Search

Background: Substance abuse is an important risk factor for (violent) offending, but is mostly studied in male populations. More knowledge about women is needed.
AIM: To gain insight into possible gender differences in substance abuse and offending in forensic psychiatric patients.
METHOD: Files were analysed of 275 women and 275 men who have been admitted between 1984 and 2014 to one of four Dutch forensic psychiatric facilities and related to incidents of violence during treatment or recidivism after discharge (for 78 women).
RESULTS: Although substance abuse was common in women (57%), it was significantly more prevalent in men (68%). Men were more often diagnosed with substance dependency and more often committed the index-offense whilst intoxicated. Predictive accuracy for violent incidents during treatment was better for men. Both women and men with substance abuse had significantly more historical risk factors compared to those without substance abuse. A history of substance abuse was not a significant predictor for recidivism after discharge in women.
CONCLUSION: There are gender differences in substance abuse and the relationship with offending was stronger for men. These differences may have implications for substance use treatment in forensic mental health services.

Background: Violence perpetrated by women has attracted more and more attention in the past few years. However, there is lack of background information about women admitted to forensic psychiatric hospitals and about risk factors for recidivism., Aim: To conduct a multicenter study which will give more insight into female psychiatric patients and which will probably have implications for psychodiagnostics, risk assessment and treatment in (forensic) psychiatric settings., Method: We coded the files of 297 women who, between 1984 and 2013, had been admitted to one of four Dutch forensic psychiatric facilities by reason of violent delinquent behaviour. We used an extensive coding list and several risk assessment tools including the recently developed Female Additional Manual (fam) for women., Results: The general picture that emerged was one of severely traumatised women with complex pathology and a high level of comorbidity. Many of the women had experienced previous treatment failures and had caused many incidents during treatment., Conclusion: Female forensic psychiatric patients are a complex group that deserves more specific attention. Attention for traumas from the past, intensive supervision in relationships and training for staff in dealing with, for instance, manipulative behaviour are the most important implications from this study.

Objective: To describe the short and long term results of neurological second opinions with regard to medical aspects and patient satisfaction., Design: Prospective observational cohort study, Methods: Data regarding medical relevance and patient satisfaction were collected for all patients referred to the neurological out-patient clinic for a second opinion over a period of 6 months. Treating neurologists were asked to fill out a questionnaire to assess the medical relevance of the consultation. Patient satisfaction was assessed using the 'Patient Satisfaction Questionnaire' which was filled out by the patient directly after the consultation and after 2 years follow-up., Results: 183 patients were included during the study period and 78 of these patients returned the follow-up questionnaire. A neurological second opinion led to a different diagnosis in 66 patients (33%). For 42 patients (23%) the new diagnosis had treatment implications. Second opinions were nevertheless considered of low medical relevance by the treating neurologist; the psychological relevance was considered higher. Second opinions led to a short-term increase in patient satisfaction, but after 2 years satisfaction had decreased to the level seen prior to the second opinion. Only 7% of patients indicated their intention to visit another healthcare provider for the same problem directly following the consultation, whereas 2 years later it was found that 30% had done so., Conclusion: The benefit of second opinion consultations at an academic neurology out-patient clinic was reasonable in the short term, but limited in the long term.

A recent trial revealed a reduction in ischaemic infarcts after carotid endarterectomy in patients with asymptomatic carotid stenosis. However, the number needed to treat (NNT) was 22 to prevent 1 stroke in 10 years (including perioperative death as a primary outcome measurement). This is a modest effect in comparison to the trials with symptomatic patients with a 70-99% stenosis (NNT: 6). Furthermore, the number of surgical complications outweighs the benefits of surgery during the first 2 years after treatment. Finally, current medical treatment is significantly more effective than the medical treatment used in the control arm of this trial. Therefore, in our opinion, endarterectomy should not be performed routinely in asymptomatic patients.

In the European Cooperative Acute Stroke Study 3 (ECASS3), the efficacy of intravenous thrombolysis between 3 and 4.5 hours following onset of ischaemic stroke was investigated. Compared to the placebo group, patients treated with intravenous alteplase had a better functional outcome after 3 months (odds ratio 1.34, 95% confidence interval 1.02-1.76). The risk of symptomatic intracerebral haemorrhage was higher in the alteplase group (2.4% versus 0.3%). The time window for intravenous alteplase can be safely extended to 4.5 hours, but efforts should be made to start treatment as soon as possible, since the effectiveness ofalteplase decreases over time.

The amount of learning devoted to clinical teaching in medical schools is under pressure from increased amounts of time devoted to so-called 'basic sciences' and recent emphasis on non-medical competencies. Clinical teaching, in direct contact with real patients and supervised by experienced clinical teachers, should remain the core of medical education. Competing subjects should be regarded as important, but limited, corollaries.

A recent trial revealed a reduction in ischaemic infarcts after carotid endarterectomy in patients with asymptomatic carotid stenosis. However, the number needed to treat (NNT) was 19 to prevent one stroke in 5 years, a modest effect in comparison to the trials with symptomatic patients (a NNT of only 6 in patients with a symptomatic stenosis of 70-99%). Furthermore, the number of surgical complications outweighs the benefits of surgery during the first two years after treatment. Finally, the benefits also included the prevention of contralateral strokes, whereas it is unlikely that these are prevented by endarterectomy. Therefore, endarterectomy should not be performed routinely in asymptomatic persons.

The practice guideline for the treatment of ischemic stroke, issued by the Dutch College of General Practitioners, is a timely and most welcome update. It incorporates the new evidence and the important changes in stroke treatment of the past years, and is a good starting point for the collaboration between general practitioners and neurologists in the care of patients with a cerebrovascular accident. The guideline acknowledges the evidence for the benefit ofthrombolysis, but is somewhat vague concerning the magnitude of the effect because it compares the net effect of treatment (which incorporates the risk of bleeding) and the number of cerebral haemorrhages. Furthermore, the discussion of minor stroke could lead to the erroneous conclusion that such patients can be safely cared for at home. Apart from these reservations, the guideline fully agrees with the need to treat all patients with a cerebral infarct, in the absence of contraindications, with thrombolysis within three hours, and to offer specialised care in a dedicated stroke-unit.

Two patients with cerebral sinus thrombosis were successfully treated with neuroradiological intervention procedures, one with local thrombolysis and the other with mechanical thrombosuction using a hydrolyser catheter. The first patient, a 20-year-old woman, was treated with asparaginase for acute lymphatic leukaemia. She lapsed into coma with extensor posturing due to superior sagittal and right transverse sinus thrombosis. She recovered completely after local thrombolysis with 2,940,000 units urokinase, administered over a period of 40 hours. The second patient was a 29-year-old man who presented with clinical deterioration after seizures due to superior sagittal, left transverse and straight sinus thrombosis. A CT-scan demonstrated bilateral haemorrhagic cerebral infarctions. Since the risk of haemorrhage during thrombolysis with urokinase was considered to be high, mechanical thrombosuction with a hydrolyser catheter was performed. This procedure took only 4 hours. The patient recovered completely in two weeks. These cases add further evidence to the effectiveness of thrombolysis and thrombosuction in selected patients with severe cerebral sinus thrombosis.

Thrombolysis by intravenous application of thrombolytic drugs may improve the outcome of patients with a brain infarct, but it also entails risks. The effect of recombinant tissue plasminogen activator (rtPA) was compared with placebo in three medium-sized randomized controlled clinical trials. One study, performed in North America, showed a clear benefit of rtPA administered within 3 hours after the onset of symptoms. Two European trials showed a less strong effect, but the number of patients who were independent after 3 months' follow-up was also larger after treatment with rtPA within 6 hours. A meta-analysis of all three trials demonstrates a significant advantage of rtPA over placebo for all the usual outcome measures, without significant excess mortality in the rtPA group. The chance of being able to live independently increases by about 8% after treatment with rtPA. In conclusion there is now sufficient evidence to start with thrombolytic treatment for cerebral infarcts in hospitals with a stroke unit, if a number of additional quality standards for the acute diagnosis and treatment of stroke patients are met.

A number of Dutch medical journals recently carried an advertisement stating that clopidogrel treatment reduced the number of ischaemic complications with 26%, compared with aspirin treatment. This is a miscalculation: the actual reduction is 0.51% in absolute rates, and 8.7% in relative terms. The error by Sanofi-Synthelabo arose by comparison of the event rates for clopidogrel (5.32%) as well as for aspirin (5.83%) with that in an imaginary placebo group (7.77%), yielding a reduction of ischaemic complications of 2.45% and 1.94% respectively; erroneous comparison of these two numbers leads to a difference of 26%.

Clinical examination of the tendon reflexes is helpful in localising lesions in the nervous system, which is an important step in the diagnosis of neurological disorders. The large intra- and interindividual variations of reflex amplitudes make interpretation difficult. Published interobserver agreement studies provide conflicting results. The diagnostic specificity of unequivocally abnormal reflexes is moderate to good (70-95%, decreasing with increasing age), but the sensitivity is lower (50-70%), both for peripheral and for central lesions. This implies that the finding of a clearly abnormal reflex pattern is often helpful, but the finding of normal reflexes usually does not exclude a neurological lesion.

A consensus development meeting concerning the treatment of lumbosacral radicular syndrome (LRS) by entrapment by a herniated disc or spinal stenosis was held on June 9th, 1995. It was observed that there is a lack of good evidence on many aspects of diagnosis and treatment of LRS. Agreement was reached on the thesis that the natural course of LRS is often benign. Diagnosis and treatment can usually be left to the primary care physician. Specialist consultation and ancillary investigations are only needed if an operation is indicated or in case of persistent diagnostic uncertainty. If imaging is needed MRI is preferred to CT or myelography. MRI is highly sensitive, but less specific, and may thus give false-positive results. Neurophysiologic testing may be informative in selected cases. Plain spinal X-rays are not useful in most cases. The traditional non-invasive treatments (such as bedrest, traction, physiotherapy, spinal manipulation) are not based upon convincing scientific evidence. Diagnostic imaging and invasive treatment should be considered in patients with a severe LRS that does not improve within a 4 to 8 week period. Both discectomy and chemonucleolysis are effective treatments. The principal indication is incapacitating radicular pain. There is no sound evidence that the prognosis of paresis is improved by operation. A cauda equina syndrome urgently needs surgical treatment. The efficacy of percutaneous interventions (nucleotomy, laser therapy) has not been proven. There are no strategies for the primary or secondary prevention of LRS that have demonstrated their efficacy. Psychological, social and financial factors probably contribute significantly to the occurrence of persisting symptoms after a LRS. Advice not to work after treatment for LRS may impede rehabilitation.

Objective: To determine the effect of computer-based medical teaching (CBMT) as a supplementary method to teach clinical problem-solving during the clerkship in neurology., Design: Randomized controlled blinded study., Setting: Academic Medical Centre, Amsterdam, the Netherlands., Method: 103 Students were assigned at random to a group with access to CBMT and a control group. CBMT consisted of 20 computer-simulated patients with neurological diseases, and was permanently available during five weeks to students in the CBMT group. The ability to recognize and solve neurological problems was assessed with two free-response tests, scored by two blinded observers., Results: The CBMT students scored significantly better on the test related to the CBMT cases (mean score 7.5 on a zero to 10 point scale; control group 6.2; p < 0.001). There was no significant difference on the control test not related to the problems practised with CBMT., Conclusion: CBMT can be an effective method for teaching clinical problem-solving, when used as a supplementary teaching facility during a clinical clerkship. The increased ability to solve problems learned by CBMT had no demonstrable effect on the performance with other neurological problems.

Objective: Analysis of signs, symptoms, course and treatment of patients with cerebral venous and sinus thrombosis (CVST)., Design: Retrospective study., Setting: Neurological departments of Dutch teaching hospitals., Method: Analysis of data of patients admitted to the neurological wards of nine teaching hospitals, diagnosed from 1970 to 1990. All patients with a clinical diagnosis of CVST, confirmed by X-ray angiography, magnetic resonance imaging, surgery or autopsy were included. Patients with cavernous sinus thrombosis were excluded. The clinical condition of patients after 3 months was scored on a 4-point scale., Results: Of 93 patients 62 fulfilled the inclusion criteria. Three months after the diagnosis 41 patients (66%) had recovered, 10 patients (16%) were seriously disabled, 11 patients (18%) had died. Factors associated with a poor outcome were coma (relative risk 3.5) and hemiparesis (relative risk 2.3) at the time of diagnosis. Signs of cerebral haemorrhage or infarction (by computed X-ray tomography) were associated with disability or death. Anticoagulant treatment was not significantly associated with a better or poorer outcome in these patients., Conclusion: This study confirms the variations in causes, clinical presentation, natural history, and treatment of CVST. No conclusion could be drawn about the effect of anticoagulant treatment.

In a retrospective study the results of the screening for syphilis in one of the neurological wards of the Academic Medical Centre in Amsterdam were analysed. The Venereal Disease Research Laboratory test (VDRL) and the Treponema Pallidum Haemagglutination Assay (TPHA) in serum were used for screening. The data for analysis were obtained via the hospital computer data base and via the medical files of the department of neurology. During the 5-year study period (1986-1990) 2378 adult patients were admitted and 1247 (52.4%) of them were screened. In seven (0.56%) patients both tests were positive. Three of them had been treated for syphilis in the past and showed no symptoms of active syphilis. Four (0.32%) patients suffered from active neurosyphilis. In three of these four patients syphilis was suspected on admission and confirmed by the tests. In one patient the diagnosis of syphilis was not considered. The positive test results became available shortly before she died of pneumonia and were without consequences. None of the 32 (2.6%) patients with a positive TPHA and a negative VDRL was diagnosed as having (neuro-)syphilis. Two (0.16%) patients had a false-positive VDRL. We conclude that routine serological examination for syphilis of every patient admitted to a neurological ward is not useful. We advise a limited screening of patients who belong to a group with high risk for syphilis and patients with symptoms and signs that can be caused by syphilis, such as dementia or ischaemic strokes at a relatively young age.

The ability of senior medical students to interpret clinical research articles was examined by means of a written examination based upon two papers from general medical journals. The subjects of the articles were a diagnostic test and a therapeutic trial respectively. Knowledge of basic methodological and statistical concepts mentioned in the articles was in 86% of the students examined (n = 90) below the minimal level required for correct interpretation. 60% of the participants could not correctly apply the results mentioned in the diagnostic paper to a written clinical problem, and 11% could not apply the result of the therapeutic trial. From the reasons the participants gave for their decisions it appeared that 77% and 35% respectively had not been able to interpret the articles correctly. A comparison between self-rated knowledge and results of the test showed that the students tended to overestimate their knowledge. Knowledge of basic concepts of clinical epidemiology and statistics of these nearly graduated medical doctors is insufficient, and many of them cannot interpret clinical research articles correctly.

Four cases of avian tuberculosis in two goshawks (Accipiter gentilis gentilis), a lanner falcon (Falco biarmicus sp.) and a kestrel (Falco tinnunculus tinnunculus) are reported. All birds, except for the kestrel, were affected with generalized tuberculosis. Clinically, the lanner falcon and kestrel showed lameness due to tuberculous arthritis of a knee joint. One of the goshawks died suddenly. On post-mortem examination, the bird was found to be emaciated, and there was involvement of one knee joint. The other goshawk showed convulsive seizures for three weeks before she died. Histological examination revealed tuberculous meningitis and encephalitis. The diagnosis was based on the detection of acid-fast organisms in every case and was verified in three cases by cultures of the causative organism. Tuberculosis should be considered in the differential diagnosis of emaciation, lameness, arthritis, skin lesions, convulsions and frounce in raptors.

Diagnostic procedures in the presence of superior vena cava obstruction have been reported to be dangerous. We reviewed our experience in 58 patients who presented with this obstruction during the period 1976-1985, to establish the nature and frequency of complications. In 56 of 58 patients we could obtain a diagnosis before instituting therapy. The only complication was one case of peroperative haemorrhage.