Who gains from suicide risk assessment: Health inspectorate and health insurances, or also psychiatrist and patient?

Introduction

The number of suicides rises in the Netherlands. In 2008, 1435 suicides were recorded; in 2012: 1753 (CBS). Adequate risk assessment with suicidal behaviour (SRA) is essential for prevention. The Health Inspectorate and Insurances seek to have a stronger grip on the way suicide risk is assessed and insist on using questionnaires. This runs counter to the multidisciplinary guidelines in the Netherlands for diagnosis and treatment of suicidal behaviour, which state that “questionnaires or observation instruments cannot replace clinical diagnostic examination.”

Objective

Do questionnaires rather than ‘care as usual’ (CAU) in SRA lead to different treatment policies?

Aim

To determine whether the use of questionnaires rather than CAU in SRA leads to different treatment policies.

Methods

Patients who were seen by staff at the department of Psychiatry at the ETS Hospital, either for in-house consultation or at the MPU, in connection with attempted suicide, auto-intoxication, or psychological distress with suicidal statements. Patients were examined by conducting a questionnaire, resulting in treatment policy (admission, discharge with an appointment with patient's own practitioner, discharge with referral to a practitioner, discharge without aftercare). Then, the same patient was again examined by another colleague in a free interview (CAU). The colleague was not informed about the outcome of the first assessment. Again, treatment policy was determined as a result. The two outcomes were then compared.

Results

Data collection still continues.

Conclusions

There are signs that there are no differences in the determined treatment policies following SRA based on the use of questionnaires or CAU.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Changes in B and T-cell subsets and NMO-IgG levels after immunoglobulins and rituximab treatment for an acute attack of neuromyelitis optica

BACKGROUND

There is increasing evidence supporting that neuromyelitis optica (NMO) is an inflammatory humoral mediated disorder associated with NMO-IgG/AQP-4 antibodies. However, little is known about the subsets of B cells and T cells that contribute to the pathogenesis or therapy response.

OBJECTIVES

To describe the clinical and immunological changes associated with intravenous immunoglobulins (IV-Igs) plus rituximab (RTX) in a patient with a severe acute attack of NMO and intrathecal synthesis of NMO-IgG/AQP-4, who previously did not respond to intravenous methylprednisolone and plasma exchange.

METHODS

We sequentially analysed the levels of NMO-IgG/AQP-4 by immunohistochemistry, and B and T cells subsets by multiparametric flow-cytometry, in the CSF and peripheral blood (PB), before and alter IV-Igs plus RTX therapy.

RESULTS

In the CSF before treatment, and compared with PB, there was a higher percentage of CD4(+) T cells and a lower percentage of CD8(+) T cells and CD19(+) B cells. After therapy, the percentage of CD4(+) T cells remained high, and that of CD8(+) T cells increased. The observed decrease in the percentage of CD19(+) B cells was lower than in the PB. When the CSF was compared, it was found that the percentage of effector-memory and effector CD8(+) T cells had increased after therapy, and that of IgM memory B cells and switched-memory B cells decreased. The observed changes paralleled the decrease of NMO-IgG/AQP-4 results to negative and the clinical improvement.

CONCLUSIONS

Our findings confirm that, besides intrathecal humoral immune response against AQP4, B and T cell subsets are involved in the modulation of inflammation within and outside the central nervous system.

Hypocomplementemia in the absence of autoantibodies in women with recurrent pregnancy loss

BACKGROUND

Accumulating data suggest an immunopathogenic role for the complement system as a causative element in pregnancy loss (PL). Formation of pathogenic antibodies with activation of the classical pathway may have a role, but this mechanism fails to characterize the majority of cases with recurrent PL. We established the prevalence of hypocomplementemia without circulating autoantibodies in women with recurrent PL.

METHODS

In a retrospective case control study, 201 women with recurrent PL (two or more PL) and 30 healthy women who had normal pregnancies but no PL were studied. Serum levels of C3, C4, and factor B were determined by nephelometry. Total hemolytic activity of the complement system (CH100) was investigated by radial immunodiffusion test.

RESULTS

The prevalence of hypocomplementemia [low levels of C3, C4, FB or CH100 (with normal concentrations of C3, C4 and FB)] was significantly higher in women with recurrent PL (22.4%) in comparison with controls (6.6%; p = 0.019). C3, C4, FB hypocomplementemia or low CH100 were observed in 13 (6.5%), 19 (9.4%), 13 (6.5%) and 7 (3.5%) women with recurrent PL, respectively. Among patients with C3, C4, FB or CH100 hypocomplementemia, 10, 18, 12 and 5 patients had no circulating autoantibodies [antinuclear antibodies, anticardiolipin antibodies or antithyroid antibodies], respectively. In all, hypocomplementemia, in the absence of autoantibodies, was observed in 38 (18.9%) women with recurrent PL in a significantly higher frequency than controls (n = 2, p = 0.049).

CONCLUSIONS

Hypocomplementemia, in the absence of autoantibodies was observed in a group of women with recurrent PL which might suggest a role of the complement system in the pathogenesis of PL in these patients.

Potential role of hypothalamic ghrelin in the pathogenesis of human obesity

Ghrelin is a potent appetite stimulator, mainly synthesized in the stomach but also made in the brain. Paradoxically, obese subjects have lower plasma ghrelin than lean subjects and increase their weight in spite of low ghrelin levels. We hypothesize that central, and not peripheral ghrelin, is primarily responsible for overeating in humans. The aim of this study was to determine hypothalamic ghrelin levels in lean vs obese subjects. We collected anterior hypothalamus from lean and obese patients at the time of autopsy, and Western blots and semiquantitative RT-PCR for ghrelin and neuropeptide Y (NPY) were carried out. Our results showed that ghrelin expression was significantly higher in the hypothalamus of obese subjects compared to lean ones. This finding correlates with similar increases in NPY in the obese group. Ghrelin and NPY mRNA levels followed the same trend and were significantly higher in the hypothalamus in obese compared to lean subjects, suggesting a central origin for the increased protein content in the obese subjects. In conclusion, obesity in humans is associated with elevated central ghrelin. This data questions the significance of the role of peripheral ghrelin in the regulation of appetite in humans and suggests an important role for central ghrelin in the pathogenesis of obesity in humans.