Standardized tests of heart rate variability: normal ranges obtained from 309 healthy humans, and effects of age, gender, and heart rate.

The authors undertook this study to determine the effects of age, gender, and heart rate (HR) on the results of cardiac autonomic function tests for measuring heart rate variability (HRV) in a large sample of healthy subjects (n = 309). Conventional tests (deep breathing, maximum/minimum 30:15 ratio), and a standardized 5-minute resting study, including spectral analysis of HR, were used. The main findings included (1) the indices of all tests, except for the ratio of the low- (LF) to high-frequency (HF) spectral power (LF/HF ratio) and HR itself, are inversely related to age in both sexes; (2) the 5-minute spectral bands (except for the LF/HF ratio), the variation coefficient, expiratory-inspiratory ratio during deep breathing, and the maximum/minimum 30:15 ratio are independent of HR; (3) women up to the age of 55 years have a higher resting HR compared with men; (4) young and middle-aged women show a significantly lower LF power and LF/HF ratio compared with age-matched men, whereas no significant gender differences are observed in the absolute HF power. The authors computed age- and gender-dependent normal values for each of the HRV indices studied here and discuss the clinical consequences arising from gender differences in HRV.

Relation between electroconvulsive therapy, cognitive side effects, neuron specific enolase, and protein S-100.

OBJECTIVE: To investigate whether electroconvulsive therapy (ECT) induces brain tissue damage expressed as an increase in neuron specific enolase and protein S-100. METHODS: A total of 179 serial measurements of S-100 and NSE serum concentrations were performed on 14 patients during the course of a bilaterally stimulated ECT series. Cognitive performance was assessed by psychometric testing carried out on the day before the start of ECT as well as on the days after the third, sixth, and last ECT. Pre-ECT and post-ECT concentrations of NSE and S-100 were compared by non-parametric tests. RESULTS: On average, 9.5 (SD 2.9) (range 3-12) ECTs were applied; 13 of 14 patients received at least six ECTs. The average duration of convulsion (computed for all ECTs) was 29.0 (SD 10.5) seconds. At no point during the ECT series was there a significant increase in the average NSE or S-100 concentrations compared with the baseline investigation before the start of the ECT series. The maximal measured post-ECT values of NSE and S-100 were 26.6 ng/ml and 0.46 ng/ml, respectively. The cumulative energy doses applied, seizure durations, and ECT induced changes in cognitive performance scores were never significantly correlated with the NSE or S-100 serum concentrations. CONCLUSION: This pattern of findings suggests that a modern ECT, fulfilling current quality standards, induces no brain tissue damage detectable by changes in NSE or protein S-100.

Screening for concomitant alcohol abuse in schizophrenia: clinical significance of the Munich Alcoholism Test and laboratory tests.

For the early and correct diagnosis of the comorbidity of schizophrenia and alcoholism, a valid laboratory marker would be most helpful in clinical practice. Seventy schizophrenics admitted to a general psychiatric unit of an urban hospital located in a large industrial area in Germany prospectively underwent a detailed addiction history, the Munich Alcoholism Test (MALT) and determinations of serum gamma-glutamyltransferase (gammaGT) and carbohydrate-deficient transferrin (CDT). Cutoff levels for laboratory tests represented the 95th percentile of data obtained from 100 matched healthy controls. Using the MALT, we found evidence of concomitant alcohol consumption in 42.8% of the study patients. The sensitivities of gammaGT and CDT for detecting alcohol abuse (confirmed using DSM III-R criteria) were 70.6 and 58.8%, respectively. Our data suggest that the MALT can be used as a reliable screening test for alcohol use in schizophrenia. In neuroleptic-treated schizophrenics with pathological gammaGT, but low MALT scores, the corresponding CDT may serve as a highly specific marker to verify a concomitant alcohol abuse.

Cardiovascular autonomic reactivity in schizophrenics under neuroleptic treatment: A potential predictor of short-term outcome?

In schizophrenics cardiovascular autonomic reactivity (CAR) can be used as an indicator of autonomic arousal. Using a standardized autonomic test battery (modified according to Ewing and Clarke) we prospectively compared the CAR between 46 actually ill schizophrenics (diagnosis according to DSM-III-R) treated with either haloperidol (n = 26) or clozapine (n = 20) and 30 well-matched healthy volunteers. Multivariate analysis demonstrated a significant effect of neuroleptic medication (haloperidol vs. clozapine) on heart rate and diastolic blood pressure under resting conditions as well as on the heart rate variance (30:15 ratio, deep-breathing, Valsalva) and blood pressure tests (sustained handgrip, Schellong). In addition a positive treatment response (using predefined outcome criteria of the Brief Psychiatric Rating Scale) was independently associated with lower resting heart rates and less impaired 30:15 ratios under neuroleptic medication. Our data indicate that clozapine treatment was associated with a substantial impairment of CAR, which can be explained by the drug's anticholinergic properties in combination with an increase in norepinephrine outflow. The greater heart rate variability in responders might be due to an early neuroleptic-induced decrease of sympathetic activity in the autonomic nervous system, which may precede clinical improvement. Our findings are discussed in relation to neuroleptic-induced changes in plasma catecholamine levels suggested to be useful biological markers in predicting treatment outcome.

Sensitivity of carbohydrate-deficient transferrin (CDT) in relation to age and duration of abstinence.

Carbohydrate-deficient transferrin (CDT) serum concentrations were prospectively determined in 162 subjects (alcoholics n=62, controls n=100) using three different methods of detection (IEF, CDTect, Axis%CDT). Repeated testing in alcoholics after 3 and 5 days of abstinence demonstrated a significantly higher sensitivity of CDT in patients above 40 years of age compared to younger patients.

[Benefits and risks of electroconvulsive therapy (ECG) in elderly patients with cardiovascular risk factors]. / Nutzen und Risiken der Elektrokrampfbehandlung (EKT) bei älteren Patienten mit kardiovaskulären Risikofaktoren.

Between January 1995 and June 1996, 24 inpatients at our hospital (mean age 55.6 years) were treated with electroconvulsive therapy (ECT). Clinical improvement was observed in 80% of the patients, including those without risk factors (NRG, n = 16), as well as those with concomitant cardiovascular diseases (RG, n = 8). During a mean period of observation of 224 days after the end of ECT 7 patients (35%) relapsed. The rate of relapse was higher in RG than in NRG patients (57.1 vs 23.1%). In all cases ECT was well tolerated; 285 applications of ECT did not result in mortality or persistent morbidity. However, RG patients may be at increased risk for the development of minor cardiovascular complications, which were noted in three RG patients (37.5%), but only in one patient (6.2%) in the NRG (Fisher's test, P = 0.09). Taken together, our results demonstrate that ECT is a safe treatment regimen for depression even in medically ill patients of old age.

Alcoholism, peripheral neuropathy (PNP) and cardiovascular autonomic neuropathy (CAN).

In contrast to diabetic autonomic neuropathy, cardiovascular autonomic neuropathy (CAN) in long-term alcoholics has been studied rarely. Using both standardized bedside tests and computer-assisted analysis of heart rate variability (HRV), we prospectively compared autonomic neurocardial function between 35 strictly selected, detoxified alcoholics (DSM-III-R), and 80 well matched healthy controls. Evidence for a potential CAN was found in 25.7% of all the alcoholics studied and in 41% of those with clinically manifest PNP (n=22). Overall, our results demonstrated a significant association between the presence of a CAN and peripheral neuropathy (PNP) amongst chronic alcoholics (chi-square test P<0.05); there was no evidence of a CAN in any of the alcoholics without a clinically manifest PNP. The CAN was characterized by a dissociated appearance of parasympathetic and sympathetic disorders. Our findings provide reason to suspect that the total lifetime dose of alcohol and the duration of alcohol dependence are the most important factors contributing to the pathogenesis of both PNP and sympathetic dysfunction. As is the case with diabetics, computer-assisted measurements of HRV including spectral analysis appear to be far superior to conventional bedside tests for detecting evidence of cardiovagal dysfunction in long-term alcoholics.

Improved autonomic neurocardial balance in short-term abstinent alcoholics treated with acamprosate.

Standardized investigations on resting heart rate variability (HRV) should provide more information on acamprosate's human pharmacodynamic properties because acamprosate interacts with several neurotransmitter systems which are also involved in maintaining autonomic neurocardiac balance. We performed HRV measurements prospectively in 69 healthy controls and 19 chronic alcoholics to prove the hypotheses that: (1) compared to healthy controls, chronic alcoholics show disturbances in neurocardiac vagal function; and (2) in alcoholics, acamprosate treatment (6-8 days) should further decrease parasympathetic activity if acamprosate interacts with central gamma-aminobutyric acidA receptors in vivo. Cardiovagal dysfunction was initially present in 21% of the alcoholics. After treatment. however, their neurocardiac sympathetic-parasympathetic balance improved significantly.

[Clonidine--potential dependence risk in psychiatric patients?]. / Clonidin--Potentielles Abhängigkeitsrisiko bei psychisch kranken Patienten?

A polydrug abuser had been prescribed clonidine for hypertonia but ingested it for its sedative properties and for euphoria over a period of 6 years. Intention and risk factors for clonidine abuse are discussed and the literature is reviewed. In suicidal patients and in those who present the potential for illicit drug use, we advise that clonidine be prescribed in the outpatient setting only when a safer alternative therapy proves unrealistic. When it is necessary to use clonidine, health care workers should be informed about the possibility of abuse and should observe the patients with utmost caution. To our knowledge this is the first documented case of clonidine abuse in a non-opioid-dependent patient.

[The neuroleptic malignant syndrome]. / Malignes neuroleptisches Syndrom.

HISTORY AND CLINICAL FINDINGS: A 22-year-old oligophrenic patient had on several occasions over several months been given various neuroleptics (haloperidol, benperidol, levomepromazine) for exacerbations of paranoid schizophrenia. For a few days before hospitalization he had become quiet and withdrawn, but on the day of admission 100 mg chlorprothixene was administered intramuscularly when he had become agitated. At admission he was somnolent, his general condition was disturbed. He had hyperhidrosis and hypersalivation, as well as tachycardia (112/min) with a normal body temperature of 37.8 degrees C. He also exhibited the cogwheel phenomenon of the limbs and neck, as well as tremor of the hands. The differential diagnosis included inflammatory disease of the brain, sinus thrombosis and, especially, malignant neuroleptic syndrome and febrile catatonia. INVESTIGATIONS: The activities of creatine kinase (3840 U/l), GOT (75 U/l) and GPT (88 U/l) were all increased. Serum myoglobin was 77 micrograms/l. CSF contained blood and there was pleocytosis of 50/3 cells. The ECG showed sinus tachycardia. EEG, chest radiogram, computed tomography, magnetic resonance imaging and cerebral angiography showed no abnormalities. Febrile catatonia could not be excluded. TREATMENT AND COURSE: 4 hours after admission the patient began to respond with normal orientation. Shortly afterwards he was able to walk a few steps, i.e. there was no catatonia. But rigor, tremor, hypersalivation and tachycardia persisted and 12 hours later he developed a fever (up to 39.2 degrees C). Blood pressure varied with peak pressures up to 190/110 mm Hg. After 2 days muscle tone had clearly increased so much that voluntary movement was hardly possible. After amantadine administration (200 mg daily) the rigor improved and for the first time body temperature became normal again. There were no signs pointing to psychotic symptoms. CONCLUSION: Neuroleptic malignant syndrome is difficult to distinguish from febrile catatonia and the diagnosis can often only be made through the clinical course.

[Psychiatric anamnesis, psychiatric findings and their relevance for legal questions in psychiatric assessment before the social court]. / Die psychiatrische Anamnese, der psychische Befund und ihre Relevanz für die Beweisfragen im psychiatrischen Gutachten vor dem Sozialgericht.

Psychiatric expertise in court implies specific requirements with regard to the formal aspects. On the one hand, they are determined by psychiatry as a branch of medical research and on the other by the fact that the expert testimony serves as a piece of evidence in court. Up to now psychiatrists have focused on the legal consequences of different kinds of diseases rather than on the formal aspects of expertise testimony. In this paper, we try to reconcile the specific requirements of psychiatric exploration with the requirements that have to be fulfilled in order to convince the court.

[Myasthenia gravis--often misdiagnosed. A clinical case report]. / Myasthenia gravis--oft verkannt. Ein klinischer Fallbericht.

With the aid of a case report, the author shows that even characteristic symptoms of myasthenia gravis may easily remain undiagnosed, often over a lengthy period. Specific muscular weaknesses are frequently ascribed to other underlying diseases or misinterpreted as being psychogenic in nature.

MR imaging in multiple sclerosis: comparison with clinical, CSF, and visual evoked potential findings.

MR examinations of 136 patients with multiple sclerosis (MS) were evaluated to correlate the results with clinical, CSF, and visual evoked potential (VEP) findings. In addition, 22 of the 136 patients were studied several times during a 5-month follow-up period. It was demonstrated that MR is superior to CSF and VEP findings in establishing cerebral alterations in MS. A relationship between the results of CSF and VEP examinations and the MR results could not be detected. Negative CSF and VEP results corresponded to positive MR imaging and vice versa. In our series, five negative MR results were obtained in patients with clinically proved MS. The extent of alterations shown up by MR corresponds to the duration of the disease; in particular, more confluent abnormalities in the periventricular region were found in patients with long-standing disease. More plaques were found in patients with a primary relapsing/remitting course of the disease than with the primary chronic progressive form. The clinical course and the grade of disability did not correspond to differences in MR imaging. Follow-up demonstrated that most lesions remain unchanged (72-79%); increases and decreases in the size of the plaques seem to depend on the clinical course. These results suggest that MR is the most sensitive technique for establishing the diagnosis of MS.