[Shared decision-making in mental health care: a role model from youth mental health care]. / Gedeelde besluitvorming in de ggz: het adviesgesprek in de jeugd-ggz als voorbeeld.

BACKGROUND: In the communication and interaction between doctor and patient in Western health care there has been a paradigm shift from the paternalistic approach to shared decision-making. AIM: To summarise the background situation, recent developments and the current level of shared decision-making in (youth) mental health care. METHOD: We conducted a critical review of the literature relating to the methodology development, research and the use of counselling and decision-making in mental health care. RESULTS: The majority of patients, professionals and other stakeholders consider shared decision-making to be desirable and important for improving the quality and efficiency of care. Up till recently most research and studies have concentrated on helping patients to develop decision-making skills and on showing patients how and where to access information. At the moment more attention is being given to the development of skills and circumstances that will increase patients' interaction with care professionals and patients' emotional involvement in shared decision-making. In mental health for children and adolescents, more often than in adult mental health care, it has been customary to give more attention to these aspects of shared decision-making, particularly during counselling sessions that mark the transition from diagnosis to treatment. This emphasis has been apparent for a long time in textbooks, daily practice, methodology development and research in youth mental health care. Currently, a number of similar developments are taking place in adult mental health care. CONCLUSION: Although most health professionals support the policy of shared decision-making, the implementation of the policy in mental health care is still at an early stage. In practice, a number of obstacles still have to be surmounted. However, the experience gained with counselling and decision-making in (youth) mental health care may serve as an example to other sections of mental health care and play an important role in the further development of shared decision-making.

[Counseling in the Dutch youth mental health care: a survey]. / Het adviesgesprek in de Nederlandse jeugdgeestelijke gezondheidszorg: een inventarisatie.

BACKGROUND: A recent survey amongst 48 key figures from all 51 Dutch institutions for youth mental health care service confirmed the hypothesis that counselling in the Dutch youth mental health care service hardly ever follows a standard pattern. In their reactions to this survey, professionals seem to be strongly in favour of a methodical form of counselling that is firmly based on scientific principles. Based on this survey, a review of the literature and panel discussions, an evidence-based counseling procedure for the youth mental health care was developed.

Conceptual evaluation of the potential role of fractures in unsaturated processes at Yucca Mountain.

A wide array of field observations, in situ testing, and rock and water sampling (and subsequent analyses) within the unsaturated zone (UZ) of Yucca Mountain demonstrate the importance of fractures to flow and transport in the welded tuffs. The abundance of fractures and the spatial variability in their hydraulic properties, along with the heterogeneity within lithologic formations, make evaluation of unsaturated processes occurring within the potential repository horizon complex. Fracture mapping and field testing show that fractures are well connected, yet considerable variation is seen within and between units comprising the potential repository horizon with regard to fracture trace length, spacing, permeability, and capillarity. These variations have important implications for the distribution and movement of water and solutes through the unsaturated zone. Numerical models designed to assess such phenomena as unsaturated flow, transport, and coupled thermal-hydrological processes each require their own conceptual model for fracture networks, in order to identify the subset of all fractures that is relevant to the particular study. We evaluate several process-dependent conceptual models for fractures and identify the relevant fracture subsets related to these processes.

Alterations in calcium and magnesium content of red cell membranes in patients with primary hypertension.

A cellular calcium-magnesium antagonism seems to be involved in the pathogenesis of primary hypertension. Total plasma, intracellular, and membranous calcium (Ca) and magnesium (Mg) contents were determined in 39 untreated patients with essential hypertension (EH) and 40 normotensive healthy subjects (NT). Membranous and intracellular measurements were performed in erythrocytes. Ca and Mg contents were measured by atomic absorption spectroscopy and membrane protein was determined according to Bradford's method as a membranous reference. There was no significant difference in plasma Ca (NT: 2.60 +/- 0.15 v EH: 2.64 +/- 0.17 mmol/L) and Mg concentrations (NT: 0.83 +/- 0.12 v EH: 0.87 +/- 0.14 mmol/L) in the studied groups. Intracellular Mg (NT: 1.72 +/- 0.15 mmol/L v EH: 1.64 +/- 0.19 mmol/L) and Ca (NT: 2.06 +/- 0.20 mmol/L v EH: 2.10 +/- 0.24 mmol/L) contents were also not significantly different between groups. Membrane Ca content was significantly increased in the EH group (2.23 +/- 0.32 micromol/g membranous protein) compared to controls (1.05 +/- 0.30 micromol/g membranous protein, P < .01). On the contrary, membranous Mg content was significantly decreased compared to controls (0.31 +/- 0.09 v 0.50 +/- 0.10 mmol/g membranous protein content, P < .01). The Ca/Mg ratio in membranes was significantly increased in EH as compared to healthy subjects (P < .01) and correlated to mean arterial blood pressure values (r = 0.47, P < .01). We conclude that the membranous alterations of Ca and Mg metabolism, shown by increased Ca/Mg ratio in red cell membranes of hypertensive subjects, may play a role in the pathogenesis of primary hypertension.

[Necrobiotic xanthogranuloma with skin and liver amyloidosis]. / Nekrobiotisches Xanthogranulom mit Haut- und Leberamyloidose.

BACKGROUND: Necrobiotic xanthogranuloma is a largely unknown disease. Both the frequency of this disease and the involvement of internal organs have clearly been underestimated until now. CASE REPORT: A patient was admitted because of ulcerating, xanthomatous, subcutaneous nodules, scleritis and conjunctivitis. Laboratory studies revealed an elevated erythrocyte sedimentation rate, a monoclonal IgG-lambda protein, a pancytopenia and later a hypocomplementemia. Furthermore, a hepatosplenomegaly and esophageal varices were found. A skin biopsy specimen showed a granulomatous infiltrate consisting of lymphocytes, histiocytes, plasma cells, foam cells as well as Touton and bizarre-appearing foreign-body giant cells and cholesterol clefts typical of necrobiotic xanthogranuloma besides a deposit of amyloid. A liver biopsy sample disclosed an amyloidosis of the parenchyma, too. Neither a therapy with chlorambucil and prednisolone nor with interferon alpha-2a resulted in improvement. CONCLUSION: Apart from treatment of skin lesions and ophthalmic manifestations further investigations are necessary because necrobiotic xanthogranuloma can be associated with malignancy and can involve internal viscera like lungs, heart and liver.

[Classic case of benign recurrent intrahepatic cholestasis (Summerskill-Halshe-Tygstrup syndrome)]. / Ein klassischer Fall der benignen rekurrierenden intrahepatischen Cholestase (Summerskill-Walshe-Tygstrup-Syndrom).

BACKGROUND: The benign recurrent intrahepatic cholestasis is an autosomal recessively inherited liver disease. The gene was mapped to a region on chromosome 18q21-22. Because of its rareness this disease is first considered in the differential diagnosis of cholestasis after many years of extensive investigations. CASE REPORT: We report about a 17-year-old patient, who suffered from intermittent attacks of cholestatic jaundice and pruritus. Clinical course, laboratory data and invasive investigations led to the diagnosis of a typical case of benign recurrent intrahepatic cholestasis (Summerskill-Walshe-Tygstrup syndrome). CONCLUSION: This disease is remarkable for a discrepancy between a rise of serum bile acids at the onset of each attack and a later rise of bilirubin. Typically high bilirubin levels are noted, and bilirubin can even reach more than 50 mg/dl. The serum alkaline phosphatase is increased, too, whereas the values for the transaminases and gamma GT are normal or only slightly elevated. Histological studies reveal a cholestasis, bile plugs in the bile canaliculi, a perilobular fibrosis and inflammatory infiltrations of the periportal zones. Differential diagnosis includes an abundance of diseases with cholestasis. Treatment is difficult, purely symptomatic and often without marked effect. Nevertheless prognosis is good, histories of about 50 years were without evidence of progression to cirrhosis.

[Signet ring cell carcinoma of the stomach--a case of diagnostic dilemma]. / Siegelringzellkarzinom des Magens--ein Fall von diagnostischem Dilemma.

Inguinal lymphonodal metastases of an adenocarcinoma were diagnosed in a 40-year-old patient by ultrasound guided puncture. The leading symptom was elephantiasis preferentially of the right lower extremity. In addition, atypical mycobacteriosis was detected later on. The causal gastric cancer had not been identified during two years until the fourth gastroscopy assisted by endoscopic ultrasonography revealed the lesion. No regional lymph node metastases were found while distant metastases in terms of inguinal lymph nodes were already present.

Lowered Total Intracellular Magnesium Status in a Subgroup of Hypertensives.

A new method to determine total Mg++ content in lymphocytes was developed, offering advantages for routine measurements as compared to fluorescence methods. Intracellular total Mg++ measurements were performed in lymphocytes of 18 healthy subjects and 19 untreated essential hypertensive patients. Mg++ content was referred to lymphocytic and membrane protein, which was determined according to Bradford's method. Mg++ measurements were performed by atomic absorption spectroscopy using a Video 12 apparatus of Thermo Electron Instrumentation Laboratory, Andover, USA. The results show that in patients with essential hypertension total intralymphocytic Mg++ content is significantly lower (0.07 +/- 0.05 mmol/g lymphocytic protein, mean +/- s.d.) as compared to controls (0.11 +/- 0.04 mmol/g lymphocytic protein, mean +/- s.d., p < 0.05). Free intracellular Mg++ content was measured in lymphocytes by the fluorescent indicator mag-fura-II, showing no significant differences in normotensives and hypertensives (0.30 +/- 0.16 versus 0.38 +/- 0.17 mmol/l). Additionally, in platelets free intracellular Mg++ concentrations were not found of significant difference in normotensives and hypertensives (0.52 +/- 0.23 versus 0.47 +/- 0.27 mmol/l) using mag-fura-II. In plasma Mg++ concentrations there was no significant difference in the normotensive and hypertensive group (0.92 +/- 0.07 versus 0.88 +/- 0.07 mmol/l). There was no correlation between plasma or free or total cellular magnesium concentrations in both groups. Furthermore this method seems also suitable for routine measurements of total intracellular Mg++ concentrations in even larger measurements like mag-fur-II. Lowered total intracellular Mg++ concentrations in a subgroup of primary hypertensives may contribute to the development of this disorder, perhaps due to different buffering systems.http://link.springer-ny.com/link/service/journals/00547/bibs/8n3p154.html

Chronic intoxication by doxycycline use for more than 12 years.

We report the clinical case of a 12-years' intoxication by doxycycline. A patient with a depersonalization and derealization syndrome took 1 g doxycycline per day. In addition to hepatocellular necrosis with cholestasis, nephrotoxicity, leukopenia, anaemia and skin hyperpigmentation he suffered from hitherto unreported adverse cardiac events as intermittent supraventricular tachycardia and sporadic Wenckebach heart block. Despite a long period of self-medication these side-effects were reversible.

Plasma and membrane Ca2+ and Mg2+ concentrations in normal pregnancy and in preeclampsia.

OBJECTIVE: Changes in intracellular Ca2+ and Mg2+ concentrations seem to be involved in the pathogenesis of preeclampsia, whereas the role of cell membranes has not been studied in detail yet. To investigate the changes in Ca2+ and Mg2+ metabolism in normal pregnancy and preeclampsia, plasma and membrane Ca2+ and Mg2+ concentrations were determined in a clinical study as compared to healthy subjects. STUDY DESIGN: 25 healthy female subjects, 22 untreated healthy pregnant and 20 preeclamptic women were investigated. In each patient, plasma and membrane Ca2+ and Mg2+ content were measured. Ca2+ and Mg2+ concentrations were measured by atomic absorption spectroscopy. Erythrocyte membranes were chosen for membranous Ca2+ and Mg2+ determination. RESULTS: Plasma Mg2+ concentrations were significantly lowered in the healthy pregnant group and the preeclamptic group as compared to controls (p < 0.0001). In erythrocyte membranes, Mg2+ content was found significantly decreased in the preeclamptic women as compared to healthy subjects (p < 0.001). In plasma Ca2+ concentrations there was a significant decrease in the preeclamptic group as compared to controls or healthy pregnant women (p < 0.05). Membranous Ca2+ content was significantly increased in the preeclamptic group versus controls or healthy pregnant women (p < 0.001). CONCLUSION: Lowered plasma and membrane Mg2+ concentrations in preeclampsia may contribute to the development of hypertension in pregnancy. Additionally, a disturbed Ca2+ homeostasis is observed in preeclampsia.

Elemental mercurial poisoning.

A 39-year-old man injected 40 mL of elemental mercury in an attempted suicide 3 years before coming to our facility. No specific treatment regimen had been done since then. Chest x-ray films showed mercury deposits in the lungs, as well as around the injection site. The mercury concentration in his blood was at 96.3 micrograms (0.480 nmol/L), thus significantly elevated (given a reference range of up to 2 micrograms Hg/L), as was the renal mercury elimination. Despite mercurial deposits within the pulmonary circulation, the pulmonary function showed normal values, with no reduction of the diffusion capacity. There were signs of polyneuropathy. The patient was given sodium dimercaptopropanesulfate (Dimaval) for mercury complexation. This case report outlines the diagnosis and therapy for mercurial poisoning through metallic mercury.