Are antidepressants less effective in the acute treatment of bipolar I compared to unipolar depression?

BACKGROUND

Using our routine documentation system we evaluated the hypothesis that antidepressants may be less effective in the acute treatment of bipolar I depressed patients compared to unipolar depressed patients.

METHOD

Based on the data from 2032 consecutively admitted inpatients with unipolar or bipolar I depression we compared the efficacy of antidepressants in both groups. The outcome was assessed by the Global assessment scale (GAS), the duration of hospitalisation and the Apathic-, Depressive- and Manic Syndrome subscales of the Association for Methodology and Documentation in Psychiatry system.

RESULTS

Cohorts were comparable in treatment regimens and severity of depression at admission. At discharge, there were no statistically significant differences between bipolar I and unipolar depression for the outcome criteria Depressive Syndrome scale, GAS score and days in hospital. Bipolar patients showed a slightly decreased score of the Apathic Syndrome scale at discharge, also reflected by a slightly elevated score of the Manic Syndrome scale.

LIMITATIONS

This study did not check for differences in side effects such as switching or cycling commonly attributed to the use of tricyclic antidepressants in bipolar patients. Naturalistic data were obtained prospectively, analysis, however, was done retrospectively, thus limiting, but not completely excluding a possible selection bias.

CONCLUSION

Evaluating different outcome criteria, our naturalistic data of a large cohort seem to reject the hypothesis that antidepressants may be less effective in the acute treatment of bipolar I compared to unipolar depressed patients.

Deficit states in schizophrenia and their association with the length of illness and gender

The present study investigated the association between the frequency of deficit states (DS) and the length of illness and gender in schizophrenic patients. The following hypotheses were examined: 1) there is an association between the length of schizophrenic illness and the frequency of DS and 2) the frequency of DS in patients with comparable length of illness is higher in males than in females. Patients, included in the study, were consecutively hospitalized and diagnosed according to ICD-9 criteria (ICD-9: 295-295.9). Psychopathological assessment was performed in a standardized manner. Group differences were evaluated by using the t-test or the chi-square statistics. Variables with a possible impact on the occurrence of DS were entered into a backward multiple logistic regression model. 622 patients (total = 3914) were classified as having a DS. Logistic regression analysis revealed that the risk of having a DS was increased with a longer duration of illness (OR =1.68) and was reduced for female gender (OR = 0.56). The findings are in line with the hypothesis that apart from a neurodevelopmental origin, the schizophrenic illness may also have a progressive neurodegenerative component, which clinically emerges as DS.

Sonographic cervical volumetry in higher order multiple gestation

OBJECTIVE

The aim of this study of multifetal pregnancies was the comparison of three-dimensional (3D) volumetry of the cervix, conventional sonographic cervical length measurement and clinical assessment.

METHODS

10 mothers were investigated in an observational study between 5/1999 and 9/2000. A total of 34 consecutive 2D- and 3D-transabdominal ultrasound measurements were performed.

RESULTS

Volumetry of the cervix was possible in all 34 exams. 2D-cervical length assessment could not be obtained in 6% because the presenting fetal part obstructed the sonographic plane. Both methods allowed equal judgement of the configuration of the cervix. A significant correlation was found between mean 2D-cervical length (28.7 mm, 7.7 SD) and mean cervical volume (30.0 cm3, 16.0 SD). Parity, subjective preterm labor or need of tocolytics showed no correlation with any biometrical parameter studied.

CONCLUSION

Volumetry was superior for the assessment of cervical biometry and conformation in women when the transabdominal 2D-plane was obstructed. When cervical length was obtainable by a conventional scan, the technically more complex 3D-imaging did not provide further information.

[Prune belly syndrome and congenital kidney tumors]

BACKGROUND

High end sonography allows the prenatal localization of the kidneys and the corresponding urine drainage system as early as 10-13 weeks of gestation. In mid second trimester, the voiding and filling of the urinary bladder can be demonstrated by ultrasound. Obstructions are the most common abnormalities of the urogenital tract. Though less frequent in incidence, more complex sequences of anomalies such as Prune Belly Syndrome or Megacystis-Microcolon-Intestinal-Hypoperistalsis-Syndrome (MMIHS) can also be detected in early gestational age.

MATERIALS AND METHODS

Pathogenesis, prenatal diagnosis, pre- and postnatal treatment options and prognosis are discussed.

RESULTS AND DISCUSSION

The same risk-adapted procedures aimed to protect the fetal urinary excretory function known in the therapeutic regimen of obstructive uropathy are available as treatment options. These range from non-invasive ultrasound for diagnosis and surveillance to needle procedures or even endoscopic interventions. Another rare entity of renal abnormalities are congenital neoplasm's--megaloblastic nephroma, nephroblastoma and neuroblastoma.

CONCLUSION

Prognosis and obstetrical management are to be determined individually for each patient.

Telemedicine in ultrasound: new solutions

The transport of dynamic ultrasound (US) pictures as video files or streams no longer presents a problem. Despite teleconferencing, this method of transfer provides no active influence on the data sent for the receiving expert. We are evaluating a software-based 3-D US system that provides the new opportunity of an active US re-evaluation of a virtual patient. The 3-D volumes can be reanalyzed, time- and examiner-independent, wherever the device is installed. To test the clinical feasibility of this virtual US investigation, we installed the device in a peripheral hospital and in our US unit. The transfer of the volume (about 10 to 15 MB) could be done with two parallel Integrated Services Digital Network (ISDN) lines with a conduction capacity of 128 KB/s. In this basic assessment, the transmission of US volumes of patients proved to be easy in the acquisition, quick in off-line transmission and reliable in off-line re-evaluation of the data.

[Effect of repetitive prenatal corticosteroid medication on intrauterine growth and growth in early childhood]

OBJECTIVE

The evaluation of the effects of repeated antenatal corticosteriod (CS) medication on birth size and size at the age of 4 years.

METHODS

82 children exposed to CS initially between 26 and 28 weeks of gestation were matched with 82 controls of the same gestational age and sex.

RESULTS

No differences were observed between the CS and control groups with regard to weight, head circumference, and length at birth and at the age of 4 years.

CONCLUSIONS

Our study failed to demonstrate that repetitive antenatal medication with CS in order to induce lung maturation has a negative impact on intrauterine growth and growth in early childhood.

Suicidality in bipolar compared to unipolar depressed inpatients

The aim of the present analyses was to evaluate differences in suicidality (past suicide attempts, suicidal thoughts at time of admission and completed suicides during the hospital stay) between bipolar and unipolar depressed inpatients. Apart from a higher frequency of past suicide attempts in bipolar depressed patients (26.6% in bipolar vs. 17.8% in unipolar patients), findings do not indicate any further differences in suicidality (suicidal thoughts (about 40% in both groups) and completed suicides during the hospital stay (0.8% in both groups)) between bipolar and unipolar patients. Factors with a predictive value for suicidal thoughts at the time of admission were a positive family history for affective disorders, past suicide attempts, and the depressive and paranoid hallucinatory syndrome (all associated with an increased risk). Female gender, an older age at hospitalisation and a longer duration of the illness were found to be associated with a lower probability for having suicidal tendencies at the time of admission. The risk for committing suicide during the hospital stay was increased if the patients had a history of past suicide attempts and suicidal thoughts at the time of admission. A more pronounced depressive syndrome at time of admission was slightly associated with a lower risk of committing suicide.

Analysis of phase-specific gene expression at the single-cell level in the white-opaque switching system of Candida albicans

The opportunistic fungal pathogen Candida albicans can switch spontaneously and reversibly between different cell forms, a capacity that may enhance adaptation to different host niches and evasion of host defense mechanisms. Phenotypic switching has been studied intensively for the white-opaque switching system of strain WO-1. To facilitate the molecular analysis of phenotypic switching, we have constructed homozygous ura3 mutants from strain WO-1 by targeted gene deletion. The two URA3 alleles were sequentially inactivated using the MPA(R)-flipping strategy, which is based on the selection of integrative transformants carrying a mycophenolic acid (MPA) resistance marker that is subsequently deleted again by site-specific, FLP-mediated recombination. To investigate a possible cell type-independent switching in the expression of individual phase-specific genes, two different reporter genes that allowed the analysis of gene expression at the single-cell level were integrated into the genome, using URA3 as a selection marker. Fluorescence microscopic analysis of cells in which a GFP reporter gene was placed under the control of phase-specific promoters demonstrated that the opaque-phase-specific SAP1 gene was detectably expressed only in opaque cells and that the white-phase-specific WH11 gene was detectably expressed only in white cells. When MPA(R) was used as a reporter gene, it conferred an MPA-resistant phenotype on opaque but not white cells in strains expressing it from the SAP1 promoter, which was monitored at the level of single cells by a significantly enlarged size of the corresponding colonies on MPA-containing indicator plates. Similarly, white but not opaque cells became MPA resistant when MPA(R) was placed under the control of the WH11 promoter. The analysis of these reporter strains showed that cell type-independent phase variation in the expression of the SAP1 and WH11 genes did not occur at a detectable frequency. The expression of these phase-specific genes of C. albicans in vitro, therefore, is tightly linked to the cell type.

[Prenatal diagnosis of kidney parenchyma diseases]

BACKGROUND

Aside from congenital anomalies of the urogenital tract, fetal renal tissue itself can be dysplastic. Prenatal ultrasound allows the differential diagnosis of simple cysts, different degrees of renal dysplasia and agenesis of the kidneys.

MATERIALS AND METHODS

This article focuses on the multifactorious complex of parenchymal renal disease. According to the classification of Potter Syndrome and cystic renal dysplasia/Potter Sequences I-IV, pathogenesis, prenatal diagnosis, pre- and postnatal treatment options and prognosis are discussed.

RESULTS AND DISCUSSION

Concomitant absence of amniotic fluid frequently refutes diagnosis until artificial amniotic fluid infusion has been performed. Although intrauterine therapy is rarely possible, the frequent association with other abnormalities and fetal syndromes may be of consequence. The sonographic appearance of parenchymal renal disease is heterogeneous. This inconsistency has lead to different classifications. This study uses the "modified Potter Classification" of parenchymal disease in kidneys (Zerres).

Long-term course of schizophrenic, affective and schizoaffective psychosis: focus on negative symptoms and their impact on global indicators of outcome

OBJECTIVE

The aim of this study was to compare indicators of outcome between different types of psychosis and to verify whether or not negative symptoms (NS) have a special relevance for schizophrenia.

METHOD

This is a follow-up study on functional psychosis according to ICD-9. Patients were assessed standardized at the time of first hospitalization and about 12.5 years later.

RESULTS

Comparison of global outcome parameters and NS revealed that schizophrenia had the poorest outcome of all types of psychosis. NS had the highest impact on global functioning and the severity of illness in schizophrenia. NS assessed at the first hospitalization were associated with the different outcome parameters only in schizophrenia at follow-up.

CONCLUSION

The course of schizophrenia is a more deteriorating one than that of affective or schizoaffective psychosis. The findings point to the special relevance of NS for the outcome and their relative specificity for schizophrenia.

[Fetal obstructive uropathy--diagnosis and possible treatments]

BACKGROUND

Abnormalities of the urinary tract are found in up to 5% of newborns. They account for 25% of all prenatally diagnosed congenital defects and contribute 4% to perinatal mortality. When considering the prognosis of these anomalies, association with other pathological conditions has to be taken into account.

MATERIALS AND METHODS

We discuss the state of the art in detection and management of fetal urinary tract abnormalities as are standard at this tertiary center of fetal medicine.

RESULTS AND DISCUSSION

Posterior urethral valve, megaureter or ureteropelvic junction obstruction represent one end of a wide spectrum of obstructive uropathies, ranging from pathophysiologically minor deviations to severe impairment of renal function. Organ development, physiology of urine production and excretion as well as their potential disorders are presented.

CONCLUSION

Sonographic and invasive diagnostic options in the evaluation of the urogenital tract are discussed. Careful assessment of each individual case and prognosis determine pre- and postnatal treatment.

Gene regulation and host adaptation mechanisms in Candida albicans

The yeast Candida albicans is a harmless member of the normal microflora on the mucosal surfaces of most healthy persons, but it can cause severe opportunistic infections in immunosuppressed patients. To become a successful human commensal and pathogen, C. albicans has evolved host adaptation mechanisms on different levels. The regulated expression of virulence and other genes in response to environmental signals allows an optimal adaptation to new host niches during the course of an infection. In addition, C. albicans is able to switch between different cell types in a reversible and apparently random fashion. Phenotypic switching involves the coordinated regulation of phase-specific genes, and the resulting generation of selected, pre-programmed cell types may represent an additional strategy to adapt to certain host environments. Finally, C. albicans produces genetically altered variants at a high rate. This microevolution ensures survival when the pathogen encounters new adverse conditions, as exemplified by the development of stable drug-resistant variants under the selection pressure caused by antimycotic therapy. Thus, rather than the possession of single dominant virulence factors, it is its remarkable versatility that makes C. albicans the most important fungal pathogen of humans.

Mood-stabilisers reduce the risk of developing antidepressant-induced maniform states in acute treatment of bipolar I depressed patients

BACKGROUND

The aim of this study was to give further support to the available evidence that mood stabilizers can reduce the risk of antidepressant-induced maniform switch phenomena in bipolar I depressed patients.

METHODS

Medical records of 158 patients with bipolar I depression were analysed for the incidence of switch phenomena from depression to maniform states (mania and hypomania). The impact of mood stabilizers on reducing the risk of switching was analyzed using logistic regression analyses.

RESULTS

Maniform switches during inpatient treatment were observed in 39 (25%) patients out of the total of 158 patients. Results indicate that especially patients receiving tricyclic antidepressants are at risk of switching to maniform states. This risk was shown to be significantly less when patients also received a mood stabilising medication (lithium, carbamazepine or valproic acid).

LIMITATIONS

This was a retrospective study with patients receiving naturalistic treatment. A prospective, double-blind design would probably lead to more conclusive findings.

CONCLUSIONS

Treatment with mood stabilizers may be a potent strategy to reduce the risk of antidepressant-induced maniform switches in bipolar I depressed patients.

Prenatal diagnosis of congenital heart disease and neonatal outcome--a six years experience

BACKGROUND

Prenatal diagnosis of congenital heart disease (CHD) is important for proper perinatal and neonatal management, as CHD occurs in approximately eight of 1000 live births. Antenatal detection of cardiac malformations is crucial as altered obstetric and neonatal management may be required and the neonate will benefit from delivery at a tertiary care center.

METHODS

A retrospective comparison between pre- and postnatal diagnoses was accomplished. All fetal echocardiographic scans performed and CHD's detected postnatally between January 1994 and December 1999 by the department of obstetrics and gynecology and pediatric cardiology - Grosshadern, Munich University Hospital were reviewed.

RESULTS

The incidence of CHD was 1.5% (116/ 7913). CHD was suspected by prenatal ultrasound in 57 fetuses. Postnatally, 116 congenital cardiac anomalies were diagnosed. Overall, the intrauterine detection rate was 38% (44/116). 72% (84) of the diagnosed anomalies were Septal Defects, 16% (19) disorders of the Atrioventricular Valves and 11% (13) Anomalies of the Great Vessels. In 10% (11) of fetuses chromosomal abnormalities were found. 8% (9) newborns suffered from congenital syndromes. In 55% (64) children were delivered preterm (<37 weeks of gestation). 5% (6) of the neonates required surgery within their first year of life. 28% (33) of children with CHD did not survive the first year of life.

CONCLUSION

As the prenatal diagnosis is important for pre-, peri- and postnatal management, diagnostic accuracy is essential. Nevertheless, the accuracy of postnatal pediatric echo still exceeds that of the prenatal scan.

[Quality criteria and risks for malpractice in ultrasound prenatal diagnosis. What is allowed--what may be missed?]

BACKGROUND

As with all new diagnostic options in medicine, great hope was placed in the introduction of high-resolution prenatal sonography. Progress tends to carry with it a demanding attitude of higher expectations. Patients and doctors alike may initially overestimate the possibilities of medical advances.

QUESTIONS

The question at hand is whether objective criteria can validate a positive influence of prenatal ultrasound on fetal outcome. How should a sonographic routine screening be structured, and what legal aspects need to be taken into consideration?

MATERIAL AND METHODS

This is an attempt to survey the heterogeneous pool of internationally published data with regard to these critical questions. Only a rationally devised analysis of possibilities and restrictions of routine prenatal sonography can answer the question of "what--if anything--may be missed?"

RESULTS AND CONCLUSIONS

Screening ultrasound matches sonography on indication. Despite controversial data a discussion of different studies leads to a positive conclusion on the benefits of ultrasound monitoring in pregnant women. Ultrasound-screening has an explicit effect on medical and economic issues as well as on litigation.

Single point mutations in either gene encoding the subunits of the heterooctameric yeast phosphofructokinase abolish allosteric inhibition by ATP

Yeast phosphofructokinase is a heterooctameric enzyme subject to a complex allosteric regulation. A mutation in the PFK1 gene, encoding the larger -subunits, rendering the enzyme insensitive to allosteric inhibition by ATP was found to be caused by an exchange of proline 728 for a leucine residue. By in vitro mutagenesis, we introduced this mutation in either PFK1 or PFK2 and found that the exchange in either subunit drastically reduced the sensitivity of the holoenzyme to ATP inhibition. This was accompanied by a lack of allosteric activation by AMP, fructose 2,6-bisphosphate, or ammonium and an increased resistance to heat inactivation. Yeast cells carrying either one mutation or both in conjunction did not display a strong phenotype when grown on fermentable carbon sources and did not show any significant changes in intermediary metabolites. Growth on non-fermentable carbon sources was clearly impaired. The strain carrying both mutant alleles was more sensitive to Congo Red than the wild-type strain or the single mutants indicating differences in cell wall composition. In addition, we found single pfk null mutants to be less viable than wild type at different storage temperatures and a pfk2 null mutant to be temperature-sensitive for growth at 37 degrees C. The latter mutant was shown to be respiration-dependent for growth on glucose.

[What do medical students in the 6th clinical semester know about psychiatric emergencies?]

OBJECTIVE

The aim of the present study was to evaluate the knowledge of medical students in psychiatric emergencies.

METHODS

Medical students were questioned concerning their knowledge about psychiatric emergencies, shortly before finishing their theoretical part of the medical training program.

RESULTS

Findings indicated that medical students have significant deficits in psychiatric knowledge. Nevertheless, most students reported to be interested in psychiatry and to acknowledge the importance of psychiatric knowledge for general practioners.

CONCLUSIONS

The reasons for the reported deficits cannot be sufficiently explained by a lack of interest in psychiatry or a negation of the importance of knowledge in psychiatry for general practioners and may hint to conceptual problems in the organisation of the medical training programs.

Impact of duration of symptoms prior to first hospitalization on acute outcome in 998 schizophrenic patients

The hypothesis that a longer duration of symptoms prior to first hospitalization is associated with a poorer treatment response was prospectively investigated in 998 first-hospitalized schizophrenic patients. Results indicate that most indicators of outcome were worse when the duration of symptoms was long. This was also true when age, gender, as well as the acuteness of illness were controlled for in the analyses.

Deficit syndromes in schizophrenic patients 15 years after their first hospitalisation: preliminary results of a follow-up study

This study is a follow-up study on broadly defined schizophrenic disorders. Patients were assessed standardized at the time of their first hospitalization (admission and discharge) and reassessed in an standardized manner 15 years later. The aim of the analyses presented here was to evaluate the frequency of patients with markedly expressed negative symptoms in terms of deficit syndrome and to analyze which of the variables assessed at the time of first hospitalization were predictive concerning deficit syndromes at follow-up. Results indicate that nearly one third of patients have developed a deficit syndrome 15 years after their first hospitalization. These patients are characterized by severe impairments in important areas of life, such as partnership or employment. Furthermore, apart from more pronounced negative symptoms, these patients also have more paranoid-hallucinatory symptoms than schizophrenic patients without deficit syndromes. Predictive signs for non-development of a deficit syndrome 15 years later were good global functioning, female gender, pronounced depressive symptoms and good treatment response concerning negative and paranoid-hallucinatory symptoms at first hospitalization. A longer duration of symptoms prior to first hospitalization, lack of a partnership, pronounced negative symptoms at admission and at discharge were predictive of developing a deficit syndrome. Results are discussed with regard to the literature and to methodological limitations.