Updating the Read Codes: user-interactive maintenance of a dynamic clinical vocabulary

The Read Codes are a hierarchically-arranged controlled clinical vocabulary introduced in the early 1980s and now consisting of three maintained versions of differing complexity. The code sets are dynamic, and are updated quarterly in response to requests from users including clinicians in both primary and secondary care, software suppliers, and advice from a network of specialist healthcare professionals. The codes' continual evolution of content, both across and within versions, highlights tensions between different users and uses of coded clinical data. Internal processes, external interactions and new structural features implemented by the NHS Centre for Coding and Classification (NHSCCC) for user interactive maintenance of the Read Codes are described, and over 2000 items of user feedback episodes received over a 15-month period are analysed.

The HSM sentence test as a tool for evaluating the speech understanding in noise of cochlear implant users

The German HSM Sentence Test, available on compact disc (CD), consists of 30 lists of 20 everyday sentences. It was developed in the desire to have a sufficient number of test sentences for the repeated evaluation of speech understanding of CI users. A noise with speech-shaped spectrum on the CD allows the evaluation of speech understanding in noise. With the HSM Sentence Test we evaluated the speech understanding of participants of the Combi-40 European Multicentric Study. Results are shown for sentences presented without noise and with signal-to-noise ratios of 15, 10, 5 and 0 dB.

The growth of non-pyramidal neurons in the primary motor cortex of man: a Golgi study

In Golgi-Cox-impregnated motor cortex (regio precentralis) of six children (36 weeks of gestation to 13 month after birth) four types of interneurons of laminae II-VI have been investigated qualitatively and quantitatively and finally, compared with interneurons of a child (3 month of age) with Down's Syndrome. All cell measurements have been made by using a computerized digital morphometric system. In order to study the developmental stage of interneurons in our cases we statistically compared analogue neuron types in the brains. As parameters for characterizing non-pyramidal neurons served the pattern of dendritic branching, dendritic length for all dendritic orders within single dendritic fields, and of the whole neuron. The quantitative morphological study of dendritic arborizations revealed that bitufted and large multipolar interneurons had significantly more branching material in the postnatal brains than their prenatal counterparts. These differences were due to the increase of both length and number of branches during perinatal period. Such constant increment in dendritic span and branching provides larger receptive areas and that should improve the development of connections in functional intracortical columns. The quantitative parameter area of dendritic fields and number of branching points of the brain with Down's syndrome revealed in comparison with normal brain of the same age differences such as lower dendritic areas and a higher amount of branching points.

Low body weight in male children and adolescents with schizoid personality disorder or Asperger's disorder

This study explored the hypothesis that body weight is reduced in male children and adolescents with schizoid personality disorder or Asperger's disorder. The body weights of 33 consecutively admitted male subjects with one of these disorders were retrospectively assessed with percentiles for the body mass index (BMI). The mean percentile (+/- SD) for the BMI was 31.6 +/- 27.6 and differed significantly from the expected value of 50 (P<0.001). Ten subjects had a BMI of < or = 10th age percentile. Post hoc comparisons revealed that BMI percentiles were (a) reduced to a similar extent in patients with schizoid personality disorder and Asperger's disorder and (b) reduced to a greater extent in patients with abnormal eating behaviour. During childhood and adolescence both diagnoses are associated with an increased risk of being underweight. Population-based BMI percentiles are useful for detecting associations between specific psychopathological syndromes and body weight.

Anorexia nervosa and sudden death in childhood: clinical data and results obtained from quantitative neurohistological investigations of cortical neurons

A crude rate of mortality of 5.9% has been quoted for Anorexia nervosa (AN) in recent studies. There are different causes of death ranging from suicide to sudden death. Autopsy data are extremely rare about brain alterations in deceased AN patients. Reported in this study is a female patient, aged 13.5 years, who died of acute AN. Quantitative neurohistological investigation post mortem was performed on her brain. Results were compared with data obtained from a girl of the same age with no contributory neuropsychiatric findings. In the cortex of the anorexia case beside typical pyramidal neurons, a slim neuron type with one extremely long basal dendritic field was found to occur more frequently than normal. In the neurons of the AN case, the ramification pattern of single basal dendritic fields was found to be reduced and changes in the spine morphology, as well as reduction in spine density, were observed. However, a simultaneous lengthening of the terminal dendrites of higher order gave some evidence for repair mechanisms and neuronal plasticity. The AN-specific implications of these findings are discussed. The conclusion is that all AN deaths should be reported together with descriptions of causes and cerebral alterations.

[Anti-inflammatory and analgesic actions of of long-chain phenyl substituted alpha-aminoketones]

The investigated phenyl substituted alpha-amino ketones have anti-inflammatory and analgesic activities as could be shown in animal models (rats and mice). The effectiveness depends on the length of the alkyl chain. After i.p. application the most active amino ketones are ten times more effective than acetyl salicylic acid, but the activity did not reach that of indomethacin. The effective analgesic dose is ten times lower than that for anti-inflammatory action. Including the results of the toxicity the analgesic efficiency of the amino ketones could be lead to substances with high analgesic activity. After oral administration only in high doses anti-inflammatory and analgesic effectivities were found. The structural analog keto group instead of the ester or amid group leads not to the expected increase in p.o. effectivity.

Correlated changes in symptoms and neurotransmitter indices during maintenance treatment with clozapine or conventional neuroleptics in adolescents and young adults with schizophrenia

A study of 40 young patients (age 14-22 years) with DSM-III-R schizophrenia (without substance abuse) was conducted following a mean of 3.4 years of neuroleptic treatment. After failing on conventional agents in clinical trials lasting a mean of 2 years, 20 patients were prospectively maintained on open-label clozapine (mean 324 mg daily), and another 20 patients continued on typical neuroleptics (mean 465 mg chlorpromazine-equivalents daily). Patients were then sampled for biochemical measures and assessed for psychopathology (Brief Psychiatric Rating Scale, Scales for the Assessment of Positive/ Negative Symptoms) on six occasions at consecutive 6-week intervals-during maintenance treatment on clozapine or conventional neuroleptics. There were 22-fold interindividual differences in clozapine levels and also high intraindividual differences over time. Maintenance dosage was linearly related to plasma levels of clozapine and its metabolites. Prolactin levels were elevated with typical neuroleptics but not clozapine. Blood levels of serotonin, methoxyhydroxyphenylglycol (MHPG), norepinephrine, and epinephrine (but not dopamine) were significantly higher in clozapine-treated patients than in conventionally treated patients. Higher serotonin levels were associated with significantly fewer negative symptoms, whereas higher MHPG levels were correlated with less depression. These findings suggest involvement of norepinephrine and serotonin in the pathophysiology of schizophrenia (with depression associated with lower MHPG levels and negative symptoms associated with lower serotonin levels) and in the therapeutic actions of clozapine. Speculatively, a treatment strategy of targeting specific neurotransmitter systems might be based on the presence of specific symptoms in adolescents and young adults with schizophrenia.

A new type of bradykinin B2 receptor antagonists: bradykinin analogs with N-alkyl amino acids at position 2

It is commonly assumed that bradykinin B2 receptor antagonists bind to a receptor site partially different from that for agonists. Thus, it is likely that there exists more than one key modification to convert bradykinin receptor agonists into antagonists. In this respect, [L-NMePhe2]-BK represents the basic structure of a new type of bradykinin B2 receptor antagonists without any replacement at position 7. This compound inhibits both in vitro bradykinin-induced contraction of the guinea pig lung strip and in vivo bradykinin-induced bronchoconstriction. Furthermore, this analog shows analgesic activity, blocks in a dose-dependent manner the bradykinin-induced Ca2+ release from macrophages and inhibits at a concentration of 10(-13) M the bradykinin-induced cytokine release from mononuclear cells. Combinations with structural modifications previously performed for other B2 receptor antagonists rather reduce than enhance the potency.

Course and outcome in adolescent anorexia nervosa

OBJECTIVE

To investigate course, outcome, and psychiatric comorbidity in adolescent anorexia nervosa by repeated follow-up assessment.

METHOD

Thirty-four subjects (88%) of an original sample of 39 inpatients were followed up personally 3 and 7 years after discharge and classified according to DSM-III-R eating disorder categories. Standardized psychometric instruments were used to assess specific eating disorder symptoms, concomitant general psychopathology, and comorbid psychiatric diagnoses.

RESULTS

After 7 years, 1 patient (3%) had anorexia nervosa, 4 patients (12%) bulimia nervosa, and 10 patients (29%) eating disorder not otherwise specified (EDNOS). Anxiety disorders (41%) and affective disorders (18%) were the most prevalent comorbid psychiatric disorders. Concomitant general psychopathology was significantly related to the outcome of the eating disorder.

CONCLUSIONS

According to our results, the majority of former adolescent anorexic inpatients had shown substantial improvement in their eating disorders symptomatology after 7 years. Patients with persisting eating disorders mostly suffered from restrictive symptoms. The prevalence and distribution of psychiatric comorbidity were similar to those of adult-onset anorexia nervosa. Subjects with a worse outcome of the eating disorder also displayed higher levels of general psychopathology.

[Longitudinal study of 24-hour blood pressure behavior in pregnancy and puerperium in patients with normal pregnancy, pre-eclampsia and HELLP syndrome]

Ante- and postpartum noninvasive 24-hour ambulatory blood pressure measurements were performed in 18 normotensive pregnants and 36 patients with mild (n = 16) or severe preeclampsia (n = 12) or HELLP-syndrome (n = 8). In contrast to normotensive pregnancy (n = 18) displaying a decline of systolic and diastolic blood pressure in comparison with normotensive non-pregnant, preeclamptic women demonstrate significantly elevated blood pressure profiles before delivery that remain elevated up to the eighth week postpartum. 9 out of 12 patients with severe preeclampsia and 6 of 8 women with HELLP-syndrome show a nocturnal increase of blood pressure within the first week postpartum and a non-dipping up to the eighth week after delivery. As a result of this, in preeclamptic women blood pressure control should be extended into the night and antihypertensive therapy should include a sufficient evening dose.

[The medical certificate--contents, form, deficiencies, fees]

The medical certificate ist a written health certificate based on the results of a medical diagnosis or examination. It does not contain scientifically base conclusions. The various forms of the certificate can be, for example, certificates of unfitness for work, certificates for insurance companies, certificates for exemption from school sports, diet certificates for tax returns, confirmation of a stable diabetes condition for driving licence authorities, certificates as proof of unfitness to plead in the process of criminal law. It is an offence (section 278 German Penal Code) to issue false health certificates for use with a public authority or insurance company contrary to one's knowledge. The form of some certificates is free, in some cases forms are used. "Standard form certificates" for insurance company are extended certificates. Certificates, especially free-form certificates, often have deficiencies: the purpose or addressee is not quoted; the date of the examination has not been entered; it is not apparent whether the statement is based on objective results; "catchword" like diagnostic terms are used: the necessary form ist not adhered to. The "Law concerning Compensation for Witnesses and Experts" (ZSEG) and the Scale of Medical Fees (GOA) set the standards for assessing the fee for a certificate.

Estimation of accommodation in early childhood: Targets and preliminary results

Accommodative disorders can be found in a variety of patients of the pediatric ophthalmology age group. Detection and measurement of (insufficient) accommodation is necessary for adequate management of these patients. Dynamic retinoscopy reversal was used to estimate the accommodative amplitude. Subjective point of blur was compared in two groups of healthy and ophthalmologically normal preschool children: (1) six weeks to one year, (2) one year to six years, in comparison to a group of (3) five years to 12 years, who underwent two different tests. Four targets, mounted on a hand-held occluder, are introduced and tested, 1-3 showing different, more or less detailed and fine drawings of faces, 4 showing a grating of lower spatial frequency with a center of high spatial frequency. The subjective near point for the targets was also tested and compared in 12 young adults (16 to 31 years). The finest drawing appeared to be most adequate for reproducing the closest near point in young adults. This also applies for children above 2% years, while younger children showed better performance and more constant fixation with roughly outlined, schematic drawings of a smiling face. The grating was met with no (babies below two months) or little interest (older infants). The amplitude of accommodation seemed less good with the grating in preschool children. Thus, dynamic retinoscopy is an adequate method to estimate the amplitude of accommodation in early childhood, and the drawing of a smiling face on a 5 cm target is an adequate stimulus attracting attention and accommodation of preverbal children and even babies.

Effects of endothelin on hemodynamics, prostaglandins, blood coagulation and renal function

The interaction of the endogenous vasoconstrictors endothelin (ET), angiotensin II (Ang II) and catecholamines with the kallikrein-kinin-, prostaglandin and renin-aldosterone systems in the pathogenesis of acute renal failure (ARF) is still to be defined. In 18 anesthesized pigs the influence of i.v. bolus applications of ET (2 micrograms/kg), Ang II (10 micrograms/kg) and norepinephrine (NE; 20 micrograms/kg) on hemodynamics, plasmatic coagulation and fibrinolysis system, prostaglandins and renal function was studied. ET induced a biphasic change in blood pressure, starting with an initial short-lasting reduction followed by a long-lasting elevation of systolic and diastolic blood pressure. Endothelin bolus resulted in a significant increase of 6-keto-PGF1 alpha, PGE2 and TXB2 plasma levels (P < 0.05 against preinjection values), whereas prostaglandins remained unchanged in the Ang II and NE groups. There was a distinct correlation between the plasma ET and 6-keto-PGF1 alpha levels (r = 0.82). In contrast to Ang II or NE, ET induced a shortening of the activated partial thromboplastin time (aPTT) and increase of antithrombin III levels (ATIII), fibrin monomers (FM), prekallikrein (PKK) and factor VIII activity at the beginning. Finally a pronounced decrease of ATIII, FM and PKK occurred, indicating a consumptive coagulopathy. At the end of the experiment, elevated plasma renin activity and pCO2, significantly decreased creatinine clearance, blood pH, pO2, base excess, HCO3-, oxygen saturation (P < 0.01), a distinct glomerular proteinuria, and a final anuria were observated. These results reveal that ET activates the plasmatic coagulation system and induces an ARF accompanied by impairment of pulmonary function.(ABSTRACT TRUNCATED AT 250 WORDS)

Bilateral posterior fracture-dislocation of the shoulders: management by bilateral shoulder hemiarthroplasties

Bilateral posterior fracture-dislocation of the shoulders is rare, with only 26 reported cases in the literature. We present the case of a patient who sustained bilateral posterior fracture-dislocations after a first time seizure. Due to significant articular surface involvement, bilateral hemiarthroplasties were performed. The literature on this injury and current treatment options is also reviewed.

Determination of clozapine and its major metabolites in serum samples of adolescent schizophrenic patients by high-performance liquid chromatography. Data from a prospective clinical trial

This report describes a method for determination of clozapine and its major metabolites N-desmethylclozapine and clozapine N-oxide in serum samples of adolescent schizophrenic patients during maintenance therapy. The method includes deproteinization and subsequent high-performance liquid chromatography with electrochemical detection. The method shows sufficient sensitivity to quantitate clozapine, clozapine N-oxide and N-desmethylclozapine accurately at 0.5, 5, and 0.5 ng/ml, respectively. We were able to demonstrate for 16 patients receiving fixed doses of clozapine that the individual mean values calculated from six consecutive measurements revealed a strong linear dosage and serum level relationship (Pearson's coefficient of correlation): clozapine (r = 0.82, p = 0.0001); N-desmethylclozapine (r = 0.81, p = 0.0001); clozapine N-oxide (r = 0.91; p = 0.0001). Preliminary pharmacokinetic data are presented and dose-response relationship are discussed.

[Effect of clozapine on biogenic amines within the scope of drug treatment of schizophrenic psychoses in adolescence]

Longitudinal assessments (every six weeks for one year) were made of plasma norepinephrine, dopamine, epinephrine and 3-methoxy-4-hydroxyphenylglycol (MHPG) in 40 adolescents with schizophrenia, 20 on clozapine therapy and 20 on conventional medication. In addition to the plasma catecholamine determinations, serum levels of 5-HT were determined as a measure of serotoninergic status. All analyses were performed by HPLC-ECD (high-performance liquid chromatography with electrochemical detection). Clinical ratings of symptomatology were obtained with the Brief Psychiatric Rating Scale (BPRS) and the Andreasen scales for negative and positive symptoms (SANS and SAPS). Compared with the typical neuroleptic medication, clozapine administration was accompanied by a significant increase in plasma norepinephrine and MPHG and serum serotonin levels. The fluctuations in the biogenic amines were closely associated with the observed symptomatology. Plasma MHPG was linked to depressive symptoms (BPRS), and negative symptoms (SANS) were related to changes in the serum serotonin levels. The pathophysiological implications and clinical consequences of these findings are discussed.

[Early manifestations of schizophrenic psychoses]

Schizophrenic disorders in childhood are rare. Only about 0.5 to 1% of all such disorders have their onset before age 9 and about 4% before age 14. In puberty and early adolescence, however, there is a marked increase in the frequency of such disorders. In childhood more boys seem to be affected, but during adolescence this difference seems to disappear. Possible etiological factors currently under discussion are genetic factors, neurointegrative deficits, attentional deficits, communication deficits and conspicuous premorbid features. With regard to the latter, the authors could show that positive and negative symptoms appear months or even years before the first manifestation of the disorder requiring inpatient treatment. From this perspective schizophrenic disorders in general and those with early onset in particular fit a dimensional model of illness better than a categorical one. In the development of preventive measures more attention to premorbid features is essential.