisting of brainstem, thalamus, insula, anterior cingulate cortex, (lateral) orbitofrontal and prefrontal cortex, superior temporal cortex and cerebellum. However, the role of primary and secondary somatosensory cortical regions (SI/SII) in the processing of visceral sensation or pain in general and gastric sensation in particular remains unclear. The aim of this study was to localize activations in the SI/SII area from our previously published functional brain imaging studies on gastric distension more precisely, using newly available cytoarchitectonic probability maps of SI/SII, implemented in the SPM Anatomy toolbox. In healthy volunteers, we found two clusters to be overlapping with SII (mainly the OP4 subregion) and, to a lesser extent, SI, although this overlap was small in size. In functional dyspepsia patients, we found two clusters to be overlapping with SII (mainly OP4), of which the cluster in the right hemisphere also overlapped with SI. These findings were confirmed in a conjunction analysis of both groups. Activation in right SI/SII was significantly higher in healthy volunteers when formally compared to patients. These results provide more detailed information on the brain processing of gastric sensation, supporting the hypothesis that SI/SII are involved. This is in line with some previously published studies on visceral sensation, but at variance with some other studies. Methodological differences between the brain imaging studies on gastric distension may account for these somewhat discrepant findings.

[When is psychosis dangerous? Ethical, professional en juridical considerations concerning psychosis and coercion in Belgium]

BACKGROUND

In Belgium a patient can only be compulsorily admitted to a psychiatric hospital if he is a danger to himself or others (law concerning coercion in Belgium, 26/06/1990).

AIM

To explore the relationship between psychosis and danger, and to analyse the various interpretations of the 'dangerousness' criterion in the context of psychotic disorders and the underlying ethical positions.

METHOD

We studied the literature by means of PubMed, PsycINFO, manuals and references and used the search terms: 'coercion', 'commitment of mentally ill', 'dangerous behaviour', and 'psychotic disorders'. results The correlation between psychosis and danger is limited but is strengthened by comorbid substance abuse and non-compliance. The clinical assessment of danger does not have a firm scientific basis. The underlying ethical position determines when danger is regarded as being serious enough to justify coercion.

CONCLUSION

Danger is a problematical criterion for coercion. We propose a model that weighs up the likelihood of danger against the expected pros and contrasts of coercion and the extent to which the disorder can be treated. The fluid nature of the 'dangerousness' criterion and the principle of proportionality call for a more varied arsenal of coercive measures which are less drastic than compulsory admission.

[Neurosarcoidosis as a cause of manic psychosis]

A case report and a systematic review of the literature show that neurosarcoidosis can present initially as a manic episode with psychotic features. The diagnosis of neurosarcoidosis is based on a combination of clinical features, and radiological and histopathological findings. Contrast-enhanced MRI and lumbar puncture are the most sensitive investigations for detecting neurosarcoidosis. Corticosteroids are the treatment of choice. Very few data are available concerning the efficacy of psychotropic drugs for the treatment of psychiatric symptoms caused by neurosarcoidosis.

[Does evidence-b(i)ased psychiatry have its limitations?]

Evidence-based medicine (EBM) is an algorithm that integrates information technology and the results of outcome research into clinical work. EBM, if well understood, is a valuable and critical bottom-up method that promotes a dialectical process by which the practitioner is able to arrive at an informed treatment choice; the method starts from the individual patient and involves discussion with the patient and critical reading of the relevant literature. However, there is a risk that EBM will become an ideology unless we are aware of its assumptions and epistemology. It is not valuefree, but is driven by an implicit objectivist view of man. EBM attaches greater value to biomedical sciences that to the humanities, to empiricism than to hermeneutics and to quantitative research than to qualitative research. EBM focuses on internal validity, but is in danger of neglecting factors such as qualitative changes that are difficult to measure, ecological validity and effectiveness and may hinder the generalisation of research results to clinical practice. The limitations of EBM are even more poignant in psychiatry, because psychiatry is highly sensitive to context and values. EBM is a blessing if we use it critically and remain aware of its limitations and underlying philosophy and if we supplement it with strategies such as value-based medicine (VBM). EBM, however, does not teach us what is useful or valuable, whereas VBM helps us to explain and weigh up the values that are at stake.

[Civil commitment of mentally ill patients: developments in Flanders]

The Belgian law of 1990 concerning the protection of the mentally ill was the principal achievement of the last 25 years in the field of civil commitment of mentally ill patients in Flanders. Since that time there have been very few alterations in the criteria determining civil commitment. Very little legislation has been passed on this subject. The pragmatic and casuistic way in which the law is applied hinders any discussion of the principles on which these criteria are based. In spite of the large increase in the number of civil commitments, so far the law has remained unchanged.

The impact of major depressive disorder on the short- and long-term outcome of Crohn's disease treatment with infliximab

BACKGROUND

Major depressive disorder is the most common psychiatric diagnosis in Crohn's disease. In other chronic diseases, evidence suggests that depression influences the course of the disease. Strong evidence of such a mediating role of major depressive disorder in Crohn's disease has never been found.

AIM

To assess the relationship between major depressive disorder and outcome of treatment of luminal Crohn's disease with infliximab.

METHODS

In this prospective study, 100 consecutive unselected patients underwent assessment of psychosocial, demographical disease-related biological and clinical parameters at baseline and at 4 weeks after infliximab. Major depressive disorder was diagnosed using the Patient Health Questionnaire. Subsequently, the patients were followed up clinically until the next flare or during 9 months.

RESULTS

The Crohn's disease responded in 75% of the patients, and remission was achieved in 60%. The presence of major depressive disorder at baseline predicted a lower remission rate (OR = 0.166, 95% CI = 0.049-0.567, P = 0.004). At follow-up, 88% of the patients needed retreatment. At univariate regression analysis, major depressive disorder significantly decreased time to retreatment (P = 0.001). Multivariate Cox regression confirmed major depressive disorder as an independent determinant of active disease both at baseline and at re-evaluation (hazard ratio = 2.271, 95% CI: 1.36-3.79, P = 0.002).

CONCLUSION

Major depressive disorder is a risk factor for failure to achieve remission with infliximab and for earlier retreatment in patients with active luminal Crohn's disease. Assessment and management of major depressive disorder should be part of the clinical approach to patients with Crohn's disease.

Dyspeptic patients with visceral hypersensitivity: sensitisation of pain specific or multimodal pathways?

BACKGROUND AND AIMS

Patients with functional dyspepsia who have hypersensitivity to gastric distension have more prevalent pain, suggesting the presence of hyperalgesia. It is unclear whether this reflects activation of pain specific afferent pathways or multimodal afferent pathways that also mediate non-painful sensations. In the former case, hyperalgesia should occur when intensity of non-painful sensations is still low. The aim of the study was to analyse whether the symptom profile during gastric dissentions in functional dyspepsia patients with hyperalgesia reflects sensitisation of pain specific or multimodal pathways.

METHODS

Forty eight consecutive dyspeptic patients (35 female) underwent gastric sensitivity testing with a barostat balloon using a double random staircase protocol. At the end of every distending step, patients scored perception of upper abdominal sensations on a graphic 0-6 rating scale and completed visual analogue scales (VAS 0-100 mm) for pain, nausea, satiety, and fullness. The end point was a rating scale of 5 or more.

RESULTS

Hypersensitivity was present in 20 patients (40%); gastric compliance did not differ between normo- and hypersensitive patients. At maximal distension (score 5 or more), hypersensitive patients had significantly lower distending pressures and intra-balloon volumes, but similar VAS scores for pain, nausea, satiety, and fullness compared with normosensitive patients. In both normosensitive and hypersensitive patients, elevation of pain VAS scores with increasing distending pressures paralleled the elevation in VAS scores for nausea, satiety, and fullness.

CONCLUSIONS

Hypersensitive dyspeptic patients reach the same intensity of painful and non-painful sensations as normosensitive patients but at lower distending pressures. Hyperalgesia occurs in hypersensitive dyspeptic patients at distending pressures that also induce intense non-painful sensations. These findings argue against isolated upregulation of pain specific afferents in functional dyspepsia patients with visceral hypersensitivity.

Visceral hypersensitivity in functional disorders of the upper gastrointestinal tract

Visceral hypersensitivity is now recognised as a major pathophysiological mechanism in functional gastrointestinal disorders of the upper gastrointestinal tract. In patients with non-cardiac chest pain and functional dyspepsia, a high prevalence of visceral hypersensitivity has been indeed observed. In these patients, luminal physiological stimuli can be perceived as unpleasant or even painful. Although the fine mechanisms underlying such "aberrant perceptions" are yet not fully clarified, it is thought that an altered activation of the gut-wall receptors, an altered conduction of sensory inputs at the level of neural pathways, or an impaired processing of the sensations at the level of brain, may occur along the brain-gut axis. So far, drugs able to reduce hypersensitivity, that target each of the constituents of the stimuli-perception chain, have the therapeutic potential to reduce visceral hypersensitivity and, thus, to improve the symptoms. In this context, the availability of new agonists/antagonists to neurotransmitters offers a new exciting tool for the treatment of functional disorders of the upper gastrointestinal tract.

Vibrio kanaloae sp. nov., Vibrio pomeroyi sp. nov. and Vibrio chagasii sp. nov., from sea water and marine animals

The taxonomic position of the fluorescent amplified fragment length polymorphism fingerprinting groups A46 (five isolates), A51 (six isolates), A52 (five isolates) and A53 (seven isolates) obtained in a previous study were further analysed through a polyphasic approach. The 23 isolates were phylogenetically related to Vibrio splendidus, but DNA-DNA hybridization experiments proved that they belong to three novel species. Chemotaxonomic and phenotypic analyses further disclosed several features that differentiate between the 23 isolates and known Vibrio species. The names Vibrio kanaloae sp. nov. (type strain LMG 20539(T) = CAIM 485(T); EMBL accession no. AJ316193; G + C content 44.7 mol%), Vibrio pomeroyi sp. nov. (type strain LMG 20537(T) = CAIM 578(T); EMBL accession no. AJ491290; G +C content 44.1 mol%) and Vibrio chagasii sp. nov. (type strain LMG 21353(T) = CAIM 431(T); EMBL accession no. AJ316199; G + C content 44.6 mol%) are respectively proposed to encompass the five isolates of A46, the six isolates of A51 and the 12 isolates of A52/A53. The three novel species can be distinguished from known Vibrio species by several phenotypic features, including utilization and fermentation of various carbon sources, beta-galactosidase activity and fatty acid content (particularly of 12 : 0, 14: 0, 14 : 0 iso and 16 : 0 iso).

Xpa and Xpa/p53+/- knockout mice: overview of available data

DNA repair deficient Xpa-/- and Xpa-/-/p53+/- knock-out mice in a C57BL/6 genetic background, referred to as respectively the XPA and XPA/p53 model, were investigated in the international collaborative research program coordinated by International Life Sciences Institute (ILSI)/Health and Environmental Science Institute. From the selected list of 21 ILSI compounds, 13 were tested in the XPA model, and 10 in the XPA/p53 model. With one exception, all studies had a duration of 9 months (39 weeks). The observed spontaneous tumor incidence for the XPA model after 9 months was comparable to that of wild-type mice (total 6%). For the XPA/p53 model, this was somewhat higher (9%/13% for males/females). The 3 positive control compounds used, B[a]P, p-cresidine, and 2-AAF, gave positive and consistent tumor responses in both the XPA and XPA/p53 model, but no or lower responses in wild-type mice. From the 13 ILSI compounds tested, the single genotoxic carcinogen (phenacetin) was negative in both the XPA and XPA/p53 model. Positive tumor responses were observed for 4 compounds, the immunosuppressant cyclosporin A, the hormone carcinogens DES and estradiol, and the peroxisome proliferator WY-14,643. Negative results were obtained with 5 other nongenotoxic rodent carcinogens, and 2 noncarcinogens tested. As expected, both DNA repair deficient models respond to genotoxic carcinogens. Combined with previous results, 6 out of 7 (86%) of the genotoxic human and/or rodent carcinogens tested are positive in the XPA model. The positive results obtained with the 4 mentioned nongenotoxic ILSI compounds may point to other carcinogenic mechanisms involved, or may raise some doubts about their true nongenotoxic nature. In general. the XPA/p53 model appears to be more sensitive to carcinogens than the XPA model.

Xpa and Xpa/p53+/- knockout mice: overview of available data

DNA repair deficient Xpa-/- and Xpa-/-/p53+/- knock-out mice in a C57BL/6 genetic background, referred to as respectively the XPA and XPA/p53 model, were investigated in the international collaborative research program coordinated by International Life Sciences Institute (ILSI)/Health and Environmental Science Institute. From the selected list of 21 ILSI compounds, 13 were tested in the XPA model, and 10 in the XPA/p53 model. With one exception, all studies had a duration of 9 months (39 weeks). The observed spontaneous tumor incidence for the XPA model after 9 months was comparable to that of wild-type mice (total 6%). For the XPA/p53 model, this was somewhat higher (9%/13% for males/females). The 3 positive control compounds used, B[a]P, p-cresidine, and 2-AAF, gave positive and consistent tumor responses in both the XPA and XPA/p53 model, but no or lower responses in wild-type mice. From the 13 ILSI compounds tested, the single genotoxic carcinogen (phenacetin) was negative in both the XPA and XPA/p53 model. Positive tumor responses were observed for 4 compounds, the immunosuppressant cyclosporin A, the hormone carcinogens DES and estradiol, and the peroxisome proliferator WY-14,643. Negative results were obtained with 5 other nongenotoxic rodent carcinogens, and 2 noncarcinogens tested. As expected, both DNA repair deficient models respond to genotoxic carcinogens. Combined with previous results, 6 out of 7 (86%) of the genotoxic human and/or rodent carcinogens tested are positive in the XPA model. The positive results obtained with the 4 mentioned nongenotoxic ILSI compounds may point to other carcinogenic mechanisms involved, or may raise some doubts about their true nongenotoxic nature. In general. the XPA/p53 model appears to be more sensitive to carcinogens than the XPA model.

Vibrios associated with Litopenaeus vannamei larvae, postlarvae, broodstock, and hatchery probionts

Several bacteriological surveys were performed from 1994 to 1996 at different Litopenaeus vannamei hatcheries (in Ecuador) and shrimp farms (in Mexico). Samples were taken from routine productions of healthy and diseased L. vannamei larvae, postlarvae, and their culture environment and from healthy and diseased juveniles and broodstock. In Ecuador, the dominant bacterial flora associated with shrimp larvae showing symptoms of zoea 2 syndrome, mysis mold syndrome, and bolitas syndrome has been determined. Strains were characterized by Biolog metabolic fingerprinting and identified by comparison to a database of 850 Vibrio type and reference strains. A selection of strains was further genotypically fine typed by AFLP. Vibrio alginolyticus is predominantly present in all larval stages and is associated with healthy nauplius and zoea stages. AFLP genetic fingerprinting shows high genetic heterogeneity among V. alginolyticus strains, and the results suggest that putative probiotic and pathogenic strains each have specific genotypes. V. alginolyticus was found to be associated with larvae with the zoea 2 syndrome and the mysis mold syndrome, while different Vibrio species (V. alginolyticus and V. harveyi) are associated with the bolitas syndrome. V. harveyi is associated with diseased postlarvae, juveniles, and broodstock. The identities of the strains identified as V. harveyi by the Biolog system could not be unambiguously confirmed by AFLP genomic fingerprinting. Vibrio strain STD3-988 and one unidentified strain (STD3-959) are suspected pathogens of only juvenile and adult stages. V. parahaemolyticus, Photobacterium damselae, and V. mimicus are associated with juvenile and adult stages.

Review of alternative methods of carcinogenicity testing and evaluation of human pharmaceuticals

Hundreds of pharmaceuticals have been reported to give a positive result in the standard "Chronic Bioassay", which consists of an 18 to 24 month daily administration of the test compound in mice and rats. This is in contrast with 20 pharmaceuticals, which are known to be carcinogenic to humans. The high incidence of apparently false-positive results in the Chronic Bioassay may be related to differences in mechanism of pharmacological action between rodents and humans, but also to the very high dose levels that have to be administered to rodents in accordance to regulatory guidelines. Lack of relevance to man therefore often has to be demonstrated by additional mechanistic studies. Based upon the deficiencies of the Chronic Bioassay and on the increased knowledge on cellular and molecular mechanisms involved in carcinogenicity, extensive discussions have recently taken place between regulatory agencies and industry associations at the occasion of International Conferences on Harmonization (ICH). These discussions have resulted in the possibility to use alternative short-to-medium-term carcinogenicity models in combination with a single two-year carcinogenicity study for evaluation of carcinogenicity. A description of these models is provided in this review as well as possible strategies for carcinogenicity testing and evaluation in the future.

Carcinogenicity studies of astemizole in mice and rats

The histamine H1 antagonist astemizole (Hismanal) was tested for carcinogenicity in Swiss mice and Wistar rats. Astemizole was administered with the food to mice for 18 and to rats for 24 consecutive months. The doses given--approximately 5, 20, and 80 mg/kg body weight.day--were equivalent to 25, 100, and 400 times, respectively, the recommended human dose of 10 mg/day. Survival of both mice and rats was comparable between groups. Peto's age-adjusted, dose-related trend analysis for the tumor-bearing rats did not reveal a statistically significant difference for males or females. There was no evidence that astemizole led to an increased incidence of spontaneously or unusually occurring neoplastic lesions in either mice or rats. Special attention was given to the effect of astemizole on the progression of spontaneously occurring mammary gland adenomas and fibroadenomas. Peto's analysis applied to the number of female rats bearing these benign mammary gland tumors disclosed no statistically significant dose-related trend. There was no positive trend for the onset of this tumor type, and the median size of the tumor over time per rat was also not statistically significantly different in a comparison of the control group with each of the dosed groups. The findings from these carcinogenicity studies suggest that astemizole is not tumorigenic and that it does not promote tumor growth.

Safety aspects of oral antifungal agents

Four main targets have to be considered when evaluating the safety of new systemically acting, oral antifungals: the liver, the endocrine system, serum cholesterol and the developing embryo. The major endocrine targets for high levels of the antifungal azoles are the adrenal cortex and the gonads. Endocrine studies demonstrate that itraconazole has little potential for interfering with steroid hormones in man. Available data also indicate that itraconazole has low predictable hepatotoxicity potential in man. In rats, serum cholesterol levels are raised during treatment with itraconazole, especially after chronic exposure. This is, however, a species-specific phenomenon which leads to secondary events at toxic doses, especially in long-term toxicity studies. In man, including patients with existing hypercholesterolaemia, serum cholesterol levels are not raised. Ketoconazole has been shown to be teratogenic at high, toxic doses in pregnant rats. The same observation has been made for itraconazole, and it may also be true for fluconazole. However, all three azoles show no teratogenicity in the rabbit. Studies with itraconazole in adrenalectomised rats and in rats given exogenous arachidonic acid indicate that adrenal effects occurring at toxic dose levels are important mediators of teratogenicity. Since itraconazole does not affect adrenal function at levels used to treat infections in man, the teratogenic risk is estimated to be low. Itraconazole is therefore a promising new drug, especially with regard to the assessment of its safety in the liver and endocrine system. Moreover, it is more potent and has a broader antifungal spectrum than other azole antifungals, and its development is considered to be an important step forward in chemotherapy.

Toxicological profile and safety evaluation of antifungal azole derivatives

For the development of new systemically acting, oral antifungal azoles, it is of key importance to compare them with ketoconazole, the first available drug in this therapeutic class. Ketoconazole is a major breakthrough although hepatic side-effects as well as interactions with mammalian steroids might rarely occur during prolonged treatment. The prediction of these side-effects is difficult but the potential to interact with mammalian cytochrome P-450 enzymes is considered to be important. Therefore, for the selection of itraconazole a multidisciplinary approach was applied to study this potential. The present paper deals with the toxicological profile of itraconazole and its safety evaluation. In addition, a further comparison with ketoconazole and also with fluconazole is provided, in so far sufficient information is available. For the liver as a potential target organ, the available data indicate that itraconazole is not a predictable hepatotoxic drug in man. The major endocrine targets for overdosing with antifungal azoles are the adrenal cortex and the gonads. Endocrine studies show that itraconazole is not bearing a potential to interfere with steroid hormones in patients, which is a major improvement when compared to ketoconazole. In rats, elevation of serum cholesterol is observed especially after chronic exposure to itraconazole. This species-specific phenomenon leads at toxic dose levels to secondary events, especially in the long-term toxicity studies. In man, including those with existing hypercholesterolemia, serum cholesterol is not adversely affected by itraconazole. In pregnant rats, ketoconazole was shown to be teratogenic at high, toxic doses. The same observation has been made for itraconazole and this also might be true for fluconazole.(ABSTRACT TRUNCATED AT 250 WORDS)

Mutagenic and leukemogenic activity of haloperidol: a negative study

The mutagenic and leukemogenic potential of haloperidol, a neuroleptic of the butyrophenone class, has been studied in an in vitro Ames Salmonella/microsome test and in an 18-month carcinogenicity study in mice. Three variants of the Salmonella mutation assay were included: the spot test, the standard plate incorporation test and the preincubation test. There was no evidence that haloperidol had any mutagenic activity in any of the Salmonella mutation tests with any of the Salmonella typhimurium tester strains in the presence or absence of Aroclor 1254-induced rat- or mouse-liver S9-mix. In the 18-month study, haloperidol was injected intraperitoneally as a solution (HaldolR) at a dosage of 5 mg/kg daily for 5, 10 and 20 consecutive days in 5-week-old mice. Leucocyte counts at several time points and histopathological tumor evaluation 18 months later did not reveal any leukemogenic or other carcinogenic effect. On the basis of these data, it may be concluded that haloperidol is not mutagenic in Salmonella nor leukemogenic in mice.

Toxicological properties of closantel

The acute, subacute and chronic toxicity studies in laboratory animals showed that closantel is a well tolerated substance. At multiples of the clinical dose, overdosing might result in central nervous system effects and death. Repeated oral dosing was without effects up to 40 mg/kg in rats and dogs except for focal swelling of the epididymis in male rats at 40 mg/kg due to formation of spermatic granulomas. In sheep repeated dosing at 10 and 40 mg/kg orally and at 5 and 20 mg/kg intramuscularly every four weeks during 40 weeks demonstrated an acceptable safety margin in this target species. Reproduction studies including a three-generation study in rats showed that fertility was not affected except slightly in male rats at 40 mg/kg whereas an embryotoxic or teratogenic potential in rats and rabbits was absent. Peri- and postnatal parameters in rats were not affected. In target animals, reproduction was extensively studied in bulls, rams and ewes showing no risk of closantel for reproduction parameters. A mutagenic potential was found to be absent in a Salmonella Ames test, a sex-linked recessive lethal test in Drosophila melanogaster and a dominant lethal test in male and female mice. In 400 mice and 400 rats closantel was shown not to be carcinogenic. Tolerance studies in sheep and cattle demonstrated that oral and parenteral clinical doses were very well tolerated and devoid of serious side-effects.

Spontaneous adenocarcinoma of the ascending colon in Wistar rats: the intracytoplasmic presence of a Campylobacter-like bacterium

Campylobacter-like bacteria were demonstrated in the neoplastic cells in 15 of 17 naturally occurring endophytic adenocarcinomas of the ascending colon in Wistar rats. These bacteria were also present in the cytoplasm in metastases in the regional lymph nodes. The microorganisms penetrated the epithelial layer and their presence was associated with a chronic productive inflammatory reaction. A possible causal association of Campylobacter-like organisms in carcinoma of the colon in man and in the Wistar rat is discussed.