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BACKGROUND: Many untreated psychiatric problems occur in families where there is child abuse. It is very important to find ways of ensuring that the hard-to-reach families receive adequate psychiatric assessment and appropriate treatment. AIM: To describe the treatment method and first results of multisystemic therapy for child abuse and neglect (mst-can). METHOD: We report the psychiatric problems of the first 18 families that were treated and we report the follow-up during the first 18 months. In addition, the mst-can treatment and the psychiatrist's role are illustrated by taking two cases as an example. RESULTS: Most of the families agreed to a psychiatric assessment and subsequent treatment. In most families safety improved considerably and out-of-house placements were avoided. CONCLUSION: The first results suggest that mst-can is a promising treatment for families where there is child abuse. Essential elements of mst-can are targeted psychiatric diagnostic assessment and subsequent treatment.

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INTRODUCTION: Cystinosis is an autosomal recessive disorder leading to intralysosomal cystine accumulation in various tissues. It causes renal Fanconi syndrome and end stage renal failure around the age of 10 years if not treated with cysteamine. Children with cystinosis seem to have a normal intelligence but frequently show learning difficulties. These problems may be due to specific neurocognitive deficits rather than impaired renal function. Whether cysteamine treatment can improve cognitive functioning of cystinosis patients is thus far unknown. We aim to analyze neurocognitive functioning of school-aged cystinosis patients treated with cysteamine in order to identify specific deficits that can lead to learning difficulties. PATIENTS AND METHODS: Fourteen Dutch and Belgian school-aged cystinosis patients were included. Glomerular filtration rate was estimated using the Schwartz formula. Children were tested for general intelligence, visual-motor integration, inhibition, interference, sustained attention, accuracy, planning, visual memory, processing speed, motor planning, fluency and speed, and behavioural and emotional functioning using standardized methods. RESULTS: Glomerular filtration rate ranged from 22 to 120 ml min(-1) 1.73 m(-2). Median full-scale intelligence was below the average of a normal population (87, range 60-132), with a discrepancy between verbal (median 95, range 60-125) and performance (median 87, range 65-130) intelligence. Over 50% of the patients scored poorly on visual-motor integration, sustained attention, visual memory, planning, or motor speed. The other tested areas showed no differences between patients' and normal values. CONCLUSION: Neurocognitive diagnostics are indicated in cystinosis patients. Early recognition of specific deficits and supervision from special education services might reduce learning difficulties and improve school careers.

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OBJECTIVE: To determine the rate of rejection for prosthetic use in children and to investigate reasons for this rejection. DESIGN: Cross-sectional study of a cohort of children. SETTING: Rehabilitation centre, St Maartenskliniek, Nijmegen, The Netherlands. SUBJECTS: Thirty-two children (0-18 years) with a unilateral congenital arm defect who visited the clinic between September 1991 and December 1996. METHODS: Parents of all children and 19 children (> or =6 years) completed a questionnaire. RESULTS: Eleven children (34%) rejected the prosthesis. A survival function shows that the rejection can be characterized by three periods: 0-40 months, 40-162 months and after 162 months. In the first and last period a high rate of rejection is seen, while in the second period a low rate exists. Fitting for the first time after 2 years of age seems to be related with higher rejection rate. Lack of functional gain with the prosthesis, as perceived by the subjects and the parents, is significantly associated with increased rejection rate. Increased rejection rate is associated with the parents' disappointment, insufficient involvement of the parents in treatment, and dissatisfaction pertaining to emotional and social guidance. CONCLUSIONS: Rejection seems to occur in two main periods: within 3.5 years after being provided with a prosthesis and after 13.5 years of prosthetic use, when most children experience puberty. Fitting before the age of 2 years seems to reduce rejection rate. Preventing the parents' disappointment about prosthetic benefits as well as providing them with sufficient involvement in treatment and adequate guidance are essential for optimal results of prosthetic rehabilitation.

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OBJECTIVE: To compare the conventional socket for through-knee amputees with an open socket system for skin problems and other relevant items. DESIGN: All data were collected during three visits to the prosthetic clinic. At the second visit the conventional socket was replaced by the open socket. The use of both socket types was evaluated with a questionnaire and stump inspection. SETTING: The subjects were evaluated at the Rehabilitation Centre, St Maartenskliniek, Nijmegen, the Netherlands. SUBJECTS: Twenty subjects with a unilateral through-knee amputation were included and 13 subjects had a trial with the open socket. RESULTS: There is a significant decrease of hyperhydrosis when wearing the open socket, there is no significant decrease in skin irritation or ulcers. The open socket also gives more comfort in sitting position. CONCLUSION: A further trial is needed in a selected group of prosthesis users among through-knee amputees to establish the long-term acceptance and benefits of the prosthesis with an open socket.

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The reflex sympathetic dystrophy syndrome (RSD) is a neurogenic pain syndrome that is characterized by pain, vasomotor and dystrohic changes and often motor impairments. Although the exact pathogenesis of RSD is unknown, for long the sympathetic nervous system was thought to play a dominant role and pharmacological and surgical sympathectomies have been a mainstay in treatment procedures. However, there is growing evidence of a pivotal role of C- and A delta-fibres in the aetiology of RSD. These fibres subserve a dual sensory-effector function. Besides the initiation of afferent impulses, they release neuropeptide mediators that cause a peripheral neurogenic inflammatory reaction and central neuroplastic reactions. Brachial plexus blockade (BPB) with local anaesthetic drugs interferes with the conduction of action potentials along both sympathetic efferents and the somatosensory C- and A delta-afferents and therefore seems a potential treatment modality in RSD. The aim of this study was to draw attention on this regional anaesthetic technique that is not commonly used in RSD. In this study six patients with severe RSD of an upper extremity in varying stages were treated with BPB in the multidisciplinary setting of an out-patient rehabilitation clinic with a follow-up of 12 to 21 months. The study was not placebo controlled. Three patients responded well. In these cases the treatment interval varied from 3 to 6 months, one case had RSD stage 1 and the two others stage 2. Three patients showed poor response. In one of these patients the initial effect was good but due to an infection at the insertion site of the catheter BPB had to be discontinued. The other two poor-responders had treatment intervals of 7 and 25 months and both had stage 3 RSD. We conclude that there is theoretical and clinical support to further evaluate the effect of BPB as a treatment modality in the early stages of RSD.

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The postural organization in patients with hereditary motor and sensory neuropathy (HMSN) type I or II was studied clinically by means of a force platform. Balance was registered in 14 barefooted HMSN patients and healthy matched control subjects during quiet stance. The effect of visual deprivation was tested to determine the degree of visual dependency. The effect of the simultaneous performance of a concurrent attention-demanding task (Stroop task) was tested to estimate the level of balance automaticity. In comparison with control subjects, the HMSN patients showed a basically decreased efficiency of postural control (p less than .01) as well as an increased visual control of posture (p less than .05) in both directions of sway. No loss of balance automaticity was found, which suggested an on-line central adaptation to the slowly developing peripheral impairments. The results provide a starting point for understanding the balance problems and gross motor disabilities in HMSN patients.

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Postural control was assessed in persons with a unilateral lower limb amputation before and after their rehabilitation. The centre-of-pressure fluctuations during quiet upright standing on a dual-plate force platform were registered with and without visual information in order to identify relevant determinants of balance restoration. In addition, static (weight distribution) as well as dynamic (control activity) asymmetry characteristics were examined. Besides a small improvement in balance control with full visual information (fore-aft sway, p less than 0.06; lateral sway, p less than 0.05), there was a major decrease in visual dependency (fore-aft and lateral sway, p less than 0.05) indicating a somatosensory re-integration process. Postural asymmetry in comparison with matched control subjects was most apparent and only significant in dynamic terms and remained constant across rehabilitation. It is concluded that after a lower limb amputation a central reorganization of postural control takes place, in which sensory determinants of motor recovery may play a critical role.

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Postural control in persons with lower limb amputation was studied using a cognitive approach to motor learning. The aim of this study was to show that an important characteristic of the central reorganization process after a lower limb amputation is the gradually decreasing need of attentional resources to perform a motor task. A dual-task procedure was developed to estimate the level of automaticity of a quiet, upright standing task. The effect of a concurrent attention-demanding task (Stroop task) on the efficiency of balance control was determined using force-platform measurements at the start and the end of the rehabilitation process. In contrast with a control group, the amputation group showed interference effects on body sway caused by the concurrent task both at the start (p less than .05) and, less severe, at the end of rehabilitation (p less than .05). Improvement of balance control was significant only for the dual-task condition (p less than .05). The results corroborated the hypothesis that dual tasks give information about the restoration of automaticity of postural control as an essential characteristic of the central reorganization process in persons with lower limb amputation. The role of dual-task procedures as a useful approach to skill assessment is discussed.

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Asymmetric somatic hybrids of Lycopersicon esculentum and Lycopersicon peruvianum were obtained by fusion of leaf protoplasts from both species after irradiation of protoplasts or leaf tissue of L. peruvianum with 50, 300, or 1,000 Gy of gamma-rays. These radiation doses were sufficient to abolish the growth of the L. peruvianum protoplasts. The hybrids were selected for their ability to regenerate plants; this regeneration capacity derived from L. peruvianum. All asymmetric hybrid plants were aneuploid. The ploidy level, the morphology, and the regeneration rate were analyzed in relation to the radiation dose applied to L. peruvianum. After a low dose (50 Gy), most hybrids had near-triploid chromosome numbers, whereas after a high dose (300 or 1,000 Gy), most hybrids had near-pentaploid numbers. The morphology of the asymmetric hybrids was intermediate between that of L. esculentum and symmetric somatic hybrids of both species (obtained without irradiation treatment), and approached the morphology of L. esculentum to a greater extent after a high dose of irradiation. The asymmetric hybrids regenerated more slowly than the symmetric hybrids and regeneration proceeded more slowly after a high dose than after a low dose of irradiation. The high-dose hybrids also grew more slowly, flowered less, and set fruits less than the low-dose hybrids. No seeds could be obtained from any asymmetric hybrid.

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Although phantom sensations and phantom pain are quite common sequelae of amputation and other related surgical procedures, these phenomena are not well understood. There are many, often conflicting theories which attempt to explain their nature and causes, and to provide a foundation for more effective treatment. This paper reviews recent literature on this topic. The review encompasses information about the prevalence and nature of phantom phenomena; evidence from empirical studies concerned with identification of possible predictors; and various psychological and neurophysiological theories that have been proposed in an attempt to explain why phantom sensations and pain are experienced. It is concluded that the fragmented approach adopted in the past has resulted in pockets of knowledge that are not too well integrated. There is therefore an outstanding need for a general theory to synthesise the knowledge gained to date about the multiplicity of factors associated with phantom phenomena. In this context, Melzack and Loeser's (1978) concept of "pattern generating mechanisms" may offer the most useful model for future research.

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