Acute neurotoxicology of drugs of abuse.

Many substances can affect the central nervous system, and may cause patients to become critically ill. Acute central neurotoxicologic syndromes associated with drugs of abuse are usually caused by an overdose of sedative-hypnotic agents (including alcohol) or opioids, withdrawal from sedative-hypnotic agents, or an overdose of anticholinergic or sympathomimetic agents. Clinical findings are often syndromic, making physical examination the most important diagnostic tool in the approach to the patient with an unknown ingestion. Treatment focusses on supportive care as the most important intervention for all such patients, augmented by antidotal therapy when appropriate.

[Pathological fractures due to malignant bone tumors]. / Pathologische Frakturen bei malignen Knochentumoren.

BACKGROUND: Malignant bone tumors should be treated within interdisciplinary treatment concepts. The prognosis of pathological fractures is on the whole relatively poor because the fracture is indicative of a large and highly aggressive tumor and the hematoma associated with the fracture could possibly result in spreading of the tumor into the surrounding soft tissues. OBJECTIVES: This article summarizes the current interdisciplinary treatment concepts under special consideration of pathological fractures in primary bone tumors. METHODS: A selective literature search was carried out taking own experience into consideration. RESULTS: Due to the multimodal therapy approach for osteosarcoma and Ewing's sarcoma, the 5-year survival rate could be increased to 60-70 %. CONCLUSION: The therapeutic treatment should always be carried out within the framework of an interdisciplinary, oncological bone expert team, especially in cases of pathological fractures of malignant bone tumors.

[Treatment of flexor tendon injuries in children]. / Die Behandlung von Beugesehnenverletzungen im Kindesalter.

In contrast to the standard therapy of flexor tendon injuries in adults, the postoperative treatment program for children remains a controversial topic. Some prefer immobilization therapy in a variety of forms and for different periods of time. Others prefer early mobilization programs. We present results for twenty-eight children with thirty-seven flexor tendon injuries. The average age was 5.8 years. After primary tendon suture in children six years and younger (group A), our postoperative program consisted of immobilization for three weeks. The older children (group B) were treated with an early passive mobilization program. Follow-up examinations were carried out on twenty six of the children at three months and at 3.7 years. Three months after surgery, the children in group A showed only average results while those in group B presented good finger motion. After 3.7 years both groups showed good results.

[Autologous osteochondral transplantation on various joints]. / Osteochondrale autologe Transplantation an verschiedenen Gelenken.

A chondral/osteochondral defect involving the articular surface of a joint is still a therapeutic problem. The goal of articular cartilage repair is restoration of cartilage congruity, accomplishing full painfree range of motion and elimination of cartilage detoriation. The use of autologous grafts was first reported by Wagner 1964. Now the use of cylindrical autograft plugs was described by Bobic 1996 and Hangody 1996. Operative management and early results of osteochondral cylindrical autograft plugs in the femoral condyle, patella, elbow and talar dome are presented. The arthroscopic/open use of autologous osteochondral grafts from the knee is indicated in osteochondral lesions in diameter from 1 to 3 cm, which can not be primarily refixed and in osteonecrosis at femoral condyle, patella, elbow, talar dome as well as shoulder.

A New Test of Image Theory.

This paper investigates two hypotheses of the screening phases of two-staged multiattribute choice procedures: the editing phase in which dominated choice alternatives are eliminated and the compatibility test of image theory. As the importance weights and rejection thresholds of the compatibility test are recalcitrant to elicitation, we develop a new method to examine the compatibility phase treating importance weights and rejection thresholds as latent parameters. Our method allows a checkup of the application of a compatibility test without any knowledge of subjects' importance weights and rejection thresholds. Our experimental findings show that the compatibility test enjoys consistency rates of some 70% as compared to consistency rates of about 15% for the editing hypothesis of the elimination of dominated choice alternatives. This result is supported by applying Selten's measure of predictive success. Copyright 1998 Academic Press.

[Modified Krukenberg-plasty with callus distraction of the stump and complete skin closure of both forearm branches]. / Die modifizierte Krukenberg-Plastik mit Kallusdistraktion des Stumpfes und vollständigem Hautverschluss der Branchen.

In 1917, Hermann Krukenberg first reported on the conversion of a forearm stump into tongs by separating the ulna and radius in a bilateral forearm amputee. Up to now, this technique still has its indication in patients with bilateral loss of the hand or forearm. The main problem is still the coverage of both forearm branches with sensitive skin, especially when the muscles are preserved for surface management and strength. The two case reports of bilateral amputation injuries of the upper extremities illustrate our modification of the Krukenberg procedure. First, callus distraction of the short forearm stump by an external fixator was used in one case. After implantation of tissue expanders, enough sensitive skin was gained to resurface both arms of the Krukenberg forearm during a second procedure in both patients nearly completely.

Adiposity, plasma leptin concentration and reproductive function in active and sedentary females.

OBJECTIVE: Circulating leptin has recently been proposed as the peripheral signal indicating the adequacy of nutritional status for reproductive function. To test whether low plasma leptin concentration for a given degree of adiposity is associated with menstrual dysfunction, we measured plasma leptin concentration and body composition in young premenopausal women with normal or abnormal reproductive function. DESIGN: Fasting plasma leptin concentration (ELISA), body composition (dual energy X-ray absorptiometry) and menstrual status (menstrual history and hormonal profile) were assessed in 34 premenopausal women characterized by different levels of physical activity. RESULTS: Body fat content and plasma leptin concentration were both reduced in women with impaired reproductive function (amenorrheic < anovulatory < eumenorrheic women). However, after adjusting plasma leptin concentration for percentage body fat, there was no independent association between leptin and menstrual function. CONCLUSION: Menstrual abnormalities in young premenopausal women seem to occur as a consequence of the linear decline in adiposity and plasma leptin concentration observed in response to inadequate nutritional status. Levels of adiposity below 15% and plasma leptin concentration below 3 ng/ml are more likely to be associated with impaired reproductive function.

Mutual influences of health and poverty. Evidence from German panel data.

While a large body of literature is concerned with the interplay of health and poverty in developing countries, comparable studies for developed countries are rare. Using data drawn from the German Socio-Economic Panel (GSOEP), this paper investigates the relationships between changes in relative income poverty, income changes and health-related quality of life in Germany, i.e. in an environment with nominally equal access to medical care, education and social security. A fundamental five-dimensional health concept is introduced and tested for its empirical performance. The background of the causal analysis is formed by two hypotheses, one regarding low income as a possible cause for poor health (prevention hypothesis) and the other assuming the opposite causal direction (deprivation hypothesis). By means of a descriptive analysis and a structural equations model, the existence of a more complex relational web between health and poverty is demonstrated.

The psychoimmunological association of panic disorder and allergic reaction.

During treatment of out-patients suffering from DSM-III R panic disorder (PD) with and without agoraphobia, our attention was drawn to a high frequency of comorbid allergic reactions. In a controlled study, the prevalence of immediate type I reactions was determined in panic patients. Conversely, the prevalence of psychological disorders was recorded among allergic patients. Altogether, 79 out-patients with PD, 100 type I allergic out-patients and 66 controls underwent structured clinical interviews and tests for allergies. Of the patients suffering from PD, 70 per cent displayed type I immediate reactions (controls = 29 per cent). Vasodilatation (often approaching circulation collapse) is a frequently occurring allergic syndrome which is a very dramatic experience. Fifty per cent of the allergic patients showed mild to severe psychological disturbances (controls = 25 per cent); and 16 per cent had problems requiring treatment (controls = 9 per cent). Ten per cent of the allergic patients revealed PD (controls = 2 per cent). The association between PD and allergic (vasomotor) reactions was found to be highly significant. A functional relationship is hypothesized in terms of conditioning cognitive and vasomotor interactions during autonomic arousal.

Does physical activity improve sleep in impaired nursing home residents?

OBJECTIVES: To determine if two physical activity programs of varying intensity would result in improved sleep among incontinent and physically restrained nursing home residents. DESIGN: Controlled trials of two physical activity programs. SETTING: Seven community nursing homes in the Los Angeles area. PARTICIPANTS: Residents were included if they had urinary incontinence or were physically restrained. Sixty-five subjects were studied. Mean age was 84.8 years, 85% were female, mean length of residency in the nursing home was 19.9 months, and mean Mean Mini-Mental State Exam score was 13.1. INTERVENTION: The first physical activity program involved sit-to-stand repetitions and/or transferring and walking or wheelchair propulsion. These activities were performed every 2 hours during the daytime, 5 days per week for 9 weeks. The second, less frequent physical activity program involved rowing in a wheelchair-accessible rowing machine plus walking or wheelchair propulsion once per day three times per week for 9 weeks. MEASUREMENTS: The physical function measures reported here include mobility endurance (maximum time walking or wheeling) and physical activity as measured by motion sensors (Caltrac). Nighttime sleep was estimated by wrist activity monitors. Nighttime sleep measures included total time asleep, percent sleep, average duration of sleep, and peak duration of sleep. Daytime sleep was measured by timed behavioral observations of sleep versus wakefulness performed every 15 minutes during the day. RESULTS: Nighttime sleep was markedly disrupted in both groups at baseline. Across all subjects at baseline, the average total sleep time was 6.2 hours and the percent sleep was 72.0%, but the average duration of sleep episodes was only 21.2 minutes and the peak duration of sleep episode averaged only 83.8 minutes. During the daytime, subjects were observed asleep during 14.5% of observations. Although there was improvement in mobility endurance in the intervention subjects compared with controls (MANOVA F = 4.36, P = .042), there were no differences in the night and day sleep measures at follow-up testing. Even among a subgroup of intervention subjects who showed a 30% or greater improvement in mobility endurance, sleep did not improve at follow-up compared with baseline. CONCLUSION: This study supports our previous findings of marked sleep disruption in impaired nursing home residents. In addition, despite documented improvements in physical function with activity, we did not find improvements in sleep in the intervention versus control groups. These results suggest that increasing daytime physical activity alone is not adequate to improve sleep in impaired NH residents. Future efforts to improve sleep in this population should take into account the multifactorial nature of sleep disruption, including individual health problems that effect sleep and the disruptive nature of the nighttime NH environment.

[The psychoimmunological network og panic disorders, agoraphobia and allergic reactions]. / Das psychoimmunologische Netzwerk von Panikstörung, Agoraphobie und allergischer Reaktion.

While treating panic and agoraphobia patients with behaviour therapy, a high frequency of allergic reaction of the IgE-mediated type I was observed. Panic disorder, agoraphobia, allergic disorder, and vasomotor reactions are briefly discussed in the framework of psycho-endocrino-immunological research. A pilot study had shown a high correlation between panic disorder with and without agoraphobia and allergic reaction. A controlled study was then planned to test the hypothesized psychoimmunological relationship. 100 allergic patients, 79 panic/agoraphobic patients, and 66 controls underwent psychodiagnostic and allergic screening. 70% of the anxiety patients responded to test allergens with IgE-mediated type-I immediate reactions in comparison to 28% of the control persons. Another 15% of the panic patients reacted to nickle compound with type-IV delayed skin reactions (7% of the controls). Conversely, 10% of the allergic patients suffered from panic disorder (45% had experienced panic attacks) in contrast to 2% of the controls (24% of these reported panic attacks). The relative risk for allergic patients to develop panic disorder with and without agoraphobia is obviously five times as high as for controls. With this assumption of a psychoimmunological preparedness in mind, a behavioural medical diagnostic and therapeutic concept seems more adequate in coping both with panic/agoraphobia and allergic disorder.

Clinical skills training of U.S. medical students.

BACKGROUND: Although there is general agreement that the teaching of clinical procedures needs vast improvement, little appears to have been done to achieve this goal, particularly with regard to medical students. METHOD: In the summer and fall of 1992, 60 U.S. medical schools participated in a telephone survey about how they taught clinical procedures to medical students. The schools were in 30 states and the District of Columbia; 36 were public and 24 were private. The schools were asked to describe what procedures were taught, how, and over what duration of time, with a focus on whether students were taught procedures prior to their clinical rotations. RESULTS: More than three-fourths of the schools (47 of 60) offered nothing other than an introduction to phlebotomy. Only four schools offered more extensive courses (40-50 hours) that covered a variety of topics. CONCLUSION: Few schools had adopted any formal method for training students to perform clinical procedures. In light of this problem, the authors describe a solution that has proven popular at the Stanford University School of Medicine--an elective course in surgical skills developed in 1988-89 and continuing to the present. Although the content of this particular course focuses on surgical procedures, important topics from other disciplines could easily be added or substituted. The course incorporates techniques that have previously been shown to be successful, such as the use of plastic models and cadavers. It also enables students to learn by performing procedures on each other, and to benefit from continuity of supervision by being taught by one faculty member.

[Psychoimmunologic correlation between allergies, panic and agoraphobia]. / Psychoimmunologischer Zusammenhang zwischen Allergien, Panik und Agoraphobie.

The present behavioral medical paper is a contribution to basic research in neuroimmunology. The relationship of panic/agoraphobia and allergy/anaphylaxis (IgE-mediated immediate reaction) is demonstrated and discussed with specific consideration of vasomotor reactions, tachycardia and hyperventilation in panic patients and allergies with anaphylactic reactions. The vegetative symptoms of panic reactions and anaphylaxis showed a high correlative correspondence. 74% of 23 panic and/or agoraphobia patients in a pretest to an epidemiologic study turned out to have an allergic illness that needed treatment; but there were no more anxiety disorders disclosed in 50 allergic patients than in the general population according to expectancies found in epidemiologic publications. If these data are confirmed then panic and agoraphobia cannot be seen as merely a cognitive-emotional event, but also as a further kind of allergic disease with genetic, ecological, psychological and social determinants; they would then have to be diagnosed as psychoimmunological disturbances and treated with behavior medicine (preferably with exposition and immunotherapy or hyposensitization). Anxiety therapies would improve qualitatively and could be cut down in duration.

[Anxiety and immunologic disorder: phobia, generalized anxiety syndrome and panic attacks from the psychoimmunologic viewpoint with the intention of generating hypotheses]. / Angst und immunologische Störung: Phobien, generalisiertes Angstsyndrom und Panikattacken psycho-immunologisch betrachtet in hypothesengenerierender Absicht.

From a behaviour therapist's viewpoint anxiety is perceived in a framework expanded to the psycho-neuro-immunological dimension. After describing phobic anxieties, cognitive mechanisms, and allergic-immunological disturbances, clinical experience won from 34 phobic patients treated with behavior therapy is demonstrated. 31 of these proved to be poly-allergic. A comparison of both physiological fear and allergic symptoms lets a relationship seem obvious between anaphylactic or collapse inclination and psychological fear reaction. Mediated by cognitive variables persons with emphatic perception may develop an association between anxiety and allergic processes with high probability, the reciprocal influence of which can increase with vehemence. Comprehensive psychologic-medical diagnostic and therapeutic measures could improve the effectivity of therapy as well as anxious patients' "compliance" and "coping skills".