[Psychiatric morbidity in the oldest old. Results of the Berlin Aging Study]

An increasing life expectancy leads to a higher number of persons aged 70-84 years and persons aged 85 years and older. Information concerning changes in the spectrum of psychiatric morbidity is rare. The Berlin Aging Study was based on a representative age- and gender-stratified sample (n = 516) of Berlin citizens aged 70-100 years and older. In this inter-disciplinary study, an intensive investigation was carried out by psychologists, sociologists, internists and psychiatrists. This report focuses on subjectively reported complaints (Beschwerdeliste, BL), observed psychopathological symptomatology (Brief Psychiatric Rating Scale, BPRS) and psychiatric diagnoses following the criteria of DSM-III-R (based on the Geriatric Mental State Examination, GMSA). On the self-rating scale (BL) 10% of all persons reported severe subjective complaints, 32% moderate complaints. On the BPRS, 17% showed severe psychopathological symptomatology, 75% at least mild symptoms. Following the criteria of DSM-III-R, 23.5% of all persons had a psychiatric disease, 4.2% a disease of severe intensity. When the DSM-III-R diagnoses "Not Otherwise Specified" (NOS) were included 40.4% of all subjects were diagnosed by the clinical judgement of the psychiatrists to have a psychiatric disease. The most frequent psychiatric diseases were insomnia (18.8%), depression NOS (17.8%) and dementia (13.8%). Dementia showed the well-known age-related increase, whereas no other incidences of psychiatric morbidity were age-related. Persons aged 70-84 years did not differ in the investigated psychiatric variables from persons aged 85 years and older, the only exception being the prevalence of dementia.

Is there a suicidality syndrome independent of specific major psychiatric disorder? Results of a split half multiple regression analysis

Biological findings such as low 5-HIAA levels in cerebrospinal fluid (CSF) in suicidal patients compared to non-suicidal patients independent of the type of psychiatric disorder indicate a broad basis for suicidality. It is therefore important to ask whether a suicidality syndrome can be delineated on a phenomenological level, and whether it is independent of specific major psychiatric disorders which are otherwise considered to be aetiologically different. This paper reports on a study of 2383 schizophrenic and 1920 depressive unselected patients with and without suicidality. They were assessed during the first 24 h after admission to a psychiatric in-patient facility using a comprehensive psychopathological assessment (AMDP system). Using multiple variance analysis and logistic regression analysis based on single symptoms, for both suicidal and non-suicidal patients it was shown that a suicidality syndrome independent of the underlying illness can be delineated. In schizophrenia as well as in major affective disorders it was found that hopelessness, ruminative thinking, social withdrawal and lack of activity are core symptoms of this suicidal syndrome. The finding of a suicidality syndrome, not associated with a specific major affective disorder, indicates the need to identify this syndrome, which should be seen as an independent dimension and diagnosed separately, and not regarded merely as a secondary symptom of major psychiatric disorders, particularly affective disorders.

[Psychotherapy in psychiatry--an assessment of current status. Report on the DGPPN Status Colloquium "Psychotherapy in Psychiatry" 22-24 February 1996 in Heidelberg]

The German psychiatrists have agreed to new training regulations which now include psychotherapy. On this occasion the German Psychiatric Association organized a symposium "psychotherapy within psychiatry". Psychotherapy researchers of all psychiatric departments in German speaking countries were invited. As a result, a cross-sectional picture of current psychotherapy research within psychiatry showed a great variety of methods and ways of thinking about research on psychotherapeutic process, outcome, and applications. Even non behavioural approaches showed a trend towards operationalized and quantifying, but also standardized qualitative research. All participants agreed on the necessity of better and in comparison with psychopharmacological research more fair financing of psychotherapy research.

Adverse events and tolerability of the combination of fluoxetine/lithium compared with fluoxetine

Data from an intensive observational drug utilization study were analyzed to determine whether patients who received the combination of fluoxetine and lithium had more and different adverse events as compared with those receiving fluoxetine alone. In a matched cohort control design, we compared 110 patients per group. Results showed no significant difference in side effects between groups. Also, the incidence of "serotonergic" adverse events showed no significant differences between groups during the 7-week study period. In conclusion, the results show that the combination of fluoxetine/lithium is generally well tolerated in spite of a somewhat increased rate of minor side effects.

[Psychiatric diseases and their treatment in general practice in Germany. Results of a World Health Organization (WHO) study]

As part of an international study initiated by the World Health Organization (WHO) about psychological disorders in primary health care, patients in the Federal Republic of Germany were compared with patients in other European centres. Patients from Germany do not differ from other European patients in respect to sociodemographic variables or psychiatric disorders. The most frequent CIDI-based diagnoses recorded in patients attending general practices are current depressive episodes (8.6%), generalized anxiety disorders (8.5%), neurasthenia (7.5%), and alcohol dependence (6.3%). In 20.9% of the patients at least one psychiatric diagnosis based on ICD-10 was recorded. In Germany significantly lower global ratings of health status are given than in other European centres although there is no difference in diagnostic prevalence rates. The recognition rate, i.e. the agreement between the CIDI-based ICD-10 diagnoses and the recognition as a case by the physician, is 56.2%-60.2%. On the other hand, the CIDI detects 90% of the patients described as psychologically ill by the physicians if subthreshold cases are also counted, or 46.4% if only defined diagnoses are taken into account. There is a significant correlation between severity of the psychiatric disorder and disability in social functioning. In Mainz and in the other European countries the disability rate of patients with a well-defined disorder is between 67.0% and 72.7%, whereas in Berlin this relation is not as clear, because especially in East Berlin there is a higher rate of unemployment in view of the political situation. Drug treatment is prescribed for 16.1% of the patients in primary care for psychiatric disorders. Half the patients recognized by physicians as cases receive medication. In the rest of Europe patients receive significantly more tranquillizers than in Germany, where the use of herbal drugs is more wide spread.

A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities

Eighteen children with ADD/ADHD, some of whom were also LD, ranging in ages from 5 through 15 were randomly assigned to one of two conditions. The experimental condition consisted of 40 45-minute sessions of training in enhancing beta activity and suppressing theta activity, spaced over 6 months. The control condition, waiting list group, received no EEG biofeedback. No other psychological treatment or medication was administered to any subjects. All subjects were measured at pretreatment and at posttreatment on an IQ test and parent behavior rating scales for inattention, hyperactivity, and aggressive/defiant (oppositional) behaviors. At posttreatment the experimental group demonstrated a significant increase (mean of 9 points) on the K-Bit IQ Composite as compared to the control group (p <.05). The experimental group also significantly reduced inattentive behaviors as rated by parents (p < .05). The significant improvements in intellectual functioning and attentive behaviors might be explained as a result of the attentional enhancement affected by EEG biofeedback training. Further research utilizing improved data collection and analysis, more stringent control groups, and larger sample sizes are needed to support and replicate these findings.

Development of instrumentation and protocol to measure the dynamic environment of a modified van

The dynamic environment of a van modified to accommodate a person driving from a wheelchair was measured to determine the effects of position within the van and the type of seat used. The project measured accelerations as a subject sat in three positions within the van and upon two different seats. Three separate van maneuvers at different speeds were used to change the dynamic environment. Van accelerations at the different positions varied significantly. A wheelchair transmitted more accelerations to the subject than the original equipment manufacturers (OEM) seat, making it harder to maintain a stable posture. These results should prove useful to others studying the functional abilities of wheelchair users within a vehicle environment.

Cytokine modulation by glucocorticoids: mechanisms and actions in cellular studies

Glucocorticoids inhibit the expression and action of most cytokines. This is part of the in vivo feed-back system between inflammation-derived cytokines and CNS-adrenal produced corticosteroids with the probable physiological relevance to balance parts of the host defence and anti-inflammatory systems of the body. Glucocorticoids modulate cytokine expression by a combination of genomic mechanisms. The activated glucocorticoid-receptor complex can (i) bind to and inactivate key proinflammatory transcription factors (e.g. AP-1, NF kappa B). This takes place at the promotor responsive elements of these factors, but has also been reported without the presence of DNA; (ii) via glucocorticoid responsive elements (GRE), upregulate the expression of cytokine inhibitory proteins, e.g. I kappa B, which inactivates the transcription factor NF kappa B and thereby the secondary expression of a series of cytokines; (iii) reduce the half-life time and utility of cytokine mRNAs. In studies with triggered human blood mononuclear cells in culture, glucocorticoids strongly diminish the production of the 'initial phase' cytokines IL-1 beta and TNF-alpha and the 'immunomodulatory' cytokines IL-2, IL-3, IL-4, IL-5, IL-10, IL-12 and IFN-gamma, as well as of IL-6, IL-8 and the growth factor GM-CSF. While steroid treatment broadly attenuates cytokine production, it cannot modulate it selectively, e.g. just the TH0, the TH1 or the TH2 pathways. The production of the 'anti-inflammatory' IL-10 is also inhibited. The exceptions of steroid down-regulatory activity on cytokine expression seem to affect 'repair phase' cytokines like TGF-beta and PDGF. These are even reported to be upregulated, which may explain the rather weak steroid dampening action on healing and fibrotic processes. Some growth factors, e.g. G-CSF and M-CSF, are only weakly affected. In addition to diminishing the production of a cytokine, steroids can also often inhibit its subsequent actions. Because cytokines work in cascades, this means that steroid treatment can block expression of the subsequent cytokines. The blocked cytokine activity does not depend on a reduced cytokine receptor expression; in fact available in vitro investigations show that while the cytokine expression is blunted, its receptor is upregulated. The cellular studies presented here may represent the maximum potential of steroids to modulate cytokine expression in human mononuclear cells. It remains to be determined by clinical-experimental studies how effective cytokine modulation can be achieved in situ in inflamed bowel by systemic or by topical steroid therapy. Such studies may also answer whether a blocked cytokine production/action is the key or just a secondary mechanism behind the unique efficacy of steroids in active inflammatory bowel disease.

Haemodynamic and haemoximetric aspects of experimental orthotopic liver transplantation: comparison between two different doses of propofol

OBJECTIVE

Evaluation of haemodynamic and gas exchange modifications using propofolnitrous oxide anaesthesia after ketamine induction during experimental orthotopic liver transplantation (OLT).

DESIGN

Measurements of haemodynamic and haemoximetric effects of two anaesthesiological conditions, differing each other for the different dose of propofol, performed in an experimental model characterized by temporary anhepatism followed by revascularization.

SETTING

Surgical experimental laboratory of the University Hospital of Florence.

ANIMALS

Thirty experimental OLT on female pigs (weight 30 +/- 2 kg) were performed.

MEASUREMENTS AND MAIN RESULTS

The following haemodynamic: HR, MAP, MPAP, PCWP, CI, SI, RVSWI, LVSWI, SVR, PVR, RPP and gas-exchange parameters: PaCO2, etCO2, D(aA)CO2, PaO2/PAO2, VD/VTphys, HB, PaO2, SaO2, DO2, O2ER, VO2, SvO2, VO2/DO2 relationship were evaluated. Anaesthesia was induced by ketamine and maintained by N2O and propofol infusion using 0.28 mg x kg(-1)x min(-1) (Group 1) and 0.19mg x kg(-1) x min(-1) (Group 2). During the anhepatic phase we used cavalportal-jugular by-pass (CPJ). Haemodynamic preoperative data confirmed the absence of any myocardial depressant effect at the lower dose of propofol. During the most critical stages of surgery a progressive decrease of CI associated with low values of PCWP was observed. The decrease of etCO2 during the anhepatic phase is due to the VD/VT increase following CI reduction and CO2 production decrease. VO2 decreased significantly during the anhepatic phase and successively increased during the reperfusion phase whereas CI remained low, during both surgical phases. These results demonstrated that VO2 was largely independent from DO2 because cellular O2ER gradually increased as DO2 remained constantly low, thus indicating a good cellular metabolism reuptake. The decrease of SVO2 is related to the decrease of CI and to the increase of VO2 and O2ER.

CONCLUSION

The VO2/DO2 relationship showed a complete O2 supply-non-dependency suggesting an adequate cellular metabolism maintenance during the anhepatic and postanhepatic phases. According to these results, the authors suggest that propofol, within the two different anaesthesiological protocols at two different doses, surely favoured a good cellular perfusion also under low cardiac output conditions, undoubtedly contributing to the realization of stress-resistant conditions and influencing a good recovery and postoperative outcome.

Research diagnosis of current depressive disorder: a comparison of methods using current symptoms and lifetime history

Data from the WHO international study of Psychological Problems in General Health Care were used to compare two alternative algorithms for diagnosing current major depression using the Composite International Diagnostic Interview: the traditional method based on lifetime diagnosis and an alternative method based on number of current symptoms. Using DSM-IV criteria for current major depression, 6.2% of 5394 primary care patients were diagnosed by both methods, 2.0% by the lifetime-based method only, and 1.9% by the current symptom method only. Measures of severity (current symptoms, lifetime symptoms, disability, and comorbid anxiety) indicated that those diagnosed by only one method were only slightly less ill than those diagnosed by both. While the symptom-based method identifies a slightly more ill group, use of either method alone may exclude many who differ little from those classified as cases.

[Vecuronium for anesthesia in developing countries]

BACKGROUND

Some authors affirm that vecuronium efficacy is modified by anthropometric characteristics of people. However this drug is useful in several clinical conditions, it has very few collateral effects and it is easily stored and carried.

AIM OF THE WORK

To evaluate the difference in efficacy of vecuronium in Brasilian and Italian patients.

PATIENTS AND SETTING

48 patients (21 children) submitted to ophthalmological surgical procedures in San Francisco Hospital of Grajaù (Maranhao, Brazil) and in Eye Clinic of University of Florence.

STATISTIC

Student "t" and chi 2 tests.

MEASURES

Myorelaxation was evaluated by a clinical score of intubation, clinical evaluation of TOF response after induction of anesthesia, recovery time after decurarization.

MAIN RESULTS AND CONCLUSIONS

The two adult people (Brazilian and Italian) had significantly different weight. Children had different age/weight correlation. No significant differences exist in myorelaxation evaluation. Our results don't confirm the vecuronium efficacy differences in anthropometrically different people.

The impact of somatic morbidity on the Hamilton Depression Rating Scale in the very old

The Hamilton Depression Rating Scale (HDRS) is world-wide the most important observer rating scale for depression. Many items of this scale refer to somatic symptoms of depression which cast doubt on the validity of HDRS scores in the presence of somatic comorbidity as, for example, in elderly patients. The present study, therefore, was planned to investigate the validity of the HDRS in cases in which the patient is suffering from a depressive illness together with somatic illnesses. The study population (n = 516) is a representative sample of citizens aged 70 years and older in West Berlin. They were assessed independently by internists and psychiatrists. Each positive item of the HDRS scale was then rated by the internists as to what degree it reflects somatic morbidity. Results show that multimorbidity interferes with the validity of the HDRS. There were 8 items for which more than half of all positive scores as rated by psychiatrists were seen by the internists as being possibly related to somatic disorders. Patients with corrections in the HDRS score showed a somewhat increased rate of medicines and cardiovascular diagnoses. There was less ambiguity for items with greater severity.

[Gelatin for volume replacement in hemodilution: hemodynamic study]

OBJECTIVE

To evaluate whether volume replacement with gelatine infusion with 3.5% urea bridges during normovolemic intentional hemodilution manages to stabilize hemodynamic parameters.

EXPERIMENTAL DESIGN

Randomized prospective study.

SETTING

Operating theatre for general surgery.

PATIENTS

ASA 1 and 2 patients undergoing major abdominal surgery. Criteria of admission: a) age < 70 years old; b) starting hematocrit > 30%; c) absence of coronary diseases or coagulative pathologies.

INTERVENTIONS

Blood lost during surgery was replaced with gelatine and crystalloid in a ratio of 1:1. Hemodynamic monitoring was performed by inserting an Opticath catheter in the pulmonary artery and the resulting data were processed using an Oximetrix computer.

FINDINGS

Oxygen transport (DO2), oxygen consumption (VO2) and heart rate (HR) were measured before the start of the operation and at the peak of hemodilution.

RESULTS

At times T0 = Hct 35 and T1 = Hct 28, studied parameters (DO2, VO2, HR) did not show statistically significant variations.

CONCLUSIONS

On the basis of the hemodynamic parameters studied gelatine was found to be an efficacious volume replacement solution during the course of moderate, intentional hemodilution.

Anaesthesia for urological endoscopic procedures in adult outpatients

The aim of this study was to establish whether propofol in combination with fentanyl or ketamine provides a good quality of anaesthesia and recovery time in urological endoscopic outpatient surgery. Sixty patients (ASA I-II) were assigned randomly to receive either 2.5 micrograms kg-1 fentanyl or 1 mg kg-1 ketamine. In both groups anaesthesia was induced with propofol 1.5 mg kg-1 and maintained with 7 mg kg-1 h-1. Patients breathed nitrous oxide and oxygen 3:2 spontaneously. Cardiovascular parameters were more stable after ketamine. The most important side effect was the presence of apnoea lasting longer than 60 s in 14 patients receiving fentanyl. The time to establish alertness was shorter in the ketamine group, who also had a better (P < 0.05) as well as post-anaesthetic recovery room score.

Effect of allergen provocation on inflammatory cell profile and endothelin-like immunoreactivity in guinea-pig airways

The effect of allergen challenge on the number of leucocytes and the concentration of endothelin 1-like immunoreactivity (ET-LI) in bronchoalveolar lavage fluid (BALF) was investigated in guinea-pigs sensitized to Ascaris suum. The animals were twice exposed to allergen aerosol. All animals responded to the second challenge with bronchoconstriction. Twelve hours later, a significant increase in the number of eosinophilic granulocytes in BALF, compared to unsensitized and unprovoked control animals, was noted. Twenty-four hours after provocation, there was also an elevation of ET-LI concentration and content of neutrophils. During the first day post-challenge, the ET-LI values were moderately correlated to the eosinophil levels. One week after challenge, the ET-LI level and the neutrophil count did not differ from corresponding values in control animals whereas the number of eosinophils remained elevated. Pretreatment with dexamethasone before the second allergen challenge did not consistently affect the parameters studied during the first 24 h. Bronchoconstriction induced by carbachol aerosol affected significantly neither the ET-LI concentration nor the number of inflammatory cells in BALF. It is concluded that the allergen-induced inflammation in the guinea-pig airways causes an elevation in the ET-LI concentration in BALF and that this is moderately correlated to the influx of eosinophils during the first 24 h.

Nasal cytokines in common cold and allergic rhinitis

Coronavirus-induced common cold and allergen-induced rhinitis are characterized by nasal mucosal exudation of bulk blood plasma. The mucosal exudation process involves 'flooding' of the lamina propria with plasma-derived binding proteins and it is possible that subepithelial inflammatory cytokines and mediators may be moved by the exudate to the mucosal surface. In this study, we have analysed cytokine levels in nasal lavage (NAL) fluids from non-allergic subjects inoculated with coronavirus (n = 20) and from subjects with allergic (birch pollen) rhinitis subjected to additional allergen challenge (samples were obtained 35 min post challenge) in the laboratory (n = 10). Ten of the 20 inoculated subjects developed common cold and 10 remained healthy. Interferon-gamma (IFN gamma), interleukin-1 beta (IL-1 beta), granulocyte-macrophage colony-stimulating factor (GM-CSF), IL-4, and IL-6 were analysed in unprocessed NAL fluids using immunoassays. The subjects who developed common cold had increased NAL fluid levels of IFN gamma (P < 0.05) that correlated well with the symptoms (P < 0.001). IFN gamma did not increase in subjects with allergic rhinitis. IL-1 beta levels were similar in NAL fluids obtained from all inoculated subjects. In the subjects with allergic rhinitis NAL fluid levels of both IL-1 beta and GM-CSF were increased (P < 0.05). GM-CSF was not detected in common cold. IL-4 and IL-6 were not detectable in any of the NAL fluids. The present cytokines may not only emanate from superficial mucosal cells. By aiding plasma exudation subepithelial cytokines may potentially also be retrieved on the mucosal surface.(ABSTRACT TRUNCATED AT 250 WORDS)

Filling the bone defect with osteogenic material. An experimental study

In this experimental study with bone defects, we focussed on the one hand on external and internal osteogenic callus formation after filling the defect and on the other on the osteochondrogenic differentiation capacity of 4-day-old fibrous-like callus grafts and 12-day-old woven bone grafts in an osteogenic environment. A standard cortical bone defect of the femur was created in 95 young rats. The defect was filled with a cortical bone graft and 4- and 12-day-old callus grafts. The grafts were transplanted as such or in Nucleopore chambers. Follow-up was done at 1, 2, 3 and 6 weeks. The osteochondrogenic tissue formed was studied histologically and histomorphometrically. The results suggest that the filling of the bone defect had no influence on the primary external and internal osteogenic callus formation at 1 and 2 weeks. At 3 and 6 weeks in the chamber groups the persisting internal bridging woven bone was converted into more compact lamellar bone whereas periosteal callus remained at the edges of the defect. In the other groups at 3 and 6 weeks the normal shape of the cortex was reconstituting. Four-day-old fibrous-like callus formed bone in the Nucleopore chamber, indicating that fibrous-like callus tissue at 4 days contains osteogenic cells. Twelve-day-old callus consisting of woven bone was partially differentiated to cartilage, showing that woven bone contains cells capable of chondrogenic differentiation.

Seasonal variation in the function of blood monocytes obtained from healthy nonsmokers, asymptomatic smokers, and smokers with chronic bronchitis

The present study focused on two questions: What effects do cigarette smoking and chronic bronchitis have on the function of the precursors of alveolar macrophages, the blood monocytes? Can seasonal variations affect the function of these cells? Phagocytic activity (the proportion of yeast-ingesting cells and the mean number of yeast particles per ingesting cell) and metabolism of arachidonic acid [secretion of prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) in zymosan-stimulated cultures] were studied as markers of monocyte function during three seasons: spring (May-June), autumn (November-December), and winter (February). Smokers with chronic bronchitis (SCBs) and asymptomatic smokers (ASs) had a lower proportion (p < 0.05) of ingesting monocytes than healthy nonsmokers (HNSs) during spring, but not during the other two seasons. The secretion of PGE2 was highest during autumn and lowest during spring in the monocytes of all three groups. In autumn, LTB4 secretion was increased in the monocytes of HNSs (p < 0.05) but not in those of ASs and SCBs. LTB4 secretion was similar in all groups during the other two seasons. Cigarette smoking and chronic bronchitis seem to impair the function of monocytes and may thereby affect the systemic host defense activity. Cells collected during autumn were generally more active than those sampled in spring, indicating marked seasonal variation in the function of monocytes from all three groups.

Therapeutic standards in psychopharmacology and medical decision-making

Treatment surveys regularly show deviations of routine treatment from treatment guidelines. An analysis of the scientific basis of classical treatment standards, as derived from controlled treatment trials, shows that they do not take into account many variables with major impact on routine treatment. A better theoretical framework for understanding medical decision-making under complex stimulus conditions is provided by action theory. Studies that test treatment strategies instead of treatments and field observational studies, for both of which examples are given, are necessary adjuncts to controlled clinical trials in the quest for more scientifically based treatment guidelines.

Structure and feasibility of a standardized stepwise drug treatment regimen (SSTR) for depressed inpatients

"Standardized stepwise treatment regimes" (SSTR) are one way to rationally guide treatment in cases where the first treatment intervention did not yield satisfactory results. At the Department of Psychiatry of the Free University of Berlin a SSTR has been implemented into routine drug treatment for depressive disorders. The SSTR consists of eight consecutive treatment steps. If there is no sufficient change in the Bech-Rafaelsen Melancholy Scale (< 25% score reduction) in the course of two weeks, treatment has to progress to the next step. This paper describes the overall feasibility and efficacy of the strategy and the progress of the patients within the SSTR. Of those who enter the "antidepressant monotherapy phase" 52% finish treatment successfully at this stage or during the following "lithium augmentation phase". The results of this treatment-monitoring study also show that during consecutive phases of the SSTR a considerable proportion of patients in a university inpatient setting had their treatment modified according to special attitudes and clinical experiences of physicians and patients. The reasons for deviating from the SSTR obviously were more convincing than the rationale for progressing to the next step. SSTR, therefore are an important tool to give complex treatment courses a rational basis, even in patients where clinical case management requires deviations from the outlined sequence of treatment steps.

Clinical recognition and drug treatment of depression in cases found by standardized assessment

The determination of need of care is an important problem for public health. In an epidemiological perspective the question is whether the right people get the right treatment. The answer depends on a variety of methodological issues such as case-definition, case-identification, sampling, and treatment assessment. Case-definition is done by patients themselves and by experts such as physicians or scientists. This study compares the clinical approach of family physicians with the standardized approach of epidemiologists. In two epidemiological studies, the Berlin Aging Study (BASE) and the WHO Study on Psychological Problems in General Health Care (WHO/PPGHC), diagnosis and treatment of major depression in the field were analyzed. In spite of different methods, both studies showed a high rate of unrecognized major depressions as defined by DSM-III-R criteria. This lack of case-recognition by the primary care physicians corresponds to the fact that less than then percent of these patients were treated with antidepressants and none of them had been seen by a psychiatrist. The question to be discussed is whether these results speak for an underrecognition of cases that are in need of care under clinical conditions or an inflation of the respective numbers by standardized methods.

Interactions between brain mitochondria and cytoskeleton: evidence for specialized outer membrane domains involved in the association of cytoskeleton-associated proteins to mitochondria in situ and in vitro

The surface distribution of several proteins (porin, hexokinase, and two proteins associated with microtubules or actin filaments) on the outer membrane of brain mitochondria was analyzed by immunogold labelling of purified mitochondria in vitro. The results suggest the existence of specialized domains for the distribution of porin in the outer mitochondrial membrane. Similarities between the distribution of porin and the distribution of microtubule-associated proteins bound in vitro to mitochondria suggested that mitochondria and microtubules interact by binding microtubule-associated proteins to porin-containing domains of the outer membrane. This hypothesis was supported by biochemical studies on outer mitochondrial proteins involved in in vitro binding of cytoskeleton elements. In vitro interactions between mitochondria and microtubules or neurofilaments were analyzed by electron microscopy. These studies revealed cross-bridging between the outer membrane of mitochondria and the two cytoskeleton elements. Cross-bridging was influenced by ATP hydrolysis and by several proteins associated with the surface of mitochondria or with microtubules. In addition, unidentified proteins which were recognized by antibodies to all intermediate filaments subunits were associated either with the mitochondrial surface or with microtubules. This data suggest the participation of additional cytoplasmic proteins in the interactions between cytoskeleton elements and mitochondria.

Effects of a corticosteroid, budesonide, on alveolar macrophage and blood monocyte secretion of cytokines: differential sensitivity of GM-CSF, IL-1 beta, and IL-6

Down-regulation of cytokine production in activated human blood monocytes (BMs) and alveolar macrophages (AMs) can be achieved in vitro by treatment with corticosteroids. The inhibition of cytokine secretion by corticosteroids may have important therapeutic consequences in e.g. asthma. However, relatively little is known about possible differences in the sensitivity of different cytokines to corticosteroid treatment. Homologous BMs and AMs were obtained from six healthy volunteers. Secretion of interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6) and granulocyte-macrophage colony-stimulating factor (GM-CSF) in the cultures of lipopolysaccharide (LPS) stimulated adherent BMs and AMs was analysed using specific immunoassays. Sensitivity of the IL-1 beta, IL-6, and GM-CSF secretion to the in vitro treatment with a synthetic corticosteroid, budesonide, was compared. BMs and AMs displayed significant differences in both cytokine secretion and susceptibility to regulation by budesonide. When added to the BM cultures concomitantly with LPS, budesonide suppressed IL-1 beta and IL-6 only partially (to 30% of the control level). In contrast, GM-CSF release in these cultures was almost totally inhibited by budesonide (> or = 10(-8) M). The IC50 for inhibition of the GM-CSF secretion was as low as 2 x 10(-10) M. In the AM cultures, budesonide had very little effect on IL-1 beta and IL-6 secretion (inhibition to 80% and 60% of control levels, respectively), while GM-CSF secretion was suppressed to 20% of control by budesonide concentrations > or = 10(-7) M.(ABSTRACT TRUNCATED AT 250 WORDS)

Antioxidant activity of some diarylselenides in biological systems

The selenoorganic compounds di(4-aminophenyl)selenide (10) and 4-nitro-4'-amino-diphenylselenide (36) were shown to inhibit lipid peroxidation in ADP/Fe2+/ascorbate-treated microsomes and tert-butylhydroperoxide-treated hepatocytes with IC50s of 3 and 10 microM, and 14 and 10 microM, respectively. In the former system, these inhibition constants compare favourably with those of Ebselen and classical antioxidants such as butylated hydroxytoluene (BHT) and butylated hydroxyanisole (BHA). In the cell system, these selenium compounds were equipotent with BHA but more potent than Ebselen and its analogues. The diamino compound (10) was also an effective inhibitor of lipid peroxidation initiated by diquat redox cycling in hepatocytes, again being equipotent with BHA but more potent than Ebselen and its analogues, which actually stimulated lipid peroxidation in this test system. Manipulation of the amino functions of (10) and (36) by alkylation or acylation altered the antioxidant capacity. Optimal activity in this series was achieved by N-ethylation or N-isobutylation of (10). This produced antioxidants having IC50s below 1 microM in the microsome system, 3-13 microM in the tert-butylhydroperoxide system, and being 100% effective in the diquat model at 50 microM. On the other hand, acylation or alkylation of the amino groups with long chain acyl or alkyl groups reduced the efficacy of the structures below that of the parent diamine. As with other antioxidant compounds, several of the chalcogenides were relatively selective inhibitors of monocyte 5'-lipoxygenase-dependent secretion of LTB4 as compared to their effect on cyclooxygenase-dependent secretion of PGE2 (for example compound 42 had IC50s of 0.6 microM and 10 microM, respectively). No correlation was observed between the redox-properties of the chalcogenides and their respective abilities to inhibit these enzymes.

Airway inflammation in smokers with nonobstructive and obstructive chronic bronchitis

To assess the manifestation and location of airway inflammation in smokers with chronic bronchitis (CB) or chronic obstructive pulmonary disease (COPD), we lavaged the airways of 12 smokers with CB and 11 smokers with COPD and coexisting CB (OCB). For comparison, the airways of 5 asymptomatic smokers (AS) and 10 healthy nonsmokers (HNS) were lavaged. In all cases, the first lavage aliquot, labeled "bronchial lavage" (BL), was processed separately from the four subsequent aliquots, which were combined and labeled "bronchoalveolar lavage" (BAL). The composition of BL and BAL fluids indicate an ongoing inflammatory process in the airways of all three groups of smokers. CB patients with obstruction had significantly lower concentrations of inflammatory cells in the BL and BAL fluids compared with subjects with nonobstructed CB. Furthermore, airway obstruction, indicated by a reduced FEV1, was significantly correlated with the concentrations of glutathione (p < 0.001), myeloperoxidase (MPO; p < 0.01), and eosinophil cationic protein (ECP; p < 0.01) in BAL fluids. Taken together, these findings suggest that the manifestations of inflammation present in the airways of smokers with CB are different in those who have developed obstruction compared with those who have not.

Early neuroleptic intervention in schizophrenia: are prodromal symptoms valid predictors of relapse?

All recently completed controlled two-year studies on intermittent, early neuroleptic intervention treatment have failed to compare favourably with studies on maintenance treatment concerning relapse prevention. The reason for this failure is still unclear. Therefore the implicit, but as yet unproven, hypothesis that a relapse can be predicted from prodromal symptoms was tested from the perspective of our German multicentre study. Results demonstrate that this is not the case. Possible reasons for and clinical implications of this negative finding are discussed.

Benzodiazepine substitution in medical practice. Analysis of pharmacoepidemiologic data based on expert interviews

Pharmacoepidemiologic data have shown a consistent reduction in benzodiazepine (BZ) prescriptions over the past decade. The question remains as to whether BZs are simply put aside or whether other medications are used as substitutes. Expert interviews, at which a stratified sample of 114 psychiatrists, internists, and general practitioners were presented with case studies, were conducted to learn about the therapeutic alternatives in the field of benzodiazepine-related indications administered in daily practice. These results were used to analyze trends in pharmacoepidemiologic prescription data for all patients under the general health insurance plan from 1981 to 1988. The experts identified distinct alternatives to BZs in different clinical situations, including neuroleptics, antidepressants, phototherapeutics, and analgesics. When these findings were transferred to pharmacoepidemiologic data, results revealed an increase in the prescription of alternative medications that apparently compensated for reduced BZ use. Overall there was no change (or, rather, no increase) in the total of psychotropic prescriptions during the period of reduced BZ prescriptions. Our findings indicate that reduction in benzodiazepines prescription is associated with substitution by various other psychotropic drugs. This has positive as well as negative consequences, and there must be discussed in detail before sound recommendations can be given as to which type of drug. BZs included, is the best choice in which type of illness.

Drug monitoring study (phase IV) of xantinolnicotinate (Complamin) in general practice

For 30 years, xantinolnicotinate has been on the market for the treatment of impaired brain function, i.e., organic brain syndromes of various etiologies. Controlled double-blind phase-III clinical trials have shown that xantinol-nicotinate is an effective drug in the treatment of dementia. Nevertheless, it is also important to assess xantinolnicotinate under routine treatment conditions in order to learn what type of patient is preferably treated, which ADRs can be observed how often, and whether the efficacy claimed by phase III studies can still be seen under routine treatment conditions. Theoretically, the more complex treatment situation in routine practice could lead to major changes in the selection of patients, the type and frequency of ADRs, or efficacy. The treatment of 10,134 patients was monitored in a treatment observation study. Results show that target illnesses are not cases of 'pure dementia', but more complex cases, in which multimorbidity plays an important role, so that the older term 'cerebrovascular insufficiency' seems more appropriate to describe this group of patients. Another interesting group is made up of younger patients suffering from a variety of psycho-organic syndromes. The assessment of therapeutic efficacy, e.g., with the SCAG, shows highly significant improvements during treatment, which are well comparable to those reported in controlled studies. The success of treatment was most expressed in the target symptoms "dizziness", "fatigue", "disturbance of concentration", "affective disorders", and "disturbance of vigilance and vitality". In 87% of these cases, no adverse drug reactions were reported.(ABSTRACT TRUNCATED AT 250 WORDS)

Therapist individuality in the diagnosis and treatment of depression

The influence of physician variables on the diagnosis and treatment of depression was analysed by presenting a trained pseudo-patient to four physicians each with different professional backgrounds. Although all physicians had earlier given their informed consent to the study design, they thought that they were treating a real patient during regular practice hours. All physicians assessed the acute psychopathology almost completely except for suicidal thoughts. Despite similar information about the case, four different diagnoses/pathogenetic concepts and four different treatments were chosen. Medical decision processes and their results can be related to the professional background and personal attitudes of physicians.

Aspirin effect on early and late changes in acute lung injury in sheep

OBJECTIVE

There have been several studies that have already explored the potential beneficial role of cyclo-oxygenase (CO) inhibitors on oleic acid (OA)-induced lung injury in different species. These studies report no significant effect of CO inhibition, though thromboxane B2 (TxB2) was effectively blocked. However, recent studies indicate that pre-treatment with aspirin (ASA) preserve gas exchange in OA lung injury in dogs. Aim of our study has been to evaluate the potential beneficial effects of the pre-treatment with low doses of ASA on gas exchange, hemodynamics, respiratory mechanics, prostanoids and lung histology in OA-induced lung injury in sheep.

DESIGN

0.09 ml/kg of OA was administered into the right atrium of 14 anaesthetized sheep. Six received a bolus of ASA (10 mg/kg i.v.) 30 min before OA, the others saline as placebo.

MEASUREMENTS AND RESULTS

Pulmonary and tissue gas exchange, pulmonary and systematic hemodynamics, respiratory system mechanics, TxB2 and 6-keto-PGF1 alpha, leukocytes and platelets concentrations were measured throughout the subsequent 3 h and lung histology was effected at end-experiment. The principal findings of our study are: 1) ASA reduces OA-induced early pulmonary vasoconstriction and bronchoconstriction, parallelled by a suppression of TxB2 generation; 2) the late increase in pulmonary artery pressure and airway resistance due to OA is not inhibited by ASA; 3) the early disturbance in pulmonary gas exchange is reduced by ASA, whereas the late severe deterioration is exaggerated by ASA; 4) the stability of tissue exchange ratio (R) at approximately 1 in ASA-group compared to its fall to approximately 0.7 in controls.

CONCLUSION

Our findings suggest that ASA: 1) is only effective to treat the very transient TxB2-induced pulmonary vasoconstriction resulting in hydrostatic edema, and it is ineffective, even accentuates, the subsequent major pulmonary endothelial cell injury leading to alveolar flooding that is unrelated to TxB2; 2) has a transient protective effect on the TxB2-induced early bronchospasm; 3) has a biphasic behaviour on gas exchange, with a benefit which lasts only one hour and then results in a worse gas exchange; 4) has an immediate, stabilizing, persisting effect on R, contrasting with its transient effect on pulmonary hemodynamics and PaO2.

Benzodiazepines in medical teaching. A survey of university departments of pharmacology, psychiatry, and internal medicine in Germany

Benzodiazepines are one of the most frequently prescribed classes of medications and by far the biggest class of psychotropic drugs. For years they have been under critical discussion both professionally and in public. The questions arise as to what view is held by university teachers on this topic and how much attention is given to benzodiazepines and benzodiazepine-related problems. Have there been changes in medical teaching in recent years? All the West German departments of psychiatry, internal medicine, and pharmacology were asked by means of a mailed questionnaire to report on their teaching practice. 84.8% of the questionnaires were returned. Results show that mainly psychiatrists and pharmacologists place special emphasis on benzodiazepines in medical teaching. Additionally, in recent years they have devoted more time to this drug class and to related risks in particular. In particular, psychiatrists deal more with benzodiazepines in postgraduate training and the further training of physicians as well as in their scientific research. When the responses of university teachers in psychiatry, internal medicine and pharmacology are summed up, they show that chiefly psychiatrists have responded in their teaching to the current discussion. This contrasts particularly with internists. This has to be discussed in the light of the fact that, in terms of quantity, minor tranquilizers are predominantly prescribed by nonpsychiatrists.

The effects of beta 2-adrenoceptor agonists and a corticosteroid, budesonide, on the secretion of inflammatory mediators from monocytes

1. The in vitro effects of the beta 2-adrenoceptor agonists (1 x 10(-9)-10(-5) M), terbutaline, salmeterol, and formoterol, on the release of inflammatory mediators, i.e. the eicosanoids leukotriene B4 (LTB4) and prostaglandin E2 (PGE2) and the cytokine interleukin-1 beta (IL-1 beta), were assessed in cultures of human blood monocytes. For comparison, the effects of a 5-lipoxygenase inhibitor, BW A4C (1 x 10(-9)-10(-5) M), and a corticosteroid, budesonide (1 x 10(-10)-10(-5) M) were also examined. Sotalol was used to investigate whether the actions of beta 2-agonists were mediated through beta-adrenoceptors. 2. Terbutaline, like budesonide, had no significant effect on LTB4 release, whereas BW A4C (IC50 = 2 x 10(-8) M) was a potent inhibitor. All concentrations of formoterol approximately halved the LTB4 secretion, whereas high concentrations (1 x 10(-7)-10(-5) M) only, of salmeterol, inhibited release. Only salmeterol, at high concentrations (greater than 1 x 10(-6) M), lowered the secretion of PGE2 in monocyte cultures. Formoterol and salmeterol reduced the secretion of IL-1 beta only at the highest dose (1 x 10(-5) M). In contrast, budesonide (greater than or equal to 1 x 10(-9) M) was a potent suppressant of this secretion. 3. Treatment of monocyte cultures with sotalol (1 x 10(-5) M) did not significantly antagonize the inhibitory effects of salmeterol and formoterol. These results suggest that the inhibitory action of these beta 2-agonists on the release of eicosanoids or IL-1 beta, is not mediated via beta 2-adrenoceptors.4. This study does not support a therapeutic importance of the anti-release effects of beta2-agonists since high concentrations were generally required. Furthermore, the anti-secretory action of beta2-agonists was distinct from that of corticosteroids.

Effects of endothelin and relaxin on rat uterine segment contractility

In order to determine the effects of endothelin (ET) and relaxin on uterine contractility, immature female rats were treated with estrogen (E, 1 microgram s.c., Days 1-3) or estrogen and progesterone (2 mg s.c. [E + P], Days 2 and 3), and killed; the uterine horns were removed and suspended in muscle baths. Initially, we determined the contractile response to varying doses of ET and how this response was altered by pretreatment with progesterone. Uterine strips from animals treated with E + P (n = 10) were less sensitive to the stimulatory effects of ET than were strips from E-treated animals (n = 10). This difference was significant at ET doses above 2.5 nM. After completion of the dose-response studies, contractile patterns in response to ET and relaxin were then studied in animals treated with E (n = 10) or E + P (n = 9). ET (5 nM) significantly increased uterine contractility, mostly through an effect on the frequency of contractions (p less than 0.01). Relaxin (25 ng/ml) decreased contractility, affecting all contractile parameters measured (p less than 0.01). ET stimulated contractility in uterine horn segments previously inhibited by relaxin (p less than 0.01), and relaxin reduced the increased contractility produced by earlier exposure to ET (p less than 0.01). These data indicate that ET and relaxin can interact reversibly to control contractility in uterine horn segments in vitro, and that progesterone pretreatment can diminish the contractile response to the stimulatory effects of ET.

Depressive syndromes in schizophrenic patients under neuroleptic therapy. ANI Study Group Berlin, Düsseldorf, Göttingen, Munich, Federal Republic of Germany

Schizophrenic outpatients (= 364) were assigned at random to three different treatment strategies: (1) continuous medication with neuroleptic drugs, (2) intermittent medication with crisis intervention and (3) intermittent medication with early intervention. Depressive syndromes were rated according to three different scales for depressive syndromes (Brief Psychiatric Rating Scale anxious depression factor, Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie/depression, and the self-rating Paranoid Depression Scale) after 1 and 2 years of treatment. No differences in depression scores were found between the three treatment strategies. Comparisons between patients treated with neuroleptic drugs at the time and patients without neuroleptics revealed significantly higher depression scores in the neuroleptics group in most comparisons. No differences were found between patients treated with low versus high potency neuroleptics and between oral versus depot neuroleptics. However, depression correlated with extrapyramidal symptoms.

Recoveries of phosphatidylcholine and alveolar macrophages in lung lavage from healthy light smokers

Twenty-one healthy volunteers, 11 light smokers and 10 non-smokers, were studied by broncho-alveolar lavage. The levels of the phosphatidylcholine (PC) in broncho-alveolar lavage were measured and used as an index of surfactant. The PC levels in broncho-alveolar lavage obtained from the smokers were significantly lower than in lavage fluid from the non-smokers. There was an inverse correlation between PC levels and cumulated tobacco smoke exposure, as estimated by the number of pack-years, and to current smoking habits as estimated by the number of cigarettes smoked per day. The number of alveolar macrophages was significantly higher in broncho-alveolar lavage obtained from smokers, and there was a significant inverse correlation between PC levels and numbers of alveolar macrophages in the lavage fluids. The potential role of alveolar macrophages in the elimination of surfactant lipids is discussed.

Granulocytes and their secretory products, myeloperoxidase and eosinophil cationic protein, in bronchoalveolar lavage fluids from two lung lobes in normal subjects

The interlobar variability of lavage neutrophils and eosinophils was studied in twelve healthy subjects. In addition, the interlobar variation of the neutrophil cell marker myeloperoxidase (MPO) and the eosinophil cell marker eosinophil cationic protein (ECP) was assessed. Bronchial washes (BW), as defined by the first aspirated lavage aliquot, and bronchoalveolar lavage (BAL) fluids were compared. One subsegment of the right middle lobe and one subsegment of the right lower lobe were lavaged in the same session. Interlobar consistency of neutrophil and eosinophil cell recoveries was observed but, in contrast, the levels of MPO or ECP did not correlate in lavage fluids aspirated from the two lobes. These results suggest that BAL cell content from a single lobe of the lung in healthy subjects does reflect the cell populations throughout the airways, while the levels of soluble proteins may differ between the lobes. Such a variation questions the correlation between cells and their secretory products or the correlation between levels of solutes in lavage fluid and in the underlying tissue. Further methodological studies appear warranted to elucidate whether cell and solute recoveries accurately reflect the underlying pathology.

Granulocytes and their secretory products, myeloperoxidase and eosinophil cationic protein, in bronchoalveolar lavage fluids from two lung lobes in normal subjects

The interlobar variability of lavage neutrophils and eosinophils was studied in twelve healthy subjects. In addition, the interlobar variation of the neutrophil cell marker myeloperoxidase (MPO) and the eosinophil cell marker eosinophil cationic protein (ECP) was assessed. Bronchial washes (BW), as defined by the first aspirated lavage aliquot, and bronchoalveolar lavage (BAL) fluids were compared. One subsegment of the right middle lobe and one subsegment of the right lower lobe were lavaged in the same session. Interlobar consistency of neutrophil and eosinophil cell recoveries was observed but, in contrast, the levels of MPO or ECP did not correlate in lavage fluids aspirated from the two lobes. These results suggest that BAL cell content from a single lobe of the lung in healthy subjects does reflect the cell populations throughout the airways, while the levels of soluble proteins may differ between the lobes. Such a variation questions the correlation between cells and their secretory products or the correlation between levels of solutes in lavage fluid and in the underlying tissue. Further methodological studies appear warranted to elucidate whether cell and solute recoveries accurately reflect the underlying pathology.