Psychiatric patients' experiences in complementary and alternative medicine (CAM), and in religious support--a pilot study

In the Psychiatric Hospital "Vrapce" an investigation on a 200 patient sample was carried out in the year 2000. The purpose of the investigation was to analyze the examinees' experiences of complementary and alternative medicine (CAM) and religious support. 35.5% of the examinees had had previous experiences of CAM and religious support. The examinees born in towns used CAM methods and religious support significantly more often. The schizophrenic patients used CAM methods and religious support significantly more frequently than the patients with affective and anxiety disorders. Non-significantly more often CAM methods and religious support were utilized by women, examinees between 21 and 30 years of age, persons who graduated from junior college, those who live in cohabitation and patients of Islamic religion. Patients consulted priests most often. Significantly more often patients did not pay for the CAM treatments and religious support and non-significantly more often patients considered CAM therapy and religious support to be successful. Non-significantly more often patients consulted CAM practitioners and religious practitioners without being previously advised by their relatives or friends. Relatives ofthe patients advised them to consult CAM practitioners and religious practitioners significantly more often than the friends of the patients did. Considering the possible missed benefits and harm effects of CAM treatment as well as of the interaction between utilization of CAM methods/religious support and conventional treatment, this problem should be given full attention. Further investigations are required.     

Gezamenlijke besluitvorming zorgt voor een betere toepassing van evidence-based medicine in de geriatrische patiënt

Evidence based medicine (EBM) is the integration of the best research evidence, clinical expertise and patient values in the decision making process for patient care. However, elderly people are often excluded from participating in scientific studies and they often have multiple morbidities, which complicates the application of EBM. Shared decision making (SDM), a process where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve appropriate treatment can help to shape EBM for this group of patients.In this article, we provide tools for finding relevant literature for the geriatric patient population and for shaping the SDM process to achieve personalized care.     

Alexithymia,impulsiveness, emotion,and eating dyscontrol: similarities and differences between narcolepsy type 1 and type 2

Sleep and Biological Rhythms - Non-sleep symptoms, as depression, anxiety and overweight, are often encountered in narcoleptic patients. The purposes of this study are to evaluate mood,...     

Toxic shock syndrome in a patient with systemic lupus erythematosus.

A case is presented of toxic shock syndrome in a patient with systemic lupus erythematosus. Toxic shock syndrome is rarely reported in patients who are immunosuppressed, perhaps because such patients are often treated vigorously with antibiotics at the earliest sign of infection. The association in this case may have been coincidental.     

Five years of heartsink patients in general practice.

"Heartsink" patients exasperate, defeat, and overwhelm their doctors by their behaviour. A group of such patients was followed up over five years in a general practice, and this paper describes what happened to them. As a group they were often in employment and in stable relationships, though women were over represented. Half the group were subjected to a management plan which seemed to make them less heartsink over the five year period. While heartsink patients often have serious medical problems, they are a disparate group of individuals whose only common thread seems to be the distress they cause their doctor and the practice. Heartsink as a phenomenon has features that are unique to general practice.     

MANAGEMENT OF UPPER GASTROINTESTINAL HEMORRHAGE

In the past few years gastric resection has become the therapy of choice for patients with massive hemorrhage from duodenal ulcer. When this is done as an emergency procedure the ability of the surgeon is often taxed to the limit. Although sometimes easy, control is often extraordinarily difficult. Many important technical details must be considered in order to attain a successful outcome. This method of therapy has proved to be very satisfactory with patients who are in good condition for operation, and even in the poorer risks seen on ward service has resulted in a surgical mortality of only 7 per cent in all patients less than 60 years of age treated for this extremely severe type of hemorrhage. In the older age groups mortality rates still remain high.     

Use of 65-kDa mannoprotein gene primers for real-time identification of Candida albicans

Invasive candidiasis is associated with high morbidity and mortality, especially in immunocompromised patients. Early diagnosis is often difficult because most clinical signs and symptoms are nonspecific and blood cultures are often negative or become positive too late. Consequently, effective treatment is often delayed. Therefore, there has been an increased interest in the development of molecular-based technology in the diagnosis of invasive candidiasis. In this review, we compare molecular diagnostic tests currently adopted and those under evaluation. We highlight the advantages and the limitations of these methods for the diagnosis of invasive candidiasis. We also describe recent methods based on real time with primers of a gene coding for a 65-kDa mannoprotein of Candida albicans.     

The Executive and Neurosis

Executives are prone to overwork, to need to achieve and to need to compete. The dynamics responsible for this pattern were also the dynamics of the breakdown in 16 executives with neurosis. Overcompensation for inferiority feelings, often originating in low socioeconomic childhood background, and ambivalence to the father with repression of hostility were prominent, the main ego mechanisms of defence being repression and denial. The patients often attempted to turn psychotherapy into discussions and had difficulty in accepting a non-directive approach.     

Management of asymptomatic ventricular preexcitation

An incidental discovery of Wolff Parkinson White (WPW) pattern on the electrocardiogram (ECG) is not an infrequent finding facing the physician. Most patients discovered incidentally are asymptomatic and it is hard to justify further management of such patients given the time-honored adage to “first do no harm.” However, this finding does have implications. This article is an attempt to guide clinicians about this important issue that is often faced in the office.     

Cytologic diagnosis of the papillary variant of renal-cell carcinoma

The papillary variant of renal-cell carcinoma is characterized by distinctive histologic, clinical and angiographic features. A study was undertaken to delineate the cytologic features of this tumor as it is encountered in cellular samples. Cytologic specimens containing tumor cells from eight patients who underwent resection for papillary renal-cell carcinoma were examined and compared to corresponding cytologic samples obtained from ten other patients who had nonpapillary renal-cell carcinoma. The cytologic appearance of papillary renal-cell carcinoma, which is deceptively benign, is marked by distinctive papillary structures that often resemble branched chains. The cells are usually small and contain uniform nuclei; numerous macrophages with foamy cytoplasm are often found in the background. These cytologic features were not observed in the cellular specimens from the nonpapillary renal carcinomas. We conclude that papillary renal-cell carcinoma can be confidently recognized in cytologic specimens.     

Debate: A subversive view of subsets - a dissident clinician's opinion

Clinical trialists and statisticians are very wary of subgroup analysis, for good reasons. Clinicians have to deal with situations in which subgroups of patients differ widely from one another in their prognosis and response to treatment. Few trials are large enough to demonstrate convincingly these differences in outcome, but often provide suggestive evidence. Should we ignore this and treat all patients as the same, or should we allow dubious statistical evidence to buttress biological plausibility in making clinical decisions?     

Puberty in chronically diseased patients

Delayed onset of puberty and a reduced pubertal growth spurt are often reported in patients suffering from chronic diseases. The basis of abnormal puberty in these patients is multifactorial. Nutritional deficiency may contribute to growth disorders and delayed puberty. Insufficient food supply and/or eating disorders and/or malabsorption of nutrients can be observed in these patients. Moreover, increased energy supplies are often needed in patients with chronic lung disease, infection or inflammation. More specific factors due to the disease itself may be involved in growth and puberty disorders. Abnormalities of the growth hormone (GH)-insulin-like growth factor (IGF)1 axis and gonadotrophin secretion have been described in patients with chronic renal failure, cystic fibrosis and Crohn's disease. More recently, it has been shown that cytokines produced during chronic diseases such as juvenile idiopathic arthritis may affect the GH-IGF1 axis. Finally, concomitant medication, namely corticosteroids, which are often given to these patients, may contribute to delayed puberty and poor pubertal growth.     

Brief Psychotherapy: Current Status

In the past decade, stimulated by public concern with issues of mental health, there has been a new spurt of interest in techniques of brief treatment with circumscribed goals. These are applicable to groups as well as to the single patient. There are still differences of opinion about the effectiveness of brief psychotherapy, particularly the lastingness and depth of the results obtained, yet it is often highly beneficial, especially to previously well-functioning individuals who are involved in a situational crisis. Although probably the best results of brief psychotherapy are with disturbances of moderate severity and recent onset, in practice, it is often tried with a wide spectrum of patients. Brief psychotherapy aims at relief of the patient''s major current conflicts rather than at change of his personality structure, which generally requires long-term treatment. Brief psychotherapy is of special relevance for the general physician because the patients whom he sees in large numbers are precisely those best suited for this form of treatment.     

Preventing progression in men with mild symptoms of benign prostatic hyperplasia: a potential role for phytotherapy

Prevalence of benign prostate hyperplasia (BPH) is increasing with the aging population worldwide. Throughout the 20th century, men with minimally symptomatic BPH were generally advised to defer treatment. Treatment deferral or watchful waiting has always appeared reasonable because mild lower urinary tract symptoms suggestive of bladder outlet obstruction are not bothersome and are often regarded as part of the aging process, progression is usually slow, and symptoms often regress spontaneously. This review examines the evidence of the natural history of BPH, highlighting the group of patients with mild symptoms, the risk factors for progression, and the potential role of phytotherapy in this group of men.     

Leveraging external knowledge on molecular interactions in classification methods for risk prediction of patients

Classification of patients based on molecular markers, for example into different risk groups, is a modern field in medical research. The aim of this classification is often a better diagnosis or individualized therapy. The search for molecular markers often utilizes extremely high-dimensional data sets (e.g. gene-expression microarrays). However, in situations where the number of measured markers (genes) is intrinsically higher than the number of available patients, standard methods from statistical learning fail to deal correctly with this so-called "curse of dimensionality". Also feature or dimension reduction techniques based on statistical models promise only limited success. Several recent methods explore ideas of how to quantify and incorporate biological prior knowledge of molecular interactions and known cellular processes into the feature selection process. This article aims to give an overview of such current methods as well as the databases, where this external knowledge can be obtained from. For illustration, two recent methods are compared in detail, a feature selection approach for support vector machines as well as a boosting approach for regression models. As a practical example, data on patients with acute lymphoblastic leukemia are considered, where the binary endpoint "relapse within first year" should be predicted.     

“Ik kan mijn acceptgiro niet meer invullen”

Visual problems occur frequently in elderly patients and are often caused by ophthalmological problems. In this clinical lesson we show that visual problems can also be caused by posterior cortical atrophy (PCA). PCA is a clinico-radiological syndrome that is often caused by Alzheimer’s disease and other neurodegenerative diseases as Lewy body dementia and corticobasal degeneration. It is characterized by progressive decline in visual information processing. In addition, there is relative retention of memory and language in early stages. Brain imaging shows atrophy of the posterior brain areas.     

Impact of Dental Atmosphere and Behaviour of the Dentist on Children’s Cooperation

During dental treatment children are usually under psychological pressure. With the Sarnat Behaviour Score five different types of patients can be distinguished. There is no method that measures the impact of dental atmosphere and dentist's behaviour on the young patients' readiness to cooperate. The objective of the present study was the implementation and evaluation of a questionnaire on this subject. Eighty-eight patients participated in this study. In the first part of the new questionnaire personal information was collected. The second part consists of 43 items and investigates the relationship between dentist and patient and reflects the atmosphere of the environment. Statistical analysis was performed using the Chi-square test. There were statistically significant differences between the cooperative and non-cooperative group, as regards the perceived honesty of the dentist, the ability to explain and wish to help. Uncooperative children are significantly more often afraid of the dental environment. Sympathy alone has only a minor effect on children's cooperation. Children should be treated with empathy. Especially younger patients appreciate detailed explanations by the dentist. Children's non-cooperative behaviour results often from their aroused interest in the unknown environment, which causes an unpleasant perception of the whole setting.     

Psychosocial and legal aspects of oncological treatment in patients with cognitive impairment

With society getting older and affected by many diseases, more and more people suffer from severe cognitive disorders. As practice shows, the legal situations of such people is often problematic. This is due to a number of factors, such as short time since the deterioration of patient''s condition, initial symptoms ignored, social prejudice towards the idea of incapacitation or taking decisions for a patient, complicated procedures and, sometimes, insufficient knowledge of legal regulations. Cognitive disorders also occur in patients treated for cancer. To be effective, oncological treatment needs to be started as early as possible. This, however, does not meet the criteria of sudden threat to life. The present article relates to both the psychosocial and legal aspects of care of people suffering from intense disorders of memory, attention, problem solving, executive functions, and other. Surely, physicians know how to handle patients with the above dysfunctions. However, legal procedures aimed to protect patients’ rights are often unclear and time consuming. In practice, this often amounts to a dilemma whether to treat or follow the applicable law. Certainly, solutions in this regard should be clearer and better adapted to the needs arising from specific treatment needs of particular groups of patients.     

Burying our mistakes: Dealing with prognostic uncertainty after severe brain injury

Prognosis after severe brain injury is highly uncertain, and decisions to withhold or withdraw life-sustaining treatment are often made prematurely. These decisions are often driven by a desire to avoid a situation where the patient becomes ‘trapped’ in a condition they would find unacceptable. However, this means that a proportion of patients who would have gone on to make a good recovery, are allowed to die. I propose a shift in practice towards the routine provision of aggressive care, even in cases where the probability of survival and acceptable recovery is thought to be low. In conjunction with this shift, I argue in favour of a presumption towards withdrawing life-sustaining treatment, including artificial nutrition and hydration, when it becomes clear that a patient will not recover to a level that would be acceptable to them. I then respond to three potential objections to this proposal.     

Nasal reconstruction with full-thickness cranial bone grafts and rigid internal skeleton fixation through a coronal incision

The use of iliac and rib bone as onlay grafts to the nasal dorsum often fails because endochondral grafts resorb unpredictably. Membranous cranial bone grafts are less likely to resorb, especially when used with rigid internal fixation techniques. However, when split, they are often too thin and can be difficult to contour. Full-thickness cranial bone grafts were used to achieve nasal augmentation in 26 patients with end-stage nasal skeleton deficiency. All procedures were carried out using only a coronal incision. Grafts were harvested through a craniotomy, carved meticulously, and secured rigidly with miniplates or bicortical screws. Donor sites were reconstructed with split cranial grafts, leaving an intact cranial vault. No graft was lost to infection, and there was no significant donor-site morbidity. In carefully selected patients this method of full-thickness cranial bone graft reconstruction yields good results.