Multimodal nocturnal seizure detection: do we need to adapt algorithms for children?

Objective

To assess the performance of a multimodal seizure detection device, first tested in adults (sensitivity 86%, PPV 49%), in a pediatric cohort living at home or residential care.

Methods

In this multicenter, prospective, video‐controlled cohort‐study, nocturnal seizures were detected by heartrate and movement changes in children with epilepsy and intellectual disability. Participants with a history of >1 monthly major motor seizure wore Nightwatch bracelet at night for 3 months. Major seizures were defined as tonic–clonic, generalized tonic >30 s, hyperkinetic, or clusters (>30 min) of short myoclonic or tonic seizures. The video of all events (alarms and nurse diaries) and about 10% of whole nights were reviewed to classify major seizures, and minor or no seizures.

Results

Twenty‐three participants with focal or generalized epilepsy and nightly motor seizures were evaluated during 1511 nights, with 1710 major seizures. First 1014 nights, 4189 alarms occurred with average of 1.44/h, showing average sensitivity of 79.9% (median 75.4%) with mean PPV of 26.7% (median 11.1%) and false alarm rate of 0.2/hour. Over 90% of false alarms in children was due to heart rate (HR) part of the detection algorithm. To improve this rate, an adaptation was made such that the alarm was only triggered when the wearer was in horizontal position. For the remaining 497 nights, this was tested prospectively, 384 major seizures occurred. This resulted in mean PPV of 55.5% (median 58.1%) and a false alarm rate 0.08/h while maintaining a comparable mean sensitivity of 79.4% (median 93.2%).

Significance

Seizure detection devices that are used in bed which depend on heartrate and movement show similar sensitivity in children and adults. However, children do show general higher false alarm rate, mostly triggered while awake. By correcting for body position, the false alarms can be limited to a level that comes close to that in adults.

Cancer cachexia in adult patients: ESMO Clinical Practice Guidelines☆

•This ESMO Clinical Practice Guideline provides key recommendations for managing cancer-related cachexia. •It covers screening, assessment and multimodal management of cancer cachexia. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the author's expert opinion.

Current practice in nutrition after allogeneic hematopoietic stem cell transplantation - Results from a survey among hematopoietic stem cell transplant centers

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (alloHSCT) is frequently associated with impaired oral intake and malnutrition, which potentially increases morbidity and mortality. Therefore, nutrition is one of the major challenges in the post-transplant period.

METHODS

To document the current clinical approach in nutritional treatment, we designed a questionnaire concerning the current practice in nutrition after alloHSCT and distributed it to German speaking centers performing alloHSCT in Germany, Austria and Switzerland between November 2018 and March 2020. Twenty-eight (39%) of 72 contacted centers completed the survey, 23 from Germany, two from Austria and three from Switzerland, representing 50% of alloHSCT activity within the participating countries in 2018.

RESULTS

All centers reported having nutritional guidelines for patients undergoing alloHSCT, whereby 86% (n = 24) provided a low-microbial diet during the neutropenic phase. The criteria to start parenteral nutrition (PN) directly after alloHSCT seemed to be consistent, 75% (n = 21) of the corresponding centers started PN if the oral nutritional intake or the bodyweight dropped below a certain limit. In the setting of intestinal graft-versus-host disease (GvHD) the current practice appeared to be more heterogenous. About 64% (n = 18) of the centers followed a special diet, added food stepwise modulated by GvHD symptoms, while only four centers regularly stopped oral intake completely (intestinal GvHD grade >1). Half of the centers (54%, n = 15) applied a lactose-free diet, followed by 43% (n = 12) which provided fat- and 18% (n = 5) gluten-free food in patients with intestinal GvHD. Supplementation of micronutrients in acute intestinal GvHD patients was performed by 54% (n = 15) of the centers, whereas vitamin D (89%, n = 25) and vitamin B₁₂ (68%, n = 19) was added regularly independently of the presence of GvHD. Only 5 (18%) participating centers ever observed a food-associated infection during hospitalization, whereas food-associated infections were reported to occur more often in the outpatient setting (64%, n = 18).

CONCLUSION

The survey documented a general consensus about the need for nutritional guidelines for patients undergoing alloHSCT. However, the nutritional treatment in clinical practice (i.e. lactose-, gluten- or fat-free in intestinal GvHD) as well as the use of food supplements was very heterogeneous. In line with current general recommendations the centers seemed to focus on safe food handling practice rather than providing a strict neutropenic diet. More high-quality data are required to provide evidence-based nutrition to patients during and after alloHSCT.

P3669Impact of the endocarditis team on management strategies and mortality: the Dutch experience

Background

Infective endocarditis (IE) was associated with poor survival. In 2015, the European Society of Cardiology (ESC) introduced the multidisciplinary IE team to improve diagnostics, treatment and outcome in patients with IE.

Purpose

This study evaluated the clinical implementation of the IE team in the Netherlands.

Methods

Retrospective cohort of all IE patients diagnosed between 2012–2016 in a tertiary single center. Clinical characteristics, data on imaging techniques, surgical procedures, IE-related complications and all-cause mortality were collected. Differences before and after installation of the IE team in 2015 were analyzed.

Results

Overall, 257 IE patients were included with a minimal follow-up of 1 year. No significant differences in baseline characteristics or imaging method were observed. The annual incidence of IE gradually increased over time from 36 cases in 2012 to 50 cases in 2016. This was caused by an increase in native IE cases. No difference in mortality was observed before and after 2015 (22% vs. 26%, P=0.43).

After 2015, a reduction in hospitalization duration was observed (37 vs. 32 days; P=0.09) and median time to surgery had significantly decreased (18 vs. 8 days; P=0.01). Although an increase in congestive heart failure and valvulair abscess were observed a downtrend in acute renal failure (25% vs. 16%, P=0.08) was observed. Multivariate analysis demonstrated that age, COPD, diminished LV function and surgery were important predictors for mortality but not the IE team.

Conclusion(s)

The introduction of a multidisciplinary IE team led to earlier surgical intervention and was associated with a reduction in hospital duration but not an important predictor for mortality. These results are important in view of designing novel clinical trials.

The difficulty of diagnosing NCSE in clinical practice; external validation of the Salzburg criteria

To improve the diagnostic accuracy of electroencephalography (EEG) criteria for nonconvulsive status epilepticus (NCSE), external validation of the recently proposed Salzburg criteria is paramount. We performed an external, retrospective, diagnostic accuracy study of the Salzburg criteria, using EEG recordings from patients with and without a clinical suspicion of having NCSE. Of the 191 EEG recordings, 12 (12%) was classified as an NCSE according to the reference standard. In the validation cohort, sensitivity was 67% and specificity was 89%. The positive predictive value was 47% and the negative predictive value was 95%. Ten patients in the control group (n = 93) were false positive, resulting in a specificity of 89.2%. The interrater agreement between the reference standards and between the scorers of the Salzburg criteria was moderate; disagreement occurred mainly in patients with an epileptic encephalopathy. The Salzburg criteria showed a lower diagnostic accuracy in our external validation study than in the original design, suggesting that they cannot replace the current practice of careful weighing of both clinical and EEG information on an individual basis.

Social cognitive group treatment for impaired insight in psychosis: A multicenter randomized controlled trial

PURPOSE

The majority of people with schizophrenia has impaired insight, which is related to a poorer outcome. In this study, we evaluate a new psychosocial intervention 'REFLEX' aimed at improving insight in people with schizophrenia. REFLEX focuses on targeting stigma-sensitivity, perspective taking and self-reflection in people with schizophrenia and low insight. Primary objective is to improve insight and subsequently to improve functional outcome and symptoms.

METHOD

A total of 121 people diagnosed with schizophrenia according to DSM IV criteria with impaired insight was included in 2012-2015 from seven sites in a multicenter randomized controlled trial. REFLEX was compared to an active control condition consisting of group-wise simplified cognitive remediation training. Primary outcome of the study were the preconditions of insight: internalized stigma, self-reflection, mental flexibility and perspective taking. Clinical insight and cognitive insight were secondary outcomes.

RESULTS

Although perspective taking, self-reflection, mental flexibility and stigma sensitivity remained unchanged after the intervention, results showed a significant improvement of clinical insight in both conditions directly after treatment (SAI-E Rater, p < .001, PANSS G12, p < .005) and at follow-up (SAI-E Rater, p < .01, SAI-E interview, p < .001, PANSS G12, p < .0001). Improvement of clinical insight directly after treatment was larger in the REFLEX condition (SAI-E Rater, p < .05). Other outcomes (self-esteem, quality of life and depression) remained unchanged.

CONCLUSION

Though insight improved in both conditions, REFLEX was not superior to simplified drill-and-practice cognitive remediation training. Nevertheless, this study indicates that structured interventions can significantly improve insight. Further research on the underlying mechanisms of both conditions is needed, as insight is unlikely to improve spontaneously in chronic patients.

Design and methods of the 'monitoring outcomes of psychiatric pharmacotherapy' (MOPHAR) monitoring program - a study protocol

Background

At many outpatient departments for psychiatry worldwide, standardized monitoring of the safety of prescribed psychotropic drugs is not routinely performed in daily clinical practice. Therefore it is unclear to which extent the drugs used by psychiatric outpatients are prescribed effectively and safely. These issues warrant structured monitoring of medication use, (pre-existing) co-morbidities, effectiveness and side effects during psychiatric outpatient treatment. Improvement of monitoring practices provides an opportunity to ensure that somatic complications and adverse drug effects are detected and dealt with in a timely manner. Structural support for data collection and follow-up tests seems essential for improvement of monitoring practices in psychiatric outpatients. The implementation of a structured somatic monitoring program as part of routine clinical practice, as we describe in this study protocol, may be a solution.

Methods

In order to address these issues, we developed the innovative program ‘Monitoring Outcomes of Psychiatric Pharmacotherapy (MOPHAR)’. MOPHAR is an infrastructure for implementation of standardized routine outcome monitoring (ROM; including standardized monitoring of treatment effect), monitoring of adverse psychotropic medication effects in psychiatric outpatients, encompassing both somatic adverse effects (e.g. metabolic disturbances) and subjective adverse effects (e.g. sedation or sexual side effects) and medication reconciliation.

Discussion

In the MOPHAR monitoring program, a nurse performs general and psychotropic drug-specific somatic screenings and provides the treating mental health care providers with more and better information on somatic monitoring for treatment decisions. Given our experience regarding implementation of the MOPHAR program, we expect that the MOPHAR program is feasible and beneficial for patients in any MHS organisation. This paper describes the objectives, target population, setting and the composition and roles of the treatment team. It also indicates what measurements are performed at which time points during outpatient treatment in the MOPHAR monitoring program, as well as the research aspects of this project.

Trial registration

MOPHAR research has been prospectively registered with the Netherlands Trial Register on 19th of November 2014. (NL4779).

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3951-2) contains supplementary material, which is available to authorized users.

Prevalence Rate and Risk Factors of Victimization in Adult Patients With a Psychotic Disorder: A Systematic Review and Meta-analysis

Psychotic disorders often have been linked with violence. However, studies have shown that people with a psychotic disorder are more often victim than perpetrator of violence. The objective of this meta-analysis was to review prevalence rates for different types of victimization and to identify risk factors associated with victimization. Based on a search in MEDLINE, PsycINFO, and Web of Science, 27 studies were found with samples consisting of adults with a psychotic disorder and possible victimization occurring during adulthood and data on "violent victimization," "sexual victimization," "non-violent victimization," and/or "victimization not otherwise specified." The median prevalence rate for violent victimization was 20%, for sexual victimization 20%, nonviolent victimization 19%, and for victimization not otherwise specified 19%. Victimization rates were approximately 4-6 times higher than in the general community. Meta-analyses showed the following significant risk factors: delusion (OR = 1.69), hallucinations (OR = 1.70), manic symptoms (OR = 1.66), drugs (OR = 1.90) or alcohol abuse (OR = 2.05), perpetration of a crime (OR = 4.33), unemployment (OR = 1.31), and homelessness (OR = 2.49). Other risk factors like previous victimization, impaired social functioning, personality disorder, and living in a disadvantaged neighborhood were found only in 1 or 2 studies. Based on the results, we conclude that, depending on the examined time period, 1 in 5 (assessment period ≤3 y) or 1 in 3 (assessment period entire adulthood) people with a psychotic disorder was victim of a crime. Clinical, behavioral, and sociodemographic factors were significantly associated with victimization, as well as previous victimization. Prospective research into risk factors is needed to capture causal trajectories of victimization.

Epileptic seizures associated with syncope: Ictal bradycardia and ictal asystole

INTRODUCTION

Heart rate decrease during epileptic seizures is rare and should be considered in patients with unusual or refractory episodes of syncope or in patients with a history suggestive of both epilepsy and syncope. We systematically reviewed the literature to better understand the clinical signs and risk factors of ictal heart rate decreases.

MATERIAL AND METHODS

We performed a literature-search on "ictal bradycardia" and "ictal asystole" in Pubmed and added papers from the references and personal archives. Articles relating to animal studies, seizures without ictal decrease of heart rate, cases without simultaneous electroencephalography (EEG) and electrocardiography (ECG), convulsive syncopes, or cases with bradycardia before seizure onset and articles written in other languages than English, Dutch, German, French, or Spanish were excluded. Full texts of the remaining articles were screened for cases of ictal bradycardia or ictal asystole. Cases were selected on the basis of a self-designed quality score. The relationship of RR wave interval of at least 5 s, signs of syncope, and EEG signs of ischemia were analyzed with chi-square test and identifying 95% confidence intervals.

RESULTS

Ictal bradycardia and ictal asystole predominantly occurred during focal seizures with loss of awareness (proportion in the combined group of bradycardia and asystole (p1 + 2) = 0.85) in people with mainly left lateralized (p1 + 2 = 0.64; p = 0.001) temporal lobe seizures (p1 + 2 = 0.91). Seizures with ictal asystole typically started with a heart rate decrease. During ictal asystole in the majority of cases, not only the clinical signs of syncope occurred (change of proportion (Δp) = 0.67; 95% CI: 0.48-0.86; p < 0.0001), i.e., interrupting the seizure semiology, but also the characteristic EEG signs of ischemia (Δp = 0.50; 95% CI: 0.26-0.74; p < 0.001). We found a statistically significant relation between signs of syncope and EEG signs of ischemia (Δp = -0.37; 95% CI: (-0.64)-(-0.10); p < 0.01) but not between duration of asystole (5 s) and either signs of syncope (Δp = -0.36; 95% CI: (-0.77)-0.05; p = 0.03) or EEG signs of ischemia (Δp = -0.37; 95% CI: (-1.07)-0.33; p = 0.16).

CONCLUSION

In the ictal bradycardia syndrome, signs of syncope disrupt the semiology of ongoing seizures and are associated with EEG signs of brain ischemia and the duration of the cardiac arrhythmia.

Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia

BACKGROUND

Impaired metacognition is associated with difficulties in the daily functioning of people with psychosis. Metacognition can be divided into four domains: Self-Reflection, Understanding the Other's Mind, Decentration, and Mastery. This study investigated whether Metacognitive Reflection and Insight Therapy (MERIT) can be used to improve metacognition.

METHODS

This study is a randomized controlled trial. Patients in the active condition (n = 35) received forty MERIT sessions, the control group (n = 35) received treatment as usual. Multilevel intention-to-treat and completers analyses were performed for metacognition and secondary outcomes (psychotic symptomatology, cognitive insight, Theory of Mind, empathy, depression, self-stigma, quality of life, social functioning, and work readiness).

RESULTS

Eighteen out of 35 participants finished treatment, half the drop-out stemmed from therapist attrition (N = 5) or before the first session (N = 4). Intention-to-treat analysis demonstrated that in both groups metacognition improved between pre- and post-measurements, with no significant differences between the groups. Patients who received MERIT continued to improve, while the control group returned to baseline, leading to significant differences at follow-up. Completers analysis (18/35) showed improvements on the Metacognition Assessment Scale (MAS-A) scales Self Reflectivity and metacognitive Mastery at follow-up. No effects were found on secondary outcomes.

CONCLUSIONS

On average, participants in the MERIT group were, based on MAS-A scores, at follow-up more likely to recognize their thoughts as changeable rather than as facts. MERIT might be useful for patients whose self-reflection is too limited to benefit from other therapies. Given how no changes were found in secondary measures, further research is needed. Limitations and suggestions for future research are discussed.

Multimodal nocturnal seizure detection in a residential care setting: A long-term prospective trial

Objective

To develop and prospectively evaluate a method of epileptic seizure detection combining heart rate and movement.

Methods

In this multicenter, in-home, prospective, video-controlled cohort study, nocturnal seizures were detected by heart rate (photoplethysmography) or movement (3-D accelerometry) in persons with epilepsy and intellectual disability. Participants with >1 monthly major seizure wore a bracelet (Nightwatch) on the upper arm at night for 2 to 3 months. Major seizures were tonic-clonic, generalized tonic >30 seconds, hyperkinetic, or others, including clusters (>30 minutes) of short myoclonic/tonic seizures. The video of all events (alarms, nurse diaries) and 10% completely screened nights were reviewed to classify major (needing an alarm), minor (needing no alarm), or no seizure. Reliability was tested by interobserver agreement. We determined device performance, compared it to a bed sensor (Emfit), and evaluated the caregivers’ user experience.

Results

Twenty-eight of 34 admitted participants (1,826 nights, 809 major seizures) completed the study. Interobserver agreement (major/no major seizures) was 0.77 (95% confidence interval [CI] 0.65–0.89). Median sensitivity per participant amounted to 86% (95% CI 77%–93%); the false-negative alarm rate was 0.03 per night (95% CI 0.01–0.05); and the positive predictive value was 49% (95% CI 33%–64%). The multimodal sensor showed a better sensitivity than the bed sensor (n = 14, median difference 58%, 95% CI 39%–80%, p < 0.001). The caregivers' questionnaire (n = 33) indicated good sensor acceptance and usability according to 28 and 27 participants, respectively.

Conclusion

Combining heart rate and movement resulted in reliable detection of a broad range of nocturnal seizures.

Towards a comprehensive routine outcome monitoring program for people with psychotic disorders: The Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS)

BACKGROUND

Patients with psychotic disorders are at risk of developing mental health and social problems, and physical disorders. To monitor and treat these problems when indicated, an annual routine outcome monitoring program, Pharmacotherapy Monitoring and Outcome Survey (PHAMOUS), was developed. This paper presents the background and content of PHAMOUS, implementation of PHAMOUS, characteristics of the patients screened in 2015, and the outcome of patients with three annual screenings between 2011 and 2015.

METHODS

PHAMOUS was implemented in four mental health institutions in the Northern Netherlands in 2006. During the PHAMOUS screening, patients are assessed on socio-demographics, psychiatric symptoms, medication, physical parameters, lifestyle, (psycho)social functioning and quality of life, using internationally validated instruments.

RESULTS

In 2015, 1955 patients with psychotic disorders were enrolled in the PHAMOUS screening. The majority (72%) was receiving mental healthcare for ten years or longer. A small group was hospitalized (10%) in the past year. Half of the patients were in symptomatic remission. Less than 10% had a paid job. More than half of the patients fulfilled the criteria for metabolic syndrome (54%). The subsample with three annual screenings from 2011 to 2015 (N = 1230) was stable, except the increasing prevalence of high glucose levels and satisfaction with social relationships (Cochran's Q = 16.33, p = .001 resp. Q = 14.79, p = .001).

CONCLUSION

The annual PHAMOUS screening enables to follow the mental, physical and social health problems of patients, which offers a good basis for shared-decision making with regard to updating the annual treatment plan, next to a wealth of data for scientific research.

Systematic review and meta-analysis of the evidence for oral nutritional intervention on nutritional and clinical outcomes during chemo(radio)therapy: current evidence and guidance for design of future trials

Background

Driven by reduced nutritional intakes and metabolic alterations, malnutrition in cancer patients adversely affects quality of life, treatment tolerance and survival. We examined evidence for oral nutritional interventions during chemo(radio)therapy.

Design

We carried out a systematic review of randomized controlled trials (RCT) with either dietary counseling (DC), high-energy oral nutritional supplements (ONS) aiming at improving intakes or ONS enriched with protein and n-3 polyunsaturated fatty acids (PUFA) additionally aiming for modulation of cancer-related metabolic alterations. Meta-analyses were carried out on body weight (BW) response to nutritional interventions, with subgroup analyses for DC and/or high-energy ONS or high-protein n-3 PUFA-enriched ONS.

Results

Eleven studies were identified. Meta-analysis showed overall benefit of interventions on BW during chemo(radio)therapy (+1.31 kg, 95% CI 0.24-2.38, P = 0.02, heterogeneity Q = 21.1, P = 0.007). Subgroup analysis showed no effect of DC and/or high-energy ONS (+0.80 kg, 95% CI -1.14 to 2.74, P = 0.32; Q = 10.5, P = 0.03), possibly due to limited compliance and intakes falling short of intake goals. A significant effect was observed for high-protein n-3 PUFA-enriched intervention compared with isocaloric controls (+1.89 kg, 95% CI 0.51-3.27, P = 0.02; Q = 3.1 P = 0.37). High-protein, n-3 PUFA-enriched ONS studies showed attenuation of lean body mass loss (N = 2 studies) and improvement of some quality of life domains (N = 3 studies). Overall, studies were limited in number, heterogeneous, and inadequately powered to show effects on treatment toxicity or survival.

Conclusion

This systematic review suggests an overall positive effect of nutritional interventions during chemo(radio)therapy on BW. Subgroup analyses showed effects were driven by high-protein n-3 PUFA-enriched ONS, suggesting the benefit of targeting metabolic alterations. DC and/or high-energy ONS were less effective, likely due to cumulative caloric deficits despite interventions. We highlight the need and provide recommendations for well-designed RCT to determine the effect of nutritional interventions on clinical outcomes, with specific focus on reaching nutritional goals and providing the right nutrients, as part of an integral supportive care approach.

ESPEN expert group recommendations for action against cancer-related malnutrition

Patients with cancer are at particularly high risk for malnutrition because both the disease and its treatments threaten their nutritional status. Yet cancer-related nutritional risk is sometimes overlooked or under-treated by clinicians, patients, and their families. The European Society for Clinical Nutrition and Metabolism (ESPEN) recently published evidence-based guidelines for nutritional care in patients with cancer. In further support of these guidelines, an ESPEN oncology expert group met for a Cancer and Nutrition Workshop in Berlin on October 24 and 25, 2016. The group examined the causes and consequences of cancer-related malnutrition, reviewed treatment approaches currently available, and built the rationale and impetus for clinicians involved with care of patients with cancer to take actions that facilitate nutrition support in practice. The content of this position paper is based on presentations and discussions at the Berlin meeting. The expert group emphasized 3 key steps to update nutritional care for people with cancer: (1) screen all patients with cancer for nutritional risk early in the course of their care, regardless of body mass index and weight history; (2) expand nutrition-related assessment practices to include measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure, and physical function; (3) use multimodal nutritional interventions with individualized plans, including care focused on increasing nutritional intake, lessening inflammation and hypermetabolic stress, and increasing physical activity.

Multimodal, automated detection of nocturnal motor seizures at home: Is a reliable seizure detector feasible?

Objective

Automated seizure detection and alarming could improve quality of life and potentially prevent sudden, unexpected death in patients with severe epilepsy. As currently available systems focus on tonic–clonic seizures, we want to detect a broader range of seizure types, including tonic, hypermotor, and clusters of seizures.

Methods

In this multicenter, prospective cohort study, the nonelectroencephalographic (non‐EEG) signals heart rate and accelerometry were measured during the night in patients undergoing a diagnostic video‐EEG examination. Based on clinical video‐EEG data, seizures were classified and categorized as clinically urgent or not. Seizures included for analysis were tonic, tonic–clonic, hypermotor, and clusters of short myoclonic/tonic seizures. Features reflecting physiological changes in heart rate and movement were extracted. Detection algorithms were developed based on stepwise fulfillment of conditions during increases in either feature. A training set was used for development of algorithms, and an independent test set was used for assessing performance.

Results

Ninety‐five patients were included, but due to sensor failures, data from only 43 (of whom 23 patients had 86 seizures, representing 402 h of data) could be used for analysis. The algorithms yield acceptable sensitivities, especially for clinically urgent seizures (sensitivity = 71–87%), but produce high false alarm rates (2.3–5.7 per night, positive predictive value = 25–43%). There was a large variation in the number of false alarms per patient.

Significance

It seems feasible to develop a detector with high sensitivity, but false alarm rates are too high for use in clinical practice. For further optimization, personalization of algorithms may be necessary.

Treatment of negative symptoms: Where do we stand, and where do we go?

Negative symptoms, e.g. social withdrawal, reduced initiative, anhedonia and affective flattening, are notoriously difficult to treat. In this review, we take stock of recent research into treatment of negative symptoms by summarizing psychosocial as well as pharmacological and other biological treatment strategies. Major psychosocial approaches concern social skills training, cognitive behavior therapy for psychosis, cognitive remediation and family intervention. Some positive findings have been reported, with the most robust improvements observed for social skills training. Although cognitive behavior therapy shows significant effects for negative symptoms as a secondary outcome measure, there is a lack of data to allow for definite conclusions of its effectiveness for patients with predominant negative symptoms. With regard to pharmacological interventions, antipsychotics have been shown to improve negative symptoms, but this seems to be limited to secondary negative symptoms in acute patients. It has also been suggested that antipsychotics may aggravate negative symptoms. Recent studies have investigated glutamatergic compounds, e.g. glycine receptor inhibitors and drugs that target the NMDA receptor or metabotropic glutamate 2/3 (mGlu2/3) receptor, but no consistent evidence of improvement of negative symptoms was found. Finally, some small studies have suggested improvement of negative symptoms after non-invasive electromagnetic neurostimulation, but this has only been partly replicated and it is still unclear whether these are robust improvements. We address methodological issues, in particular the heterogeneity of negative symptoms and treatment response, and suggest avenues for future research. There is a need for more detailed studies that focus on different dimensions of negative symptoms.

The Application of in Vitro Models to Research on Demineralization and Remineralization of the Teeth: Reaction Paper

Despite the advantages of in situ model studies, in vitro models are most important to provide insight into the mechanism of dental caries, the mechanisms of fluoride action, and profile screening.

In this reaction paper following Dr. White's review, the emphasis is, first, on the role of mobile fluoride (FL) in fluoride efficacy, the formation of "CaF2-like" material as fluoride reaction product, and on fluoride reaction product localization. Second, mineral assessment techniques are discussed. Finally, the main differences between caries lesion formation in vitro and in situ are considered.

Deposit Formation on Prosthetic Materials in Vivo After One Year: a Quantitative Study of Twelve Materials

In vivo-formed deposits on prosthetic materials are of considerable interest. Deposit quantification is important to gain insight into the mechanisms of formation and removal.

A new method is presented for the quantitative investigation of deposit formation in vivo on 12 experimental materials after one year. The parameter assessed is the deposition parameter, D, the fraction of the surface covered by deposits. The materials were arranged in a given sequence in the prosthesis flanges and carried in two investigations by 11 and 20 participants for one year.

The results show that the parameter D is strongly material-, participant-, and site-dependent. Differences between materials varied by a factor of at least 25; PMMA (Polymethylmethacrylate) was always lowest in D value. The D values in the upper prosthesis were always larger than in the lower prosthesis; the ratio Dupper /D lower was 2.3 ± 0.5.

The material parameters strongly influencing the deposit formation were of both the monomer and the filler type. Attempts were made to correlate D with surface hardness, surface roughness, and water absorption. Only the last parameter was clearly linearly related to D.

LASMA (Laser Mass Spectrometry) studies showed that the chemical nature of the deposits formed in vivo on prosthetic materials is. in general, initially different from that of calculus.

Review of Fluoride Release and Secondary Caries Reduction by Fluoridating Composites

Secondary caries is one of the main reasons to replace restorations. Due to the pressure to eliminate or reduce the number of amalgam restorations in many countries, fluoride-releasing composites have gained in importance. This review limits itself to information relevant to secondary caries near fluoride-releasing anterior or posterior composites. Although many parameters are very important in composite functioning, a weak spot near a filling is always the interface and the locally present interfacial gap between the composite and the hard tissues, where secondary caries takes place due to plaque action. Relevant parameters such as the amount of fluoride released in vitro in μg.cm-2, the rate of fluoride release, and the period of fluoride release are compared for several composites. In vitro F release has been measured for some fluoridating composites for more than five years. Unfortunately, F release in vivo or in situ cannot be measured adequately.

The fluoride released by the composites considered is partly taken up by the surrounding tissues, partly released to the saliva, and partly efficacious in possible marginal gaps and defects. A major part of this paper pertains to in vitro, in situ, and in vivo secondary caries reduction experiments. In vitro caries reductions in the order of 40% from F-releasing composites vs. controls have been found. In in situ model investigations under plaque and saliva conditions, secondary caries reduction percentages of between 40 and 50% have been experimentally measured in gaps in enamel near F composites.

Surface Changes of Fluoride-Releasing Composites: a Comparison of in Vivo and in Vitro Results

Fluoride-releasing composites lose fluoride very slowly over time. An interesting question is the possible change in mechanical properties related to the F release. If this happens, it might be expected that the mechanical properties of the outer surface of a fluoridating composite are affected first. The purpose of this study was to investigate in vivo and in vitro the changes in surface microhardness and surface structure of three fluoride-releasing composites and a non-F-containing control after 28 days. In the in vitro experiment, the composites were stored in tap water at 37°C. The results show that all composites stored in water were significantly softened after 28 days.

In vivo, however, a very different picture emerged: The surface microhardness of the fluoride-releasing composites did not change significantly. In vitro, the data indicate that the amount of softening of the fluoridating composites is related to the amount of fluoride released. No relation was found between the amount of F released in one month in vitro and the microhardness changes in vivo. SEM micrographs of fluoridating composites do not reflect the microhardness changes mentioned.

Recording system and data fusion algorithm for enhancing the estimation of the respiratory rate from photoplethysmogram

The respiratory rate is a vital parameter that can provide valuable information about the health condition of a patient. The extraction of respiratory information from photoplethysmographic signal (PPG) was actually encouraged by the reported results, our main goal being to obtain accurate respiratory rate estimation from the PPG signal. We developed a fusion algorithm that identifies the best derived respiratory signals, from which is possible to extract the respiratory rate; based on these, a global respiratory rate is computed using the proposed fusion algorithm. The algorithm is qualitatively tested on real PPG signals recorded by an acquisition system we implemented, using a reflection pulse oximeter sensor. Its performance is also statistically evaluated using benchmark dataset publically available from CapnoBase.Org.

BEATVIC, a body-oriented resilience training with elements of kickboxing for individuals with a psychotic disorder: study protocol of a multi-center RCT

BACKGROUND

Individuals with a psychotic disorder are at an increased risk of becoming victim of a crime or other forms of aggression. Research has revealed several possible risk factors (e.g. impaired social cognition, aggression regulation problems, assertiveness, self-stigma, self-esteem) for victimization in patients with a psychotic disorder. To address these risk factors and prevent victimization, we developed a body-oriented resilience training with elements of kickboxing: BEATVIC. The present study aims to evaluate the effectiveness of the intervention.

METHODS/DESIGN

Seven mental health institutions in the Netherlands will participate in this study. Participants will be randomly assigned to either the BEATVIC training or the control condition: social activation. Follow-ups are at 6, 18 and 30 months. Short term effects on risk factors for victimization will be examined, since these are direct targets of the intervention and are thought to be mediators of victimization, the primary outcome of the intervention. The effect on victimization will be investigated at follow-up. In a subgroup of patients, fMRI scans will be made before and after the intervention period in order to assess potential neural changes associated with the effects of the training.

DISCUSSION

This study is the first to examine the effectiveness of an intervention targeted at victimization in psychosis. Methodological issues of the study are addressed in the discussion of this paper.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN21423535 . Retrospectively registered 30-03-2016.

Treatment of negative symptoms: Where do we stand, and where do we go?

Negative symptoms, e.g. social withdrawal, reduced initiative, anhedonia and affective flattening, are notoriously difficult to treat. In this review, we take stock of recent research into treatment of negative symptoms by summarizing psychosocial as well as pharmacological and other biological treatment strategies. Major psychosocial approaches concern social skills training, cognitive behavior therapy for psychosis, cognitive remediation and family intervention. Some positive findings have been reported, with the most robust improvements observed for social skills training. Although cognitive behavior therapy shows significant effects for negative symptoms as a secondary outcome measure, there is a lack of data to allow for definite conclusions of its effectiveness for patients with predominant negative symptoms. With regard to pharmacological interventions, antipsychotics have been shown to improve negative symptoms, but this seems to be limited to secondary negative symptoms in acute patients. It has also been suggested that antipsychotics may aggravate negative symptoms. Recent studies have investigated glutamatergic compounds, e.g. glycine receptor inhibitors and drugs that target the NMDA receptor or metabotropic glutamate 2/3 (mGlu2/3) receptor, but no consistent evidence of improvement of negative symptoms was found. Finally, some small studies have suggested improvement of negative symptoms after non-invasive electromagnetic neurostimulation, but this has only been partly replicated and it is still unclear whether these are robust improvements. We address methodological issues, in particular the heterogeneity of negative symptoms and treatment response, and suggest avenues for future research. There is a need for more detailed studies that focus on different dimensions of negative symptoms.

Non-EEG based ambulatory seizure detection designed for home use: What is available and how will it influence epilepsy care?

OBJECTIVE

This study aimed to (1) evaluate available systems and algorithms for ambulatory automatic seizure detection and (2) discuss benefits and disadvantages of seizure detection in epilepsy care.

METHODS

PubMed and EMBASE were searched up to November 2014, using variations and synonyms of search terms "seizure prediction" OR "seizure detection" OR "seizures" AND "alarm".

RESULTS

Seventeen studies evaluated performance of devices and algorithms to detect seizures in a clinical setting. Algorithms detecting generalized tonic-clonic seizures (GTCSs) had varying sensitivities (11% to 100%) and false alarm rates (0.2-4/24 h). For other seizure types, detection rates were low, or devices produced many false alarms. Five studies externally validated the performance of four different devices for the detection of GTCSs. Two devices were promising in both children and adults: a mattress-based nocturnal seizure detector (sensitivity: 84.6% and 100%; false alarm rate: not reported) and a wrist-based detector (sensitivity: 89.7%; false alarm rate: 0.2/24 h).

SIGNIFICANCE

Detection of seizure types other than GTCSs is currently unreliable. Two detection devices for GTCSs provided promising results when externally validated in a clinical setting. However, these devices need to be evaluated in the home setting in order to establish their true value. Automatic seizure detection may help prevent sudden unexpected death in epilepsy or status epilepticus, provided the alarm is followed by an effective intervention. Accurate seizure detection may improve the quality of life (QoL) of subjects and caregivers by decreasing burden of seizure monitoring and may facilitate diagnostic monitoring in the home setting. Possible risks are occurrence of alarm fatigue and invasion of privacy. Moreover, an unexpectedly high seizure frequency might be detected for which there are no treatment options. We propose that future studies monitor benefits and disadvantages of seizure detection systems with particular emphasis on QoL, comfort, and privacy of subjects and impact of false alarms.

[Metacognition in psychotic disorders: from concepts to intervention]

BACKGROUND

Persons with a psychotic disorder commonly experience difficulties with what is considered to be metacognitive capacity. In this article we discuss several definitions of this concept, the measurement instruments involved and the clinical interventions that target this concept.

AIM

To present a review of various frequently used definitions of metacognition and related concepts and to describe the measurement instruments involved and the treatment options available for improving the metacognitive capacity of persons with a psychotic disorder.

METHOD

We present an overview of several definitions of metacognition in psychotic disorders and we discuss frequently used measurement instruments and treatment options. The article focuses on recent developments in a model devised by Semerari et al. The measurement instrument involved (Metacognition Assessment Scale - A) is discussed in terms of it being an addition to existing methods.

RESULTS

On the basis of the literature it appears that metacognition and related concepts are measurable constructs, although definitions and instruments vary considerably. The new conceptualisation of social information processing also leads to the development of a new form of psychotherapy that aims to help patients suffering from psychotic disorders to improve metacognitive capacity.

CONCLUSION

There seems to be evidence that metacognitive abilities are a possible target for treatment, but further research is needed.

Using photoplethysmography in heart rate monitoring of patients with epilepsy

Heart rate is a useful neurophysiological sign when monitoring seizures in patients with epilepsy. In an ambulatory setting, heart rate is measured with ECG involving electrodes on the skin. This method is uncomfortable which is burdensome for patients and is sensitive to motion artifacts, which decrease the usability of measurements. In this study, green light photoplethysmography, an optical technique arising from the fitness industry, was evaluated for usefulness in a medical setting. Simultaneous overnight measurements of HR with a commercially available optical heart rate (OHR) sensor and with ECG (HRECG) were performed in 7 patients with epilepsy. Overall, there was no significant difference between OHR and HRECG in random 10-minute periods during wakefulness (p=0.69) and sleep (p=1.00). The Bland-Altman analysis showed negligible mean differences. Limits of agreement were higher during wakefulness and during the occurrence of two seizures possibly because of less reliable HRECG measurements due to motion artifacts. Optical heart rate seems less sensitive to these motion artifacts, and measurements are more user-friendly. The optical heart rate sensor may fill the gap of systems for ambulatory heart rate monitoring and can be especially useful in the context of seizure detection in patients with epilepsy.

[Cost-effectiveness in Dutch mental health care: future because of ROM?]

BACKGROUND

The document reporting Dutch mental health care negotiations for 2014-2017 calls for a cost decrease based on cost-effectiveness. Thanks to ROM, the Dutch mental health care seems well prepared for cost-effectiveness research.

AIM

Evaluate how valid cost-effectiveness research should be established in mental health care and the role of rom therein.

METHOD

Evaluation of requirements of cost-effectiveness research, trends, and a translation to Dutch mental health care.

RESULTS

Valid cost-effectiveness research in mental health care requires the application of a societal perspective, a long time-horizon and an adequate evaluation of quality of life of patients. Healthcare consumption, outcome of care and characterisation of the patient population should be measured systematically and continuously. Currently, rom-data are not suitable to serve as a basis for cost-effectiveness research, although a proper basis is present. Further development of rom could lead to a situation in which mental health care is purchased on the basis of cost-effectiveness. However, cost-effectiveness will only really be improved if quality of care is rewarded, rather than rewarding activities that are not always related to outcome of care.

CONCLUSION

Cost-effectiveness research in mental health care should focus on societal costs and benefits, quality of life and a long time-horizon. If developed further, rom has the potential to be a basis for cost-effectiveness research in the future.

[Diagnosis of and therapy for hepatocellular carcinoma]

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence- and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

Cognitive effects of interictal epileptiform discharges in children

Frequent interictal epileptiform discharges (IEDs) may have effects on cognition. We analysed a group of 182 children with different epilepsy syndromes as well as children with IEDs without observed seizures [corrected], with 24-h ambulatory EEG and cognitive tests. The IED index was estimated, in wakefulness and in sleep, as percentage of time in five categories (0%, <1%, 1-10%, ≥10-50% and ≥50%). IEDs were defined as spikes or spike-wave complexes, isolated or occurring serially (in runs) without evident clinical signs of a seizure. The IED categories were correlated to cognitive test results and epilepsy characteristics. The group of patients with diurnal IEDs in ≥10% of the EEG record showed impaired central information processing speed, short-term verbal memory and visual-motor integration. This effect was seen independently from other EEG-related and epilepsy-related characteristics, and independently from epilepsy syndrome diagnosis. The impact of the nocturnal IEDs was of less importance; only contributing partially to the slowing of central information processing speed. We conclude that frequent IEDs (in more than 10% of the record) in the awake EEG can impair cognitive performance in children. Whether children with a high diurnal spike frequency and low seizure frequency can benefit from antiepileptic treatment should be examined in controlled trials.

The cognitive effects of interictal epileptiform EEG discharges and short nonconvulsive epileptic seizures

PURPOSE

Educational difficulties or even severe cognitive deterioration is seen in many childhood epilepsy syndromes. Many of those cognitive deficits are related directly to the brain disorder underlying the epilepsy syndrome. However, in other types of epilepsy, the epileptic seizures and/or epileptiform activity can be the dominant factor. This is especially unknown for the more "subtle" short nonconvulsive seizure types. For this reason, we analyzed a new cohort of children.

METHODS

A cross-sectional study of 188 children with epilepsy. Electroencephalography (EEG)-video recordings and cognitive testing were performed simultaneously. The results of children with short nonconvulsive seizures during a 2-h testing session were compared with all children with epilepsy without seizures during the 2-h cognitive testing session and with controls without epilepsy. In a second analysis the cognitive effects of frequency of epileptiform EEG discharges were analyzed.

KEY FINDINGS

The cognitive effects of short nonconvulsive seizures were large, ranging from 0.5 to 1 standard deviation and concerned global cognitive function, speed of central information processing, and memory function. In children without seizures during cognitive testing, the occurrence of frequent epileptiform discharges showed more subtle effects. These effects were independent from the occurrence of short nonconvulsive seizures.

SIGNIFICANCE

We concluded that although the effect is less pronounced in number of areas involved and magnitude, the type of association between frequent epileptiform activity (>1% of the time) and cognitive function in children with epilepsy is comparable to the association between short nonconvulsive seizures and cognitive function.

Obstructive sleep apnea in combat-related posttraumatic stress disorder: a controlled polysomnography study

BACKGROUND

Obstructive sleep apnea (OSA) may be highly prevalent in posttraumatic stress disorder (PTSD) and may exacerbate PTSD complaints.

OBJECTIVE

Our objective was to determine whether the prevalence of OSA was high in a sample of Dutch veterans with PTSD as compared to age- and trauma-matched controls, and whether OSA was associated with more severe PTSD complaints.

METHODS

We determined the apnea hypopnea indices (AHI) with polysomnographic registrations in 20 veterans with PTSD, 24 veterans without PTSD, and 17 healthy controls. PTSD severity and nightmare complaints were assessed with the Clinician-Administered PTSD Scale (CAPS).

RESULTS

The prevalence of an AHI>10 was 29% in PTSD, 21% in trauma controls, and 29% in healthy controls (χ(2)= 0.60, df=2, p=n.s.). The mean CAPS score in patients with OSA (n=6) was significantly higher than in patients without OSA (p<0.05), while nightmare severity was similar in PTSD patients with OSA as compared to PTSD patients without OSA (p=n.s.). Furthermore, there was a significant correlation between AHI and CAPS score in PTSD patients (r=0.46, p<0.05, df=14).

CONCLUSIONS

Our results indicate that PTSD is not necessarily associated with a higher prevalence of OSA. However, PTSD severity was related to OSA, which may possibly mean that comorbid OSA leads to an increase in PTSD complaints. However, future research should indicate whether OSA exerts a negative influence on PTSD, and treatment of OSA alleviates PTSD symptoms.

Decreased nocturnal growth hormone secretion and sleep fragmentation in combat-related posttraumatic stress disorder; potential predictors of impaired memory consolidation

BACKGROUND

Healthy sleep facilitates the consolidation of newly acquired memories. Although patients with posttraumatic stress disorder (PTSD) often complain of sleep disturbances and memory deficits, the interrelatedness of these symptoms is not well understood. Sleep may be disturbed in PTSD by increased awakenings during sleep, which has been associated with decreased growth hormone (GH) secretion. We conducted a controlled study in which we assessed sleep fragmentation, nocturnal secretion of GH, and memory consolidation in patients with PTSD.

METHODS

While sleep EEG was being monitored, 13 veterans with PTSD, 15 trauma controls (TC) and 15 healthy controls (HC) slept with an iv catheter, through which blood was collected every 20 min from 23:00 h to 08:00 h. Declarative memory encoding was assessed with the 15 word task before sleep, and consolidation was assessed the next morning by a free recall.

RESULTS

Sleep was more fragmented in patients with PTSD, with more awakenings in the first half of the night (p<0.05). Plasma levels of GH during the night were significantly decreased in PTSD compared with HC (p<0.05). Furthermore, GH secretion and awakenings were independent predictors for delayed recall, which was lower in PTSD compared to HC (p<0.05).

CONCLUSIONS

These data show that PTSD is associated with increased awakenings during sleep and decreased nocturnal GH secretion. Furthermore, decreased GH secretion may be related to sleep fragmentation and both variables may exert a negative effect on sleep dependent memory consolidation.

Association between the ROBO1 gene and body mass index in patients using antipsychotics

BACKGROUND

Weight gain is one of the major problems in patients using antipsychotic medication, leading to relevant morbidities and reduced compliance to pharmacotherapy. Recently, an association has been reported between a single nucleotide polymorphism (rs1455832) of the roundabout axon guidance receptor, homolog 1 (ROBO1) gene and body mass index (BMI) in persons younger than 30 years. The aim of this study is to investigate the association between BMI and rs1455832 in patients with a psychotic disorder using antipsychotics.

METHODS

A cross-sectional design was used in a pooled sample of Caucasian psychiatric patients obtained from three comparable Dutch psychiatric populations. Patients were eligible for inclusion in this study if they met the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for a nonaffective psychotic disorder, were 18 years or older, and used one or more antipsychotics. Genotyping was performed according to standard protocols. Linear (for BMI) and logistic (for obesity, defined as BMI > 30) regression analyses, corrected for age and sex, were applied in the statistical analyses.

RESULTS

A total of 435 patients were included in this association analyses. The rs1455832 polymorphism studied was significantly associated with BMI and obesity in female patients. Female patients had a statistically significant (P = 0.025) decrease of 1.76 kg/m in BMI values per C allele. In contrast to female patients, this association was not exhibited in male patients.

CONCLUSION

The rs1455832 polymorphism may play a role in inducing obesity in female patients using antipsychotics.

Vascular and pharmacokinetic effects of EndoTAG-1 in patients with advanced cancer and liver metastasis

BACKGROUND

EndoTAG-1 (ET), a novel formulation of cationic liposomes carrying embedded paclitaxel (Taxol), shows antitumoral activity, targeting tumor endothelial cells in solid tumors. Patients with advanced metastatic cancer were evaluated investigating effects on pharmacokinetics and tumor vasculature using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and contrast-enhanced ultrasound (CEUS).

PATIENTS AND METHODS

The pharmacokinetic (PK) profile of ET (22 mg/m(2) i.v.) was evaluated after single and repeated doses. DCE-MRI and CEUS explored hepatic metastases before, during and after the 4-week treatment cycle. Angiogenic biomarkers were assessed. Tumor response was evaluated by modified RECIST.

RESULTS

The PK profile demonstrated slight accumulation of paclitaxel after repeated doses. DCE-MRI parameters K(trans) and/or iAUC(60) showed a trend to decrease. Changes of blood flow-dependent parameters of DCE-MRI and CEUS were well correlated. Angiogenic biomarkers revealed no clear trend. ET was generally well tolerated; common toxic effects were fatigue and hypersensitivity reactions. Nine (9 of 18) patients had stable disease after the first treatment cycle. Four patients without disease progression continued treatment.

CONCLUSIONS

This study including multiple pretreated patients with different metastatic cancer revealed individually distinctive hemodynamic alterations by DCE-MRI. The PK profiles of ET were similar as observed previously.

Pleural effusion as a complication of clozapine treatment

Introduction

Clozapine treatment has been recognized as a superior treatment in schizophrenia. Clozapine treatment has also be accompanied with several rare but severe adverse events, like neutropenia, agranulocytosis, myocarditis, pericarditis and polyperositis. We report a patient that suffers from hyperleucocytemia, eosinophilia and pleuritis, due to clozapine treatment, the adverse events disappeared after a switch to aripiprazole.

Objectives

To review the literature on reports on pleuritis and polyserositis in order searching for guidance in these clinical situation, like the need tot interrupt the medication, the prognosis and if rechallenges are reported. Another objective was to discover if something is known about the underlying mechanism.

Methods

To review the literature, we used the following terms: clozapine, treatment, immunological reaction, neutropenia, leucopenia, epicarditis, polyserositis, pleuritis, pleural effusion, underlying mechanisms, risk factors.

A literature search was performed in Pubmed® and Embase Psychiatry® in the period longing from 1972 till October 2010

Results

Risk factors as well as the underlying mechanisms offer no guidance for dealing with the clinical critical situations.

There are only a few reports on pleural effusion, there are some reports on pleural effusion in combination with epicarditis, there are some reports on polyserositis including pleural effusion.

No rechallenges are reported of clozapine on pleural effusion.

There is no information in the literature on the risk that a pleuritis will extend to other organs, like the heart and the liver, when continuing the clozapine treatment.

Conclusion

Hypotheses about the underlying mechanism will be presented. A program of additional diagnostics will be described