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Eline C Jochems,1,2 Christina M van der Feltz-Cornelis,1–3 Arno van Dam,3,4 Hugo J Duivenvoorden,5 Cornelis L Mulder1,6 1Department of Psychiatry, Epidemiological and Social Psychiatric Research Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands; 2GGz Breburg, Top Clinical Center for Body, Mind and Health, Tilburg, the Netherlands; 3Tilburg University, Faculty of Social Sciences, Tranzo Department, Tilburg, the Netherlands; 4GGZ Westelijk Noord Brabant, Bergen op Zoom, the Netherlands; 5Erasmus MC University Medical Center, Rotterdam, the Netherlands; 6BavoEuropoort, Parnassia Psychiatric Institute, Rotterdam, the Netherlands Objective: To evaluate the effectiveness of providing clinicians with regular feedback on the patient’s motivation for treatment in increasing treatment engagement in patients with severe mental illness.Methods: Design: cluster randomized controlled trial (Dutch Trials Registry NTR2968). Participants: adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians, treated in 12 community mental health teams (the clusters) of two mental health institutions in the Netherlands. Interventions: monthly motivation feedback (MF) generated by clinicians additional to treatment as usual (TAU) and TAU by the community mental health teams. Primary outcome: treatment engagement at patient level, assessed at 12 months by clinicians. Randomization: teams were allocated to MF or TAU by a computerized randomization program that randomized each team to a single treatment by blocks of varying size. All participants within these teams received similar treatment. Clinicians and patients were not blind to treatment allocation at the 12-month assessment.Results: The 294 randomized patients (148 MF, 146 TAU) and 57 clinicians (29 MF, 28 TAU) of 12 teams (6 MF, 6 TAU) were analyzed according to the intention-to-treat principle. No statistically significant differences between treatment groups on treatment engagement were found (adjusted mean difference =0.1, 95% confidence interval =-2.2 to 2.3, P=0.96, d=0). Preplanned ancillary analyses showed statistically significant interaction effects between treatment group and primary diagnosis on treatment motivation and quality of life (secondary outcomes), which were beneficial for patients with a primary diagnosis of a personality disorder but not for those with a psychotic disorder. There were no reports of adverse events.Conclusion: The current findings imply that monitoring and discussing the patient’s motivation is insufficient to improve motivation and treatment engagement, and suggests that more elaborate interventions for severe mental illness patients are needed. Keywords: randomized controlled trial, feedback, motivation, adherence, psychotic disorders, personality disorders

Importance: Continuous morphine infusion as standard postoperative analgesic therapy in young infants is associated with unwanted adverse effects such as respiratory depression.Objective: To determine whether intravenous paracetamol (acetaminophen) would significantly (>30%) reduce morphine requirements in neonates and infants after major surgery.Design, Setting, and Patients: Single-center, randomized, double-blind study conducted in a level 3 pediatric intensive care unit in Rotterdam, The Netherlands. Patients were 71 neonates or infants younger than 1 year undergoing major thoracic (noncardiac) or abdominal surgery between March 2008 and July 2010, with follow-up of 48 hours.Interventions: All patients received a loading dose of morphine 30 minutes before the end of surgery, followed by continuous morphine or intermittent intravenous paracetamol up to 48 hours postsurgery. Infants in both study groups received morphine (boluses and/or continuous infusion) as rescue medication on the guidance of the validated pain assessment instruments.Main Outcome Measures: Primary outcome was cumulative morphine dose (study and rescue dose). Secondary outcomes were pain scores and morphine-related adverse effects.Results: The cumulative median morphine dose in the first 48 hours postoperatively was 121 (interquartile range, 99-264) μg/kg in the paracetamol group (n = 33) and 357 (interquartile range, 220-605) μg/kg in the morphine group (n = 38), P < .001, with a between-group difference that was 66% (95% CI, 34%-109%) lower in the paracetamol group. Pain scores and adverse effects were not significantly different between groups.Conclusion and Relevance: Among infants undergoing major surgery, postoperative use of intermittent intravenous paracetamol compared with continuous morphine resulted in a lower cumulative morphine dose over 48 hours.Trial Registration: trialregister.nl Identifier: NTR1438. [ABSTRACT FROM AUTHOR]

Background: In this paper, we aim to test the long-term benefit of an integrative reactivation and rehabilitation (IRR) program compared to usual care in terms of improved psychogeriatric patients on multiple psychiatric symptoms (MPS) and of caregivers on burden and competence. Improvement was defined as >30% improvement (≥ a half standard deviation) compared to baseline.Methods: We used the following outcome variables: difference in the number of improved patients on MPS (Neuropsychiatric Inventory, NPI) and improved caregivers on burden (Caregiver Burden, CB) and competence (Caregiver Competence List, CCL). Assessments were taken after intake (T1) and after six months of follow-up (T3). Risk ratios (RR), number needed to treat (NNT), and odds ratios (ORs) were calculated.Results: IRR had a significant positive effect on NPI-cluster hyperactivity (RR 2.64; 95% CI: 1.26-5.53; NNT 4.07). In the complete cases analysis, IRR showed significant ORs of 2.80 on the number of NPI symptoms and 3.46 on the NPI-sum-severity; up to 76% improved patients. For caregivers, competence was a significant beneficiary in IRR (RR 2.23; 95% CI: 1.07-4.62; NNT 5.07). In the complete cases analysis, the ORs were significantly in favor of IRR on general burden and competence (ORs range: 2.40-4.18), with up to 71% improved caregivers.Conclusion: IRR showed a significantly higher probability of improvement with a small NNT of four on multiple psychiatric symptoms in psychogeriatric patients. The same applies to the higher probability to improve general burden and competence of the caregiver with an NNT of five. The results were even more pronounced for those who fully completed the IRR program. (Inter)national psychogeriatric nursing home care and ambulant care programs have to incorporate integrative psychotherapeutic interventions. [ABSTRACT FROM AUTHOR]

BACKGROUND: In neonatal intensive care, a child's death is often preceded by a medical decision. Nurses, social workers and pastors, however, are often excluded from ethical case deliberation. If multiprofessional ethical case deliberations do take place, participants may not always know how to perform to the fullest. SETTING: A level-IIID neonatal intensive care unit of a paediatric teaching hospital in the Netherlands. METHODS: Structured multiprofessional medical ethical decision-making (MEDM) was implemented to help overcome problems experienced. Important features were: all professionals who are directly involved with the patient contribute to MEDM; a five-step procedure is used: exploration, agreement on the ethical dilemma/investigation of solutions, analysis of solutions, decision-making, planning actions; meetings are chaired by an impartial ethicist. A 15-item questionnaire to survey staff perceptions on this intervention just before and 8 months after implementation was developed. RESULTS: Before and after response rates were 91/105 (87%) and 85/113 (75%). Factor analysis on the questionnaire suggested a four-factor structure: participants' role; structure of MEDM; content of ethical deliberation; and documentation of decisions/conclusions. Effect sizes were 1.67 (p<0.001), 0.69 (p<0.001) and 0.40 (p<0.01) for the first three factors respectively, but only 0.07 (p=0.65) for the fourth factor. Nurses' perceptions of improvement did not significantly exceed those of physicians. CONCLUSION: Professionals involved in ethical case deliberation perceived that the process of decision-making had improved; they were more positive about the structure of meetings, their own role and, to some extent, the content of ethical deliberation. Documentation of decisions/conclusions requires further improvement. [ABSTRACT FROM AUTHOR]

AIM: the aim of this study was to evaluate cognitive and motor development in children with major congenital anomalies and the predictability of development at age 5 years. METHOD: a prospective, longitudinal follow-up study was undertaken. The Dutch version of the Bayley Scales of Infant Development - Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) - were administered at the ages of 6, 12, and 24 months. The Revised Amsterdam Children's Intelligence Test - IQ and the Movement Assessment Battery for Children - Total impairment score (TIS) were used at age 5 years. A total of 117 children participated in the study. After excluding 12 children who had a major chromosomal or syndromal abnormality, the analysis was limited to 105 children (50 females, 55 males). Seven groups of congenital anomalies were distinguished: (1) small intestinal anomalies; (2) abdominal wall defects, comprising gastroschisis and omphalocele; (3) oesophageal atresia; (4) congenital diaphragmatic hernia; (5) Hirschsprung disease; (6) anorectal malformations; and (7) miscellaneous diagnoses. Logistic regression analyses served to determine the ability of MDI and PDI to predict IQ and TIS at age 5 years. RESULTS: at age five, 83.7% of 104 children had an IQ of 85 or above and 16.3% an IQ of less than 85. TIS was normal in 71.3% of 87 children, while 17.2% demonstrated a borderline score and 11.5% a definite motor problem. MDI and PDI scores showed equal sensitivity to predict IQ (p=0.004 at 6 and 12mo, p=0.001 at 24mo) and TIS (p<0.001 at 6 and 12mo, p=0.002 at 24mo). MDI and PDI were positively correlated with IQ and TIS; TIS was positively correlated with IQ. INTERPRETATION: IQ scores at 5 years of age corresponded to Dutch population scores, but TIS scores differed significantly. Early development of children with major congenital anomalies is predictive of development at 5 years, which can guide individualized follow-up for this vulnerable group of children. [ABSTRACT FROM AUTHOR]

The aim of the present study is to compare the effectiveness of experiential-existential group psychotherapy with a social support group for women with a primary breast cancer on psychosocial adjustment. A total of 67 well-adjusted women, who had been operated not earlier than 4 months before start of the study, were randomized into one of the two conditions: participating in the group psychotherapy or in the support group. They were questioned at the start of the study, at the end of the intervention, and 1 year after completion of the intervention. Results at follow-up were mixed: Positive changes were reported for Body Image and Recreation, regardless of type of intervention. Other psychosocial adjustment indicators did not change. In general, we may conclude that well-adjusted women diagnosed with breast cancer do not specifically benefit from these types of interventions. [ABSTRACT FROM AUTHOR]

Purpose. To investigate the efficacy of TouchSpeak (TS), a handheld computerised communication aid for aphasia. Method. A pre-post one-group design was used with a referred sample of 34 patients with a severe aphasia and a need for alternative and augmentative communication (AAC). The participants were trained to use TS in two self-chosen communicative situations. The ability to navigate the hierarchical vocabulary and overall communicative ability were assessed. Participants rated their communicative success with and without TS. Three years after completion of the training, participants were interviewed about their present use of TS. Results. In total, 76% used TS outside the clinic in two trained communicative situations. Overall communicative ability improved, as tested in untrained scenarios. Quality of communication with TS was rated higher than without TS. Fifty per cent obtained their own TS after the training and after 3 years 6% still used TS. Conclusions. Aphasic communication can be supported effectively by TS. Patients with a severe aphasia are able to master a hierarchical computerised vocabulary and to use it in daily life for specific communicative situations. In addition, TS may also have a generalised effect on overall communicative ability. For most patients, the supportive role of TS is temporary. [ABSTRACT FROM AUTHOR]

Background: Increasingly, computerised communication aids are used by people with severe, chronic aphasia. Although the candidacy for these devices is relatively unknown, it has been hypothesised that cognitive deficits have a negative impact on the functional use of Augmentative and Alternative Communication (AAC). Deficits of executive functioning are assumed to be particularly important, but other functions, such as memory and semantic processing, may also be relevant. In a previous study (van de Sandt-Koenderman, Wiegers, Wielaert, Duivenvoorden, & Ribbers, in press) we reported the functional effect of TouchSpeak (TS), a computerised communication aid, in a group of stroke patients with severe aphasia. The successful participants showed different levels of proficiency. Some were able to use the system independently and creatively in many situations, some used it independently for trained situations, and others remained partner dependent in using TS. Aims: To find factors associated with the functional success of TS in people with severe aphasia, focusing on memory, executive functioning, semantic processing, and communication skills. Methods & Procedures: The data of 30 patients with severe aphasia were analysed retrospectively. All were trained to use TS in two self-chosen communicative situations. Four outcome levels were differentiated: no use, dependent use, independent use, and extensive use of TS. Pre-training assessment included memory, executive functioning, semantic processing, and communication skills. The four outcome groups were compared regarding age, time post onset, gender, and aphasia type. The role of the cognitive variables was analysed with univariate ANCOVAs with contrast analysis, with correction for age, gender, aphasia type, or time post onset in case of significant differences between the groups on these variables. Outcomes & Results: Seven participants were classified as extensive users of TS, five were independent TS users, and five were partner dependent. In 13 cases there was no functional use of TS. Extensive users were younger than the other outcome groups. Independent of this age effect, there was an effect of semantic processing; the no-use group scored significantly lower on semantics than all other groups. Conclusions: Only a minority of patients with severe aphasia may be expected to become independent, flexible users of high-tech AAC. The finding that functional success was related to semantic processing is clinically important. Prospective studies are needed to support the predictive value of semantic processing for high-tech AAC use. The importance of intact executive functioning is not supported in this study. The broad concept of 'executive functioning' needs to be studied in more detail in relation to aphasia. [ABSTRACT FROM AUTHOR]

Frontotemporal dementia (FTD) is the second most prevalent dementia after Alzheimer's disease (AD). We compared 29 FTD and 90 AD caregivers with respect to burden, health-related quality of life (HQoL) and coping. FTD caregivers were more burdened than AD caregivers, and caregivers of patients who were demented for shorter duration had lower HQoL. We furthermore compared the 29 FTD caregivers with 34 caregivers of institutionalized FTD patients to understand their specific caregiver issues. Caregivers of FTD patients institutionalized after shorter dementia duration were most burdened and affected in their HQoL. Overall, passive coping strategies were associated with increased burden and decreased HQoL. We recommend that FTD caregivers be offered more support than AD caregivers. Furthermore, we suggest that interventions target passive coping strategies. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This prospective, observation study (from June 2001 to October 2002) estimated the prevalence and co-occurrence of psychiatric function disorders (PFDs) in psychogeriatric patients suffering from cognitive function disorders at referral to clinical as well as non-clinical (transmural) psychogeriatric programmes. It is expected that PFDs, both total and individual, are positively related to the cognitive function disorders as well as the activities of daily living (ADL) handicaps. This expectation will be adjusted for general details particularly gender, age, marital status, domicile and type of primary caregiver. Exploratively, the structure of the interrelationship of PFDs, cognitive function disorders and ADL handicaps will be analysed. In addition, the general details and the structure to be identified will be described. METHODS: We studied patients aged > or = 65 years (n = 487), who were suspected to suffer from cognitive function disorders (MMSE < or = 29) and were referred to trans-/intramural nursing home care in the Nieuwe Waterweg Noord region. General details, i.e. gender, age, marital status, domicile, primary caregiver, as well as PFDs (the Neuropsychiatric Inventory, NPI), cognition (MMSE) and ADL (Barthel Index, BI) were assessed. RESULTS: Mean score NPI was 3.6 (SD = 2.3). Of the patients, 91.7% scored one or more NPI symptom; 81.6% two or more. Depression (43.9%), apathy (43.1%), anxiety (41.6%) and agitation/aggression (31.2%) had a high prevalence. With respect to the NPI symptoms, i.e. delusion, hallucination, anxiety (more in women), agitation/aggression and irritability (more in men), there were significant gender differences on the same MMSE level. Compared with women, men were significantly younger, ADL independent, lived together with their spouse, who was often the primary caregiver. The performance of the logistic regression models for total NPI score with MMSE, BI separately as well as combined with general details was minor. The results of the regression analyses for the individual NPI symptoms showed comparable low R(2) values; they explained a small proportion of the variance. However, in the PRINCALS analysis the MMSE and BI highly correlated with the cognitive dimension, and the NPI with the psychiatric dimension. The model fit was good; 82.6% of the variance was explained. CONCLUSION: At the moment of referral to nursing home care, the prevalence and co-occurrence of PFDs was high. The four main NPI symptoms were depression, apathy, anxiety and agitation/aggression. On the same level of MMSE score, gender difference was important for 3 NPI symptoms: delusion, hallucination and anxiety. NPI scores (total and per symptom) were relatively independent from MMSE, BI and general details. The PFDs--measured by the NPI--were a dimension on their own. Therefore, in psychogeriatrics it is of clinical relevance to think and act in terms of dimensions. Irrespective of a more rational psychopharmaceutical regime, this opens the door to the regular psychiatric domain for (psycho)therapeutic strategies, e.g. for depression and anxiety adapted to the kind and level of the cognitive function disorder of the psychogeriatric patient. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Development of Tetraplegia Hand Activity Questionnaire (THAQ). SETTING: Patients and spinal cord injury (SCI) professionals from five rehabilitation centres in the Netherlands and Belgium. OBJECTIVE: To construct a disease-specific questionnaire to evaluate interventions to the arm-hand of tetraplegics in terms of gained and lost activities relevant to the patient. METHODS: All arm-hand function-related activities were inventoried by examining existing scales and interviewing spinal cord injury patients and professionals in the field. Subsequently, item reduction was achieved; first, in the technical construction by incorporating all activities in an item list, then reducing the list by selecting the items most likely to be sensitive to change after surgical or functional electro stimulation interventions on the arm-hand as judged by an expert panel, using a Delphi method. RESULTS: The arm-hand-related activity inventory comprised 652 activities. The technical construction of the items and the Delphi procedure resulted in a questionnaire with 153 items. The experts considered many of the 'new' activities more relevant for the evaluation of hand function interventions than those found in scales studied in the literature. This is reflected in a relatively large proportion of new activities (69%) for the item list of the THAQ, and even more in the domains work/admin/telecom (88%) and leisure (100%). CONCLUSION: The questionnaire constructed to assess hand function-related activities contains relevant activities to evaluate arm-hand function-related interventions for tetraplegic SCI patients. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the effect of intrauterine and neonatal growth, prematurity and personal and environmental risk factors on intelligence in adulthood in survivors of the early neonatal intensive care era. METHODS: A large geographically based cohort comprised 94% of all babies born alive in the Netherlands in 1983 with a gestational age below 32 weeks and/or a birth weight >1500 g (POPS study). Intelligence was assessed in 596 participants at 19 years of age. Intrauterine and neonatal growth were assessed at birth and 3 months of corrected age. Environmental and personal risk factors were maternal age, education of the parent, sex and origin. RESULTS: The mean (SD) IQ of the cohort was 97.8 (15.6). In multiple regression analysis, participants with highly educated parents had a 14.2-point higher IQ than those with less well-educated parents. A 1 SD increase in birth weight was associated with a 2.6-point higher IQ, and a 1-week increase in gestational age was associated with a 1.3-point higher IQ. Participants born to young mothers (<25 years) had a 2.7-point lower IQ, and men had a 2.1-point higher IQ than women. The effect on intelligence after early (symmetric) intrauterine growth retardation was more pronounced than after later (asymmetric) intrauterine or neonatal growth retardation. These differences in mean IQ remained when participants with overt handicaps were excluded. CONCLUSIONS: Prematurity as well as the timing of growth retardation are important for later intelligence. Parental education, however, best predicted later intelligence in very preterm or very low birthweight infants. [ABSTRACT FROM AUTHOR]

Objective: To study the effects of continuous morphine infusion on arterial blood pressure in ventilated neonates.Design: Blinded randomised placebo controlled trial.Setting: Level III neonatal intensive care unit in two centres.Patients: A total of 144 ventilated neonates. Inclusion criteria were postnatal age <3 days, ventilation <8 hours, and indwelling arterial line. Exclusion criteria were severe asphyxia, severe intraventricular haemorrhage, major congenital anomalies, neuromuscular blockers.Intervention: Arterial blood pressure was measured before the start and during the first 48 hours of masked infusion of drug (morphine/placebo; 100 micorg/kg + 10 microg/kg/h).Outcome measures: Arterial blood pressure and blood pressure variability.Results: There were no significant differences in overall mean arterial blood pressure between the morphine group (median (interquartile range) 36 mm Hg (6) and the placebo group (38 mm Hg (6)) (p = 0.11). Although significantly more morphine treated patients (70%) showed hypotension than the placebo group (47%) (p = 0.004), the use of volume expanders and vasopressor drugs was not significantly different (morphine group, 44%; placebo group, 48%; p = 0.87), indicating the limited clinical significance of this side effect. Blood pressure variability was not influenced by routine morphine analgesia (p = 0.81) or additional morphine (p = 0.80). Patients with and without intraventricular haemorrhage showed no differences in blood pressure (Mann-Whitney U test 1953; p = 0.14) or incidence of hypotension (chi [2] test 1.16; df 1; p = 0.28).Conclusions: Overall arterial blood pressure, use of inotropes, and blood pressure variability were not influenced by morphine infusion. Therefore the clinical impact of hypotension as a side effect of low dose morphine treatment in neonates is negligible. [ABSTRACT FROM AUTHOR]

Introduction: Surgical procedures are increasingly carried out in a day-case setting. Along with this increase, psychological outcomes have become prominent. The objective was to evaluate prospectively the prognostic effects of sociodemographic, medical, and psychological variables assessed before day-case surgery on psychological outcomes after surgery., Methods: The study was carried out between October 2010 and September 2011. We analyzed 398 mixed patients, from a randomized controlled trial, undergoing day-case surgery at a university medical center. Structural equation modeling was used to jointly study presurgical prognostic variables relating to sociodemographics (age, sex, nationality, marital status, having children, religion, educational level, employment), medical status (BMI, heart rate), and psychological status associated with anxiety (State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS-A)), fatigue (Multidimensional Fatigue Inventory (MFI)), aggression (State-Trait Anger Scale (STAS)), depressive moods (HADS-D), self-esteem, and self-efficacy. We studied psychological outcomes on day 7 after surgery, including anxiety, fatigue, depressive moods, and aggression regulation., Results: The final prognostic model comprised the following variables: anxiety (STAI, HADS-A), fatigue (MFI), depression (HADS-D), aggression (STAS), self-efficacy, sex, and having children. The corresponding psychological variables as assessed at baseline were prominent (i.e. standardized regression coefficients ≥ 0.20), with STAI-Trait score being the strongest predictor overall. STAI-State (adjusted R2 = 0.44), STAI-Trait (0.66), HADS-A (0.45) and STAS-Trait (0.54) were best predicted., Conclusion: We provide a prognostic model that adequately predicts multiple postoperative outcomes in day-case surgery. Consequently, this enables timely identification of vulnerable patients who may require additional medical or psychological preventive treatment or-in a worst-case scenario-could be unselected for day-case surgery.

The current study tested the Integral Model of treatment motivation (IM) in a sample of 294 outpatients with severe mental illness, using structural equation modelling. The obtained structural model was not consistent with original theory, nor was the model invariant across time and patient groups (psychotic disorders and personality disorders). The patient's perceived suitability of treatment, perceived costs of treatment and outcome expectancy were most strongly associated with motivation and treatment engagement. The model explained between 22 and 86% of variance in clinical outcomes, depending on the timing of the assessment. Currently, the IM does not constitute a robust framework for patterns through which patients become motivated to engage in treatment, but does explain substantial amounts of variance in clinical outcomes. The future potential of IM as a basis for interventions in the mental health care is discussed, including suggestions for subsequent research and potential alterations of the IM to improve its utility for application in clinical practice., Competing Interests: Compliance with ethical standardsThe current study was funded by GGZ Westelijk Noord Brabant. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data collection was performed in GGZ Westelijk Noord Brabant and in GGz Breburg by the first author and several collaborating students and clinicians. Analyses were performed by the first author at the Erasmus University Medical Center. GGz Breburg contributed time, energy and resources to the study for the inclusion of patients, but was otherwise not a funder of the study. ECJ and HJD report no competing interests. AD reports that he has paid employment by the funder. The funder had no commercial interest in the results of the current study. CFC reported grants from Eli Lilly, NIHR, EU FP7 program, ZonMw, and Achmea outside the submitted work. CLM reports reported grants from Johnson&Johnson, Janssen Cilagg, NWO, ZonMw outside the submitted work.

Currently, it is unclear whether Self-Determination Theory (SDT) applies to the mental health care of patients with severe mental illness (SMI). Therefore, the current study tested the process model of SDT in a sample of outpatients with SMI. Participants were 294 adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians (n = 57). Structural equation modelling was used to test the hypothesized relationships between autonomy support, perceived competence, types of motivation, treatment engagement, psychosocial functioning and quality of life at two time points and across the two diagnostic groups. The expected relations among the SDT variables were found, but additional direct paths between perceived competence and clinical outcomes were needed to obtain good model fit. The obtained process model was found to be stable across time and different diagnostic patient groups, and was able to explain 18% to 36% of variance in treatment engagement, psychosocial functioning and quality of life. It is concluded that SDT can be a useful basis for interventions in the mental health care for outpatients with SMI. Additional experimental research is needed to confirm the causality of the relations between the SDT constructs and their ability to influence treatment outcomes., (Copyright © 2016 John Wiley & Sons, Ltd.)

Objectives: Caring for a patient with dementia is a real challenge and can have considerable psychological consequences in the long run. Many caregivers, mostly relatives, feel highly burdened. To develop effective caregiver support to prevent caregivers from getting overburdened, insight is needed into the determinants of burden. The objective of this study is to explore which patient and caregiver characteristics determine the different kinds of caregiver burden over time, both in the short and in the long run., Method: The study was longitudinal. Data on patients and caregivers, general burden and emotional distress were collected at three times: at baseline, at the end of treatment and at nine months. The study was conducted in a psychiatric skilled nursing home with a unit for integrative reactivation and rehabilitation (IRR) and at different sites of home-/day care, assisted living arrangements and nursing home wards (usual care)., Results: General burden is shown to be determined by severity of patient's neuropsychiatric symptoms, caregiver's sense of competence, health-related quality of life. Emotional distress is determined by severity of patient's neuropsychiatric symptoms, caregiver's sense of competence, high affiliation and patient gender., Conclusion: In preventing or treating caregiver burden, professional interventions need to aim specifically at diminishing the neuropsychiatric symptoms in dementia patients and improving the sense of competence in caregivers.

Background: Lorazepam is used as premedication for its anxiolytic properties. The UGT2B15 genotype is of importance for the metabolism of lorazepam. The clinical effect of genetic polymorphisms in UGT2B15 genotype on the treatment of anxiety levels in same-day surgery patients receiving lorazepam, however, is unknown., Methods: Three hundred ninety-eight same-day surgery patients of mixed sex (from a previous double-blinded randomized controlled trial who were assigned to either lorazepam [n = 198] or placebo [n = 200]) were assessed for the UGT2B15*2 variant allele. Anxiety was measured preoperatively and postoperatively by the State part of the State-Trait Anxiety Inventory. The difference between these 2 measurements served as outcome of the study. Analysis of variance was used to assess the State part of the State-Trait Anxiety Inventory difference for interactions among the following factors: UGT2B15 genotype status, treatment condition (lorazepam or placebo), patient sex, and preoperative anxiety score., Results: The anxiety difference was complex in that the interaction of lorazepam and UGT2B15 genotype status also was dependent on the joint effect of patient sex and preoperative anxiety score (F = 7.15, P = .008). Further exploration showed clinical relevant results in patients with high preoperative anxiety scores. Striking was that females with high preoperative anxiety scores and genetically reduced lorazepam glucuronidation (UGT2B15*2 homozygotes) showed more postoperative anxiety reduction than males with the same genotype., Conclusions: UGT2B15 genotype contributes to postoperative anxiety reduction after lorazepam premedication. Future research that focuses on patients with high preoperative anxiety scores could help to gain a deeper understanding in the clinical relevance of the interaction between lorazepam and UGT2B15 genotype on postoperative anxiety levels.

The present study assessed motivation for engaging in treatment as rated by clinicians (n = 57) and patients with severe mental illness (SMI, n = 294) using measures based on three different motivation theories. Questionnaires were derived from self-determination theory, the transtheoretical model and the integral model of treatment motivation. It was investigated to which extent clinicians of patients with SMI were able to estimate their patient's perspective on motivation for engaging in treatment, to which extent they agreed on the patient's motivation and which factors were associated with estimation and agreement on treatment motivation. It was found that clinicians were poorly to moderately capable of estimating their patient's type of motivation and readiness for change. Further, agreement on the level of motivation between patients and clinicians was moderate. These findings were consistent across diagnostic groups (psychotic and personality disorders). A higher quality therapeutic relationship was generally associated with higher clinician-rated motivation. The patient's ethnicity and socially desirable responding were factors that differentiated between scales of different motivation theories. It is concluded that patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment, regardless of the theoretical framework that is used to measure motivation. The findings imply that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions. Copyright © 2015 John Wiley & Sons, Ltd., Key Practitioner Message: Clinicians show poor to moderate capability in estimating how patients perceive their motivation for engaging in treatment, especially so when the patient's motives revolve around feelings of shame and guilt. Clinicians generally give higher motivation ratings for patients where they experience a higher quality therapeutic relationships with, whereas-depending on the scale that is used to measure motivation-they give lower ratings to patients who respond in socially desirable ways and to ethnic minority patients. As patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment (regardless of the theoretical framework that is used to assess motivation), this implies that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions., (Copyright © 2015 John Wiley & Sons, Ltd.)

Background: Ambulatory surgery patients are at risk of adverse psychological outcomes such as anxiety, aggression, fatigue, and depression. We developed and validated a clinical prediction model to identify patients who were vulnerable to these psychological outcome parameters., Methods: We prospectively assessed 383 mixed ambulatory surgery patients for psychological vulnerability, defined as the presence of anxiety (state/trait), aggression (state/trait), fatigue, and depression seven days after surgery. Three psychological vulnerability categories were considered-i.e., none, one, or multiple poor scores, defined as a score exceeding one standard deviation above the mean for each single outcome according to normative data. The following determinants were assessed preoperatively: sociodemographic (age, sex, level of education, employment status, marital status, having children, religion, nationality), medical (heart rate and body mass index), and psychological variables (self-esteem and self-efficacy), in addition to anxiety, aggression, fatigue, and depression. A prediction model was constructed using ordinal polytomous logistic regression analysis, and bootstrapping was applied for internal validation. The ordinal c-index (ORC) quantified the discriminative ability of the model, in addition to measures for overall model performance (Nagelkerke's R (2) )., Results: In this population, 137 (36%) patients were identified as being psychologically vulnerable after surgery for at least one of the psychological outcomes. The most parsimonious and optimal prediction model combined sociodemographic variables (level of education, having children, and nationality) with psychological variables (trait anxiety, state/trait aggression, fatigue, and depression). Model performance was promising: R (2)  = 30% and ORC = 0.76 after correction for optimism., Conclusion: This study identified a substantial group of vulnerable patients in ambulatory surgery. The proposed clinical prediction model could allow healthcare professionals the opportunity to identify vulnerable patients in ambulatory surgery, although additional modification and validation are needed. (ClinicalTrials.gov number, NCT01441843).

Introduction: Benzodiazepines are frequently used as a premedication. In day-case surgery, anesthetists are reluctant to administer benzodiazepines preoperatively for reasons of delayed recovery. However, premedication with benzodiazepines might be beneficial regarding postoperative somatic symptoms/complaints (i.e. time to recovery and postoperative side effects) and psychological phenomena., Evidence Acquisition: A systematic review with meta-analysis was performed using all important search engines. Study methodological quality was assessed using risk of bias tables. Mean differences (MD) and odds ratios (OR) were used for continuous data (time to recovery and psychological phenomena) and categorical data (postoperative somatic symptoms) respectively. Random effects modelling was applied. Nineteen studies were included. Overall time to recovery was significantly delayed in patients receiving benzodiazepines (MD 1.75; 95% CI 0.82 to 2.69) although time to discharge was not significantly affected. Postoperative side effects were significantly reduced in patients receiving benzodiazepines (OR 0.47; 95% CI 0.36 to 0.63). Regarding psychological outcome, only anxiety could be statistically analyzed showing no statistical difference (MD 1.47; 95% CI -1.01 to 3.96)., Evidence Synthesis: Although overall time to recovery was significantly prolonged by benzodiazepine premedication, withholding premedication in day-case surgery patients is not justified for such reason, as time to discharge was not negatively affected. Furthermore, benzodiazepines show to have beneficial effects on postoperative side effects., Conclusions: For a firm conclusion regarding psychological phenomena, more research is needed. Anaesthetists should take into account this new evidence when they apply their premedication regime in day-case surgery.

Background: There is no consensus regarding the optimal adjuvant treatment after resection of non-pancreatic periampullary adenocarcinoma (NPPC; distal common bile duct, ampulla, duodenum)., Objectives: The present study was conducted to evaluate the impacts on longterm survival and recurrence of adjuvant intra-arterial chemotherapy (IAC) and concomitant radiotherapy (RT) in patients submitted to resection for NPPC or pancreatic ductal adenocarcinoma (PDAC) in a randomized controlled trial., Methods: A total of 120 patients with PDAC (n = 62) or NPPC (n = 58) were prestratified at a ratio of 1:1 for tumour origin and randomized. Half of these patients were treated with adjuvant IAC/RT and the other half were treated with surgery alone. Follow-up was completed for all patients up to 5 years after resection or until death., Results: There was no survival benefit in either the whole group (primary endpoint) or the PDAC group after IAC/RT. In the NPPC group, longterm survival was observed in 10 patients in the IAC/RT group and five patients in the control group: median survival was 37 months and 28 months, respectively. The occurrence of liver metastases was reduced by IAC/RT from 57% to 29% (P = 0.038). Cox regression analysis revealed a substantial effect of IAC/RT on survival (hazard ratio: 0.44, 95% confidence interval 0.23-0.83; P = 0.011)., Conclusions: This longterm analysis shows that median and longterm survival were improved after IAC/RT in patients with NPPC, probably because of the effective and sustained reduction of liver metastases. The present results illustrate that NPPC requires an adjuvant approach distinct from that in pancreatic cancer and indicate that further investigation of this issue is warranted., (© 2015 International Hepato-Pancreato-Biliary Association.)

Background: The COMFORT behaviour scale (COMFORT-B scale) is widely used in paediatric intensive care units to assess young children's pain and distress. It is also used to assess the impact of treatment interventions, but little is known on the scale's sensitivity to detect changes between before and after measurements following an intervention. This study explored the sensitivity to change of the COMFORT-B scale., Methods: COMFORT-B scores, originally and prospectively collected as part of standard care, were retrieved from the digital patient data management system. We analysed scores obtained in 747 paired observations, i.e., before and after a pharmacological intervention in 180 paediatric intensive care patients between September 2009 and September 2010., Results: The mean scores before and after an intervention were 20.0 [standard deviation (SD) 3.7] and 14.1 (SD 4.7), respectively. Multilevel regression analysis showed a 6-point mean decline after an intervention (p < 0.0001). The magnitude of this decline was not statistically significantly related to number and type of interventions or time between assessments. In almost three-quarters of cases (74%), the COMFORT-B score dropped to below 17 after a pharmacological intervention, indicating good responsiveness., Conclusions: This is the first study demonstrating that the COMFORT-B scale detects treatment-related changes in pain or distress intensity. This implies that COMFORT-B assessments can effectively guide analgesic and sedation treatment in critically ill children., (© 2014 European Pain Federation - EFIC®)

Background: The relationship of clinical variables for cognitive functioning and other variables such as multiple neuropsychiatric symptoms and quality of life are usually analyzed bivariately and multivariately. In randomized controlled trials analyses are mostly performed on individual outcome variables. To unravel interdependencies of determinants and outcome variables, Structural Equation Modeling (SEM) was applied., Methods: Using SEM, we explored interdependencies of clinical determinants (MMSE, BI, and NPI-sum severity) and quality of life (EQ5D) in psychogeriatric patients (including dementia) suffering from cognitive problems and multiple neuropsychiatric symptoms., Results: MMSE and BI showed direct and indirect impact on EQ5D, but the association with NPI-sum severity was minor. The identified model showed that R(2) of EQ5D varied from 0.21 to 0.48., Discussion: This clinical-empirical study showed that SEM could be utilized to unravel and identify a model of complex direct and indirect effects of MMSE and BI on EQ5D. In relation to NPI-sum severity, however, the validity of EQ5D seemed insufficient in psychogeriatric patients. Consequently, the cost-benefit analyses and cost-effectiveness analyses using quality-adjusted life-year measures of an intervention in psychogeriatric patients with multiple neuropsychiatric symptoms, based on EQ5D, are considered questionable. Construction of a quality of life instrument that is more sensitive with regard to multiple neuropsychiatric symptoms in psychogeriatric patients is highly recommended., (Copyright © 2014 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Self-determination theory is potentially useful for understanding reasons why individuals with mental illness do or do not engage in psychiatric treatment. The current study examined the psychometric properties of three questionnaires based on self-determination theory-The Treatment Entry Questionnaire (TEQ), Health Care Climate Questionnaire (HCCQ), and the Short Motivation Feedback List (SMFL)-in a sample of 348 Dutch adult outpatients with primary diagnoses of mood, anxiety, psychotic, and personality disorders. Structural equation modeling showed that the empirical factor structures of the TEQ and SMFL were adequately represented by a model with three intercorrelated factors. These were interpreted as identified, introjected, and external motivation. The reliabilities of the Dutch TEQ, HCCQ, and SMFL were found to be acceptable but can be improved on; congeneric estimates ranged from 0.66 to 0.94 depending on the measure and patient subsample. Preliminary support for the construct validities of the questionnaires was found in the form of theoretically expected associations with other scales, including therapist-rated motivation and treatment engagement and with legally mandated treatment. Additionally, the study provides insights into the relations between measures of motivation based on self-determination theory, the transtheoretical model and the integral model of treatment motivation in psychiatric outpatients with severe mental illness., (© The Author(s) 2013.)

Introduction: Pancreatic cancer is among the five most lethal malignancies in the world. Unfortunately, many malignant tumors go undetected by the current primary diagnostic tools. (18)FDG-PET and (18)FDG-PET/CT might be useful to confirm suspected pancreatic cancer., Methods: A meta-analysis was performed using all major search engines. Methodological quality of included studies was assessed as well as quality of the PET-protocol. The following pooled estimates served as primary outcome measures: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy., Results: Thirty-five studies were included. Pooled estimates for (18)FDG-PET were: sensitivity 90%, specificity 76%, PPV 90%, NPV 76% and accuracy 86%. Pooled estimates for (18)FDG-PET/CT were: sensitivity 90%, specificity 76%, PPV 89%, NPV 78% and accuracy 86%. The pooled sensitivity and specificity for (18)FDG-PET to differentiate between pancreatic cancer and chronic pancreatitis were 90% and 84%, respectively., Conclusion: Both (18)FDG-PET and (18)FDG-PET/CT offer no benefit over the current primary diagnostic tools in diagnosing pancreatic cancer. However, the (18)FDG-PET/CT systems are still improving. We should investigate the sensitivity and specificity of these new systems while reevaluating the tradeoff between false positive and false negative results. Yet, (18)FDG-PET/CT may have a role in the staging of pancreatic cancer, in survival prediction, and may add to other diagnostic information, like histology., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Burden in dementia caregivers is a complex and multidimensional construct. Several models of burden and other representations of burden like depression or mental health are described in literature. To clarify the state of science, we systematically reviewed complex models that include both patient and caregiver determinants of caregiver burden., Objective: A review of determinant models of caregiver burden., Design: Systematic review., Data Sources: Electronic databases PubMed, PsycInfo and EMbase were searched in December 2013., Study Selection and Analysis: Research studies with quantitative outcome measures of caregiver burden or burden-related concepts, including both patient and caregiver functional characteristics as determinants. We categorized the determinant variables in the models and calculated the percentages of proven determinants within each category., Results: We found 32 studies with burden models and 24 depression and mental health models. Patient behavioral problems, caregiver coping and personality traits and competence are most consistent determinants of caregiver burden, depression and mental health. Behavioral problems are more significant than cognitive disorders or lack of self-care. Of all measured caregiver personality traits, neuroticism has the strongest impact on caregiver burden. Regarding caregiver competences, feeling competent or enjoying higher self-efficacy in general diminish caregiver burden and promote caregiver mental health., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Although routine outcome monitoring (ROM) has been developed and widely used in the course of patient centered outcome research in the Netherlands, so far the technique has hardly ever been used to improve the treatment of individual patients., Aim: To describe how a rom technique based on the principles of shared decision-making (SDM) was developed and evaluated at the Center for Body, Mind and Health at GGz Breburg, a specialised mental health institution in the Netherlands., Method: We have developed a conceptual model for SDM that involves patient participation and the use of evidence-based decision-aids with cut-off scores., Results: According to the conceptual model for SDM that we developed, the patient and the health professional involved took 'shared' decisions in three phases; the decisions related to triage, the drawing-up of a treatment plan and a follow-up treatment course. At the end of the 6 month intake-phase 7 of the 67 patients who were deemed eligible for ROM/SDM were dropped from the study because they were incapable of performing ROM assessments. Due to diagnostic advice and referral at the end of the intake-phase, 25 patients did not require further treatment. Of the remaining 35 patients, 33 delivered at least one follow-up ROM assessment during the subsequent treatment phases. In these patients somatic and psychiatric symptoms were found to be significantly reduced., Conclusion: ROM combined with sdm can be used successfully with patients who have a combination of physical and psychiatric symptoms and the technique can be applied by the professional in charge. Very few patients dropped out of the follow-up measurements and somatic as well as depressive or psychiatric symptoms diminished significantly. These findings indicate that a Randomised Clinical Trial is warranted in order to test the effectiveness of sdm combined with ROM as a decision-making instrument.

Background: In day-case surgery, the effects of the anxiolytic lorazepam as premedication on the quality of postoperative recovery are unknown., Objective: To evaluate whether lorazepam as a premedication beneficially affects quality of recovery (primary outcome) and psychological manifestations (secondary outcome) after day-case surgery., Design: A randomised, double-blind, placebo-controlled clinical trial., Setting: Single tertiary centre., Inclusion Criteria: day-case surgery; age at least 18 years., Exclusion Criteria: insufficient knowledge of the Dutch language; intellectual disability; ophthalmology surgery; extracorporeal shock wave lithotripsy; endoscopy; botulinum toxin A treatment; abortion; chronic pain treatment; preceding use of psychopharmaceuticals; contraindication to lorazepam., Intervention: Lorazepam (1 to 1.5 mg) intravenously vs. NaCl 0.9% as a premedication prior to surgery., Main Outcome Measure: Quality of Recovery-40 (QoR-40) score., Secondary Outcomes: State-Trait Anxiety Inventory (STAI-State/Trait); State-Trait Anger Scale (STAS-State/Trait); Multidimensional Fatigue Inventory (MFI); Hospital Anxiety and Depression Scale (HADS). Timing of evaluation: T0: preoperatively (all scales); T1: before discharge (STAI-State/Trait); T2: first postoperative working day (QoR-40); T3: 7th day after surgery (all scales). Robust regression analysis was applied. Statistical analyses were adjusted for the corresponding baseline value and sex., Results: Four hundred patients were randomised; 398 patients were analysed. Postoperative mean QoR-40 scores were similar in both groups at T2 (174.5 vs. 176.4, P = 0.34) and T3 (172.8 vs.176.3, P = 0.38). Postoperative mean STAI-State/Trait scores decreased less in the group with lorazepam at T1 (32.3 vs. 29.3, P < 0.0001; 32.7 vs. 30.8, P = 0.0002). STAI-Trait and HADS-Anxiety decreased less in the group with lorazepam at T3 (31.1 vs. 30.0; P = 0.03, 3.3 vs. 2.5, P = 0.003). STAS-State increased in the group with lorazepam at T3 (10.8 vs. 10.3, P = 0.04)., Conclusion: In day-case surgery, lorazepam as a premedication did not improve quality of recovery. Furthermore, this premedication may delay the decrease in postoperative anxiety and aggression., Trial Registration: ClinicalTrials.gov identifier: NCT01441843.

Objective: The Sophia Observation withdrawal Symptoms scale is an instrument for screening benzodiazepine and opioid withdrawal syndrome in pediatric critical care patients. The objectives of this study were to establish cutoff scores and to test sensitivity to change. Second, risk factors for withdrawal syndrome were explored., Design: Prospective observational study with repeated measures., Setting: Level IV ICU at a university children's hospital., Patients: A total of 154 children with median age 5 months (interquartile range, 0-42 mo) who received continuous infusion of benzodiazepines and/or opioids for 5 or more days., Interventions: None., Measurements and Main Results: Nurses repeatedly applied the Sophia Observation withdrawal Symptoms scale and the Numeric Rating Scale withdrawal when children were weaned off benzodiazepines and opioids. The latter represents the nurse's expert opinion. We analyzed 3,754 paired assessments; the median number per child was 15 (interquartile range, 7-31) over a median of 5 days (interquartile range, 3-11 d). Sensitivity and specificity were 0.83 and 0.93, respectively, for the Sophia Observation withdrawal Symptoms scale cutoff score of 4 or higher against a Numeric Rating Scale-withdrawal score of 4 or higher. Sensitivity to change was determined by comparing 156 Sophia Observation withdrawal Symptoms scale assessments (n = 51 patients) before and after additional sedatives or opioids. Multilevel regression analysis showed a mean decline of 1.5 points (at score range 0-15) after intervention (p < 0.0001). Logistic regression analysis identified duration of preweaning of midazolam, duration of weaning of midazolam, duration of preweaning of morphine, duration of weaning of morphine, and number of additional sedatives/opioids as statistically significant risk factors for withdrawal syndrome in these children., Conclusions: The Sophia Observation withdrawal Symptoms scale is a valid tool with good psychometric properties to assess withdrawal symptoms in PICU patients.

Background: There is an 80% prevalence of two or more psychiatric symptoms in psychogeriatric patients. Multiple psychiatric symptoms (MPS) have many negative effects on quality of life of the patient as well as on caregiver burden and competence. Irrespective of the effectiveness of an intervention programme, it is important to take into account its economic aspects., Methods: The economic evaluation was performed alongside a single open RCT and conducted between 2001 and 2006. The patients who met the selection criteria were asked to participate in the RCT. After the patient or his caregiver signed a written informed consent form, he was then randomly assigned to either IRR or UC.The costs and effects of IRR were compared to those of UC. We assessed the cost-utility of IRR as well as the cost-effectiveness of both conditions. Primary outcome variable: severity of MPS (NPI) of patients; secondary outcome variables: general caregiver burden (CB) and caregiver competence (CCL), quality of life (EQ5D) of the patient, and total medical costs per patient (TiC-P). Cost-utility was evaluated on the basis of differences in total medical costs). Cost-effectiveness was evaluated by comparing differences of total medical costs and effects on NPI, CB and CCL (Incremental Cost-Effectiveness Ratio: ICER). CEAC-analyses were performed for QALY and NPI-severity. All significant testing was fixed at p<0.05 (two-tailed). The data were analyzed according to the intention-to-treat (ITT)-principle. A complete cases approach (CC) was used., Results: IRR turned out to be non-significantly, 10.5% more expensive than UC (€ 36 per day). The number of QALYs was 0.01 higher (non-significant) in IRR, resulting in € 276,290 per QALY. According to the ICER-method, IRR was significantly more cost-effective on NPI-sum-severity of the patient (up to 34%), CB and CCL (up to 50%), with ICERs varying from € 130 to € 540 per additional point of improvement., Conclusions: No significant differences were found on QALYs. In IRR patients improved significantly more on severity of MPS, and caregivers on general burden and competence, with incremental costs varying from € 130 to € 540 per additional point of improvement. The surplus costs of IRR are considered acceptable, taking into account the high societal costs of suffering from MPS of psychogeriatric patients and the high burden of caregivers. The large discrepancy in economic evaluation between QALYs (based on EQ5D) and ICERs (based on clinically relevant outcomes) demands further research on the validity of EQ5D in psychogeriatric cost-utility studies. (Trial registration nr.: ISRCTN 38916563; December 2004).

Objective: To shorten and validate the EMpowerment of PArents in THe Intensive Care (EMPATHIC) questionnaire of optimal length to measure satisfaction of parents whose child has been admitted to pediatric intensive care units (PICUs)., Study Design and Setting: A total of 3,354 (55.4%) parents in eight PICUs completed the 65-item EMPATHIC questionnaire. Multiple regression analysis was applied to evaluate the statistical performances. The reduced domains were intercorrelated by the Pearson's product moment correlation coefficient. The robustness of the findings was evaluated by adjusted R(2) for internal cross-validations. Reliability was assessed by internal consistency., Results: Multiple regression analysis based on statistical redundancy established the optimal length at 30 items over five different domains: information (5 items), care and cure (8 items), organization (5 items), parental participation (6 items), and professional attitude (6 items). The explained variances of the domains ranged from 85% to 93%. The domains of the full and optimal version showed strong correlations (r = 0.92-0.97). Cross-validation among eight centers and across time provided adjusted R(2) values on domain level between 85% and 95%. The reliability estimates of the domains, assessed by Cronbach's α, varied between 0.73 and 0.93., Conclusion: By statistically eliminating the redundant items, the EMPATHIC questionnaire could be reduced from 65 to 30 items., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Cystic fibrosis (CF) is primarily characterised by bronchiectasis and trapped air on chest computed tomography (CT). The revised Cystic Fibrosis Questionnaire respiratory symptoms scale (CFQ-R RSS) measures health-related quality of life. To validate bronchiectasis, trapped air and CFQ-R RSS as outcome measures, we investigated correlations and predictive values for pulmonary exacerbations. CF patients (aged 6-20 years) underwent CT, CFQ-R RSS and 1-year follow-up. Bronchiectasis and trapped air were scored using the CF-CT scoring system. Correlation coefficients and backward multivariate modelling were used to identify predictors of pulmonary exacerbations. 40 children and 32 adolescents were included. CF-CT bronchiectasis (r = -0.38, p<0.001) and CF-CT trapped air (r = -0.35, p = 0.003) correlated with CFQ-R RSS. Pulmonary exacerbations were associated with: bronchiectasis (rate ratio 1.10, 95% CI 1.02-1.19; p = 0.009), trapped air (rate ratio 1.02, 95% CI 1.00-1.05; p = 0.034) and CFQ-R RSS (rate ratio 0.95, 95% CI 0.91-0.98; p = 0.002). The CFQ-R RSS was an independent predictor of pulmonary exacerbations (rate ratio 0.96, 95% CI 0.94-0.97; p<0.001). Bronchiectasis, trapped air and CFQ-R RSS were associated with pulmonary exacerbations. The CFQ-R RSS was an independent predictor. This study further validated bronchiectasis, trapped air and CFQ-R RSS as outcome measures in CF.

Aim: To examine neonatal and parental predictors of executive function in very preterm (gestational age ≤30 weeks) children aged 4.0-12.0 years., Methods: Two-hundred very preterm (mean age 8.2 ± 2.5 years) children without severe disabilities, born between 1996 and 2004, were assessed with measures of executive function including working memory, verbal fluency, planning and inhibitory control. Neonatal predictors were obtained from clinical records. Parental predictors included parental education, which was derived from questionnaires. Multiple linear regression analyses identified associations between neonatal and parental predictors and executive function in very preterm children., Results: Better postnatal growth at 6 weeks of corrected age-predicted better spatial span (R² = 0.03, β = 0.17, p = 0.02) and planning (R² = 0.03, β = 0.16, p = 0.04). A higher level of parental education predicted better verbal fluency (R² = 0.02, β = 0.12, p = 0.02). Verbal working memory was not predicted by neonatal risk factors or by parental education (β(s ) < 0.09, p(s ) > 0.20)., Conclusions: Executive function in very preterm children is associated with early postnatal growth and level of parental education but not with neonatal complications., (©2012 The Author(s)/Acta Paediatrica ©2012 Foundation Acta Paediatrica.)

Background: Some women at risk for hereditary breast cancer are at increased risk of psychological distress. In order to tailor support for individual women, the availability of a tool enabling the identification of psychologically vulnerable women at an early stage is warranted. The objectives of this study were (1) to explore long-term psychological distress in women at risk for hereditary breast cancer adhering to regular surveillance, and (2) to identify women being vulnerable for long-term psychological distress, defined in terms of a multifactorial risk profile., Methods: General distress and cancer-related distress were assessed at baseline (T0) and after 5-8 years (T1) in 197 high-risk women adhering to breast cancer surveillance. Coping styles, occurrence of breast cancer in the family of origin, breast cancer risk perception, and frequency of breast self-examination, as assessed at T0, were examined as predictor variables for long-term distress (T1)., Results: Across time, women reported a significant reduction in intrusion and avoidance. Intrusion levels were increased among women who had lost a first-degree relative to breast cancer. Predictors of increased long-term distress were passive and palliative coping styles, excessive breast self-examination, and overestimation of breast cancer risk. On the other hand, coping through fostering reassuring thoughts was predictive for decreased long-term distress., Conclusion: On the basis of the identified risk profile, it is possible to identify vulnerable women at an early stage, who then may be offered additional and individually tailored support., (Copyright © 2012 John Wiley & Sons, Ltd.)

Objective of this study was to examine the impact of executive function (EF) on mathematical and attention problems in very preterm (gestational age ≤ 30 weeks) children. Participants were 200 very preterm (mean age 8.2 ± 2.5 years) and 230 term children (mean age 8.3 ± 2.3 years) without severe disabilities, born between 1996 and 2004. EFs assessed included verbal fluency, verbal working memory, visuospatial span, planning, and impulse control. Mathematics was assessed with the Dutch Pupil Monitoring System and parents and teachers rated attention problems using standardized behavior questionnaires. The impact of EF was calculated over and above processing speed indices and IQ. Interactions with group (very preterm versus term birth status) were examined. Analyses were conducted separately for two subsamples: children in preschool and children in primary school. Very preterm children performed poorer on tests for mathematics and had more parent and teacher rated attention problems than term controls (ß(s)>.11, P(s)<.01). IQ contributed unique variance to mathematics in preschool and in primary school (ß(s)>.16, P(s)<.007). A significant interaction of group with IQ (ß = -. 24, P = .02) showed that IQ contributed unique variance to attention problems as rated by teachers, but that effects were stronger for very preterm than for term infants. Over and above IQ, EF contributed unique variance to mathematics in primary school (ß = .13, P<.001), to parent rated inattention in preschool and in primary school (ß(s)>-.16, P(s)<.04), and to teacher rated inattention in primary school (ß = -.19; ß = .19, P(s)<.009). In conclusion, impaired EF is, over and above impaired IQ, an important predictor for poor mathematics and attention problems following very preterm birth.

This study evaluates the impact of congenital and acquired facial disfigurement on social functioning in adults and whether this differs from adults without facial disfigurement. Moreover, the predictive value of objective and subjective appearance on social functioning is explored. Fifty-nine adults with severe congenital facial disfigurement, 59 adults with traumatically acquired facial deformities in adulthood, and 120 adults without facial disfigurement, completed the Scale for Interpersonal Behaviour, Social Avoidance and Distress Scale, and Visual Analogue Scale for facial appearance satisfaction. The impact of congenital and acquired facial disfigurement on social functioning in adults is similar and significantly differed from the reference group. The level of stress evoked by interpersonal behaviour, and social anxiety and distress were not significantly different between the groups. Only the patient's subjective appearance was a predictor of social functioning. Avoiding stress caused by stigmatization and uncertainty about reactions of others, leads to less frequent interpersonal behaviour in adults with facial disfigurement. The fact whether the deformity is congenital or acquired in adulthood has no influence on social functioning. Patient's satisfaction with facial appearance is more important than the objective severity of the deformity; in this context realistic expectations of the patient considering additional surgery are important., (Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Treatment disengagement and non-completion poses a major problem for the successful treatment of patients with severe mental illness. Motivation for treatment has long been proposed as a major determinant of treatment engagement, but exact mechanisms remain unclear. This current study serves three purposes: 1) to determine whether a feedback intervention based on the patients' motivation for treatment is effective at improving treatment engagement (TE) of severe mentally ill patients in outpatient psychiatric treatment, 2) to gather insight into motivational processes and possible mechanisms regarding treatment motivation (TM) and TE in this patient population and 3) to determine which of three theories of motivation is most plausible for the dynamics of TM and TE in this population., Methods/design: The Motivation and Treatment Engagement Intervention Trial (MotivaTe-IT) is a multi-center cluster randomized trial investigating the effectiveness of feedback generated by clinicians regarding their patients' treatment motivation upon the patients' TE. The primary outcome is the patients' TE. Secondary outcomes are TM, psychosocial functioning and quality of life. Patients whose clinicians generate monthly motivation feedback (additional to treatment as usual) will be compared to patients who receive treatment as usual. An estimated 350 patients, aged 18 to 65 years, with psychotic disorders and/or severe personality disorders will be recruited from outpatient community mental health care. The randomization will be performed by a computerized randomization program, with an allocation ratio of 1:1 (team vs. team or clinician vs. clinician) and patients, but not clinicians, will be blind to treatment allocation at baseline assessment. Due to the nature of the trial, follow-up assessment can not be blinded., Discussion: The current study can provide important insights regarding motivational processes and the way in which motivation influences the treatment engagement and clinical outcomes. The identification of possible mechanisms through which changes in the outcomes occur, offers a tool for the development of more effective future interventions to improve TM and TE., Trial Registration: Current Controlled Trials NTR2968.