[Alcohol intoxication in emergency medicine]. / Alkoholintoxikierte in der Notfallmedizin.

Every year more than 100,000 people with an alcohol intoxication are admitted to German hospitals. Many of them refuse inpatient observation or treatment. Therefore the physician in charge at the emergency room has to decide, how to proceed. The capacity to consent has to be judged, especially if the patient insists on being discharged. In this context the risks of injuries, complicated alcohol withdrawal, aggressive and suicidal behavior must be evaluated. In this article the juridical aspects and the necessary mental and physical assessments especially in case of discharge of the patient against medical advice are presented. Essential aspects are summarized in checklists.

[The Neuroleptic Malignant Syndrome]. / Das maligne neuroleptische Syndrom (MNS)--Eine systematische Übersicht.

BACKGROUND: Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening medication-induced syndrome. Core symptoms are hyperthermia, diaphoresis, rigidity, impaired consciousness, and creatinine kinase elevation. Additionally, patients show vegetative dysregulation including blood pressure fluctuations. The purpose of this paper is to summarize current findings, to facilitate diagnostics and to distinguish NMS from other syndromes. METHODS: We performed a systematic review of the literature. We included scientific publications, books and guidelines. RESULTS: In this review we summarize the current diagnostic criteria, differential diagnosis, pathogenesis and therapeutic options. CONCLUSION: Clinical symptoms of NMS are heterogeneous and it is difficult to diagnose early states. Early interventions are important to ensure fast and complete recovery. Since NMS is a rare condition, publications on NMS-therapy are based on single-case reports, meta-analysis or expert opinions. Core symptoms should be considered: Exposure to dopamine-antagonists, hyperthermia, diaphoresis, rigidity, mental status alteration, creatinine kinase elevation, and vegetative dysregulation.

Ethyl glucuronide (EtG): better than breathalyser or self-reports to detect covert short-term relapses into drinking.

AIMS: The assessment of relapses is widely used as an outcome measure of alcohol dependence treatment. However, the methods of assessing relapses range from questionnaires to biological markers of alcohol for different time spans. The aim of this study was to compare the relapse rates of weekend home stays during long-term alcohol dependence treatment, assessed by ethyl glucuronide (EtG), breath alcohol tests and self-reports. METHODS: Two hundred and ninety-seven alcohol-dependent patients receiving a long-term inpatient treatment programme participated. After a weekend at home (Friday to Sunday) they were evaluated for relapse by personal interviews and with breath alcohol tests. A concomitantly collected urine sample was later assessed for EtG with liquid chromatography-tandem mass spectrometry (LC-MS/MS analysis). RESULTS: Of the total, 37.7% of the patients were positive for EtG at least once. Breath alcohol tests had been positive in only 4.4% and in personal interviews only 5.7% of the patients had admitted relapse. 15.6% of EtG tests were positive, but breath alcohol tests were negative (Cohen's kappa = 0.056). Ninety-three per cent of the relapses were only detected by EtG. CONCLUSION: In addition to breath alcohol tests and interviews, urinary EtG can clearly improve the verification of relapse in inpatient treatment programmes allowing for weekend stays at home. Without EtG testing, a high amount of relapses will stay undetected.

Psychological and neuroendocrine responses to social stress and to the administration of the alpha-2-receptor antagonist, yohimbine, in highly trained endurance athletes in comparison to untrained healthy controls.

INTRODUCTION: Several clinical studies suggest antidepressive and anxiolytic effects of regular endurance training. The mechanisms by which exercise exerts these effects are still unclear. It was hypothesized that athletes might show a diminished reaction to psychosocial stress and noradrenergic stimulation. METHODS: 12 male athletes and 12 healthy untrained male controls underwent a challenge paradigm on 3 separate days: the alpha-2-receptor antagonist yohimbine (0.4 mg/kg), placebo or a psychosocial stress test (SST) were administered. Responses were measured by psychometric scales, plasma cortisol, blood pressure and heart rate. RESULTS: Before testing, psychometric variables and cortisol levels were not different between the 2 groups. In comparison to placebo conditions, both the social stress test and the administration of yohimbine were followed by significant increases of anxiety symptoms, plasma cortisol, heart rate and blood pressure in both groups. However, these responses were not significantly different between the group of athletes and the control group. DISCUSSION: These results do not support the hypotheses that high aerobic fitness is associated with attenuated psychological and neuroendocrine responses to yohimbine or to psychosocial stress.

Attenuated salivary cortisol secretion under cue exposure is associated with early relapse.

AIMS: To test whether the risk of relapse in alcohol dependence is predicted by the subjective experience of cue exposure (CE) and/or cortisol reactivity to alcohol cues. METHODS: Salivary cortisol and self-ratings of 'tension' and 'desire to drink' were measured in 32 detoxified alcohol-dependent inpatients during CE sessions conducted in the first and third week of motivation enhancement therapy. Subjects completed the Toronto Alexithymia Scale (TAS-20) and the Abbreviated Alcohol Expectancy Questionnaire (B-AEQ) towards the end of the inpatient treatment to measure emotional self-awareness and the expected positive effects of alcohol. RESULTS: Six weeks after the end of the inpatient treatment, 15 patients were abstinent. Relapse was verified or was presumed for 17 patients. Those who had relapsed had shown an attenuated response to CE in the third week as an inpatient but did not differ from abstainers in terms of subjective reaction to cues. Subjective ratings of CE were not related to salivary cortisol or relapse but showed several associations with factors one and two of the TAS-20. The expectancy of enhanced social contacts by using alcohol (factor 1 of the B-AEQ) correlated negatively with the decline in salivary cortisol during the CE session in the third week of treatment. Subjective ratings of CE correlated with Alexithymiascores. CONCLUSIONS: Alcoholic patients who use alcohol to enhance their social contacts typically lack hypothalamo-hypophysical-pituitary-adrenocortical (HPA) reactivity in the early period of abstention. They are at an increased risk of early relapse and perhaps use alcohol to increase cortisol secretion again.

Smooth pursuit deficits in schizophrenia, affective disorder and obsessive-compulsive disorder.

BACKGROUND: In schizophrenia, affective disorders, and obsessive-compulsive disorder (OCD) dysfunction of frontal neuronal circuits has been suggested. Such impairments imply corresponding oculomotor deficits. METHOD: Eye movement response to foveofugal and foveopetal step-ramp stimuli was recorded within the same study design in patients with schizophrenia (N= 16), affective disorder (N= 15), and OCD (N= 18) and compared with controls (N=23) using infra-red reflection oculography. RESULTS: In the foveofugal task steady-state velocity was lower in all patient groups compared with controls. Post-saccadic eye velocity was also decreased in patients with schizophrenia and affective disorder. In the foveopetal stimulus steady-state velocity was reduced in schizophrenic patients, only. Changes of saccadic latencies or position errors were not found in any of the patient groups. Also, pursuit latency was unchanged and initial eye acceleration was not decreased. CONCLUSIONS: Unaltered saccadic parameters indicate intact motion perception in cortical visual area V5. Therefore, the observed deficit of pursuit maintenance implies a dysfunction of frontal networks in all patient groups including the pursuit region of the frontal eye field (FEF). In patients with schizophrenia and affective disorder reduced post-saccadic pursuit initiation may indicate an impaired interaction between the pursuit and the saccadic system.

Impaired serum cortisol stress response is a predictor of early relapse.

AIMS: to investigate a possible association of cortisol stress response during early abstention with relapse. METHODS: Thirty-six alcohol-dependent males, half of them with a comorbid anxiety disorder, and 15 healthy controls were exposed to a standardized psychosocial stress test. Thirty-one of the patients were assessed for relapse 6 weeks after discharge. RESULTS: The relapsers showed almost no cortisol responses in the stress test. Comorbid anxiety disorder influenced neither stress response nor relapse. CONCLUSIONS: During early abstention from alcohol, reduced stress-responsivity of the hypothalamo-pituitary-adrenocortical axis seems to be connected to early relapse.

[Addiction in the elderly - an underestimated diagnosis in clinical practice?]. / Sucht im Alter Ein unterschätztes Problem in der klinischen Versorgung älterer Menschen?

According to several studies in the USA, alcohol abuse is common among elder people, particularly among those admitted to hospital. Corresponding data for Germany are lacking as yet. In this study, the frequency of addiction problems in the elderly admitted to hospital was investigated using the data from 1990 to 1998 of the psychiatric department at the General University Hospital of Lübeck, Germany. Furthermore, the documentations of all consultations in that period were reevaluated. The psychiatric consultation service covers two general hospitals providing inpatient treatment for about 200,000 inhabitants. Diagnoses were made according to the ICD-10 criteria. In 17.7% of the males older than 64 years and in 4.2% of the elderly females admitted to the psychiatric department, alcohol dependency was diagnosed, while 5.8% of the elderly patients showed substance abuse, most often of benzodiazepine. Among the patients visited in the psychiatric consultation service, 10.8% of the elderly males and 3.2% of the elderly females were alcohol addicts and 3.9% substance abusers. The frequency of alcohol-induced neuropsychiatric complications, particularly withdrawal delirium and amnestic syndrome, increased with age. Also, benzodiazepine withdrawal delirium most frequently occurred in older patients. These results underscore that, although the prevalence rate seems to be lower than among the younger population, in the elderly population substance abuse still is a relevant medical problem, since the rate of neuropsychiatric complications increased with age.

[Diagnosis and therapy of sleep disorders. Early assessment--prompt treatment]. / Diagnostik und Therapie von Schlafstörungen. Frühzeitig nachfragen--rechtzeitig behandeln.

Effective medications, as well as other effective options, are available for the treatment of insomnia. Since many patients do not inform their family doctors that they have sleep-related problems, the physician should himself question his patients on this point, with the aim of initiating specific treatment early enough to prevent such a condition becoming chronic.

Acceptance of pharmacotherapy for relapse prevention by chronic alcoholics.

The willingness to take medication is a major prerequisite for compliance with biological treatment approaches in psychiatric disorders. The aim of this study was to investigate the willingness of alcoholics to improve relapse prevention using drug therapy, since there has been little information about the acceptance of such a medication as yet. 261 chronic alcoholics consecutively referred for detoxification completed a newly developed questionnaire containing items on drinking history, recent treatments, and beliefs about drug therapy for relapse prevention. In order to draw comparisons, 67 self-help group attendees and 29 alcoholics consulting an outpatient advice service were also recruited. 67.8% of the recently detoxified alcoholics were prepared to take medication for relapse prevention, if prescribed, while 60% the self-help group attendees refused drug therapy. There was no correlation between the acceptance of drug treatment and duration of dependence. Subjects willing to take a medication more often believed their alcoholism to be curable, and they reported a higher craving frequency. 55% of those willing to take a medication were willing to pay for the drugs, but in most cases, at a level lower than the equivalent of 5 beers. As drug therapy acceptance is a crucial part of compliance with, and success of medical relapse prevention, our results underscore the necessity of a thorough exploration into the health beliefs of the patient and joint development of a treatment rationale prior to prescription.

Purification and antigenicity of flavone synthase I from irradiated parsley cells.

Flavone synthase I, a soluble 2-oxoglutarate-dependent dioxygenase catalyzing the oxidation of flavanones to flavones in several Apiaceae species, was induced in parsley cell cultures by continuous irradiation with ultraviolet/blue light for 20 h. The enzyme was extracted from these cells and purified by a revised purification protocol including the fractionation on hydroxyapatite, Fractogel EMD DEAE, and Mono Q anion exchangers, which resulted in an apparently homogeneous flavone synthase at approximately 10-fold higher yield as compared to the previous report. The homogeneous enzyme was employed to raise an antiserum in rabbit for partial immunological characterization. The specificity of the polyclonal antibodies was demonstrated by immunotitration and Western blotting of the crude ammonium sulfate-fractionated enzyme as well as of the enzyme at various stages of the purification. High titer cross-reactivity was observed toward flavone synthase I, showing two bands in the crude extract corresponding to molecular weights of 44 and 41 kDa, respectively, while only the 41 kDa was detected on further purification. The polyclonal antiserum did not cross-react with recombinantly expressed flavanone 3beta-hydroxylase from Petunia hybrida or flavonol synthase from Citrus unshiu, two related 2-oxoglutarate-dependent dioxygenases involved in the flavonoid pathway.

Detection of facial expressions of emotions in depression.

Research on perceptual and attentional processes in depression has shown that depressed as opposed to nondepressed individuals do not exhibit a positive perceptual bias in multistimulus representations. In the present study a face-in-the-crowd task was applied to examine the relationship between depression and spatial detection of facial expression of positive and negative emotions. A face-in-the-crowd task was administered to 30 subjects (15 clinically stabilized depressed inpatients and 15 normal subjects) using displays of schematic faces. Depressed subjects showed no performance differences in the detection of negative faces and no differences in decision latency for the control condition (all neutral faces) compared to normal subjects. Depressed subjects, however, were significantly slower in responding to positive faces than normal subjects. Our data suggest that depressive mood is associated with a reduced spatial attention to positive facial expression and not with an abnormal spatial processing of negative facial expression. An implication is that lowered vigilance for facial expressions of joy and happiness may affect adversely interpersonal relationships in depressed subjects.

The course of anxiety, depression and drinking behaviours after completed detoxification in alcoholics with and without comorbid anxiety and depressive disorders.

We studied the associations between comorbid anxiety and depressive disorders in treated alcoholics, the course of current anxiety and depression during the early and late post-detoxification periods, and drinking behaviours after discharge. Lifetime psychiatric comorbidity was assessed in 100 alcoholics using the Composite International Diagnostic Interview (CIDI). Three subgroups defined as group DA (comorbid depressive and anxiety disorders, n = 15), group A (anxiety disorder only, n = 23), and group NO (no comorbid disorder, n = 62) were studied. Beginning 21 +/- 13 days after cessation of drinking, state anxiety (STAI-X1), trait anxiety (STAI-X2) and depression (BDI) were assessed once per week (t1 to t4) and once more 6 months after discharge (t5, n = 68). The severity of psychopathology decreased during the first 4 weeks after detoxification in all subgroups. However, trait anxiety remained at higher levels in both the comorbid subgroups from t1 to t4. In the follow-up sample, 60.5% of the non-comorbid subjects remained abstinent, but only 26.7% of all comorbid patients and only 12.5% of those with comorbid depressive disorder plus severe current trait anxiety or depression at t1. Independent of their comorbidity status, relapsers at t5 had already reported more trait anxiety than abstainers at t1. We conclude that severe trait anxiety persisting after 3 weeks of abstinence, comorbid depressive and/or anxiety disorders, and combinations of these with moderate or severe current anxiety and depressive states represent the greatest risks of relapse and therefore may indicate a treatment need.

The severity of alcohol withdrawal is not age dependent.

Age has been considered to contribute to the severity of the alcohol withdrawal syndrome (AWS). To evaluate the relationship between age and the severity of the AWS, we examined 723 alcoholics [518 males, 205 females, mean age (+/- SD): 42.8 +/- 10.5 years, mean duration of alcohol dependence: 11.0 +/- 8.0 years] consecutively referred to a unit for detoxification of alcoholics in a general hospital. The severity of the AWS was assessed by the AWS scale of Wetterling et al. (1997; Alcohol and Alcoholism 32, 753-760). The history of alcohol abuse as well as drinking behaviour in the last 6 months was assessed by a semi-structured interview. There were 41 alcoholics aged > or =60 years; they were compared with younger patients. The average severity of AWS did not differ between age groups. Daily alcohol intake and frequency of drinking were higher in younger alcoholics, but even when adjustment was made for this, severity of AWS was equal in both age groups. A relationship between severity of AWS and age was not detected.

[Psychiatric consultation services for the elderly. Changes in utilization due to the new German legislation concerning guardianship and restructuring of health care providers]. / Psychiatrischer Konsiliardienst bei älteren Patienten. Anderungen der Anforderungen durch Inkrafttreten des Betreuungs- und Gesundheitsstrukturgesetzes?

In the discussion of increasing costs of health care in Germany, the frequent and long hospital stays of elderly patients are often pointed out. Since these patients very frequently suffer from psychiatric disorders, psychiatric consultation is often required. This study was aimed at investigating whether new German laws concerning guardianship and the structure of health care providers change conditions for psychiatric consultation services. For this purpose, the documentation of all consultations in the years 1991 to 1995 was retrospectively evaluated. In about 3% of all patients aged over 65 referred to the General University Hospital of Lübeck, psychiatric consultation was ordered. The most frequent diagnosis was senile dementia. Comparison of the requests and psychiatric recommendations show a significant increase in wishes and recommendations for guardianship. Moreover, there is evidence of the increasing need of consultation in elderly patients. Possibly due to the new law concerning the structure of health care providers and the number of requests and recommendations to transfer patients to psychiatric wards, these results show that the new laws do affect psychiatric consultation.

Craving shift in chronic alcoholics.

In order to investigate changes in the consumption of substances that stimulate the reward system, 222 recently detoxified alcoholics were asked about their consumptional habits before as compared to after detoxification (mixed prospective and retrospective design). Seventy-eight point two percent reported an increase in consumption of coffee, cigarettes, chocolate and other sweets, while 34.9% managed to reduce at least one of these substances. The increase was significant for coffee, chocolate and other sweets. The desire for consumption of these substances was correlated with the maximum ever experienced desire for alcohol (0.232 for coffee, 0.213 for cigarettes, 0.193 for chocolate and 0.176 for other sweets), and the actual consumption of coffee, cigarettes and sweets was correlated with the actual desire for alcohol (0.172, 0.157 and 0.245, respectively). The results lend some support to the hypothesis that psychotropic substances might serve as a kind of self-regulation against craving in this group. A possible link to biochemical theories is discussed.

[New antidepressive drugs in comparison with classical tricyclics. Mechanism of action and clinical evaluation]. / Neue Antidepressiva im Vergleich zu klassischen Trizyklika. Wirkmechanismen und klinische Beurteilung.

During the last decade several new agents have been introduced in the treatment of depressive disorders. In comparison to classical tricyclic antidepressants, these agents have less side effects and a very low toxicity. Selective inhibitors of serotonin reuptake do not produce sedation; however, in the initial phase of treatment this is not always an advantage. In contrast, receptor antagonists, such as mirtazapin and nefazodone have moderate sleep-inducing properties. Selective agents are also characterized by certain pharmacologic interactions which can lead to considerable inhibition of the metabolism of other drugs. Classical antidepressants still play an important role in the treatment of severe depressive episodes. Different synaptic effects of new antidepressants lead to an increased availability of monoaminergic neurotransmitters. The article summarizes the most important neurobiological consequences of these acute synaptic effects which might be more closely associated with neurobiological correlates of depression. The authors conclude about the advantages and disadvantages of the different classes of antidepressants from a clinical point of view.