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Background: Psychiatric disorders can be interpreted as a general dysregulation of the interplay between brain and behaviour. This is why, since the late 1990’s, the terms biological psychiatry and behavioural neurology have been gradually replaced by the term neuropsychiatry. Neuropsychiatry, when practiced in combination with clinical neuropsychology, have given rise to a paradigm that is not based solely on the usual classification models but is directed primarily towards diagnosis and treatment that are based on a functional-dimensional approach., Aim: To discuss the daily practice and organisation in a specialised department for neuro-psychiatry located in a psychiatric teaching hospital., Method: The interdisciplinary approach is explained and analysed on the basis of 10 case studies., Results: Most of the patients referred to the specialised department already had a long history of visits to the health care facilities where they had been treated by a variety of specialists in single disciplines. Often, however, this trajectory did not involve periodical re-evaluation and updating of the original diagnosis. If this strategy had been adopted, then a clear diagnosis with simplified treatment programme might have been devised which could have resulted in a patient’s successful reintegration into society., Conclusion: It is essential that the interdisciplinary approach is adopted in specialised centres for neuropsychiatry because it can make an important contribution to individual patient care and to the spread of specialised knowledge that can benefit the entire field of psychiatry.

Objective: To compare an early switch from intravenous to oral antibiotics with the standard intravenous therapy in patients admitted to hospital with severe community acquired pneumonia., Design: Multicentre randomised prospective trial with follow-up at 28 days., Method: Patients with severe pneumonia who were admitted to hospital were randomised for 7 days intravenous antibiotic therapy (control group) or for an early switch to oral antibiotic therapy after 3 days of intravenous antibiotic therapy (intervention group). An intention-to-treat analysis was performed. The primary outcome measure was clinical cure. The length of hospital stay was a secondary outcome measure., Results: Out of the 302 patients included in the trial, data was analysed from 265 patients. The mortality rate in the intervention group did not differ significantly from that of the control group (mean difference: 2%; 95% CI: -3-8). After 28 days, 83% of the patients in the intervention group and 85% in the control group were clinically cured (mean difference: 2%; 95% CI: -7-10). The length of hospital stay was 1.9 days shorter in the intervention group (95% CI: 0.6-3.2 days)., Conclusion: An early switch from intravenous to oral antibiotics in patients admitted to hospital for severe community acquired pneumonia is safe and reduces the length of hospital stay by approximately 2 days.

A woman aged 36 injured herself on a needle that had been used to take an iliac-crest biopsy from an HIV-positive patient and a man aged 34 and a woman aged 35 had sexual contact with their HIV-positive partners during which the condom tore. They were given post-exposure prophylaxis (PEP) which was formulated using medication and virus resistance data from the HIV-positive individual. At 3 and 6 months the patients were all still HIV-negative. After occupational or non-occupational exposure to HIV, PEP is initiated if there is a reasonable risk of transmission of HIV. In The Netherlands a combination of 3 antiretroviral drugs is advised based on demonstrated antiviral effectiveness in the regular treatment of HIV-infections. Frequently a standard PEP-regimen is prescribed. If the source patient has a history of antiretroviral therapy, the virus might be resistant to standard PEP-regimens. In these cases the choice of drugs in the PEP-regimen can be individualised based on the antiretroviral medication history of the source patient and known resistance patterns of the source virus.

As seen in several national registration systems, the morbidity and mortality due to pneumonia-related disease has increased in the Netherlands in the past 10 years. It is unlikely that the observed increase in mortality due to pneumonia is purely the result of the registration system used or misclassification. An increase in the elderly population is the most likely, albeit only partial, explanation. An increase in underlying diseases such as chronic obstructive pulmonary disease and diabetes mellitus is also a possible explanation. Increased antibiotic resistance, inadequate treatment or a shift in the spectrum of micro-organisms causing pneumonia are less likely explanations. Reducing the morbidity and mortality due to pneumonia demands an integrated approach aimed at elderly patients or patients with co-existing disease and executed by specialists in the fields of geriatrics, internal medicine, pulmonary disease and infectious diseases.

Community-acquired pneumonia is an important cause of hospital admission and mortality in the adult population. The recommended antibiotic for pneumonia caused by Streptococcus pneumoniae is a beta-lactam antibiotic and, for so-called atypical pathogens, a macrolide. In the US and elsewhere, the current recommendation is to start with a beta-lactam antibiotic and a macrolide or with one of the new quinolones. The available literature consists largely of retrospective studies. Because of possible selection bias in these analyses and inconsistencies in reported outcomes, it is not possible to draw any well-founded conclusions from these studies. Reasons for a possible additional benefit of adding a macrolide to the therapy could include: a higher prevalence of undiagnosed atypical pathogens, the anti-inflammatory effects of macrolides, and resistance of the main pathogens against beta-lactam antibiotics. None of these appear to play a significant role. There is no need to revise Dutch guidelines.

Objective: To evaluate the effect of treatment of HIV-1 infection with combination therapy consisting of since 1996 in the Netherlands available protease and reverse transcriptase inhibitors., Design: Prospective cohort study., Methods: In an observational clinical cohort of HIV-1-infected individuals, the short-term successful treatment end point of antiviral therapy including at least one antiretroviral drug licensed in the Netherlands since July 1, 1996 (protease inhibitors and reverse transcriptase inhibitors), was HIV-1 RNA plasma levels < or = 500 copies/ml (virological success). Cox proportional hazard models were used to identify prognostic markers for therapy success. The study included 2,148 infected individuals with a median follow-up of 135 weeks of treatment; 1,049 had been pre-treated with antiretroviral drugs before starting their new regimen and 1,099 were treatment naive., Results: Plasma HIV-1 RNA levels < or = 500 copies/ml at 24 weeks of treatment were seen in 61% of all patients. The chance of therapy success for naive patients was twice that for pre-treated patients (relative risk: 1.8; p < or = 0.001). Following the first 24 weeks, the chance of virological success was higher in the naive group (78% versus 63%; p < or = 0.001), and the number of naive patients failing therapy after initial success was smaller compared to pre-treated patients (22% versus 45%; p < or = 0.001). In the naive group, the CD4+ T-cell number increased from 239 to 440 (x 10(6) cells/l) in case of success, and decreased from 150 to 320 in case of treatment failure. HIV-1 related morbidity declined from 0.26 to 0.05 and mortality dropped from 0.07 to 0.03 per person-year of follow-up. Regimens were changed at least once in 76% of patients. Toxicity and therapy failure were the main reasons for regimen changes in naive and pre-treated patients, respectively., Conclusion: A combination of antiretroviral drugs, including at least one of the drugs licensed since 1996, led to a drop in HIV-1 plasma concentrations. Morbidity and mortality also decreased. The chance of a better immunological and virological response to the new drug regimens was greatest in therapy-naive patients.

In 1997 there was an outbreak of foot-and-mouth disease (FMD) among cattle in Turkey. People visiting that country were warned against importing animal products into the Netherlands. This had nothing to do with hazards to human health, as FMD virus is not a zoonotic virus, but with the risk of spread of the disease to livestock in the Netherlands, notably to cattle and pigs. A disease with similar clinical symptoms in pigs is swine vesicular disease (SVD), which is not a zoonosis either. FMD virus is an aphtovirus, SVD virus is an enterovirus. Hand-foot-and-mouth disease in humans is caused by other enteroviruses, i.e. Coxsackie virus and enterovirus 71.

The application of potent combinations of antiretroviral drugs ('highly active antiretroviral therapy' (HAART)) makes effective therapy of HIV infection feasible. Consequently, the pattern of opportunistic infections and other secondary complications has changed. The incidence of infections and mortality due to aids has declined significantly. Further, the occurrence of other infections and syndromes, till now unknown in patients with aids, has been observed. It is thought that these are caused by HAART-induced inflammation, a phenomenon due to immune enhancement following HAART. An important issue is whether primary and secondary prophylaxis against opportunistic infections can be discontinued after improvement of the immune system: indeed, there are reports that discontinuation is safe in patients with persistent CD4+ cell counts above the critical level for that particular infection while CD4+ cell counts are monitored carefully.

The prevalence of infection with Mycobacterium avium complex (MAC) has increased since the outbreak of the HIV pandemic. This complex comprises two organisms: M. avium (mostly) and M. intracellulare (rarely). The source of MAC infection is not known. The principal risk factors for disseminated MAC infection in a patient with HIV infection are a low CD4 count and a previous opportunistic infection. The symptoms of disseminated MAC infection resemble those of HIV wasting; a positive culture of normally sterile tissue confirms a MAC infection. There is reserve with regard to routine prophylaxis in HIV-infected persons because of the possible development of resistance, interaction with other drugs used in AIDS, toxicity and possible absorption disorders which might cause prophylaxis to fail. For the treatment of disseminated MAC infection, a combination of at least two medicaments (macrolides and ethambutol) is recommended.

Objective: To assess the effect of treatment of echinococcal disease with albendazole, a drug recently licensed in the Netherlands for this treatment., Setting: The University Hospital Utrecht and the Wilhelmina Children's Hospital, Utrecht., Design: Follow-up study., Method: Clinical symptoms, serology and size and morphology of cysts of all patients (n = 7) treated with albendazole with a therapeutical dose (10 mg/kg for adults and 6 mg/kg for children in two daily doses during three cycles of 28 days) were monitored for at least one year., Results: Two patients improved, two patients did not show any change, and the condition of three patients deteriorated., Conclusion: The efficacy of albendazole treatment with this regimen for hydatid disease is disappointing. If patients are treated with albendazole, the total dose administered to adults should be more than 80 g.