Cerebral network deficits in post-acute catatonic schizophrenic patients measured by fMRI

Twelve patients with catatonic schizophrenia and 12 matched healthy controls were examined with functional MRI while performing a motor task. The aim of our study was to identify the intracerebral pathophysiological correlates of motor symptoms in catatonic patients. The motor task included three conditions: a self-initiated (SI), an externally triggered (ET) and a rest condition. Statistical analysis was performed with SPM5. During the self-initiated movements patients showed significantly less activation than healthy controls in the supplementary motor area (SMA), the prefrontal and parietal cortex. Our results suggest a dysfunction of the "medial motor system" in catatonic patients. Self-initiated and externally triggered movements are mediated by different motor loops. The "medial loop" includes the SMA, thalamus and basal ganglia, and is necessary for self-initiated movements. The "lateral loop" includes parts of the cerebellum, lateral premotor cortex, thalamus and parietal association areas. It is involved in the execution of externally triggered movements. Our findings are in agreement with earlier behavioral data, which show deficits in self-initiated movements in catatonic patients but no impairment of externally triggered movements.

Initial experience with the medtronic ADVANTAGE valve prosthesis in the mitral position--clinical outcome and analysis of complications

OBJECTIVE

The Medtronic ADVANTAGE prosthetic heart valve is a bileaflet mechanical heart valve which has two main design modifications. The prosthesis has an enlarged central orifice to improve blood flow characteristics and an asymmetric butterfly pivot recess with expanded outflow component designed to enhance the blood flow washing through the pivot region. This report summarizes the initial experience with 55 patients who underwent isolated mitral valve replacement.

METHODS

We prospectively followed 55 patients undergoing mitral valve replacement with the Medtronic ADVANTAGE prosthesis in a single center study. All patients were operated on via a median sternotomy and a left atrial approach.

RESULTS

The age of the patients at implant ranged from 42 years to 77 years with a mean of 61.8 years. Forty-five percent of the patients were male. Seventy-five percent of the patients were in NYHA functional class III or IV prior to valve replacement. The diameters of the implanted prostheses were as follows: 25 mm in 2 patients, 27 mm in 12 patients, 29 mm in 20 patients, and 31 mm in 21 patients. Coronary artery bypass grafting was performed with valve replacement in 16.4 % of patients and additional tricuspid repair in 10.9 %. After one year, 97.6 % and after two years 100 % of the included patients were in NYHA functional class I or II. All patients had Coumadin (warfarin) therapy postoperatively with a target INR range of 2.5 to 3.5, or 3.0 to 4.0. There were 4 thromboembolic events (7.3 %) in the early period and 2 late events (2.6 %). Episodes of valve thrombosis were not seen during the follow-up, which consisted of 76.5 patient years. The hemodynamic performance was favorable and within clinically acceptable ranges. The incidence of valve-related mortality and morbidity in this preliminary study was extremely low, indicating good clinical results comparable to those reported for other bileaflet valves.

CONCLUSION

The ADVANTAGE valve is a safe and effective option for mitral valve replacement with a very low incidence of valve-related complications.

[Can neurological soft signs (NSS) contribute to the prediction of dangerousness in mentally disordered offenders?]

The prediction of dangerousness in mentally disordered offenders is still as well complex as insufficiently empirically proven. So far more or less valid criteria for predicting recidivism have been determined concerning historical and clinical aspects. Whereas biological, neurological and neuropsychological variables that could be of importance for the development of chronic delinquent behavior have mostly been neglected. This article deals with the relevance of neurological soft signs (NSS) for the prediction of dangerousness in mentally ill offenders as one possible factor in a multidimensional model. 155 patients were examined after a minimum time at risk of 2 years (mean 4 years). The results showed that on the one hand there is no relevant and valid connection between neurological soft signs and recidivism for the general heterogeneous group of forensic patients. On the other hand similar results arose for the subgroup of patients with a personality disorder without intellectual deficits as for the homogeneous group of offenders in prisons. Therefore a significant meaning of NSS for certain subgroups can be presumed.

Subgaleal hematoma in child abuse

The mother brought her 31/2-year-old son to a paediatric clinic as his forehead was swollen and bluish in appearance. She was unable to give any explanation for this lesion. Clinically it was noted that a very visible and also palpable, doughy swelling was present both in the forehead as well as the hard skull areas. Some hours later, a massive bilateral periocular haematoma appeared. Whilst X-rays were unable to provide any diagnostic help, the sonographic examination of the skull carried out on the same day revealed an extensive subgaleal haematoma. This phenomenon is described in radiological literature as "scalping" and is caused by the use of considerable, blunt violence against the head (shear stresses, e.g. by pulling at the hair). The mother's boyfriend later confessed forceful pulling of the hair.

Risk assessment of sexual offenders in German forensic institutions

BACKGROUND

The assessment of recidivism in sexual offenders is an urgent topic for forensic psychiatry in Germany. The call for useful predictive measures is therefore getting louder.

AIMS

The present study analyses which criteria are employed by therapists in forensic hospitals to assess the dangerousness of sexual offenders. Of particular interest is whether the criteria listed in presently known prediction scores as decisive are actually used in decision-making in current forensic psychiatric practice.

METHOD

Data are collected in a prospective prediction study funded by the German Research Association.

RESULTS

The results reveal that therapists employ mainly clinical and less historical criteria, thus indicating substantial differences from currently known prediction scores and results of other studies.

CONCLUSIONS

That therapists base their prediction of dangerousness primarily on clinical variables reveals a substantial error that has to be remedied. Further research on the extent of relevance of clinical variables is needed.

[Preliminary recidivism rates of the Essener prognosis study]

The prediction of dangerousness in mentally disordered offenders -- and here mainly the issue of safety -- is still of primary interest for forensic experts and the public. The effectiveness of treatment and therefore of the whole German forensic system is generally measured by recidivism rates of this clientele. This article presents topical recidivism rates of 255 mentally ill offenders after a minimum time at risk of 2 years (mean 4 years). Data are collected in the Essener prospective multicenter study funded by the German research association which began in 1997 and in which 23 forensic hospitals in Germany took part. Main objective of the study is the determination of valid criteria for predicting recidivism of mentally disordered offenders. Currently the rates for general recidivism are 21.6 % and for severe reoffences 7.5 % which are in comparison to other recent studies relatively low.

INR self-management permits lower anticoagulation levels after mechanical heart valve replacement

BACKGROUND

The Early Self Controlled Anticoagulation Trial (ESCAT I) showed that anticoagulation self-management after mechanical heart valve replacement decreased complication rates by maintaining INR levels closer to the target range than International Normalized Ratio (INR) home doctor management. The therapeutic range for the INR in that study was between 2.5 and 4.5 for all positions of prosthetic valves. ESCAT II should find out whether lowering the target range for INR self-management would further reduce complication rates.

METHODS

ESCAT II is a prospective controlled randomized (valves: St. Jude Medical Standard or Medtronic Hall, treatment: conventional/low-dose) multicenter study with 3,300 patients. We present interim results of 1,818 patients. 908 were categorized as having a low-dose target range, which was INR 1.8 to 2.8 for prostheses in aortic position and 2.5 to 3.5 for prostheses in mitral position or in combined valve replacement. The control group (conventional group) with 910 patients aimed at an INR of 2.5 to 4.5 for all valve positions.

RESULTS

In the conventional group, 74% of INR values measured were within the therapeutic range. In the low-dose group, 72% of the values were within that range. The linearized thromboembolism rate (% per patient year) was 0.21% for both groups. The bleeding complication rate was 0.56% in the low-dose regimen group versus 0.91% in the conventional group.

CONCLUSIONS

Early onset INR self-management under oral anticoagulation after mechanical heart valve replacement enables patients to keep within a lower and smaller INR target range. The reduced anticoagulation level resulted in fewer grade III bleeding complications without increasing thromboembolic event rates.

[INR self-management after mechanical heart valve replacement: ESCAT (Early Self-Controlled Anticoagulation Trial)]

Severe thromboembolic and hemorrhagic complications following mechanical heart valve replacement essentially occur due to intense oral anticoagulation and fluctuating individual INR values around the target range. INR self-management can help to minimize these fluctuations. Beginning this therapeutic control immediately after mechanical heart valve replacement further reduces anticoagulant-induced complications. Included in the study were 1200 patients. The quality of oral anticoagulation also improved through INR self-management. Over an observation period of two years, nearly 80% of INR values recorded by the patients themselves were within the target therapeutic range of 2.5-4.5. This corresponds to a high significance of p < = 0.001 in favor of INR self-management. Only 64.9% of INR values monitored by family practitioners were within the desired range. The results differed slightly in quality between patient groups with different levels of training (comprehensive, secondary modern, grammar with or without university). Of patients trained in INR self-management following mechanical heart valve replacement, 91.7% maintained their competence in this technique throughout the entire follow-up period. Only 8.3% of those trained immediately after surgery were unable to continue with INR self-management.

[The release of forensic patients (63 StGB) and the problem of predicting dangerousness]

This article presents first results of a prospective prediction study with participation of twenty-three forensic institutions from seven states of FRG. Main objective of this study is the determination of valid criteria for predicting recidivism of mentally disordered offenders. This evaluation (n = 188) investigates which patients are presently released from forensic institutions. In comparison to previous studies the releases per annum have decreased significantly. In the last two years there has been an increase in release of schizophrenic patients and a decrease in release of patients with a personality disorder and sexual offenders. In addition it has been analyzed which criteria therapists use to predict dangerousness from a clinical point of view.

Terminal hinge axis--Hobo point--Frankfurt horizontal relations

Aim of this investigation was to determine the spatial relations of the terminal hinge axis of the temporomandibular joints toward Frankfurt horizontal. The sample consisted of 50 examinees. Terminal hinge axis was located, using Lauritzen's technique, on the left side of face for each examinee. Arbitrary point, as proposed by Sumiya Hobo, was measured and point Orbital was defined by palpation. On designated points steel pellets 0.25 mm in diameter were stocked. Lathero--latheral cephalogram was obtained for each examinee. Cephalograms were traced down on a transparent foil and points Orbital, THA--terminal hinge axis, Hobo and Porion--as the uppermost point of the metal ear rod of the cephalostat, were designated. Connecting points Orbital and Porion, Frankfurt horizontal was defined, and shortest distance toward points THA and Hobo, as well as between them were measured. Lines parallel and perpendicular to Frankfurt horizontal were drawn through point THA. In a co-ordinate system defined in such a way, upper left quadrant was first, upper right second, lower right third, and lower left was fourth. Observation was made in which quadrant Hobo point was located. Measured values were statistically evaluated. Results revealed that Hobo point is located in first quadrant in 5 cases, in second in 7, third quadrant in 18, and in fourth in 20 cases. That means that Hobo point is located lower to the THA point in majority of our population. Points THA and Hobo were not identical in any case. Mean values of variables showed that investigated points were inferior to the FH. Measures of variability revealed great variability of both points toward FH, as well as for their mutual distance. It could be pointed out that THA point should be defined kinematically during prosthodontic procedures, and that orientation in articulator's space should not be according to the FH.

Temporary pulsatile ventricular assist devices and biventricular assist devices

BACKGROUND

During the past years several systems for mechanical circulatory support have become available. In this study we describe our experience with short-term and mid-term application of the ABIOMED and Thoratec device.

METHODS

Since 1990 the ABIOMED BVS and since 1992 the Thoratec VAD have been applied to 75 and 103 patients, respectively, with postcardiotomy heart failure, as a bridge-to-transplant procedure, and with different other indications.

RESULTS

In the ABIOMED collective 25 of 50 patients (50%) with postcardiotomy heart failure and 1 of 4 patients with miscellaneous other indications could be discharged from hospital, 7 of 14 bridge-to-transplant patients (50%) underwent transplantation with a posttransplant survival of 86%. In the Thoratec collective 6 of 10 patients (60%) with postcardiotomy heart failure and 4 of 8 patients (50%) with miscellaneous indications could be discharged from hospital, 48 bridge-to-transplant patients (74%) underwent transplantation with a posttransplant survival of 90%.

CONCLUSIONS

The results show the versatility of the Thoratec VAD for short-term and mid-term application in patients with postcardiotomy heart failure and as a bridge-to-transplant procedure. The use of the ABIOMED device is not indicated for bridging patients to transplantation. Although in case of postcardiotomy heart failure, Thoratec is also superior to ABIOMED, the high costs of the Thoratec VAD limits its wide acceptance in this patient cohort.

[Drug-dependent offenders committed for disciplinary action. Results of a cross-sectional survey]

In comparison to the middle of the 80th, the group of patients who are addicted to legal and illegal drugs and are treated in special forensic hospitals, has significantly changed. Polyvalent dependence is the predominant diagnosis. There has been an increase in violence of index delinquency. In the middle of the 80th, most of the patients were committed because of criminal offences against the BtMG (German law to sentence drug abusers). Today, robbery turns out to be the "classical" index delinquency. The problem of defining "false admission" to a forensic hospital has to be considered in a multidimensional way.

Modification of the angle of the lower third of the face

Determination of vertical dimension of occlusion by roentgencephalometric method, with the help of the angle of the lower third of the face, has been described in literature. The aim of this study was to modify the angle of the lower third of the face and correlate its determination with reference planes for orientation of casts in the articulators space, to determine mean value and measures of variability of the modified angle in a random sample, and the possibility to use this angle as a control value for establishing the height of the lower third of the face. On a sample of 131 roentgenograms in L-L projection, with teeth in maximal intercuspation, points: N, IS47, THA, SNA, SNP, Xi and Pg were traced down. By the use of this points the angle of the lower third of the face (angle K) was constructed. The values of the angle were measured and statistically analyzed. Mean value of the angle was 48.5 degrees, with standard deviation of 4.41 and coefficient of variation 9.09%. The investigated angle can serve as a control value for determination of intermaxillary relationships and should not be accepted as an strict norm.

The Ultracor tilting disc heart valve prosthesis: a seven-year study

BACKGROUND AND AIM OF THE STUDY

The Ultracor heart valve is a recent entry in the evolution of the tilting disc valve. This report summarizes the experience with the Ultracor valve from three European centers.

METHODS

Between 1990 and 1996, 446 patients received 499 Ultracor heart valve prostheses in 450 procedures, including 225 (50.0%) aortic, 172 (38.2%) mitral and 49 (10.9%) double valve replacements. An additional four (1.0%) patients had mitral valve replacement (MVR) added to a previous aortic valve replacement (AVR) and were considered double valve replacement (DVR) patients. The total follow up was 751 patient-years (pt-yr) for AVR (mean 3.4), 440 pt-yr for MVR (mean 2.6) and 125 pt-yr for DVR (mean 2.4). Nine patients (one AVR, eight MVR) were lost to follow up, which was 98% complete.

RESULTS

The actuarial survival rate, including operative mortality rate, at five years was 90% for AVR, 77% for MVR and 82% for DVR. The linearized complication rates (%/year) for AVR, MVR and DVR were: 2.1, 4.0 and 4.0 for late mortality; 0.1, 3.0 and 0.8 for thromboembolism; 0, 0.2 and 0 for thrombosis; 2.0, 1.6 and 1.6 for anticoagulant-related hemorrhage (ACH); 0.3, 0.5 and 1.6 for prosthetic valve endocarditis (PVE); and 0.5, 0.9 and 3.2 for reoperation, respectively. The actuarial rates of freedom from complications at five years were: thromboembolism, 99% for AVR and 88% for MVR; thrombosis, 100% for AVR and 99% for MVR; ACH, 91% for AVR and 94% for MVR; PVE, 99% for AVR and 97% for MVR; reoperation, 98% for AVR and 98% for MVR. No structural failure was observed.

CONCLUSIONS

Seven years' experience showed the Ultracor heart valve prosthesis to be comparable with other currently used mechanical heart valves. Continued evaluation of this prosthesis is warranted in order to obtain a more extended clinical follow up.

Estimation of referent cephalometric parameters in dental prosthetics

Estimation of the inclination of the occlusal plane and its spatial orientation during the insertion of plaster casts in the articulators space, and control during the clinical phase of the prosthetic work, is one of the key problems in dental prosthetics. The aim of this investigation was to compare the relations of the basic roentgencephalometric parameters applied and to determine their reliability. Five angular variables were analysed: OP-MdP, OP-PP, OP-CP, OP-FP and OP-SNP, on a sample of 86 radiographs of subjects with almost normal occlusion by applying basic statistical parameters and the correlation's analysis. The results gave mean values of the investigated variables with estimation of their variability and level of mutual correlation, which can be used when determining individual inclination of the occlusal plane. Parameters FP and SNP showed significant stability and reliability which can be successfully applied in prosthodontics.

[Development of forensic psychiatry (section 63 StGB) in North-Rhine-Westphalia. Comparison of the current situation with introduction of the forensic psychiatry regulation (MRVG-NW) 10 years ago]

In a cross-sectional study we analysed the present situation of mentally disordered offenders treated in forensic hospitals of North Rhine-Westphalia under section 63 StGB-in comparison with the first block sampling in 1984. One of the important findings was that there has been an increase in violence in respect of the index delinquency as well as the criminal record. Those patients who were again committed to a forensic hospital showed more violent criminal offences too. The average duration of hospitalisation has been reduced from 6.1 to 4.8 years.

Indications for compensatory extractions in orthodontic space closure in the frontal segments

This follow-up study presents patients who underwent orthodontic space closure in the maxilla after traumatic loss of frontal teeth or aplasia of a lateral incisor. Comparison covers findings obtained from casts and cephalograms in 24 patients with or without compensatory extraction. The findings indicate that acceptable results regarding axial tooth positioning and profile can be obtained without compensatory extraction. Prerequisites are distal occlusion of the first molars by one premolar width and continuous monitoring for regular overbite and uncrowded lower incisors. If orthodontic space closure can be achieved only by compensatory extraction, the indication for this space closure procedure calls for even more critical judgement.

Pathomorphological characteristics of resected mitral valves after unsuccessful valvuloplasty

OBJECTIVE

Percutaneous mitral valvuloplasty has been shown to be an acceptable alternative to surgery as treatment for selected patients with severe mitral stenosis. We examined hemodynamic, echocardiographic, and pathomorphologic findings in a series of 308 patients undergoing balloon valvuloplasty, 41 of whom underwent subsequent surgery, in search of possible predictors of an unsuccessful outcome.

INTERVENTION AND RESULTS

Patients with severe mitral stenosis underwent Inoue single ballon valvuloplasty over a 48-month period and had follow-up for a mean of 14.5+/-16.8 months (range 1 to 64 months). Of the 308 patients, 267 (Group I) were clinically improved and stable throughout follow-up, while subsequent surgery was required in 41 (Group II) after 38.2+/-143.5 days (range 1 to 1212). Significant differences between the groups were observed for NYHA class (2.7+/-0.6 vs 2.9+/-0.6, p<0.05), mitral valve area (1.0+/-0.3 vs 0.9+/-0.2 cm2, p<0.01) and left atrial endsystolic dimension by echo (51.3+/-8.0 vs 55.4+/-10.2 mm, p<0.01). Two of the 41 Group II patients underwent surgery for left to right shunting, 1 for tamponade and 2 were lost to follow-up. The excised mitral valves of the remaining 36 patients all showed calcification and/or fibrosis: 9 homogenous, 5 non-homogenous; 19 were classified as having a funnel-shaped deformity, and 3 did not fit into a discrete category. Among the funnel-shaped valves, 13 had a tear versus 6 where dilation was primarily accomplished by stretching. Only one of 9 valves with homogenous calcification was torn, whereas a tear was noted in 3 of the 5 with non-homogenous calcification.

CONCLUSION

Funnel-shaped valves and those with non-homogenous distribution of calcification and/or fibrosis appear to be least suitable for balloon valvuloplasty.

Mechanical circulatory support: lessons from a single centre

Over recent years, a number of different mechanical circulatory support (MCS) products have been developed to a stage where they are no longer investigational devices. Registry data provide some information, but this is limited by the mix of historical and contemporary data and the voluntary nature of the contributions. As yet, there are no clear guidelines for patient selection, the differential application of generically different devices or for optimal patient management. Ours is a busy centre offering a comprehensive cardiovascular service. This review details our experience since 1987 and 189 patients supported with five different types of device, used in all of the common applications. Our experience has permitted the formulation of some general principles and guidelines. Data published by registries and by individual manufacturers are, as yet, not standardized. We hope that our experience will be of interest to those centres wishing to establish a mechanical assist service.

Seven years of experience with the centrifugal pump in patients with cardiogenic shock

From September 1987 to September 1994 61 patients between 29 and 78 years of age received mechanical circulatory support by means of the Biomedicus centrifugal pump. The patients were divided into three groups by indication: Group I included 15 patients with early postcardiotomy cardiogenic shock and 24 patients with late postcardiotomy cardiogenic shock. Group II 11 patients with therapy-resistant cardiogenic shock following acute myocardial infarction, and Group III 11 patients with cardiogenic shock of other etiologies. Duration of support was 1 to 347 hours. Survival rates were 46.7% and 33.3% in patients with early and late postcardiotomy cardiogenic shock, respectively (Group I), 27.2% in Group II, and 18.1% in Group III. Most frequent complications were bleeding (40%, 58%) and acute renal failure (26.7%, 29.2%) in Group I and multiple organ failure in Groups II and III (64% and 45.5%). Major causes of death were bleeding and multiple organ failure in Group I (37.5%) and multiple organ failure in Groups II and III (87.5% and 50%). Groups II and III (87.5% and 50%).

Mechanical circulatory support: the Bad Oeynhausen experience

From September 1987 to February 1994, we treated 147 patients ranging between 11 and 82 years old with different mechanical circulatory support systems. The applied devices were the Bio-Medicus centrifugal pump in 61 patients, the Abiomed BVS System 5000 in 49 patients, the Thoratec ventricular assist device in 42 patients, and the Novacor left ventricular assist device in 7 patients. On the basis of indication for mechanical circulatory support, the patients were divided into three groups: group 1 consisted of 72 patients with postcardiotomy cardiogenic shock; group 2, 50 patients in whom mechanical support was used as a bridge to cardiac transplantation; and group 3 (miscellaneous), 25 patients in cardiogenic shock resulting from acute myocardial infarction (n = 14), acute fulminant myocarditis (n = 3), primary graft failure (n = 2), right heart failure after heart transplantation (n = 3), and acute rejection (n = 3). Time of support ranged from 1 hour to 97 days (mean duration, 10.8 days). Seventy-five patients (51%) were discharged from the hospital. The best survival rate was achieved in group 2 with 72%, followed by group 1 with 44% and then group 3 with 28%. The most frequent complications in group 1 were bleeding (44%), multiple-organ failure (24%), neurologic disorders (18%), and acute renal failure (15%). In group 2, the major complications were bleeding (34%) and cerebrovascular disorders (22%) and in group 3, multiple-organ failure and sepsis (60%) and bleeding (32%).