[Dynamic magnetic resonance tomography (MRI): a follow-up study after femur core decompression and instillation of recombinant human bone morphogenetic protein-2 (rhBMP-2) in avascular femur head necrosis]. / Dynamische Magnetresonanztomographie (MRT): Verlaufsbeobchtung nach Femurkerndekompression und Auffüllung mit rekombinantem, humanem Bone morphogenetic Protein-2 (rhBMP-2) bei avaskulärer Femurkopfnekrose.

OBJECT: The aim of the study was to test the use of dynamic magnetic resonance imaging study with Gd-DTPA-application and the dynamic changes of signal intensity at patients with avascular femoral head necrosis after having installed rhBMP-2 and/or decompressed the core. MATERIAL AND METHODS: Six patients with avascular necrosis of the femoral head ARCO-stage I- or II-lesions were treated surgically by femoral head core decompression. Three of these patients were additionally treated with rhBMP-2-instillation. The progression or regression could be confirmed by T1- and T2-weighted spinecho-sequences (zero, four, ten, sixteen weeks and 24 months follow up). RESULTS: Corresponding ARCO-classification with partly more sensitive measurement of vitality signs in comparison to the optical x-ray classification. The objective, quantitative measurement of signal intensity post contrast medium reduces the influence of experience and level of education. The dynamic sequences results are reproducible. CONCLUSION: The dynamic magnetic resonance imaging study after Gd-DTPA-application and the dynamic changes of signal intensity after Gd-DTPA enhancement in the necrotic areas of the femoral head were the important subject of our study and it seems, that these sequencies and the ascertainment of signal intensity changes will be an efficient method for judgement of vitality, vascularisation and perfusion after therapeutical intervention. Combination of femoral head core decompression and rhBMP-2-instillation for the purpose of osseous regeneration seems to stabilize the affection.

[Initial nuclear magnetic resonance tomography results of the treatment course of avascular femur head necrosis after femoral core decompression]. / Erste kernspintomographische Ergebnisse des Therapieverlaufs bei avaskulärer Femurkopfnekrose nach Femurkerndekompression.

The vascular femoral head necrosis is a serious illness, especially when appearing in patients aged 30 to 50 years. Many etiologic factors cause a femoral head necrosis such as, for example, high-dose steroids, abuse of alcohol, defect of bone marrow and trauma of the hip. Often the X-ray photograph leads to the diagnosis in the second stage (ARCO 1992) or in the third stage, when the femoral head has begun to collapse. The stage IIc and III shows an evident enhancement in contrast media in MRI. Contrast enhancement is demonstrated by STIR, FATSAT, T1-weighted and dynamic screening sequence. The characteristics of the contrast media enhancement argue for an active concomitant process of destruction and regeneration. This stage has the best chances for a drug or a surgical therapy. The evaluation of the signal intensity by the dynamic screening sequence is considered as an objective contribution for the staging of the femoral head necrosis. This enables one to differentiate between the curable stage IIc and the stage III, showing the beginning of breakdown of the femoral head.

Psychogeriatric clinical, electro-encephalographic and autopsy findings.

Demographic, psychiatric, and electro-encephalographic (EEG) data were compared with brain autopsy findings for 73 elderly psychiatric patients. A late onset of depression (60+ years) was more likely than early onset to be accompanied by Alzheimer's disease. There were strong associations between clinical and histopathological indicators of Alzheimer's disease. This was particularly evident for diffuse EEG slowing. Clinical as well as histopathological indicators of Alzheimer's disease were intensely related to EEG features, mainly EEG slowness (positive), reactivity to eye opening (negative) and dominant frequency (negative). Cerebrovascular pathology showed fewer EEG correlations. The results support the usefulness of the clinical electro-encephalogram in patients suspected to have Alzheimer's disease.

[A procedure for testing local anesthetics]. / Ein Verfahren zur Testung von Lokalanästhetika.

A method for testing intensity and duration of the effect of local anaesthetics is presented. The assessment of effectiveness is based on the subjective perception threshold after painful electrical tooth pulp stimuli. With respect to its practical applicability the method is tested in a clinical study using three commercial local anaesthetics. The results prove the possibility of giving reproducible and quantitative statements concerning the time course and intensity of anaesthesia. Using this method, only a restricted number of subjects is necessary for estimating the differences in the basic features of different local anaesthetics.

Topography and possible physiological significance of EEG amplitude variability in psychosis.

The topography and possible physiological significance of EEG average amplitude and amplitude variability in time were examined in 10 chronic psychotic patients and several groups of healthy volunteers. In confirmation of previous reports, the patients showed more slow (5.2-7.6 Hz) activity, particularly in frontal areas, and less alpha rhythm variability in posterior areas, compared to matched controls, chiefly during the resting state, while eye opening, and particularly structural sensory input, made the groups more similar. The same two EEG variables showed significant correlations with ratings of psychopathology, in the expected direction. The EEG amplitude variability is increased by unstructured perception, probably as an expression of readiness or search for structures in the input, and shows persistent topographic patterns over time in individuals. It appears to reflect a functional dimension which is different from the one represented by the average amplitude and is one of several spontaneous oscillatory functions which are diminished in chronic psychosis, perhaps as consequence of prefrontal malfunction. The results suggest a diminished guiding function by the anterior cortex, and a diminished readiness for perception of exogenous structured information, in chronic psychosis.

Prefrontal cortex dysfunction as a common factor in psychosis.

It has recently become possible to arrive at a testable biopsychological model, according to which a dysfunction of the prefrontal cortex is the common factor in psychotic disorders; if persistent, this leads to a dissolution of the highest level of brain function, in the sense of Hughlings Jackson. The model is in agreement with newer findings in normal and pathological physiology and can serve as basis for specific experimental questions. It is compatible with a unitary epistemological viewpoint.

Pathophysiological mechanisms of sudden death induced by platelet activating factor.

Platelet activating factor (Paf) (15-40 micrograms-1) kills male rabbits within 3 to 5 min. Intravenous injection of Paf at a dose of 15 micrograms kg-1 is uniformly lethal, and the rabbits died within 4.5 +/- 0.4 min. The sudden death is characterized by cessation of respiration, a marked decrease in mean arterial blood pressure (M.A.B.P.), and 8 fold increases in plasma thromboxane B2 (TxB2) concentrations with only modest elevation in plasma 6 keto-prostaglandin F1 alpha (6-keto PGF1 alpha) concentrations. Pretreatment with the cyclo-oxygenase inhibitor, ibuprofen (6.25 mg kg-1), or with the thromboxane synthetase inhibitors dazoxiben (2.5 mg kg-1), CGS-13080, or OKY-046 1 mg kg-1) increased survival rates to 83-100%. Protected rabbits showed only modest changes in M.A.B.P. and no significant increase in plasma TxB2 concentrations. The protective drugs showed a dose-related action on M.A.B.P., plasma TxB2 concentration and mortality rate in Paf-induced sudden death. The mechanisms of the protection appeared to be prevention of platelet aggregation (leading to pulmonary thrombosis) and pulmonary and coronary vasoconstriction. However, Paf does not appear to exert direct vasoconstrictor effects in isolated coronary or pulmonary arteries. The effects of Paf in vivo appear to be mediated by TxA2 released by activated platelets in the absence of the protective effects of prostacyclin. Inhibition of thromboxane synthesis effectively prevents the Paf-induced sudden death.

A psychogeriatric assessment program. V. Three-year follow-up.

In 1974, a 10-month diagnostic evaluation of 80 newly admitted psychogeriatric patients was undertaken. The diagnostic categories were functional versus organic brain disease. The present report deals with results of a follow-up evaluation three years later. To assess the prognostic validity of our measures, the initial 1974 data on survivor and nonsurvivor groups were studied, and some of the tests were repeated in 35 of the 40 survivors. Statistically significant differences between survivors and nonsurvivors were found in both "organic" and "functional" groups, with respect to performance on psychologic and psychophysiologic tests, and the level of social functioning before admission. The death rate was significantly higher in the group with organic disease.

Amantadine in senile dementia: electroencephalographic and clinical effects.

Nineteen patients with senile brain disease (including 2 with parkinsonian symptoms) were treated with amantadine in an oral dosage of 200--300 mg daily. Seven showed definite clinical benefits such as increased alertness and decreased agitation, and 2 others showed slight benefits. However, in only one instance was the benefit maintained without complications. Toxic effects such as overactivity, anxiety and visual hallucinations were observed in 8 patients. Withdrawal effects (e.g., lethargy and staggering) occurred when amantadine was discontinued. The electroencephalograms (EEGs) of all 19 patients showed a frequency increase, chiefly of occipital alpha activity, and sometimes a return to normal, irrespective of clinical changes. Toxic side effects were associated with particularly prominent EEG acceleration. In 10 of the 19 patients, the clinical changes were further validated by by additional psychologic assessments. Although the value of amantadine is limited when given in this way to patients with senile brain disease, it seems important to observe its effects in drug combinations aimed at correction of neurotransmitter imbalances.

Electroencephalograms and autopsy findings in geropsychiatry.

The relationships between post-mortem findings and electroencephalographic tests obtained during the 12 mo before death were investigated for 100 psychogeriatric subjects. The results, which due to methodological limitations are only tentative, suggest a fairly close correlation between the two sets of data, which can, however, be obscured by a number of factors, notably the presence of severe physical illness (cerebral and systemic, including severe drug effects) of a nonstructural type at the time of the EEG. In their absence, diffuse EEG slowing strongly suggests senile-Alzheimer's brain disease (it is associated with plaque and tangle formation, ventricular dilatation, and cortical atrophy); and intermittent lateralized slow waves strongly suggest hemodynamic problems due to sclerosis of cerebral arteries. Brain lesions produce EEG changes mostly if large and close to the cortex. If the necessary precuations in EEG interpretation are taken (i.e., mainly consideration of present clinical state), the EEG is diagnostically quite helpful in this group of subjects.

Sleep deprivation in the treatment of elderly depressed patients.

Fifteen elderly depressed patients were treated by 36-hour sleep deprivation (SD). The depression was unipolar in 3 cases, bipolar in 3, and secondary in 4. Nine of the 15 patients responded to SD, and 6 had a remission (1 with SD alone and 5 with SD plus an antidepressant drug). Some of the remaining 6 patients might have responded if the treatment had not been interrupted for various reasons. These favorable results in elderly patients were better than anticipated. SD was well tolerated, although in one patient with bipolar depression a manic attack was precipitated. The effectiveness of SD poses interesting theoretic questions.

Effect of acute and chronic neuroleptic therapy on serum prolactin levels in men and women of different age groups.

A single fasting level of serum prolactin was measured in each of sixty control subjects and eighty-three psychiatric patients of both sexes who had been on neuroleptic therapy for 2-4 weeks (acute treatment) or at least 5 years (chronic treatment) and who were aged either 17-45 or 48-85 years. All groups of patients had significantly higher mean prolactin levels than controls. Gender, age group of women, and exposure to acute or chronic treatment were significant variables determining the magnitude of neuroleptic-induced elevation of prolactin. In some of the groups, dose, duration of chronic therapy, and concomitant administration of anticholinergic drugs also influenced prolactin levels. Whereas all acutely treated women had prolactin values above the control range, one out of twelve (8-3%) of the women aged 17-45 years and six out of fourteen (42-9%) of the women aged 48-85 years who were under chronic treatment had normal values. Normal prolactin levels were also found in five out of sixteen (31-2%) of the acutely treated and nine out of twenty-four (37-5%) of the chronically treated men aged 17-85 years.

A psychogeriatric assessment program. IV. Interdisciplinary aspects.

The interdisciplinary aspects of the psychogeriatric assessments described in three previous papers are discussed on the basis of factor-analysis findings and their significance in diagnosis, treatment, planning and theory. The difference between basic biopsychologic dysfunctions (including pathohistologic changes and various counter-regulations) and psychosocial dysfunctions (lifestyle) becomes clear statistically as well as clinically. This difference probably is fundamental, in the sense that intact biopsychologic functions are elementary tools for the psychosocial functions.

A psychogeriatric assessment program. III. Clinical and experimental psychologic aspects.

Variables stemming from standard psychologic tests, psychophysiologic tests, and operant conditioning procedures were employed in assessing the status of 80 psychogeriatric patients with either organic brain syndromes or functional psychoses. Differences were observed in the responses between the two groups. In general, the performance of the patients with organic brain syndromes was more deviant than that of the patients with functional psychoses, and the performance of the hospitalized geriatric patients (regardless of diagnosis) was worse than that of the normal control groups.

A psychogeriatric assessment program. II. Clinical and laboratory findings.

In a Psycholgeriatric Assessment Program, the statistical evaluation of clinical and laboratory data related to thyroid function in 80 patients led to the conclusion that: 1) differences in thyroid function between psychogeriatric patients of the organic and functional types were only slight, as determined by clinical symptoms and thyroxine blood levels, and 2) factor analysis for 53 selected variables indicated that loading for "gross disturbance of psychobiologic function" may be related to the symptom complex of hyperthyroidism/hyperadrenergism, and particularly to psychobiologic symptoms rather than purely somatic symptoms of hyperthyroidism. In comparison with a group of 60 healthy old people, the psychogeriatric patients showed many more signs of hyperactivity and other characteristics of this symptom complex. The results supported the preliminary impression of an energetic (hyperthyroid-sympathicotonic) reaction to mental decline, accompanied by plasma corticosteroid and electroencephalographic changes.

A psychogeriatric assessment program. I. Social functioning and ward behavior.

Eightly newly admitted psychogeriatric patients were intensively investigated by a variety of disciplines -- medical, laboratory, and psychologic-psychiatric tests, including a Minimal Social Behavior Scale and an Integrative Social Functioning Scale. The sample of patients and methods of study for this 10-month Geriatric Assessment Program are described. Assessment of present and past social functioning revealed good agreement between ratings made by different staff members. A decline in social functioning with time differentiated organic from functional psychiatric illness. Some of the scales employed may be of value for social screening purposes in the community.

Uncontrolled diabetes in psychogeriatric subjects.

In a group of 20 long-term psychogeriatric patients with uncontrolled diabetes, data on body weight, blood pressure and blood sugar concentration (fasting and postprandial) were correlated with the electroencephalographic (EEG) findings. The patterns were similar for the study subjects and for healthy subjects of the same age. The psychogeriatric patients with diabetes in contrast to psychogeriatric patients with chronic hypoglycemia, showed an increase in body weight and blood pressure and increase in blood sugar concentration with ageing; they also showed a normal EEG whereas chronically hypoglycemic patients usually had an abnormal EEG. In terms of blood glucose levels and excess glucose in the urine despite treatment, the diabetes had to be considered uncontrolled. However, these patients were clinically asymptomatic. Apparently, in these particular circumstances, the diabetes may be an adaptive biologic phenomenon.

Biological and psychological predictors of survival in a psychogeriatric population.

Out of 206 geriatric subjects who had been assessed with respect to a number of biological and psychological features (Müller & Grad, 1974), it was possible to reach 180 (or 87%) for a 5-year follow-up. Associations of these previous data to six survival categories were examined in order to explore their prognostic value. Of the biological variables the amount of slow EEG activity showed the greatest predictive power concerning the chances of survival, with only a few subjects, who had shown a slow EEG originally, alive after 5 years. Several other biological variables also showed significant differences between survivors and nonsurvivors; the plasma cortisol levels which were determined after the EEG test were lower in the survivors. Diagnostic and predictive value of routine electroencephalographic examinations in geropsychiatric assessments is emphasized. The close relationship of psychological and biological factors is discussed in the context of a dynamic concept of organic brain syndromes.