[Electroconvulsive therapy in the Netherlands: the practice in 2015 compared to that in 2008]. / Elektroconvulsietherapie in Nederland: de praktijk in 2015 vergeleken met die in 2008.

BACKGROUND: The most recent information about the use of ECT in the Netherlands dates from 2008. An update version of the guideline for the use of ECT in the Netherlands was issued in 2010. AIM: To obtain insight into the practice of ECT in the Netherlands five years after implementation of the guideline. METHOD: Our study is based on a questionnaire about the use of ECT by psychiatrists in all Dutch institutions (n=33). Questions concerned the use and availability of ECT as well as the implementation of the updated guideline; they also served as a check on the expertise and training of ECT-psychiatrists. RESULTS: All institutions responded. The total number of ECT-sessions performed in 2015 was 15,633, a 16% increase compared to 2008. In 2015 more institutions were using 7x24 ECT and more had an ECT-nurse available. Nearly all psychiatrists were acquainted at the time with the revised guideline of 2010 and nearly 50% of them had adjusted the way they practised ECT. However, just under 40% of psychiatrists did not have the correct knowledge about some technical details regarding ECT. CONCLUSION: The revised guideline on ECT and its implementation have most likely improved the practice of ECT in the Netherlands.

[Apathetic geriatric patient benefits from methylphenidate]. / Apathische kwetsbare oudere heeft baat bij methylfenidaat.

Two independent, home-dwelling geriatric patients presented with apathy at a general practice in the Netherlands and were seen by an elderly care physician after (non-)medical interventions had failed. Both patients were treated with low-dose methylphenidate. During treatment, apathy symptoms decreased and the patients became more active. Apathy is a frequent symptom of several neuropsychiatric diseases, depression and somatic conditions. Its incidence varies from 1.3% in healthy elderly people to more than 50% in the elderly with depression or dementia. In this clinical lesson we present these two cases and discuss considerations for treatment of apathy with methylphenidate.

[Music as an uninvited guest: the auditive variant of the Charles Bonnet syndrome]. / Muziek als ongenode gast: de auditieve variant van syndroom van Charles Bonnet.

Visually handicapped patients can be tormented by complex visual hallucinations (Charles Bonnet syndrome). Likewise, deaf patients and patients with impaired hearing can be plagued by auditory hallucinations, mostly involving music. Our article focuses on three female patients who suffered from musical hallucinations. In one of these patients the hallucinations ceased when her hearing was restored. In the second patient the hallucinations ceased when carbamazepine was prescribed. Quetiapine reduced the musical hallucinations in the third patient. The differential diagnoses and therapeutic options are discussed.

[Palliative care in a psychiatric-somatic care unit]. / Palliatieve zorg op een psychiatrisch-medische unit.

Patients with severe psychiatric and somatic disorders may require admission to a combined psychiatric-somatic care unit. These units provide specialised psychiatric and somatic care as well as palliative care. This is illustrated by two case reports. A 51-year-old man with a malignant brain tumour was admitted to our psychiatric-somatic care unit after threatening his wife and children. He was aggressive and confused. Seizures were suspected and palliative care was needed. Within a few weeks his condition deteriorated. He died 1 day after terminal sedation had been initiated. A 78-year-old woman was admitted to receive daily electroconvulsive treatment (ECT) for depression with catatonia. The ECT had to be interrupted repeatedly due to comorbid infections and complications. She died 3 days after palliative care was initiated.

[Psychoses and epilepsy. A case study]. / Psychosen en epilepsie.

Over the last few decades much research has been done into the raised level of psychiatric comorbidity in epilepsy. On the basis of a case study of a patient suffering from post-ictal psychoses we explain the psychiatric differential diagnosis within the framework of epilepsy and we investigate the frequent psychiatric side-effects of anticonvulsants. It is concluded that the links between epilepsy and psychiatric symptoms are complex and that the neuropsychiatry of epilepsy is concerned with syndromes that are unique and do notfit into modern psychiatric classification systems.

[Repeated suicide attempts: a need for continued care]. / Recidiverende suïcidepogers: hulp blijven aanbieden.

Prevention of deliberate self-harm, especially suicide attempts, remains difficult and this puts a great burden on the family as well as on the health-care professionals. The risk of a subsequent suicide attempt or a successful suicide is high while the behaviour is often met with antipathy, a feeling of helplessness and anger. This is in conflict with the needs of the patient; every suicide attempt requires the health-care professionals involved to exhibit a emphatic, patient and serious attitude, even when patients refuse to cooperate, are restless, aggressive or unwilling to communicate. Prevention of the suicidal behaviour can only be achieved this way.

Diploid/triploid mosaicism in dysmorphic patients.

Diploid/triploid mosaicism is a dysmorphology syndrome consisting of mental retardation, truncal obesity, body and/or facial asymmetry, growth retardation, hypotonia, a small phallus, malformed low-set ears and micrognathia. In 75% of the cases, the blood karyotype is normal and the diagnosis can only be established after analysis of cultured fibroblasts. This chromosome abnormality may therefore be underdiagnosed. This paper focuses on the identification of mentally retarded and dysmorphic patients with diploid/triploid mosaicism. Detailed clinical description of well-defined patients may help in deciding if a skin biopsy for karyotyping of fibroblasts should be taken. Three new cases are presented, in which DNA marker analysis showed that the extra set of chromosomes in each case was derived from the mother. We present a review of 25 cases described in the literature and we discuss the inclusion of a second polar body into an early diploid embryo as the most likely mechanism.

[Perinatal asphyxia as incorrect explanation for mental retardation]. / 'Perinatale asfyxie' als onterechte verklaring voor mentale retardatie.

Three women, aged 21, 34 and 32 and with a family history of mental retardation said to be caused by perinatal asphyxia, each gave birth to a child with mental retardation. A chromosomal translocation, fragile X syndrome, and myotonic dystrophy could be diagnosed, respectively. In retrospect, the diagnosis of perinatal asphyxia in the family history had been too readily accepted. In reality the mental retardation was caused by a genetic disorder. Physicians are used to making a diagnosis, and when a diagnosis is not (yet) possible, they try to establish a working diagnosis or differential diagnosis. Too often such a working diagnosis becomes, through time, a definite diagnosis.

No evidence for paternal mtDNA transmission to offspring or extra-embryonic tissues after ICSI.

There is a risk that ICSI may increase the transmission of mtDNA diseases to children born after this technique. Knowledge of the fate and transmission of paternal mitochondrial DNA is important since mutations in mitochondrial DNA have been described in oligozoospermic males. We have used an adaptation of solid phase mini-sequencing to exclude the presence of levels of paternal mtDNA >0.001% in ICSI families. This method is more sensitive than those used in previous studies and is sufficient to detect the likely paternal contribution (approximately 0.1-0.5% from simple calculations of expected dilution during fertilization). Using this method, we were able to detect concentrations as low as 0.001% paternal mtDNA in a maternal mtDNA background. No paternal mtDNA was detected in the embryonic (blood or buccal swabs) tissue of children born after ICSI nor in extra-embryonic tissue (placenta or umbilical cord). In conclusion, we did not detect paternal mtDNA in blood, buccal swabs, placenta or umbilical cord of children born after ICSI. We have found no evidence that ICSI increases the risk of paternal transmission of mtDNA and hence of mtDNA disorders.

[From gene to disease; deletion of the DAZ-gene from the Y-chromosome in oligo- or azoospermia ]. / Van gen naar ziekte; deletie van het DAZ-gen op het Y-chromosoom en oligo- of azoöspermie.

DAZ gene deletions at the azoospermia factor (AZF) locus on the Y chromosome, have been implicated as one of the major causes of idiopathic male subfertility. Deletions of the entire DAZ gene have been reported in azoospermia as well as in oligozoospermia. The DAZ gene encodes a RNA binding protein which is expressed exclusively in germ cells. The exact biological role and function of the DAZ protein has yet to be resolved.

DAZLA: an important candidate gene in male subfertility?

PURPOSE: To study the role of the autosomal candidate gene DAZLA (Deleted in AZoospermia Like Autosome) in male subfertility. METHODS: We reviewed clinical data of subfertile men with oligozoospermia or azoospermia, mostly candidates for intracytoplasmic sperm injection (ICSI). Mutation detection was performed using polymerase chain reaction followed by single strand conformation polymorphism analysis. All shifted bands were analyzed by sequencing. RESULTS: We searched for mutations in 44 subfertile men. Nine subfertile men were included, because family history showed that their brothers also faced fertility problems. In these men a possible autosomal gene defect may contribute to their fertility problem. No mutations were found, except for two polymorphisms in intron 4 and 5. CONCLUSION: At this moment it does not seem relevant to search for possible mutations in the DAZLA gene in clinical practice.

Novel mutations in the 7-dehydrocholesterol reductase gene of 13 patients with Smith--Lemli--Opitz syndrome.

Smith--Lemli--Opitz syndrome (SLOS) is caused by mutations in the DHCR7 gene leading to deficient activity of 7-dehydrocholesterol reductase (DHCR7; EC 1.3.1.21), the final enzyme of the cholesterol biosynthetic pathway, resulting in low cholesterol and high concentrations of its direct precursor 7-dehydrocholesterol in plasma and tissues. We here report mutations identified in the DHCR7 gene of 13 children diagnosed with SLOS by clinical and biochemical criteria. We found a high frequency of the previously described IVS8--1 G > C splice acceptor site mutation (two homozygotes, eight compound heterozygotes). In addition, 13 missense mutations and one splice acceptor mutation were detected in eleven patients with a mild to moderate SLOS-phenotype. The mutations include three novel missense mutations (W182L, C183Y, F255L) and one novel splice acceptor site mutation (IVS8--1 G > T). Two patients, homozygous for the IVS8--1 G > C mutation, presented with a severe clinical phenotype and died shortly after birth. Seven patients with a mild to moderate SLOS-phenotype disclosed compound heterozygosity of the IVS8--1 G > C mutation in combination with different novel and known missense mutations.

Decreased fertilization rate and embryo quality after ICSI in oligozoospermic men with microdeletions in the azoospermia factor c region of the Y chromosome.

Microdeletions of the azoospermia factor (AZF) region of the Y chromosome occur in between 1 and 29% of oligozoospermic and azoospermic men, and most deletions are found in the AZFc region. These men can father children when intracytoplasmic sperm injection (ICSI) is used, but the success rate is unclear. Thus, the success rate of 19 ICSI treatments in eight couples with a microdeletion in the AZFc region of the Y chromosome was analysed retrospectively. These were compared with a control group of 239 ICSI treatments in 107 couples undergoing ICSI treatment with ejaculated spermatozoa. The fertilization rate was significantly lower in the group of Y-deleted men (55%; 95% CI: 41-69%) compared with controls (71%; 95% CI: 67-74%; P < 0.01). The embryo quality was also significantly poorer among Y-deleted men (P<0.001). Pregnancy, implantation and take-home baby rates were not significantly lower in the Y-deleted group. This study shows that ICSI in oligozoospermic men with microdeletions in the AZFc region of the Y chromosome leads to a lower fertilization rate and poorer embryo quality.

Y-chromosomal DNA haplotypes in infertile European males carrying Y-microdeletions.

We have determined Y-chromosomal DNA haplotypes in 73 infertile European males carrying Y microdeletions and compared them with the haplotypes of 299 infertile males lacking microdeletions. Chromosomes were typed with a set of 11 binary Y markers, which identified 8 haplogroups in the sample. Haplogroup frequencies were compared between 3 microdeletion classes and the non-deleted infertile males. Deletions arise on many different haplotypic backgrounds. No statistically significant differences in frequency were seen, although the small number of AZFa deletions lay predominantly on one branch of the Y haplotype tree.

Prenatally detected marker chromosome identified as an i(22)(p10) using (micro)FISH.

MicroFISH was used to elucidate the chromosomal origin of a prenatally detected marker chromosome. Five copies of the marker chromosome were collected from GTG-banded metaphases and amplified by means of DOP-PCR. The PCR product was labeled with blotine-14-dATP and used as a FISH probe for hybridization to metaphase chromosomes of the fetus (reverse painting). The marker appeared to be derived from the short arm of (an) acrocentric chromosome(s). After FISH with centromere-specific and band-specific probes complete characterization was possible and the marker chromosome appeared to consist of two short arms of chromosome 22. The pregnancy was continued and one year after birth the patient is developing normal.

Reproductive decisions of men with microdeletions of the Y chromosome: the role of genetic counselling.

Couples dealing with microdeletions of the Y chromosome have to make decisions about their reproductive future. Do they opt for intracytoplasmic sperm injection (ICSI), artificial insemination with donor insemination (AID) or no treatment? We analysed this decision in 28 couples and investigated the role of the counsellor and the counselling process on the final decision of the couple. Ten counsellors from six fertility clinics in The Netherlands and Belgium were interviewed about their genetic counselling of couples dealing with microdeletions. The answers to the questionnaire were converted to 11 dichotomous variables. Of the 1627 tested men in the six centres, 37 (2.3%) had a microdeletion in the AZFc region, a subregion of the AZF region on the Y chromosome important for normal spermatogenesis. The decisions of 28 of them could be analysed. Most couples chose ICSI (79%). The remaining couples chose donor insemination (7%) or refrained from treatment (14%). Several variables, including the counselling procedure, the counsellor and the available treatments in the fertility centre, influenced the decision of the couple. In conclusion, most couples dealing with microdeletions in the AZF region choose ICSI. Several aspects of the process of genetic counselling appear to be related to the final decision.

Severe, non X-linked congenital microcephaly with absence of the pyramidal tracts in two siblings.

In two siblings (a female and a male neonate), severe microcephaly, bilateral absence of the pyramids, severe hypoplasia of the cerebral peduncles, and dysplasia of the inferior olives was found together with microphthalmia, facial malformations and multiple contractures of the extremities. In both cases, the cerebral hemispheres otherwise showed a more or less normal gyral pattern with the insula incompletely covered by the opercula, and a tom but otherwise intact corpus callosum. In case 2, congenital cataract was also observed. The present cases can be characterized as a rapidly fatal, familial syndrome, probably transmitted as an autosomal recessive trait, and have several features in common with the Neu-Laxova syndrome. They differ in having a less severe form of microcephaly, a rather normal cytoarchitecture of the cerebral cortex, an apparently normal corpus callosum, no gross cerebellar abnormalities, and no other organ malformations. The present cases belong to a group of heterogeneous syndromes which have microcephaly, ocular and facial malformations, multiple contractures, and ichthyosis-like skin in common.

Radial defects and testicular dysfunction: a new syndrome?

We describe two unrelated male patients with radial ray defects and increased serum concentrations of follicle stimulating hormone due to testicular dysfunction. This combination of features has not previously been described. Several mouse genes are known to be involved in preaxial limb development and male fertility, suggesting that the combination of radial ray defects and testicular dysfunction may represent a new syndrome in humans. Abnormalities of spermatogenesis or sperm function may constitute an under-recognized feature of human multiple congenital malformation syndromes.