[Initial experiences with amisulpride, an in Germany novel, atypical neuroleptic drug in treatment of adolescents with psychiatric disorders]

OBJECTIVES

In addition to conventional antipsychotic drugs, during the past decade an increasing number of atypical neuroleptics has been introduced in the treatment of juvenile schizophrenic and schizoaffective disorders. In 1999 Germany legalized the benzamide amisulpride for the treatment of acute and chronic schizophrenic symptoms. Preliminary treatment results are reported here.

METHODS

Ten adolescent cases are presented with regard to the efficacy, side effects and dosage of amisulpride.

RESULTS

Preliminary results on the use of amisulpride are promising. The rate of side effects is tolerable.

CONCLUSIONS

Amisulprise seems to constitute a useful alternative in the treatment of juvenile schizophrenia for those who suffer from intolerable side effects of classical or atypical neuroleptics. Controlled studies are warranted to further clarify its efficacy and safety in the treatment of adolescents.

Erste Erfahrungen mit Amisulprid, einem in Deutschland neuen, atypischen Neuroleptikum in der Behandlung von Jugendlichen mit psychischen Erkrankungen

Zusammenfassung: Fragestellung: Neben den klassischen Neuroleptika finden bei Jugendlichen zunehmend atypische Neuroleptika zur Behandlung schizophrener und schizoaffektiver Psychosen Verwendung. Seit Beginn des Jahres 1999 ist in Deutschland in der Behandlung akuter schizophrener Psychosen ein neues, offensichtlich wirkungsvolles Neuroleptikum aus der Gruppe der Benzamide verfügbar: Amisulprid. Erste Erfahrungen mit der Anwendung von Amisulprid werden berichtet. Methode: Zehn gut dokumentierte Behandlungsverläufe bei Jugendlichen unter Behandlung mit Amisulprid werden hinsichtlich Effektivität, unerwünschter Wirkungen und Dosierung berichtet. Ergebnisse: Erste Erfahrungen im Einsatz von Amisulprid sind insbesondere wegen der erheblich günstigeren Nebenwirkungsprofile bei überzeugender antipsychotischer Wirksamkeit vielversprechend. Schlussfolgerungen: Amisulprid scheint bei solchen Jugendlichen eine geeignete pharmakotherapeutische Alternative zu sein, die ein erhöhtes Auftreten von Nebenwirkungen unter atypischer neuroleptischer Medikation zeigen. Kontrollierte Studien sind nötig, um die Effektivität und Sicherheit dieser Substanz auch im Jugendalter sicher einschätzen zu können.

Serum cholesterol, suicidal behavior and impulsivity in cocaine-dependent patients

Relationships between serum cholesterol and suicidal behavior have been reported. As suicidal behavior is common in cocaine dependence, we looked for a relationship with serum cholesterol. To do this, we compared 57 cocaine-dependent patients who had attempted suicide with 111 cocaine-dependent patients who had never attempted suicide for their admission total serum cholesterol levels. We found that there were no significant differences between cocaine-dependent patients who had or had not attempted suicide in their total serum cholesterol levels. Also, there were no significant correlations between total serum cholesterol levels and scores on the Barratt Impulsivity Scale. Thus, admission total serum cholesterol does not appear to be clinically useful in the assessment of suicidal behavior in cocaine-dependent patients.

Thromboregulation by endothelial cells: significance for occlusive vascular diseases

-During their 7- to 9-day lifespan in the circulation, platelets perform an ill-defined baseline function that maintains the integrity of the vasculature. In thrombocytopenic states, there is an increase in vascular permeability and fragility, which is presumably due to absence of this platelet function. In sharp contrast, biochemical or physical injury in the coronary, carotid, or peripheral arteries induces platelet activation and platelet recruitment, which can progress to thrombotic vascular occlusion. Because there is 1 death every 33 seconds from vascular occlusion in the United States, this problem has critical public health implications. In this review, we describe the characterization of a novel potential antithrombotic agent with a unique mode of action-biochemical "deletion" of ADP from an activated platelet releasate, which thereby inhibits platelet recruitment and further activation.

Hepatocyte growth factor is predominantly expressed by the carcinoma cells in non-small-cell lung cancer

Hepatocyte growth factor (HGF) exerts multifunctional regulatory roles in the growth, morphogenesis, differentiation, and motility of epithelial cells, and putatively plays important roles in tumor angiogenesis and metastasis. Aside from the full-length protein, 2 naturally occurring truncated HGF isoforms (NK1 and NK2) have been identified. Recent evidence suggests that a high level of HGF in surgically resected non-small-cell lung carcinoma (NSCLC) is a negative prognostic marker for NSCLC patients' survival. The origin of HGF in these tumors remains uncertain. We show here by in situ hybridization and immunohistochemistry that HGF messenger RNA (mRNA) and protein were predominantly expressed by the tumor cells in a high percentage of primary NSCLC. Stromal cell expression of HGF was limited to some lymphocytes and endothelial cells. Normal bronchial and bronchiolar epithelial cells also expressed HGF mRNA and immunoreactive protein. The mRNA transcripts and putative proteins of all 3 known HGF isoforms were detected in both normal lung and lung cancer tissues, but the full-length HGF was predominantly expressed. Our findings indicate that both autocrine and paracrine functions of HGF are likely to contribute to the pathobiology of lung cancer in vivo.

Life-threatening tonsil hyperplasia probably induced by severe bulimia nervosa: a case report

METHOD

A case of life-threatening tonsil hyperplasia probably induced by severe bulimia nervosa is reported. A 14-year-old obese Caucasian girl developed severe dyspnea caused by an enlarged hyperplastic lingual tonsil after referral to a child and adolescent psychiatry unit after a suicide attempt during a family conflict. The enlargement of the lingual tonsil was seen 6 months after the development of severe bulimia nervosa. Surgical extirpation of the hyperplastic tissue was done without complications. Hyperplasia of lymphatic tissue associated with bulimia nervosa has never been described before.

RESULTS AND DISCUSSION

There was no atopic or infectious history in this case. Presumably, excessive vomiting led to extreme tonsillar growth by irritating the lymphocyte tissue. The relationship between bulimia nervosa and tonsil hyperplasia is far from clear. Further clinical observations are necessary.

Improving follow-up after an abnormal pap smear: results from a quasi-experimental intervention study

The success of cervical cancer control programs depends on regular screening with the Pap smear test and prompt and appropriate treatment of early neoplastic lesions. Recognizing the potentially grave consequences of lack of follow-up for abnormal Pap smears, numerous intervention studies have tested the impact of a variety of strategies to increase return for follow-up. The majority of these studies were evaluated under controlled experimental conditions. Despite the encouraging findings of these trials, the next step in the research continuum requires that the effectiveness of these interventions be demonstrated in real world settings before full implementation is initiated. We report the results of an evaluation study assessing the combined effectiveness of three intervention modalities found effective in prior randomized studies: a tracking follow-up protocol, transportation incentives, and financial incentives. This study used a before-after, nonequivalent control group design to assess the impact of a multifaceted intervention that included a computerized tracking protocol with transportation and financial incentives. The study was implemented at two major hospitals, two comprehensive health centers (CHC), and nine public health centers (PHC) under the jurisdiction of the Los Angeles County Department of Health Services. One hospital, one CHC, and the four PHC located in the catchment area of the CHC were selected as experimental sites. The control sites - one hospital, one CHC, and five PHC - provided usual care. All women with an abnormal Pap smear at the intervention and control sites were included in the study. The study consisted of a 1-year period of baseline data collection (September 1989-August 1990), followed by a 2(1/2)-year intervention period (September 1990-February 1993). During the intervention period, the intervention protocol was implemented at the experimental sites, and the control sites provided usual care. Overall, we found that the rates of receipt of follow-up care were consistent with those found in similar studies. In contrast to results obtained in these prior randomized trials, we did not find strong and consistent evidence for intervention effects. Significant findings emerged only at the CHC and hospital levels and only for selected years. Results underscore the importance of testing interventions in real world conditions before large-scale implementation is initiated. In addition, this study highlights the challenge of detecting intervention effects in large-scale studies because of the greater measurement difficulties in field studies as compared with controlled experiments.

Hyperglycemia alone does not inhibit secretin-induced pancreatic bicarbonate secretion

Administration of exogenous insulin (INS) inhibits secretin-stimulated pancreatic bicarbonate (HCO3) output via a dose-dependent, neurally mediated mechanism. To determine whether this effect was due to systemic hyperinsulinemia or to reduced endogenous insulin production, we examined the effect of hyperglycemia on secretin-stimulated pancreatic secretion. Chronic pancreatic fistulae were created in six dogs. After 30 minutes of equilibration, a computer-assisted hyperglycemic clamp protocol was used to maintain glucose (GLU) levels 100 or 150 mg/dL above basal in clamp animals; control animals received volume- and rate-matched infusions of 0.9% saline. One hour after beginning the clamp period, intravenous secretin dose-response (16-125 ng/kg/h) was begun, doubling the dose every half hour. Unstimulated (0-30 minutes) HCO3, GLU, and INS levels did not differ between groups. INS and GLU levels in clamp animals were significantly elevated during clamp (30-90 minutes) and stimulated (90-210 minutes) periods. For the same periods, HCO3 secretion was not significantly changed despite profound hyperinsulinemia. We conclude that systemic hyperinsulinemia alone does not inhibit secretin-stimulated HCO3 output. Since exogenous INS exerts feedback regulation on the pancreas, we propose that suppression of endogenous INS secretion mediates the previously reported inhibitory response.

Diagnosis of symptomatic postmenopausal women by traditional Chinese medicine practitioners

OBJECTIVE

To learn more about the way that practitioners of traditional Chinese medicine (TCM) diagnose women who have menopausal symptoms.

DESIGN

We assembled a cohort of 23 postmenopausal women who had hot flushes and were otherwise healthy. Each woman was examined independently by nine practitioners of TCM on the same day. Examination consisted of medical history and physical examination. Diagnoses were recorded and counted.

RESULTS

The most frequent diagnosis made by the practitioners of TCM was kidney yin deficiency, which was the diagnosis made after 168 of 207 visits (81%); 23 women seen by nine TCM practitioners. Practitioners showed good agreement regarding presence of kidney yin deficiency: in 12 women (52%), this diagnosis was made by eight of nine practitioners; in 16 women (70%), seven of nine practitioners made this diagnosis; and in all 23 women (100%), at least five of nine practitioners made this diagnosis.

CONCLUSIONS

Practitioners of TCM who diagnose postmenopausal women with vasomotor symptoms are likely to make a diagnosis that includes kidney yin deficiency.

Validity of self-reported colorectal cancer screening behavior

End points for trials promoting cancer screening are often based on self-reported screening behavior. This study was designed to evaluate and optimize the reliability of a computer-assisted telephone interview for collecting self-reported colorectal cancer screening behavior. Cases who had received a fecal occult blood test (FOBT), flexible sigmoidoscopy, and/or colonoscopy, and controls who had no record of colorectal screening were identified among 40-75-year-old members of the Denver Kaiser Permanente Health Care Program and were contacted by telephone. Sensitivities and specificities of self-reported screening were calculated by comparison of subjects' recall with Kaiser Permanente records. The questionnaire was revised based upon results of the pilot phase of the study. Using the revised questionnaire, the sensitivity of self-reported screening was 96.2% for the FOBT, 94.9% for flexible sigmoidoscopy, 88.7% for colonoscopy, and 96.2% for either endoscopic screening test. The specificity of self-reported screening was 85.9% for the FOBT, 92.2% for flexible sigmoidoscopy, 96.8% for colonoscopy, and 92.0% for either endoscopic screening test. No marked differences in the accuracy of the self-reports were detected as a function of gender, age, ethnicity, or family history of colorectal cancer of the participants. Self-reports of colon cancer screening behavior can be reliably used as end points for intervention trials when carefully phrased questions are used.

Further evidence for a low body weight in male children and adolescents with Asperger's disorder

The study explores the common clinical impression and previously reported finding by Hebebrand et al. (7) of reduced body weight in male children and adolescents with Asperger's disorder (AD). Body weight and height of 36 consecutively admitted male patients with AD were retrospectively assessed for the calculation of body mass indices (BMI, kg/m2). The BMIs were transformed to percentile ranks and plotted into BMI-centiles representative for the German population. In addition, comorbid psychopathology was assessed to explore a possible relationship between associated psychopathology and body weight. The mean BMI-centile of all patients was 34.7 +/- 31.8 and, thus, differed significantly from the mean centile of an age- and gender-matched psychiatric control group, which was 52.7 +/- 28.3. Thirteen patients had a BMI below the 10th centile and five even below the third. Three of the latter presented with disturbed eating behaviour. Altogether four patients showed disturbed eating behaviour. They had a significantly lower mean BMI-centile than the rest of the group. The BMI-centiles of patients with other additional psychopathology did not differ significantly from the mean percentile of the whole cohort. The results clearly show an increased risk for underweight and disturbed eating behaviour in patients with Asperger's disorder which should be evaluated in further studies.

Preliminary report: laboratory-induced stain removal as assessed by environmental scanning electron microscopy

Environmental scanning electron microscopy (ESEM) was employed to observe stain removal during brushing with Arm & Hammer Dental Care and Crest Regular Toothpaste. ESEM allows serial examinations of the same sample, and does not require a destructive preparative process. Three extracted molars were cleaned, placed into a 96-hour broth culture of Streptococcus mutans, and stain was produced with undiluted chlorhexidine rinse, concentrated coffee and tea for a period of 23 days. After staining, the teeth were examined by ESEM, then brushed using a toothbrushing machine. Imaging was repeated after 5, 10, 15 and 30 seconds of brushing. As seen with ESEM, the Arm & Hammer product had different effects than those from the distilled water control, suggesting something other than that expected from abrasive and mechanical forces alone. There were also differences from the Crest dentifrice removal on this single sample, suggesting a possible difference between the two products. Further studies are needed to confirm and explain these effects.

Testing different formats for communicating colorectal cancer risk

This study assessed the extent to which different formats of informing men and women age 50 and over of the risks of colorectal cancer (CRC) affected their perceptions of their absolute and comparative (self versus other) 10-year and lifetime risks; emotional reactions about getting CRC; and screening intentions. Forty-four men and 78 women received information about the absolute lifetime risk of getting CRC. In addition, participants either did or did not receive information about (1) lifetime risk of getting CRC compared with other cancers, and (2) risk factors for CRC (age and polyps). Participants who received risk factors information were more likely to increase their perceived absolute 10-year and lifetime risks of getting CRC compared with participants who did not receive risk factors information. In addition, participants who received risk factors information were more likely to believe age was related to getting CRC and felt at greater risk for having polyps compared with participants who did not receive this information. None of the experimental conditions affected how worried, anxious, and fearful participants felt about getting CRC, nor did they affect screening intentions. Independent of experimental condition, participants tended to increase their intentions to get screened for CRC in the next year or two. Intention to be screened was more pronounced among participants who had been screened via a fecal occult blood test (FOBT) or sigmoidoscopy (SIG). Implications for the design of interventions involving the communication of CRC risks are discussed.

Calculating the interindividual geometric standard deviation for use in the integrated exposure uptake biokinetic model for lead in children

The integrated exposure uptake biokinetic (IEUBK) model, recommended for use by the U.S. Environmental Protection Agency at residential Superfund sites to predict potential risks to children from lead exposure and to establish lead remediation levels, requires an interindividual geometric standard deviation (GSDi) as an essential input parameter. The GSDi quantifies the variability of blood lead concentrations for children exposed to similar environmental concentrations of lead. Estimates of potential risks are directly related to the GSDi, and therefore the GSDi directly impacts the scope of remediation at Superfund sites. Site-specific GSDi can be calculated for sites where blood lead and environmental lead have been measured. This paper uses data from blood and environmental lead studies conducted at the Bingham Creek and Sandy, Utah, Superfund sites to calculate GSDi using regression modeling, box modeling, and structural equation modeling. GSDis were calculated using various methods for treating values below the analytical method detection and quantitation limits. Treatment of nonquantifiable blood lead concentrations affected the GSDi more than the statistical method used to calculate the GSDi. For any given treatment, the different statistical methods produced similar GSDis. Because of the uncertainties associated with data in the blood lead studies, we recommend that a range of GSDis be used when analyzing site-specific risks associated with exposure to environmental lead instead of a single estimate. Because the different statistical methods produce similar GSDis, we recommend a simple procedure to calculate site-specific GSDi from a scientifically sound blood and environmental lead study.

Integrated exposure uptake biokinetic model for lead in children: empirical comparisons with epidemiologic data

The concept of model validation is evolving in the scientific community. This paper addresses the comparison of observed and predicted estimates as one component of model validation as applied to the integrated exposure uptake biokinetic (IEUBK) model for lead in children. The IEUBK model is an exposure (dose)-response model that uses children's environmental lead exposures to estimate risk of elevated blood lead (typically > 10 micrograms/dl) through estimation of lead body burdens in a mass balance framework. We used residence-specific environmental lead measurements from three epidemiologic datasets as inputs for the IEUBK model to predict blood lead levels, and compared these predictions with blood lead levels of children living at these residences. When the IEUBK modeling focused on children with representative exposure measurements, that is, children who spent the bulk of their time near the locations sampled, there was reasonably close agreement between observed and predicted blood lead distributions in the three studies considered. Geometric mean observed and predicted blood lead levels were within 0.7 microgram/dl, and proportions of study populations expected to be above 10 micrograms/dl were within 4% of those observed.

Proton magnetic resonance spectroscopy in acute, juvenile anorexia nervosa

Anorexia nervosa is usually associated with a shrinkage of the brain that is at least partially reversible with weight gain. The pathogenesis of this brain abnormality is unclear. The purpose of this study was to investigate potential alterations in localized proton magnetic resonance (1H MR) spectra of anorectic patients immediately after an interval of excessive weight loss. Twelve patients and seventeen control subjects were examined. Water suppressed 1H MR spectra were recorded from two voxels placed in the thalamus and in the parieto-occipital white matter. The spectra of ten patients could be evaluated. Comparing patients and control subjects, significantly higher signal intensity ratios of choline containing compounds (Cho) relative to total creatine (Cr) as well as significantly lower ratios of N-acetyl-aspartate (NAA) relative to Cho were found in the white matter region. We hypothesize that these results indicate an abnormal starvation, associated membrane turnover, which predominantly takes place in the white matter. No evidence for neuronal degeneration was found in the thalamus or in the white matter region.

Deaf/hearing cultural identity paradigms: modification of the deaf identity development scale

The Deaf Identity Development Scale (Glickman, 1993) was modified to include hearing individuals and examine how hearing and deaf adults identify themselves. Statistical analysis based on 244 deaf, hard-of-hearing, and hearing respondents revealed a significant interaction between hearing status of self and parents on the hearing, marginal, and immersion scales of the modified version but not on the bicultural scale. Codas are more marginalized, less immersed, and similarly 'hearing' in comparison to deaf persons with deaf parents. Hard-of-hearing respondents with deaf parents endorse more hearing values and fewer deaf values in comparison to deaf counterparts and also appear to be more marginalized. There were no significant differences between deaf and hard-of-hearing individuals with hearing parents. Compared to hearing respondents with hearing parents, deaf counterparts were more marginalized, more 'hearing,' and equally 'deaf.' Strong professional affiliation with the deaf community resulted in scores that differed significantly from those for individuals not as strongly affiliated. We discuss implications for identity development.

Does oligoantigenic diet influence hyperactive/conduct-disordered children--a controlled trial

A crossover 'placebo'-controlled, double-blind design was used to examine the effectiveness of an oligoantigenic diet in 49 children with hyperactive/disruptive behavior disorder. Effects of diet were compared with those yielded by stimulant medication (methylphenidate). The study was conducted in an inpatient unit at the Department of Child and Adolescent Psychiatry, Central Institute of Mental Health, Mannheim. Change in behavior was measured in standardized situations by trained raters, including behavior assessment when testing with CPT and PAT, during a free play situation, and at school. Twelve children (24%) showed significant behavioral improvement in two behavior ratings during diet relative to control diet conditions. Methylphenidate used in 36 children yielded more responders (44%) than diet. The amount of positive changes in behavior in those who received both treatments was about the same. Although only effective in a minority of children, dietary treatment cannot be neglected as a possible access to treating hyperactive/disruptive children and merits further investigation.

[4 1/2 years later: Mannheim risk children of preschool age]

The present investigation was concerned with the impact of prenatal and perinatal complications (biological risks) and of family adversity (psychosocial risks) on developmental status at age 4 1/2. In a prospective study the developmental course of 362 children (including 210 high-risk children) was followed from birth to age 4 1/2 years. A multilevel approach was used to assess all relevant domains of functioning (i.e. motor, cognitive and social-emotional development). The goal was to obtain information about the effects of biological and psychosocial risks alone and together on outcome in the different domains of functioning. The results show that psychosocial risk factors posed the greatest threat to normal development. Children with psychosocial risks were significantly behind those without such risks in all areas of functioning. Biological risks mainly affected motor development, their negative effects on cognitive and social-emotional functioning having been largely compensated for by age 4 1/2. The extent of an adverse outcome was related to both the degree of risk load and the number of risk factors, whereas interactions among risks were of only minor relevance. An adverse outcome is not inevitable, however: Despite the risks most of the at-risk children showed normal development at age 4 1/2.

Development of the 12-item Cross-Cultural Smell Identification Test (CC-SIT)

The development of the 12-item Cross-Cultural Smell Identification Test (CC-SIT), based upon items from the University of Pennsylvania Smell Identification Test (UPSIT), is described. In developing this test, the authors initially selected UPSIT items that are familiar to most persons from North American, European, South American, and Asian cultures. The CC-SIT was then administered to 198 people ranging in age from 5 to 96 years, and the the test scores were compared to analogous items from UPSITs administered to 198 age-, sex-, race-, and smoking-habit-matched control subjects. Since the pattern of test scores did not differ for the two groups, the authors developed normative data for the 12-item test using equivalent UPSIT items sampled from a database containing UPSIT scores for 3760 subjects. Norms are provided for determining the percentile ranks of a given patient's score as a function of age and gender. The CC-SIT provides, for the first time, a self-administered means for reliably assessing olfactory function in less than 5 minutes.

Munchausen syndrome by proxy and factitious illness: symptomatology, parent-child interaction, and psychopathology of the parents

The term Munchausen syndrome by proxy is used to diagnose children presenting symptoms of an organic disorder resulting from manipulations initiated by their caretakers. Even in early infancy it happens that injuries are induced, and that drugs, poisons or medicine are administered in order to provoke and feign clinical symptoms of severe diseases. Exact data on prevalence are not available but it is obvious that Munchausen syndrome by proxy is a rare psychiatric disorder. There is a body of evidence that Munchausen syndrome by proxy is nothing but the extreme of a broader clinical entity for which the term factitious illness has been introduced. In this group children are included whose mothers invent a history of disease in order to produce symptoms without actually damaging their children. It is not well established whether such a distinction is necessary and whether there are differences in long-term outcome. Onset of symptoms is as early as three weeks up to twelve years, and mean age of diagnosis according to a more comprehensive study is 3 1/4 year. The estimated mortality rate of children with Munchausen syndrome by proxy is 9 percent. In three of the four cases of children reported here clinical presentations were dominated by symptoms of central nervous disorders. All mothers showed unsure and inconsistent parental behaviour and inefficient coping. None of them received support from their partners, if present. In interaction the children always wanted to dominate their mothers. The high amount of personality disorders observed in the caretakers might be the reason for the often reported failure of psychotherapeutic interventions.

Benzodiazepine administration induces exogenic psychosis: a case of child abuse

An 11-year-old boy with psychiatric symptoms was brought to the pediatric clinic by his father. The boy exhibited anxiety, sometimes exaggerating to panic reactions, rage, and disorientation. Because of the boy's behavior it was presumed he was having delusions. Careful physical examination revealed evidence of physical abuse. This article alerts readers to the possible combination of physical abuse and purposeful drug administration.