Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services.

PURPOSE: The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS. METHODS: Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations. RESULTS: Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS. CONCLUSION: Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

[High and intensive care as a next step in the reduction of coercion]. / High en intensive care als een volgende stap in dwangreductie.

BACKGROUND: The high and intensive care (HIC) model provides a framework for acute admission wards and is being implemented since 2013 by all mental healthcare institutions in the Netherlands. AIM: To investigate how the HIC model has been implemented between 2014 and 2018 and how the implementation of the HIC model is associated to coercive measures. METHOD: Between 2014 and 2018, 79 audits were organized in two phases within 25 institutions to measure the degree of implementation of HIC using a model fidelity scale, the HIC monitor. HIC monitor scores were compared to data on coercion to determine the relationship between implementation of the HIC model and coercive measures. RESULTS: Scores on the HIC monitor increased over time, especially in terms of vision, hospitality and facilities. However, a third of wards scored lower on the HIC monitor in the second audit compared to the first audit. Institutions that score higher use less seclusion and use less forced medication. CONCLUSION: Progress in the implementation of the HIC model is visible and institutions that are further in the implementation of the HIC model apply less coercion. Securing implementation proves difficult. Attention should be paid to the national staff shortage and systematic evaluation of coercion.

[Transitional psychiatry in the Netherlands: experiences and views of mental health professionals]. / Transitiepsychiatrie in Nederland: ervaringen en opvattingen van ggz-professionals.

BACKGROUND: Psychopathology manifests itself primarily in late adolescence and continues into adulthood. Continuity of care is essential during this phase of life. The current care service distinguishes between child/adolescent (CAMHS) and adult mental health services (AMHS). The separation of services can interfere with the continuity of care.
AIM: To map professionals' experiences of and views on the transition and associated problems that young people can experience as they are transferred from CAMHS to AMHS.
METHOD: We distributed an online questionnaire among professionals providing mental health care to young people (aged 15-25) with psychiatric problems.
RESULTS: The questionnaire was completed by 518 professionals. Decisions relating to transition were generally based on the professional's own deliberations. The preparation consisted mainly of discussing changes with the adolescent and his or her parents. The majority of transition-related problems were experienced in CAMHS, particularly with regard to collaboration with AMHS. Respondents were of the opinion that the developmental age ought to be the determining factor in the decision-making process with regard to transition and they considered it important that developmentally appropriate services should be available in order to bridge the gap.
CONCLUSION: Professionals in CAMHS and AMHS are encountering problems in preparing the transitional phase and in organising the required structural collaboration between the two separate services. The problems relate mainly to coordination, communication and rules and regulations. Professionals are keen to improve the situation and want to see greater flexibility. In their view, there should be a wider range of specialised facilities for young people, enabling them to benefit from transitional psychiatry.

Epidemiology and prognostic signs of chest injury patients.

Accidental injury is the leading cause of death in persons between the ages of 1 and 50 years in our Western society. In spite of a better knowledge of the pathophysiology involved and greater availability of specific resuscitative measures, the mortality rate of patients with severe injuries of the chest has not improved much. This study was carried out to survey and evaluate our own experience with injuries of the chest and to look for prognostic factors related to these and to the often associated injuries of other parts of the body. The case records of 828 consecutive injured patients treated in our critical care department during the period 1975-1984 were retrospectively analysed. The overall mortality rate was 15 per cent for those with injuries of the chest. The best prognostic indices were the Glasgow Coma Scale and the Injury Severity Score.

First experiences with Swan-Ganz measurements in patients with severe hypertension during pregnancy from an unselected population.

In 10 patients with severe hypertension during pregnancy (6 patients with preexisting hypertension and 4 with severe preeclampsia) Swan-Ganz measurements were done in order to detect and correct a reduced circulating volume and lower the blood pressure. It appeared that 6 patients had a reduced circulating volume (group I) and 4 patients a normal circulating volume (group II). In both groups there were 2 patients with severe preeclampsia; most patients were referred and had antihypertensive medication before and most infants had a birthweight less than the 10th centile. A difference was found in prolongation of pregnancy if counted from the first hemodynamic measurement (and start of therapy): on average 25 days in group I (despite careful volume correction and vasodilatation) versus on average 25 days in group II (vasodilatation only). Moreover, all infants but one were delivered by cesarean section, but fetal distress as indication for delivery was only noted in group I. Although Swan-Ganz measurements are very useful to determine filling state and effect of therapy it is concluded that once a reduced circulating volume is present one is too late to be able to prolong pregnancy considerably despite proper therapy of volume correction and vasodilatation. This makes Swan-Ganz measurements on "fetal indication" questionable.

Afibrinogenemia and blunt head injury.

A case is described of acute defibrination following blunt head injury in a patient with a Spitz-Holter drain. The cause of the disseminated intravascular coagulation is thought to be due to brain thromboplastins entering the systemic circulation through the Spitz-Holter drain, thus bypassing the blood-brain barrier.

Biochemical studies in Hermansky-Pudlak syndrome.

In order to find the basic defect in the Hermansky-Pudlak Syndrome (HPS), biochemical studies of platelets and leucocytes were undertaken. Glutathione levels of platelets were normal and regeneration of GSH similar to controls occurred after incubation with diamide (a specific agent for GSH oxidation). Phospholipid and fatty acid composition of HPS platelets was normal. The amount of peroxides found in platelet membranes was not elevated. A subnormal aggregation with arachidonic acid could be obtained in PRP using a high concentration of arachidonic acid (2 mM), but normal malondialdehyde levels were measured, suggesting a normal prostaglandin synthesis in HPS platelets. Glutathion peroxidase and p-phenylenediamide-mediated peroxidase (PPD-peroxidase) were normal in leucocytes of 1 HPS patient. Lysosomal enzymes as far as investigated were normal.

Correction of the bleeding time in patients with storage pool deficiency by infusion of cryoprecipitate.

Five patients with Hermansky-Pudlak syndrome: storage pool deficiency, albinism and ceroid containing bone marrow macrophages and three patients with uncomplicated storage pool deficiency were treated with cryoprecipitate from 16 donors. Within 2 h of transfusion, bleeding times decreased towards a third of initial values. This effect lasted for at least 4 h but had disappeared after 24 h. Six of these eight patients were also treated with an equal volume of human albumin solution. Infusion of albumin had no effect on the bleeding times. The abnormal platelet function tests and biochemical abnormalities (decreased values of platelet total adenosine diphosphate (ADP), adenosine triphosphate (ATP(I) and serotonin) remained unchanged. On four occasions infusion of cryoprecipitate twice daily protected patients with Hermansky-Pudlak syndrome and storage pool deficiency from bleeding during surgery. The mechanism of action of cryoprecipitate in this clinical situation is obscure.

The Hermansky-Pudlak syndrome. Evidence for a lowered 5-hydroxytryptamine content in platelets of heterozygotes.

A Dutch kindred with the Hermansky-Pudlak syndrome (HPS) is described. We show for the first time evidence of a lowered platelet 5-hydroxytryptamine content in obligate heterozygotes. Platelet ATP and ADP levels and ATP/ADP ratio were normal in these patients. Platelet aggregation with ADP, collagen and adrenaline was within the normal range. In contrast to the homozygous HPS patients the heterozygotes are normally pigmented and none has diaphanous irides, nystagmus or a bleeding tendency. All homozygous HPS patients have the typical triad of oculocutaneous albinism, pigmented macrophages in the bone marrow and a bleeding disorder, based on a platelet dysfunction. The platelets showed the typical characteristics of a storage pool deficiency. Their platelet factor 3 availability was decreased and the aggregation patterns showed an absent second wave with ADP, adrenaline and absent collagen aggregation. Platelet ADP levels were strongly decreased in all homozygous HPS patients, whereas ATP was lowered only in 3 out of 6 HPS patients. The 5-hydroxytryptamine content of their platelets was very low (15-20% of normal).

The Hermansky-Pudlak syndrome: ultrastructure of bone marrow macrophages.

The present investigation has explored the fine structure of the lipid inclusions which fill the bone marrow macrophages of patients with the Hermansky-Pudlak syndrome. Red blood cells are the major substrate of the reticular macrophages, and incomplete digestion of erythrocytes leads to formation of the massive inclusions. Progressive transformation of the macrophages results in an end-stage cell whose damaged cytoplasm is nearly replaced by huge lipid-containing vacuoles surrounded by particulate debris. This type of cell has not been found in bone marrows from patients with hemolytic, thrombocytopenic or lipid storage diseases.