Cognitive deficits in first-degree relatives of bipolar patients: the use of homogeneous subgroups in the search of cognitive endophenotypes.

Previous studies have demonstrated impairments in attention, memory and executive functions in euthymic bipolar patients (BP) as well as their unaffected first-degree relatives, albeit in an attenuated form. Subsequently, cognitive deficits are discussed as a possible endophenotype of bipolar disorder. However, recent studies showed that only a subgroup of BP shows cognitive impairments. The aim of the present study was to investigate cognitive functioning in relatives compared to BP, to find out if the differentiation in a cognitive deficit vs. non-deficit subgroup is valid for relatives of BP, too. Therefore, the performance of 27 unaffected relatives of BP, 27 euthymic BP and 27 HC were compared using a neuropsychological test battery. The results showed that BP exhibited a reduced psychomotor speed and deficits in working memory compared to relatives and HC. Relatives performed significantly slower (psychomotor speed) as compared to HC (p = 0.024); performance in the other test measures lie between BP and HC. Furthermore, a detailed evaluation of the data indicated that only subgroups of BP and relatives exhibited cognitive impairments in the implemented tests. However, the deficit and non-deficit groups did not differ in sociodemographic and clinical variables from each other, possibly due to the small sample size. In conclusion, our results suggest that reduced psychomotor speed could serve as a potential endophenotype for bipolar disorder which should be investigated along the developmental trajectory of this disorder, also to examine whether abnormalities therein precede onset of the first mood episode. Furthermore, the division of relatives into subgroups aids in the identification of stable trait markers and high-risk bipolar groups and could enable early prevention strategies. As to that more research using distinct and homogeneous subgroups is necessary.

Prosthetics in antiquity-An early medieval wearer of a foot prosthesis (6th century AD) from Hemmaberg/Austria.

Even though the earliest prosthetic devices date to the Ancient Egyptian Empire and iconographic sources attest their use in the Greco-Roman world, archaeological evidence for this practice prior to 2nd millennium AD is very scant. In 2013, a skeleton dating to the Frankish period (6th century AD) was excavated at the Hemmaberg in southern Austria. The middle adult male was missing his left foot from above the ankle. In its place, an iron-ring and wooden remains were recovered and interpreted as a prosthesis replacing the lost foot. This represents one of the oldest examples of prosthetic limb replacement associated with the skeleton of its wearer in Europe to date. Analysis through macroscopic assessment, radiography and CT-scanning revealed healing of the lesion even though it may have initially been complicated by osteomyelitis. Atrophy of the left lower leg further indicates immobilisation and suggests survival of several years. Osteoarthritis in the knees and shoulder girdle provides tentative indications towards the functionality of the prosthesis, perhaps aided through a crutch. These findings are set against the historic, archaeological, bioarchaeological and social context of the man in order to discuss whether removal of the foot was due to medical, punitive or traumatic causes.

The prevalence of psychiatric disorders in patients with alcohol and other drug problems.

A survey evaluated the lifetime and current prevalence of mental disorders in 501 patients seeking assistance with alcohol and other drug problems at an addiction research and treatment facility. Information was gathered using the National Institute of Mental Health Diagnostic Interview Schedule (DIS) and computer diagnoses were generated according to DSM-III criteria. Four fifths (78%) of the sample had a DIS lifetime psychiatric disorder in addition to substance use, and two thirds (65%) had a current DIS mental disorder. Excluding the unreliably diagnosed generalized anxiety disorder, the most common lifetime disorders were antisocial personality disorder, phobias, psychosexual dysfunctions, major depression, and dysthymia. Patients who abused both alcohol and other drugs were the most psychiatrically impaired. Patients with DIS psychiatric disorders had more severe alcohol and other drug problems. Barbiturate/sedative/hypnotic, amphetamine, and alcohol abusers were the most likely to have a DIS mental disorder.

Evidence for cognitive subgroups in bipolar disorder and the influence of subclinical depression and sleep disturbances.

Recent research in bipolar disorder (BD) points to the relevance and persistence of cognitive deficits even in euthymia. Up to now, the mechanisms behind why some bipolar patients (BP) do not reach their former level of cognitive performance and psychosocial functioning while others remit completely, are not understood. In this study we aimed to identify a "cognitive deficit" vs. "non-deficit" subgroup within BD by using an extensive neuropsychological test battery. The test performance of 70 euthymic outpatients (BD-I and II, recruited as a sample of convenience from our bipolar disorder programme) was compared to 70 matched, healthy controls (HC). Furthermore, we investigated the association between demographic/clinical variables and the cognitive performance of BP. As expected, our sample of euthymic BP performed significantly worse than HC in psychomotor speed, divided attention, working memory, verbal memory, word fluency and problem solving. However, 41.4% of the patients did not have any neurocognitive deficits at all, and whether or not a patient belonged to the non-deficit group was not influenced by disease severity. Instead, our results demonstrate that patients suffering from persistent sleep disturbances and sub-threshold depressive symptomatology show more severe cognitive dysfunctions. In addition, antipsychotic treatment and comorbid anxiety disorder were associated with cognitive deficits. In sum, these results suggest that a major part of cognitive impairment is due to current symptomatology, especially sleep disorder and sub-syndromal depression. Rigorous treatment of these symptoms thus might well improve cognitive deficits and, as a consequence, overall functioning in BD.

The promoter of the human sodium/iodide-symporter gene responds to retinoic acid.

It was shown previously that hNIS mRNA expression is stimulated by retinoic acid (RA) in human follicular thyroid carcinoma cell lines FTC-133 and FTC-238, and patients with thyroid carcinomas lacking iodide uptake respond to RA treatment with increased radioiodide transport. Here, in transient transfection experiments using FTC-238 cells, hNIS promoter/luciferase reporter constructs showed an up to 2.5-fold increase in transcriptional activity after incubation with 1 microM RA. Stimulation by 10 nM T3 was up to 2.4-fold. Deletion or block mutation of a putative nuclear receptor recognition site, 'DR10', abolished RA and T3 responses. Four copies of the DR10 cloned 5' to the thymidine kinase promoter gave a 2.6-fold and a 1.4-fold increase in transcriptional activity after RA and T3 stimulation, respectively. In electrophoretic mobility shifts, a wildtype DR10 oligonucleotide, but not block mutants of either DR10 halfsite, interacted with nuclear receptors. Thus, RA redifferentiation of advanced thyroid carcinomas may reinduce iodide uptake by stimulating hNIS expression and thereby make tumours accessible for radioiodide therapy again.

Influence of endorectal ultrasound on surgical treatment of rectal cancer.

Refined surgical treatment of carcinoma of the rectum, such as sphincter-preserving operations, pouch anal anastomosis, and pre-operative irradation require exact assessment of tumor and lymph-node involvement before therapy. To improve pre-operative staging we used endorectal ultrasound to determine the depth of tumor infiltration and the presence of lymph-node metastases. A 7.0 MHz transducer (Bruel and Kjaer, Denmark) was used in the pre-operative staging of 110 patients with rectal carcinomas. In 90% of the cases it was possible to perform a correct tumor staging pre-operatively in comparison with histopathology. Sensitivity for detection of perirectal fat infiltration was 96% and the negative predictive value was 96%. Lymph-node involvement was accurately identified in approximately 80% of the cases. Endorectal ultrasound is a highly accurate tool in the pre-operative staging of rectal carcinoma, as well as in the detection of lymph-node involvement. It will identify patients suitable for sphincter-saving procedures or local treatment and define those with a considerable risk of local recurrence, where combined surgery and radiotherapy may be considered.

Effect of dose and dose-distribution in damage to the kidney following abdominal radiotherapy.

PURPOSE: To define the effects of abdominal radiotherapy on the kidney with regard to dose-distribution parameters. MATERIALS AND METHODS: Ninety-one patients with abdominal radiotherapy were included in the study, and the minimum follow-up was 1 year. Conventional fractionation, 5 x 1.8-2.0 Gy week(-1) to total doses of 30.6-62.5 Gy, was employed. Assessment of organ function was performed before, immediately after, and at 6 months and 1 year after radiotherapy. In cases with a significant radiation response at 1 year, subsequent follow-ups were done at 6-month intervals. Documented parameters included clinical examination, static and sequential scintigraphy of the kidneys, abdominal computed tomography, and sonography. RESULTS: Twenty-one patients (23%) developed a reduction in kidney function detected by static scintigraphy. Only in 15 of these patients was impairment of renal function observed by sequential scintigraphy. The contribution of the irradiated kidney to overall renal function decreased progressively to 34-40% by the third year after treatment. Hypertension was seen in two patients. No changes were found in laboratory parameters. ED(50) for scintigraphic changes decreased from 27 Gy for 10% of the volume to 7.6 Gy for 100%. ED(5) were in the range of 3-6 Gy, and this was independent of volume. CONCLUSIONS: Sophisticated imaging techniques allow the identification of radiation effects in partial volumes of the kidneys. A dose-response relationship in relation to the volume of kidney irradiated can thus be established for scintigraphic changes. As in a number of other organs, such changes do not relate directly to loss of renal function due to the reserve capacity of unirradiated kidney tissue.

Laparoscopic extraction of a swallowed fork in a patient first diagnosed with bulimia nervosa.

Swallowed foreign bodies are relatively common problem. The first reports date back about 3000 years. The first medical report was done by Mestivier in 1759. Several studies show that up to 90% of the foreign bodies (FBs) pass spontaneously and 10% to 20% require an endoscopic removal. Surgical intervention is only indicated in approximately 1% of the cases. Surgical intervention is only necessary, for example, when large or sharp FBs are involved because of the potential risk of perforation and obstruction. The surgical therapy can be carried out by means of laparotomy or laparoscopy; laparoscopy has to be given the first priority whenever possible. The advantages of a laparoscopic procedure are well-known: reduced postoperative pain, better lung function, less postoperative bowel obstruction, shorter hospital stay, and faster reconvalescence. We report an unusual case of an unintentional ingested fork, which required a laparoscopic extraction using three trocars. The 20-year-old female patient was then subsequently diagnosed with bulimia nervosa for the first time during her hospital stay. The patient was discharged home on the fourth postoperative day after an unremarkable course.

[Results of percutaneous transluminal dilatation of cerebral vascular stenoses]. / Ergebnisse der perkutanen transluminalen Dilatation (PTD) von Hirngefässstenosen.

The present paper is a review of 37 successful catheter dilatations of supra-aortic vascular stenoses. There were sixteen patients with a total of 21 stenoses of the internal carotid, vertebral artery or common carotid artery and sixteen patients with subclavian stenoses. Amongst the patients with stenoses of the cerebral vessels, there were ten with multiple lesions and six with a single stenosis. Three patients had successful dilatations of bilateral stenoses. The indications, technique, and complications of catheter dilatation of lesions of the cerebral vessels are described and discussed.

Slouching toward a systems approach to treatment.

Both the health care sector generally and the alcohol and drug field are moving toward a truly systematic approach to treatment, accelerated by the anticipated advent of health care reform. There is considerable reluctance to develop systems. Many are not convinced of their necessity, and systematization inevitably involves a decrement in autonomy for the components of the system. Nor are systems panaceas; they have problems of their own, such as the bottleneck. But only true systems will be able to cope with the expected increase in demand for services that will accompany the universal entitlement of health care reform. Recent work giving the alcohol and drug treatment field an edge in systems development is discussed. Regrettably, the main motivation for deploying systems has become economic. They would more appropriately be justified by their potential for enhancing the efficacy of treatment.

Relationship between treatment facilities and prevalence of alcoholism and drug abuse.

Data are presented which suggest that, in the Commonwealth of Pennsylvania, the availability of treatment of drug abuse and alcoholism is inversely related to the prevalence of the problems. It is hypothesized that as the treatment response to one increases, the treatment response to the other declines. Some of the possible causes and consequences are outlined.

Use of the life table method in determining attrition from treatment.

Life table analysis of attendance at an outpatient clinic indicates levels of attrition similar to those reported by follow-up and other studies of treatment for drug dependence. With appropriate qualifications, rates of attrition may be viewed as measures of treatment outcome.

[Transesophageal echocardiography in non-rheumatic atrial fibrillation: a moderately sensitive method for assessment of risk of cerebrovascular complications]. / Transösophageale Echokardiographie bei nicht-rheumatischem Vorhofflimmern: eine mässig sensitive Methode zur Abschätzung des Risikos zerebrovaskulärer Komplikationen.

120 consecutive unselected patients with chronic non-rheumatic atrial fibrillation without anticoagulant therapy were examined by transthoracic and transoesophageal echocardiography. Patients with a history of an ischaemic cerebrovascular event (n = 4) had left atrial thrombi, spontaneous contrast or both significantly more often (n = 25, 61%) than patients in the control group (24/79 = 30%). However, when compared with controls, patients with a history of cerebrovascular events were also older, and had hypertension and left ventricular disease (ejection fraction < 45%) more often. Abnormal carotid duplex scans were also very common in this group (71%). Transoesophageal echocardiography is useful for evaluating the risk of cerebrovascular complications in non-rheumatic atrial fibrillation. However, the method is quite insensitive (61%) and therefore insufficient as the sole parameter for deciding the need for anticoagulation. It is likely that cerebrovascular complications in these polymorbid patients are partially caused by other factors than embolism from the left atrium.

[Laparoscopic adhesiolysis - results following prospective surveillance]. / Die laparoskopische Therapie des Adhäsionsbauchs. Ergebnisse einer prospektiven Beobachtungsstudie.

INTRODUCTION: About 90 % of the patients have abdominal surgery develop adhesions afterward. Studies analyzing complications and follow-up even in emergency cases are rare. METHODS: Intra- and postoperative findings and complications and follow-up were analyzed in a prospective trial between January 1994 and June 1998. RESULTS: We performed laparoscopic procedures in 56 patients with complaints of obstructing adhesive bands or adhesions. Ninety-six percent of the patients have had abdominal surgery; 51.8 % were treated as emergency cases with acute pain, 48.2 % with chronic abdominal pain. Intraoperatively, 37.5 % of the patients showed single adhesive bands; 62.5 % showed adhesions. Mean operation time was 60 min, conversion rate: 5.4 %. Complications were recorded according to the "Cologne classification": class I: 78.6 %, class II: 8.9 %, class III: 1.8 %, class IV: 10.8 %, class V: 0 %. The postoperative hospital stay was 6 days on average. CONCLUSION: Our study suggests that laparoscopic adhesiolysis can be done safely in emergency cases and in patients with extensive adhesions as well.

[Analgesic consumption--laparoscopic versus conventional cholecystectomy]. / Schmerzmittelverbrauch--laparoskopische versus konventionelle Cholecystektomie.

We compared two groups of 50 patients each with symptomatic cholecystolithiasis treated by either conventional or by laparoscopic cholecystectomy with regard to duration of postoperative pain and sort and amount of analgetics. Laparoscopic operation time was on an average 115.4 min (65-180 min), conventionally operated 78.1 min (35-140 min). Eight patients with laparoscopic cholecystectomy did not need analgetics at all. The average number of days of postoperative pain was 2.7 days for conventional operation and 1.13 days for laparoscopic cholecystectomy. In this time the conventionally operated patients needed four to five times the amount of analgetics as well morphin analogues as low-potency analgetics.

[Endosonographic diagnosis in preoperative radiotherapy of locally advanced rectal carcinoma]. / Endosonographische Diagnostik bei präoperativer Radiotherapie des lokal fortgeschrittenen Rectumcarcinoms.

Endorectal ultrasound (EUS) is important for the indication of preoperative radio(chemo)therapy of locally advanced rectal carcinomas. Preoperative radio(chemo)therapy causes an increased echogenity of the ultrasound, which histologically corresponds with increased fibrosis. After preoperative radio(chemo)therapy, the accuracy rate of EUS of tumor infiltration depth (T) and lymph-node status (N) is 75% compared with postoperative histology. With the help of EUS before and after radio(chemo)therapy (n = 28 patients) "downstaging" was noticed endosonographically in 10 patients (3 times in T and 7 times in N staging) and "upstaging" in 3 patients (3 times in T and 1 times in N staging). There was no "understaging" of local tumor infiltration depth after preoperative radio(chemo)therapy.

[Endo-anal ultrasound. Indications and results]. / Der endoanale Ultraschall. Indikationen und Ergebnisse.

Between July 1991 and November 1993 106 patients have been examined by endoanal ultrasound with a 7.0 MHz transducer and a special hard plastic cone which is attached over the transducer. Indications for endoanal ultrasound have been anal carcinoma, perirectal or perianal fistulas, perianal abscesses and sphincter insufficiencies. All anal carcinomas and 2 anal cancer recurrences could be visualized with regard to their size and extension as well as the lymphnode infiltration. 28 of 35 fistulas have been seen by endoanal ultrasound. Endosonographical differentiation in inter- (10), trans- (12) extra- (1) or suprasphincteric (5) was possible in all detected fistulas and confirmed by operation in 27 of 28 cases. 34 cryptogen abscesses could be detected (15 intersphincteric, 12 ischiorectal, 7 pelvirectal) and confirmed by the operative situs with regard to their size and localisation. In 9 patients with a myogen sphincter insufficiency the morphological defect of the sphincter muscle could be localized by endoanal ultrasound and confirmed by the operative situs in all cases.

[Internet presence of surgical clinics in Germany. Current data and future prospects]. / Internetpräsenz Chirurgischer Kliniken in Deutschland. Aktuelle Daten und Zukunftsausblick.

INTRODUCTION: The aim of this study was to obtain an overview of the use of the Internet by surgical departments in Germany as a presentation platform and information resource for their patients. METHODS: After a randomizing a total of 1,760 surgical departments in Germany, 200 were chosen and asked about their Internet use. RESULTS: Most of the questionnaires (81.5%) were received and analyzed; 32.5% of the German surgical departments are represented on the Internet; 81.4% of the clinics without a homepage are planning to have one in the future. The hospitals represent themselves on average on two HTML documents. CONCLUSION: Approximately a third of the German surgical departments currently give information over the Internet with a wide and heterogeneous spectrum. In the near future approx. 80% of the German surgical departments will have online presence. Therefore, the increasing demand for medical information by the patients will be fulfilled. The professionalism and effectiveness of the home-pages can be increased through registration with many search engines and the use of e-mail.

[Internet presence in surgical departments in Germany. II. Legal bases of medical Internet presence]. / Chirurgische Internetpräsenz in Deutschland, Teil II. Rechtliche Grundlagen ärztlicher Internetpräsenz.

In recent years, the Internet has generally been growing throughout the world, and physicians have taken to the Web as well. Besides its use for medical data research, physicians and hospitals are increasingly discovering the Internet as a vehicle for the presentation of their scope of practice. In this regard, the legal frameworks in Germany are strictly regulated. This article presents current legal standards and consequences to be faced when the law on prohibited advertising is broken. Included are references to specific laws concerning Internet pages.