[Conceptual foundation of the operational diagnostic approach in psychiatry]

Based on the pioneering work of Emil Kraepelin, Karl Jaspers, Kurt Schneider and representatives of logical empiricism, the basic principles of the operational diagnostic approach in psychiatry are described. Operational diagnostic systems like ICD-10 and DSM-IV aimed at a standardisation of psychiatric language which can be accepted by different schools in psychiatry. However, ICD-10 and DSM-IV should not be misinterpreted as "nosology" because they do not reflect a specific model of psychiatric diseases. The advantages of operational diagnostic systems as instruments for communication in a clinical and scientific context are limited by the fact that they disregard the subjective psychopathology. This dimension, however, deserves attention in clinic and research.

Einfluss der Reitdisziplin und -intensität auf die Inzidenz von Rückenschmerzen bei Reitsportlern

INTRODUCTION

The connection between morphologic changes of the spine and the intensity of training has been assessed for a number of sport activities. The influence of horseback riding on the spine has only rarely been evaluated. The aim of our study was to evaluate to what degree horseback riders suffer from back pain and whether there is an association between this parameter and the category i. e. the intensity of horseback riding. Furthermore we wanted to judge whether riding may have a positive effect on pre-existent back pain.

METHODS

508 horseback riders (63.2 % females; 36.8 % males) competing in either dressage, showjumping or vaulting were interviewed using a questionnaire. Apart from biometric data, the intensity with which riding was performed and the localisation and intensity (VAS) of back pain was assessed. Furthermore, in the case of existing back pain, riders were asked whether different riding disciplines and paces changed the intensity of pain.

RESULTS

300 dressage riders (59.1 %), 188 showjumpers (37.0 %) and 20 vaulters (3.9 %) with an average age of 33.5 Jahre (12 - 77 years) were questioned. The incidence of back pain was 72.5 %. A significant correlation between back pain and riding discipline respectively gender or riding level could not be found. Discrepancies in VAS-score for dressage riders (3.95 +/- 0.13), show jumpers (4.10 +/- 0.16) and vaulters (3.76 +/- 0.5) were marginal and not significant (p > 0.05). Overall 58.7 % resp. 15.2 % reported to have pain in the lumbar i.e cervical spine. Despite the fact that a large fraction of dressage riders claimed to have problems in these spine areas with 57.7 % resp. 68.8 %, this finding was not significant compared to the other riding disciplines. While 61.6 % of dressage riders reported an improvement of their back pain when riding, this was only the case in 40.9 % of show jumpers.

CONCLUSION

Compared to the general population, a high incidence of back pain is found among riders. A significant correlation between the intensity of riding or the riding discipline and frequency or severity of back pain could not be found. For riders with pre-existent back pain the pace "walk" seems to have a positive influence on pain intensity.

[CERAD and NOSGER. Comparing predictive scales for dementia in a Swiss gerontopsychiatric patient population]

BACKGROUND

The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) is an established screening instrument for the diagnosis of Alzheimer's disease. The Nurses Observation Scale for Geriatric Patients (NOSGER), actually developed for rating the frequency of behavioral disturbances, appears suitable for dementia screening as well.

MATERIAL AND METHOD

In this retrospective study we analyze the neuropsychological data of 400 consecutive patients at our hospital with several psychiatric diagnoses and cognitive deficits. By means of logistic calculation in single and multivariable models, the predictive value of CERAD and NOSGER for dementia diagnosis was studied.

RESULTS

All CERAD subtests were significant single predictors for dementia. The multivariable model with the highest prediction for probability of dementia diagnosis contained the subtests Verbal Fluency Test, Word List Recall, Constructional Practice Recall, and the Mini-Mental State Examination. However, NOSGER could not differentiate between demented and nondemented patients.

CONCLUSION

In our gerontopsychiatric population, CERAD separates demented patients from nondemented ones with high predictive potency. The NOSGER does not reveal any predictive value for the diagnosis of dementia.

Intravenous iloprost: a new therapeutic option for patients with post-transplant distal limb syndrome (PTDLS)

The purpose of this study was to investigate the application of intravenous iloprost as a novel therapy for the treatment of post-transplant distal limb syndrome (PTDLS). PTDLS is a benign but disabling complication in the first year after renal transplantation. It is characterized by bilateral, often incapacitating pain in the feet and or knees on motion and a significant rise in alkaline phosphatase levels on laboratory evaluation. On MRI, bone marrow edema of the affected bone regions can be demonstrated. PTDLS differs from steroid induced osteonecrosis of the hip in terms of localization, an average cumulative steroid dosage within expected limits, and a benign outcome, as PTDLS does not progress to overt cell necrosis. From August 2003 to April 2005 we treated 10 patients with MRI-proven diagnosis of PTDLS following a standardized regimen of intravenous iloprost over 5 days. Iloprost led to prompt pain relief measured on a visual analogous scale (VAS) ranging from 1 to 10 (5.6 +/- 1.5 before vs. 2.1 +/- 1.3 after treatment, p = 0.0004). PTDLS represents a benign but disabling complication following renal transplantation. Intravenous iloprost might be a promising therapeutic concept leading to a quick relief of symptoms without relevant side effects.

Ultrasonic standing wave manipulation technology integrated into a dielectrophoretic chip

Several cell-based biological applications in microfluidic systems require simultaneous high-throughput and individual handling of cells or other bioparticles. Available chip-based tools for contactless manipulation are designed for either high-precision handling of individual particles, or high-throughput handling of ensembles of particles. In order to simultaneously perform both, we have combined two manipulation technologies based on ultrasonic standing waves (USWs) and dielectrophoresis (DEP) in a microfluidic chip. The principle is based on the competition between long-range ultrasonic forces, short-range dielectrophoretic forces and viscous drag forces from the fluid flow. The ultrasound is coupled into the microchannel resonator by an external transducer with a refractive element placed on top of the chip, thereby allowing transmission light microscopy to continuously monitor the biological process. The DEP manipulation is generated by an electric field between co-planar microelectrodes placed on the bottom surface of the fluid channel. We demonstrate flexible and gentle elementary manipulation functions by the use of USWs and linear or curved DEP deflector elements that can be used in high-throughput biotechnology applications of individual cells.

Avascular osteonecrosis after hyperthermia in children and adolescents with pelvic malignancies: a retrospective analysis of potential risk factors

PURPOSE

In children with locally advanced or recurrent malignant tumours, prognosis can be improved by regional deep hyperthermia (RHT) in combination with platin-based chemotherapy. However, because of the increasing number of patients that achieve long-time remission with this therapy, it is necessary to evaluate long-term sequelae of thermochemotherapy. During the years 1993-2004 one has observed avascular osteonecrosis (AON) of the femoral head after RHT in seven children with pelvic germ cell tumours or rhabdomyosarcomas.

METHODS

Although AON may develop in patients with malignancies treated with chemo- or radiotherapy alone, RHT might nevertheless contribute to the occurrence of AON. In order to determine potential risk factors for AON after RHT, this study analysed the relationship of AON to the patient's age, medical history and treatment parameters such as thermal dose equivalent and power output.

RESULTS AND CONCLUSIONS

In the present study AON was associated with young age as well as intensity of hyperthermia indicated by high power levels that exceed 20 W per kg body weight and/or application of eight or more heat sessions as well as additional radiotherapy. Based on this observation, it was assumed that an optimized three dimensional thermal field modelling may be helpful to avoid hazardous temperatures in the femoral heads during RHT treatment and to reduce AON of the femoral heads.

Saving Implants BMP-2 Application in Revision Total Hip Surgery

OBJECTIVE

Besides others, there are two major problems in total hip replacement surgery which result in implant failure. First there is aseptic loosening due to a lack of implant biocompatibility or micromovements and second periimplant wear debris induced osteolysis which limits the survival rate of an implant. Regarding to recent data there are only limited therapeutic strategies to heal these bony defects without arthroplasty revision surgery. Since the investigation and characterization of adult mesenchymal stem cells (MSCs) from bone marrow, a cell and tissue engineering based therapy might be a promising solution to heal endoprosthesis associated bony defects. Moreover the application of growth factors in bone reconstructive surgery is another treatment concept to promote local bone regeneration.

PATIENT AND METHODS

We report about a 73-year old patient with a painful weight bearing and a large, wear debris induced pelvic osteolysis after total hip arthroplasty. To prevent from salvage surgical procedures and preserve bone, a healing attempted was performed by filling the critical bony defect zone with a BMP-2/MSC composit.

RESULTS

Clinical and radiological follow-ups showed a progressive bony healing of the critical size defect area without any complications. Fifteen months after application the patient is still pain free, has no limitations in daily life or sport activities.

CONCLUSION

The case embarks on a strategy of non-embryonic stem cell and growth factor application to heal bony defects at patients with total hip endoprosthesis.

[Bone harvesting from the iliac crest]

BACKGROUND

Autogenous bone grafts from the iliac crest are frequently harvested for autologous bone transplantation. Although an autologous bone transplant does improve the local bone healing potency, significant donor site morbidity must be considered.

METHODS

In this study we elucidate special bone harvesting techniques from the iliac crest and review the literature related to clinical significance of donor site morbidity. Furthermore, our own experiences are compared and discussed critically with relevant data of other investigators.

RESULTS

The increasing number of scientific publications which focus on bone harvesting techniques and related complications in recent years indicate the high interest and relevance of this issue. There is a tendency to alternatives such as biomaterials as bone substitutes, whereas the role of growth factors and cell therapeutics in the treatment of bony defects are still being evaluated in clinical studies.

CONCLUSION

Although autologous, heterotopic bone transplantation is still the gold standard in the treatment of bony defects, there is a tendency towards the application of biomaterials, stem cells, and growth factors. Conscientious observation of relevant anatomic considerations during bone harvesting procedures may help to avoid complications.

Proliferation and osteogenic differentiation of mesenchymal stem cells cultured onto three different polymers in vitro

In this study, the osteoinductive and cell-binding properties of three different resorbable polymers were evaluated by human mesenchymal stem cells (MSCs). MSCs were isolated, expanded, and cultivated onto resorbable D,D,L,L-polylactide (PLLA), collagen I/III, and polygalactin-910/polydioxanone (PGPD) scaffolds in vitro. To evaluate the influence of dexamethasone, ascorbic acid, and beta-glycerolphosphate (DAG) on osteoblast differentiation, MSCs were incubated in a DAG-enriched medium. After a 28-day period in vitro, the cellular loaded polymers were digested enzymatically by papain and HCl. The Ca(2+) content of the biomembranes was evaluated by an o-kresolphthalein-complexon reaction via photometer. A PicoGreen assay was performed for dsDNA quantification. Significant differences between the number of adherent MSCs were documented (collagen > PLLA > PGPD). Compared to the initial number of adherent cells, all biomaterials induced a significant decrease in cellular adherence after 28 days in vitro. The presence of DAG-enriched culture medium stimulated the cellular proliferation for PLLA and slightly for PGPD, whereas cell proliferation was inhibited when MSCs were cultivated onto collagen I/III. In comparison with the control groups, all biomaterials (PLLA, PGPD, and collagen I/III) showed a significant increase in local Ca(2+) accumulation under DAG stimulation after 28 days in vitro. Furthermore, collagen I/III and PLLA scaffolds showed osteoinductive properties without DAG stimulation. These results were verified by immunocytochemical stainings against osteoblast-typical markers (osteopontin and alkaline phosphatase) and completed by calcified matrix detection (von Kossa staining). MSCs were identified by CD105 and CD13 antigen expression. Corresponding to an absence of CD34, CD45, and collagen II expression, we found no chondrogenic or hematopoietic cell differentiation. The results indicate significant differences for the proliferation, differentiation, adherence, and Ca(2+) accumulation between the tested polymers in a MSC culture.

Behandlung vital gefährdeter Anorexia-nervosa-Patienten unter Berücksichtigung der Möglichkeiten des Betreuungsrechts

Anorexia nervosa is a psychiatric disorder occurring primarily in young women. Especially when chronic or the body mass index is less than 12 kg/m(2), it has a mortality of up to 20%. Often these patients are admitted to emergency units and treated internistically. If they accept psychiatric treatment, they are normally transferred to specialized psychosomatic units for further therapy. If patients are not able to accept necessary further therapy to overcome the danger to health and life, the question arises in terms of guardianship law of whether they are able to handle their personal concerns alone. After several vitally endangered anorexia nervosa patients had been admitted to our closed psychiatric ward, we developed a therapeutic concept for this subgroup of patients, taking the possibilities of guardianship law into account. This concept aims at restoring the body weight continuously and finally enable the patients to be transferred to less restrictive psychosomatic units. The chosen treatment is shown with the therapy courses of 25 patients treated according to this concept.

Specific induction of pp125 focal adhesion kinase in human breast cancer

The pp125 focal adhesion kinase (FAK) is involved in integrin-mediated cell signalling and overexpressed in a variety of solid tumours. Focal adhesion kinase expression has been correlated to invasion and metastasis, but the data on breast cancer are inconclusive. We analysed FAK mRNA, protein levels and expression patterns in primary breast cancer and normal breast tissue. FAK expression on the functional protein level and mRNA was determined in 55 matched pairs of breast cancer and corresponding normal tissue by Western blot, immunohistochemistry and RT–PCR. Using a score ranging from 0 to +5 for Western blots, we determined in normal breast tissue a score of 1.51±0.84 (mean±standard deviation), which was strongly induced to 2.91 (±1.22) in breast cancers (P<0.001). Overall, 45 out of 55 tissue pairs (81.8%) showed this upregulation of FAK protein in tumours in comparison to normal tissue. Immunohistochemistry confirmed these findings with a significant higher score for tumours vs physiological tissue (1.0±0.63 vs 2.27±0.91; P=0.001). Interestingly, no overall significant difference in the mRNA levels (P=0.359) was observed. In conclusion, expression levels of the FAK protein are specifically upregulated in breast cancer in comparison to matched normal breast tissue supporting its pivotal role in neoplastic signal transduction and representing a potential marker for malignant transformation.

The critical size bony defect in a small animal for bone healing studies (II): implant evolution and surgical technique on a rat's femur

In the preclinical field of orthopaedic and trauma surgery critical size bony defects (CDS) were used to evaluate the biocompatibility and allow to investigate the osteoinductivity and -conductivity of bone substitutes. Concerning the anatomical size the laboratory rat indicates a lower limit in small animals which are appropriate for experiments on bone. The aim of this study was to define a CSD, to develop a suitable fixation system to stabilize bony fragments in CSD and to point out the specialities of the surgical technique. These informations should help for to design and practice studies concerning bone healing on rat's femur. Based on previously acquired anatomical data of rat's femur, the technical challenges and anatomical specialities of different osteosynthesis techniques in rat's femur surgery are demonstrated. Our experiences with different fixation systems and techniques lead to the development of an external fixator, which guarantees for a stable bone fragment fixation, prevents severe soft tissue damage, allows of a roentgenologic evaluation of the defect zone and prevents from undesired direct biomaterial-implant interactions. Neither the proximal nor the distal femoral nailing technique is appropriate for a stable fixation in CSD of rat's femur. To evaluate the reliability of an own developed external fixator 42 nude rats with a 4.0 mm CSD were investigated clinically and roentgenologically over 10 weeks. The external fixator showed only a small implant failure rate. A solid fusion of the bone fragments was not observed within the 10 weeks follow-up period.

[In vivo and in vitro bone regeneration from cord blood derived mesenchymal stem cells]

BACKGROUND

Mesenchymal stem cells with an osteoblastic differentiating potency are investigated in regard of probable tissue engineering for further clinical application. The following report describes the use of cord blood derived stem cells as an alternative to other stem cell populations for bone regenerating tissue engineering.

METHODS

To demonstrate the multipotency of cord blood derived mesenchymal stem cells, unrestringated somatic stem cells (USSC) were isolated from cord blood and underwent an osteo-, chondro- and adipoblastic in vitro stimulation. To evaluate the osteoinductive potency of a porcine collagen I/III cell carrier USSC were incubated on this matrix. To investigate the in vivo effects of human USSC an athymic rat model was developed. These cells were transplanted into a femoral defect.

RESULTS

Cord blood derived mesenchymal stem cells (USSC) have an in vitro multipotency and show adipo-, chondro- and osteogenic differentiation. The porcine collagen I/III carrier promoted an osteoblastic differentiation. USSC survived after xenotransplantation in an athymic rat and differentiated into osteoblasts filling the bony defect zone.

CONCLUSION

Human USSC are a mesenchymal multipotent stem cell population that shows osteoblastic differentiation onto a collagen I/III carrier in vitro as well as in an athymic rat in vivo.

Osteogenic progenitor cell potency after high-dose chemotherapy (COSS-96)

BACKGROUND

Since the first trial of chemotherapy in patients with osteosarcoma the survival rate has gradually improved. For more than two decades, most osteosarcoma patients from Germany, Austria and Switzerland have been treated according to the protocols of the Cooperative Osteosarcoma Study Group (COSS). The uniform treatment concept of a high-dose polychemotherapy pre- and postoperatively improved the survival rate of these patients significantly. One severe side-effect of COSS chemotherapy is multiple osteonecrosis.

PATIENTS AND METHODS

In this study the osteogenic stem cell potency of three different tissue types was elucidated after COSS-96 chemotherapy (high-risk arm). Mononuclear cells were obtained from the periosteum, cartilage and bone marrow of a 17-year-old female with a chondroblastic osteosarcoma. The cells were cultivated for 4 weeks in standard medium and stimulated for osteogenic differentiation after the second passage with dexamethasone, glycerolphosphate and ascorbine acid. Two weeks later, the cell cultures were analysed with respect to cell morphology and immunochemical stainings.

RESULTS

All cells cultures showed an osteoblastic regeneration potential measured by osteocalcin (OC), osteopontin (OP) and alkaline phosphatase (ALP) expression. Compared to other donor tissues and localizations, the fibula periosteum showed significantly higher osteoblast rates in vitro, whereas collagen II, CD34 and CD45 were not expressed in any culture.

CONCLUSION

The results of this study demonstrate the survival of mesenchymal progenitor cells in bone marrow during COSS-96 polychemotherapy, which allows for an osteogenic regeneration in vitro and potentially in vivo.

[Pain management in non-juvenile, aseptic osteonecrosis]

BACKGROUND

Adult aseptic osteonecrosis (ON) represents a clinical picture with unexplained etiology. Since curative treatment of this disease often succeeds only in the early stage, pain therapy plays an important role in the treatment process.

METHOD

We compared established and novel treatment options for ON as well as our own results after i.v. administration of the prostacyclin analogue iloprost with corresponding studies in the literature.

RESULTS

In addition to treatment with nonsteroidal antirheumatic agents and opioids, surgical "core decompression," vasoactive medications, and hyperbaric oxygenation are effective. Treatment with iloprost for 5 days resulted in highly significant pain reduction.

CONCLUSION

Symptomatic treatment is indicated in all stages of ON and curative treatment in stage I and early stage II. In cases of disease progression in the large joints, early endoprosthetic replacement is indicated to avoid secondary damage. In addition to employing vasoactive substances, a further curative treatment approach could be the use of mesenchymal stem cells.

Thalamic volume in first-episode and chronic schizophrenic subjects: a volumetric MRI study

OBJECTIVE

The thalamus, as a composite of several functionally very different nuclei, is a major relay and filter station in the CNS and is significantly involved in information processing and gating. The aim of our study is to investigate first-episode and chronic patients and controls to shed light on the potential pathogenetic role of the thalamus in schizophrenia and to assess the relationship between thalamic volumes and psychopathology ratings.

METHODS

Forty-three male right-handed chronic and 25 male right-handed first-episode schizophrenic patients treated at the psychiatric hospital of the Ludwig-Maximilians University in Munich and 50 male control subjects were enrolled into the study. Demographic information and current symptom profile of all schizophrenic subjects were assessed using a semistructured interview, including a variety of measures relevant to the study. Volumetry of the thalamic gray and white matter was obtained with 1.5 T MRI, using the BRAINS software application.

RESULTS

No significant differences regarding thalamic volumes were detected across groups. However, negative symptoms were significantly correlated with thalamic volumes in first-episode patients, whereas duration of illness and extrapyramidal symptoms were related to thalamic volumes in chronic patients.

SUMMARY

Our findings indicate that, while the thalamus might be involved in the pathogenesis of negative symptoms, thalamic volume reduction is not a required element in the pathophysiology of the schizophrenic phenotype.

Extensive H+ release by bone substitutes affects biocompatibilityin vitro testing

Bone substitutes are widespread in orthopedic and trauma surgery to restore critical bony defects and/or promote local bone healing. Cell culture systems have been used for many years to screen biomaterials for their toxicity and biocompatibility. This study applies a human bone marrow cell culture system to evaluate the toxic in vitro effects of soluble components of different bone substitutes, which are already in clinical use. Different specimens of tricalcium phosphates (TCP) (Vitoss, Cerasorb), nondecalcified bovine bone (Lubboc), demineralized human bone matrices (DBM) (Grafton Flex/Putty), and collagen I/III matrix (ACI-Maix) were tested in Dulbecco's modified Eagle's medium (DMEM) and MesenCult culture solution and compared with a biomaterial-free cell culture. Biocompatibility parameters were cell viability evaluated by phase-contrast microscopy and laser flow cytometry, morphology, and the local H(+) release by bone substitutes. There were significant differences (p < 0.05) between the tested biomaterials and culture solutions. Collagen I/III, non-demineralized bovine bone, and TCP materials showed advantages for cell survival over other tested biomaterials (average values of vital cells/mL MesenCult/DMEM: Collagen I/III: 1090/1083; Vitoss: 893/483; Cerasorb: 471/523; Lubboc: 815/410; Grafton Putty: 61/44; Grafton Flex: 149/57). Especially the DBM materials lead to a significant decrease of pH, which is considered to be a major factor for cell death. DMEM culture solution supports cell survival for those bone substitutes that induce an alkaline reaction, whereas MesenCult media promotes cell vitality in biomaterials, which leads to an acidification of culture solution.