To establish the point prevalence and characteristics of patients with locked-in syndrome (LIS), particularly of the classic type, residing in Dutch nursing homes, a cross-sectional survey of Dutch nursing homes was conducted. The classic form of LIS was defined according to the criteria of the American Congress of Rehabilitation Medicine (1995). All Dutch long-term care organisations (n = 187) were asked if they had any patients with classic LIS as of December 5, 2011. The treating Elderly Care Physicians were then contacted to provide patient characteristics. Of all organisations, 91.4% responded, and 11 organisations reported a total of 12 patients. After analysing the questionnaires, it was determined that ten patients had LIS, and two patients were characterised with vegetative state. Only two patients met the criteria for classic LIS, while six patients showed partial LIS. One of these patients was admitted to the nursing home after December 5, 2011, and was therefore, excluded. LIS without accompanying pontine lesion was observed in the remaining two patients. For the first time, the prevalence of classic LIS has been established at 0.7/10,000 somatic nursing home beds in all Dutch long-term care organisations. Possible explanations for this low prevalence could be the Dutch provision of home care or the influence of end-of-life decisions, such as euthanasia and withholding or withdrawing all medical treatment, including artificial nutrition and hydration. These alternate outcomes should be explored in further studies.

Objectives: Establishing the prevalence and determinants of neuropsychiatric symptoms (NPS) in patients with acquired brain injury (ABI) in nursing homes. Design: Cross-sectional, observational study. Setting and Participants: Patients 18-65 years old with ABI in special care units in Dutch nursing homes. Methods: Nursing homes were recruited through the national expertise network for patients with severe ABI, regional brain injury teams, and by searching the Internet. Patient characteristics were collected through digital questionnaires. NPS were assessed with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI), cognition with the Mini-Mental State Examination, and activities of daily living with the Disability Rating Scale. Psychotropic drug use (PDU) was retrieved from the electronic prescription system. Individual NPS were clustered. Associations between determinants and NPS were examined using multilevel multivariate linear regression models. Results: In a population of 118 patients from 12 nursing homes, 73.7% had 1 or more clinically relevant NPS and 81.3% 1 or more agitated behaviors. The most common NPS were agitation, in particular aberrant motor behavior (24.6%), repetitious sentences/questions (35.5%), and constant requests for attention (34.6%), verbal (33.6%) and physical (50.5%) aggression, and irritability (28.0%). Male patients were more likely to display hyperactivity. Being married was associated with less verbally agitated behavior and pain was associated with a higher CMAI total score. PDU increased the likelihood of a higher NPI-NH total score. Conclusions and Implications: NPS are common in patients with ABI 65 years of age residing in nursing homes. This is a first step to fill in the knowledge gap concerning NPS in this population. An increasing number of patients with severe ABI may survive the acute phase and will reside many years in nursing homes. It is important to shed more light on these NPS, with regard to course, magnitude, and severity, to ultimately develop appropriate care for this vulnerable group of patients.

AimEstablishing the prevalence of neuropsychiatric symptoms (NPS), quality of life and psychotropic drug use in people aged ≤65 years with acquired brain injury in nursing homes.DesignCross‐sectional, observational study among patients aged 18–≤65 years with acquired brain injury admitted to special care units in Dutch nursing homes.MethodsAccording to the Committee on Research Involving Human Subjects in January 2017 this study did not require ethics approval. Nursing homes will be recruited through the national acquired brain injury expertise network for patients with severe brain injury, the regional brain injury teams and by searching the internet. Patient characteristics will be collected through digital questionnaires. Neuropsychiatric symptoms will be assessed with the NeuroPsychiatric Inventory‐Nursing Home version, the Cohen–Mansfield Agitation Inventory and the St. Andrews Sexual Behaviour Assessment; cognition with the Mini‐Mental State Examination, quality of life with the Quality of Life after Brain Injury Overall Scale and activities of daily living with the Disability Rating Scale. Medication will be retrieved from the electronic prescription system. Data collection commenced in 2017 and will be followed by data analysis in 2019. Reporting will be completed in 2020.DiscussionLittle is known about NPS among patients with acquired brain injury in nursing homes. In patients up to the age of 65 years, only six studies were found on prevalence rates of NPS.ImpactPatients with severe acquired brain injury experience lifelong consequences, that have a high impact on them and their environment. Although there is increasing attention for the survival of this vulnerable group of patients, it is also important to enlarge awareness on long‐term consequences, specifically the NPS, quality of life and psychotropic drug use in acquired brain injury. Insight into the magnitude of these issues is necessary to achieve appropriate care for these patients.

An 83-year-old female patient with symptomatic atrial fibrillation was referred to the Department of Cardiology for a scheduled electrocardioversion. Because of a junctional escape rhythm after the electrocardioversion she received a DDD pacemaker which was complicated by dyspnoea and ST-segment elevations in the inferior and precordial leads. Because of suspicion of an acute myocardial infarction she was transferred to a PCI centre. The coronary angiogram showed no abnormalities. In the initial phase, an echocardiogram was performed. The echocardiogram showed apical akinesis and a reduced left ventricular function. Keywords: takotsubo cardiomyopathy, apical ballooning, pacemaker implantation A pical ballooning or takotsubo cardiomyopathy is a new and rare phenomenon which is mainly seen in elderly women. It is characterised by chest pain, dyspnoea, ECG changes and normal or slightly elevated heart enzymes without coronary artery lesions. Echocardiography or left ventricle angiography shows a takotsubo-like dilatation of the left ventricle.The prognosis is favourable. We present a Dutch case of takotsubo cardiomyopathy after pacemaker implantation. CaseAn 83-year-old female patient was seen at the Department of Cardiology with symptomatic atrial fibrillation. Besides frequent episodes of rapid atrial fibrillation with an upper rate of 150 beats/min, there were several periods of long RR intervals with a longest interval of 2.7 sec. Prior to admission she complained of dyspnoea and oedema. This improved after initiation of diuretic treatment, ACE inhibition, β-blockade and oral anticoagulation. The echocardiographic findings before admission showed a left ventricular ejection fraction of 55%, a mild tricuspid valve insufficiency and a moderate mitral valve insufficiency with left atrial enlargement.Upon arrival to the hospital she had mild oedema and sometimes she felt dizzy. Except for slight peripheral oedema, the physical examination revealed no abnormalities. Blood pressure was 100/60 mmHg and she had an irregular pulse of 120 beats/min. A 12-lead ECG showed an atrial fibrillation of 118 beats/min. The chest X-ray showed cardiac enlargement and no further abnormalities. An electrocardioversion was scheduled. After cardioversion, the rhythm changed to junctional escape rhythm followed by sinus bradycardia. Because of symptomatic sick sinus syndrome the patient received a DDD pacemaker under local anaesthesia. During the pacemaker implantation, there were no complications, but after the implantation she complained about dyspnoea and a pneumothorax was suspected. A chest X-ray did not show a pneumothorax. The ECG now showed ST-segment elevations primarily in the inferior and precordial leads ( figure 1A). An inferior myocardial infarction was suspected. She was transferred to a PCI centre for a primary percutaneous transluminal coronary angioplasty. Surprisingly, the coronary angiogram was completely normal (figure 2). The echocardiogram showed apical akinesia, apical ballooning and a reduced left ventricular f...