Chronic mental illness and the limits of the biopsychosocial model

Twenty years ago, the biopsychosocial model was proposed by George Engel to be the new paradigm for medicine and psychiatry. The model assumed a hierarchical structure of the biological, psychological and social system and simple interactions between the participating systems. This article holds the thesis that the original biopsychosocial model cannot depict psychiatry's reality and problems. The clinical validity of the biopsychosocial model has to be questioned. It is argued that psychiatric interventions can only stimulate but not determine their target systems, because intervention and outcome are only loosely coupled. Thus, psychiatric interventions have in principle limited ranges which differ according to the type of intervention and according to the system to be stimulated. Psychosocial interventions face far more obstacles to be overcome than psychopharmacological therapy.

Unusual mutations in Btk: an insertion, a duplication, an inversion, and four large deletions

Mutations in Bruton's tyrosine kinase (Btk) result in the immunodeficiency X-linked agammaglobulinemia (XLA). In a previous study of 101 patients with presumed XLA, we identified seven patients with large genomic alterations in Btk. The recent completion of 100 kb of contiguous DNA sequence at the Btk locus has allowed us to characterize these mutations in detail and to identify four different types of alterations. These alterations included a 253-bp retroposon insertion at position +5 within intron 9, an inversion of greater than 48 kb that disrupted Btk between exons 4 and 5, a 12.9-kb duplication including Btk exons 2 to 5, and four deletions ranging from 2.8 to 38 kb in size. The duplication and three of the deletions resulted from unequal crossovers of Alu repeats. Further, three of the deletions terminated within a repeat-rich cluster spanning 30 kb of sequence 3' of Btk exon 19, suggesting that this region was more susceptible to unequal crossovers than the rest of the Btk gene. These studies describe the first reports of an insertion, an inversion, and a duplication in Btk and demonstrate the utility of large-scale sequencing in the elucidation of disease-causing mutations.

[What characterizes the problem psychiatric patient? Results of a study of patient descriptions using the Psychiatric Personnel Order]

In recent years, economic pressure on extended and repeated psychiatric hospitalisation have increased dramatically. At the same time, diagnostic approaches, e.g., the new concept of the "young adult chronic patient" have improved. The first part of this article summarises reports and experiences on the chronic mentally ill and the so-called "heavy users" of psychiatric hospitalisation. Although the number of studies evaluating this group is small, several characteristics can be identified. Subsequently, a study is presented that deals with psychiatric problem patients in a special way, namely the A2-categorisation according to the German Psychiatric Personnel Regulation (Psychiatrie-Personalverordnung [Psych-PV]). The study is based on 170 consecutive admissions to the Department of General Psychiatry of a large German state hospital, who are characterised as normal (A1) and intensive patients (A2), respectively. The study aimed at describing difficult-to-treat patients or those whose treatment demands large human resources. Medical histories, sociodemographic and psychopathological data as well as subjective health status data of these patients were analysed by standardised and validated instruments (e.g., BPRS, CGI, SF-36, GAF). Results show that the patients under study suffered mainly from schizophrenic psychosis according to ICD-9. Patients categorised into A2 showed a high degree of psychopathology and little insight into their disease. Further it can be demonstrated that they used more therapeutic help from general practitioners rather than from specialists in psychiatry prior to admission. In conclusion, it is suggested to evaluate concepts, e.g., new treatment methods in respect of motivating schizophrenic patients, new typological methods to better diagnosis and to treat psychiatric problem patients via new treatment modalities such as Case Management or inpatient settings for double diagnoses.

Genospecies diversity of Lyme disease spirochetes in rodent reservoirs

To determine whether particular Borrelia burgdorferi s.l. genospecies associate solely with rodent reservoir hosts, we compared the genospecies prevalence in questing nymphal Ixodes ticks with that in xenodiagnostic ticks that had fed as larvae on rodents captured in the same site. No genospecies was more prevalent in rodent-fed ticks than in questing ticks. The three main spirochete genospecies, therefore, share common rodent hosts.

Postprandial lipid, glucose, insulin, and cholecystokinin responses in men fed barley pasta enriched with beta-glucan

BACKGROUND

Fiber regulates the rate and site of lipid and carbohydrate digestion and absorption and thus can modify the alimentary responses to a meal. When fiber sources containing viscous polysaccharides are included in a meal, a slower rate of carbohydrate and lipid absorption will modify the alimentary hormone and lipid responses.

OBJECTIVE

We investigated in 11 healthy men the response of insulin, glucose, cholecystokinin, and lipid to 2 test meals containing beta-glucan.

DESIGN

One of the meals was high in fiber (15.7 g) and the other meal was low in fiber (5.0 g). The low-fiber meal contained pasta made with wheat flour. The high-fiber meals contained pasta prepared by replacing 40% of the wheat with 2 types of barley flour: barley naturally high in beta-glucan and the other a flour enriched in beta-glucan during processing.

RESULTS

Plasma glucose and insulin concentrations increased significantly after all meals but the insulin response was more blunted after the barley-containing meals. The test meals were low in fat (25% of energy) but elicited an increase in plasma triacylglycerol and cholecystokinin. Cholecystokinin remained elevated for a longer time after the barley-containing meals. After the low-fiber meal, plasma cholesterol concentrations did not change significantly; however, 4 h after the barley-containing meals, the cholesterol concentration dropped below the fasting concentration and was significantly lower than that after the low-fiber meal.

CONCLUSIONS

Carbohydrate was more slowly absorbed from the 2 high-fiber meals. Consumption of the barley-containing meals appeared to stimulate reverse cholesterol transport, which may contribute to the cholesterol-lowering ability of barley.

[Management accounting in hospital setting]

The periodic income and expenditure accounts produced at the hospital and departmental level enable successful short term management, but, in the long run do not help remove tensions between health care demand and limited resources, nor do they enable optimal medical planning within the limited financial resources. We are trying to estabilish disease category costs based on case mixing according to diagnostic categories (diagnosis related groups, DRG, or health care resource groups, HRG) and calculation of hospital standard product costs, e.g., radiology cost, preoperative nursing cost etc. The average DRG cost is composed of standard product costs plus any costs specific to a diagnostic category. As an example, current costing procedure for hip artheroplasty in the University Hospital Center Zagreb is compared to the management accounting approach based on British Health Care Resource experience. The knowledge of disease category costs based on management accounting requirements facilitates the implementation of medical programs within the given financial resources and devolves managerial responsibility closer to the clinical level where medical decisions take place.

The lymnaea cardioexcitatory peptide (LyCEP) receptor: a G-protein-coupled receptor for a novel member of the RFamide neuropeptide family

A novel G-protein-coupled receptor (GRL106) resembling neuropeptide Y and tachykinin receptors was cloned from the mollusc Lymnaea stagnalis. Application of a peptide extract from the Lymnaea brain to Xenopus oocytes expressing GRL106 activated a calcium-dependent chloride channel. Using this response as a bioassay, we purified the ligand for GRL106, Lymnaea cardioexcitatory peptide (LyCEP), an RFamide-type decapeptide (TPHWRPQGRF-NH2) displaying significant similarity to the Achatina cardioexcitatory peptide (ACEP-1) as well as to the recently identified family of mammalian prolactin-releasing peptides. In the Lymnaea brain, the cells that produce egg-laying hormone are the predominant site of GRL106 gene expression and appear to be innervated by LyCEP-containing fibers. Indeed, LyCEP application transiently hyperpolarizes isolated egg-laying hormone cells. In the Lymnaea pericardium, LyCEP-containing fibers end blindly at the pericardial lumen, and the heart is stimulated by LyCEP in vitro. These data confirm that LyCEP is an RFamide ligand for GRL106.

Characterization of the 5'-flanking promoter region of the rat somatostatin receptor subtype 3 gene

We investigated the 5'-flanking promoter region of the rat somatostatin receptor subtype 3 (rSSTR3). Using a cDNA probe, genomic clones containing the 5'-flanking promoter region of the rSSTR3 gene were isolated. A sequence of 5.4 kb directly upstream from the start codon was analyzed and two introns were found in the 5' untranslated region (UTR) of the cDNA sequence. The transcriptional initiation site was determined by 5' rapid amplification of cDNA ends (RACE), primer extension and RNase protection analysis with cerebellar RNA. Two major transcriptional initiation sites were found at position 1040 (tsp1) and -856 (tsp2) relative to the translational initiation site. Like a number of other promoters of G-protein-coupled receptors, the rSSTR3 gene lacks TATA and CAAT motifs and includes G+C-rich regions. Functional analysis of the promoter region by transfecting rSSTR3 luciferase-reporter gene constructs into rat pituitary GH3 cells and HEK 293 cells indicated that a 107-bp region upstream of tsp2 was sufficient to drive transcription. Furthermore a 562-bp region at position -1304 to -1865 upstream of the ATG start codon exerted a negative regulatory effect on transcriptional activity.

Prevention of necrotizing enterocolitis in extremely low birth weight infants by IgG feeding?

Oral immunoglobulin has been described as preventing necrotizing enterocolitis(NEC) in preterm infants. To prevent NEC in extremely low birth weight infants (ELBW), we have carried out oral IgG prophylaxis since April 1991. The efficacy of this prophylaxis was examined in a study comparing historical cohorts. ELBW infants delivered in the Department of Obstetrics and Gynaecology of the University of Ulm and treated until day 28 in the level III intensive care nursery, Division of Neonatology, University of Ulm were included. Cohort 1, born between 1.1.1988 and 31.3.1991, received no oral IgG and served as a control [n = 84, gestational age: median 26 weeks, range 24-34; birth weight: 811 g, 490-990], cohort 2, born between 1.4.1991 and 31.12.1995 [n= 137, gestational age: 26 weeks, 22-32; birth weight: 760 g, 362-995], received 6 x 100 mg/kg human IgG (Beriglobin) orally on days 1-28. NEC, stage 2a and higher according to the modified classification of Bell, was observed in 9 of 84 (10.7%) infants of cohort 1 and in 11 of 137 (8%) infants of cohort 2 until day 28. The difference did not reach statistical significance (P = 0.63 Fisher's exact test).

CONCLUSION

In this historical cohort study, ELBW infants were not protected against NEC by oral IgG. The present published evidence does not allow recommendation of oral human IgG administration in preterm infants as a prophylactic measure against NEC.

Effect of prior exposure to noninfected ticks on susceptibility of mice to Lyme disease spirochetes

To determine whether prior exposure to Nearctic Ixodes vector ticks protects native reservoir mice from tick-borne infection by Lyme disease spirochetes, we compared their infectivities for white-footed mice and laboratory mice that had been repeatedly infested by noninfected deer ticks. Nymphal ticks readily engorged on tick-exposed laboratory mice, but their feeding success on white-footed mice progressively declined. Tick-borne spirochetes readily infected previously tick-infested mice. Thus, prior infestation by Nearctic ticks does not protect sympatric reservoir mice or Palearctic laboratory mice from infection by sympatric tick-borne spirochetes.

Rat somatostatin receptor subtype 4 can be made sensitive to agonist-induced internalization by mutation of a single threonine (residue 331)

A sequence motif of 20 amino acid residues within the C-terminal portion of the rat somatostatin receptor subtype 4 (SSTR4) has been shown to prevent rapid agonist-dependent receptor internalization in transfected human embryonic kidney (HEK) cells. Molecular dissection of this motif by biochemical ligand-binding assays revealed that the block was released by mutating a single residue (threonine 331) to an alanine. These data are in line with confocal microscopic analysis of cultured primary neurons microinjected with cDNA constructs encoding either SSTR4 or the mutant T331A. Immunocytochemical analysis showed that the mutant receptor, but not SSTR4, was internalized. However, internalized T331A was not recycled to the cell surface, suggesting that it lacks sequence elements that determine intracellular sorting after endocytosis. Neither wildtype SSTR nor the mutant T331A exhibited functional desensitization when assayed for their ability to inhibit adenylate cyclase. In agreement with this, the wt receptor and its mutant were not phosphorylated in response to agonist treatment. Lack of desensitization of SSTR4 has been electrophysiologically verified by coexpressing the receptor with a G-protein-gated, inwardly rectifying potassium channel in Xenopus oocytes. A strong somatostatin 14 (SST14)-activated inward potassium current was observed that was long-lasting and which decayed only slowly after washout of the agonist. This is in contrast to another somatostatin receptor subtype, SSTR3, which mediates rapidly desensitizing currents. Binding experiments on HEK cells transfected with either SSTR3 or 4 indicated that this difference is not attributable to slow dissociation of the agonist from the receptor, suggesting that SSTR4 mediates long-lasting signalling, a property which may be relevant for clinical therapy.

Failure of Ixodes ticks to inherit Borrelia afzelii infection

To define conditions promoting inherited infection by Lyme disease spirochetes in Ixodes ticks, we variously infected ticks with Borrelia afzelii and examined their progenies by dark-field microscopy, immunofluorescence, PCR, and serial passage. No episode of inherited infection was evident, regardless of instar or gender infected or frequency of exposure. We suggest that these spirochetes rarely, if ever, are inherited by vector ticks.

[Holistic nursing--do nurses take on too much?]

The idea of holism is a central topic of contemporary nursing. This article at first reconstructs the historical background of holistic scientific thinking. For the recent nursing science and practice four divergent holistic concepts are identified: 1. the theory of the unitary human being by Martha Rogers; 2. the holistic therapeutical practice of nurses in the United States; 3. the biopsychosocial model many conceptual models of nursing are based on; 4. the holistic organization of nursing. By analysing the interaction between nurse and patient and by comparing the professional and the domestic organization of care it is argued that holistic nursing is theoretically as well as practically impossible. In order to prevent overtaxing due to holistic claims of nursing theory the limits of nursing practice have to be shown unambiguously.

Elastic intramedullary nailing: a minimally invasive concept in the treatment of unstable forearm fractures in children

The standard treatment in forearm fractures in children is usually conservative. Unstable fractures of the proximal parts of the forearm often show poor results after nonoperative management so that these fractures usually require surgical intervention. We report 30 children (ages, 4-14 years) who were treated by elastic intramedullary nailing. Sixteen patients were treated by intramedullary splinting immediately after their accident; 14 children required intramedullary nailing after failure of conservative treatment and fracture redisplacement. At the time of follow-up 6 months later, functional results were excellent in 24 children, good in five children, and fair in one child. There were no serious complications other than one delayed union. According to these results intramedullary nailing can be recommended for the treatment of unstable fractures of the proximal and middle thirds of the forearm in children.

[Distal tibial fracture--an indication for osteosynthesis with the unreamed intramedullary nail?]

In a prospective study, 50 fractures of the distal fifth of the tibia with additional involvement of the ankle joint in 18 patients were stabilized by unreamed nailing. In all, 90% of all fractures healed uneventfully without further surgical intervention after unreamed nailing, the highest ratio of complications (22%) being seen in all patients with distal fractures of the fibula without additional plating (of the fibula). Tibial fractures close to the ankle joint can be managed by unreamed nailing; distal fractures of the fibula should be additionally stabilized by fibular plating.

Repeatability and comparability of automated keratometry: the Nikon NRK-8000, the Nidek KM-800 and the Bausch and Lomb keratometer

This study assessed the repeatability of the Nikon NRK-8000, the Nidek KM-800 and the Bausch and Lomb keratometer. In addition, the comparability of the Nikon NRK-8000 and the Nidek KM-800 are evaluated relative to the Bausch and Lomb keratometer. Measurements were taken with all three techniques on two separate occasions with a test-retest separation of at least 24 hr. The right eyes of 30 normal subjects were used. Repeatability and comparability statistics and plots were generated using matrix representations of dioptric power. The Nidek KM-800 coefficient of repeatability values were found to be 0.345, 0.187, and 0.321 in the vertical, torsional, and horizontal meridians while the Nikon NRK-8000 values were 0.346, 0.232, and 0.276 respectively.

Diversity of European Lyme disease spirochetes at the southern margin of their range

We determined whether the genospecies diversity of Lyme disease spirochetes in vector ticks questing on a subtropical island is as broad as that in Central Europe. Although spirochetes infected < 1% of the ticks sampled on Madeira Island, these infections included all three genospecies implicated in human disease. Therefore, spirochetal diversity is as great at the southern margin as it is in the center of this pathogen's range.

[Ankle para-articular tibial fracture. Is osteosynthesis with the unreamed intramedullary nail adequate?]

In a prospective study, 53 fractures of the distal fifth of the tibia were stabilized by unreamed nailing. Additional involvement of the ankle joint occurred in 18 patients. 50 patients returned for follow-up. In 30 patients tibia and fibula were fractured at the same (distal) level; in 20 patients the fracture of the fibula was located more proximally. In 12 patients the fractures extended into the tibial pilon. Severe soft tissue damage was seen in 24 fractures (18 open, 6 closed). Ninety percent of all fractures healed uneventfully without further surgical intervention after unreamed nailing. In two patients the unreamed nail had to be exchanged for a reamed tibial nail. Bone grafting and secondary dynamization of the nail by removal of a proximal interlocking bolt were performed in one case each. Thirty-one fractures healed in anatomical position. Valgus or varsus angulation of less than 5 degrees occurred in 18 patients. One fracture healed with rotatory angulation of 15 degrees. The highest rate of complications (22%) was seen in patients with distal fractures of the fibula without additional plating (of the fibula). There was no deep infection. Tibial fractures close to the ankle joint can be managed by unreamed nailing. Distal fractures of the fibula should be stabilized by additional plating. Because of the unreamed technique of implantation this procedure can also be used in grade II or III open fractures.