[Follow-up dynamics of schizophrenic diseases in adolescence]

In the present study the clinical features of the first episode of schizophrenia were investigated retrospectively and the initial symptomatology was compared with follow-up findings. The study group consisted of 40 adolescents with chronic schizophrenia. During a one-year follow-up period positive and negative symptoms of schizophrenia and depressive symptomatology were evaluated every six weeks. When the patients entered the follow-up study the mean duration of their illness was 4.3 years. Our data revealed a close link between positive and negative symptoms during the period studied. Persistent positive symptomatology at the end of the first treatment period was predictive of high scores for positive and negative symptoms during the entire follow-up period. Furthermore, we were able to demonstrate that negative symptoms can be distinguished from depressive symptoms in the context of the schizophrenic symptomatology. Depressive states (Brief Psychiatric Rating Scale, BPRS) were closely related to the positive symptoms (assessed with the Andreasen scale SAPS), and the negative symptoms (SANS) were correlated with the anhedonia score on the BPRS. Our results suggest that productive symptomatology should be treated aggressively both initially and for a prolonged period of time thereafter. Positive and negative symptoms appear to be related to each other longitudinally. Thus we postulate a single disease process rather than two distinct types of adolescent schizophrenia.

The effect of FK506 versus cyclosporine on glucose and lipid metabolism--a randomized trial

In order to evaluate the effect of cyclosporine (CsA) versus FK506 on glucose and lipid metabolism, an oral glucose tolerance test (OGTT) was performed in 101 patients after orthotopic liver transplantation (OLT) (mean interval after OLT: 511 days). The liver graft recipients had been randomized prospectively to two groups prior to OLT to receive either immunosuppression with CsA, azathioprine, and corticosteroids (CsA group) or FK506 and corticosteroids (FK group). Along with the OGTT, serum insulin, insulin C-peptide and glucagon as well as serum lipids were monitored. There was no statistically significant difference in the occurrence of impaired glucose tolerance (IGT) or manifest diabetes mellitus disease between the two groups. In fact, not a single patient developed new-onset diabetes in any group. In male and female patients, serum levels of cholesterol and triglycerides increased significantly under FK506 and CsA treatment after OLT. Cholesterol was significantly higher in the CsA group in men, in women this was marked, but not significant. While triglycerides were significantly higher in women on CsA treatment, there was no such difference in men. In conclusion, both CsA and FK506 proved to have similar effects on glucose metabolism, while there was a different spectrum of serum lipid alterations.

[Synkinesia of the internal eye muscles in congenital third nerve paralysis]

Synkinetic lid and ocular movements after traumatic or non-traumatic, acquired oculomotor palsy are well known. Less often misdirection in the intraocular muscles is observed. A 20-year-old female patient suffered from congenital palsy of the third nerve of the left dominant eye. She had residual small-angle exotropia after having extraocular muscle surgery four times during childhood, e.g., after high-dosage recess-resect procedures on the horizontal recti of her left eye. There was an anisocoria with a miotic pupil in the left eye when fixating in the primary position and when attempting right gaze. The patient complained of blurred vision at far fixation in the primary position. Her visual acuity was 0.8 in the primary position and 1.25 in 7 degrees left gaze. Retinoscopy of the left eye revealed a 1-1.25 myopic increase for the primary position. Surgical and non-surgical treatment (e.g., cycloplegia plus bifocal glasses, induced change of the leading eye) is discussed.

[Pseudo-esotropia caused by nasal dislocation of the macula in patients with high infantile myopia]

Pseudostrabismus due to dislocation of the macula is a well-known clinical entity mostly reported in the outward, upward and downward directions. This heterotopia is thought to be caused by changes in the growth rate in different areas of the retina or mechanically by retinal traction due to abortive ROP, vascular abnormalities, chorioiditis or other peripheral retinal disorders. In this paper we demonstrate four cases of macular dislocation in the direction of the optic disc associated with high myopia in infants and toddlers without signs of other retinal abnormalities. These children had myopia had myopia ranging from -17 to -20 D and esotropia superimposed by pseudostrabismus. In all four cases, strabismus surgery was performed. Postoperatively, these children showed signs of some binocular interaction. This case report may indicate that in children with strabismus associated with high myopia macular dislocation should be considered as a further characteristic affecting diagnosis and therapy.

Childhood-onset schizophrenia: history of the concept and recent studies

Schizophrenic disorders in childhood are rare: 0.1-1 percent of all schizophrenic disorders manifest themselves before age 10, and 4 percent before age 15. There is, however, a remarkable increase in schizophrenia during adolescence. Age and developmental stage also influence symptoms, course, and outcome. The evidence for a male preponderance in the very early-onset group (< 14) does not apply for adolescents over age 14. The presence of positive and negative precursor symptoms can be demonstrated in child and adolescent schizophrenia before the first clinical manifestation leading to inpatient treatment. With regard to pharmacologic treatment, atypical neuroleptics such as clozapine can be used successfully. As to outcome, schizophrenic psychoses with early manifestation have a poor prognosis. The patients' premorbid personality also seems to be of great importance: A poor prognosis can be found in patients who were cognitively impaired, shy, introverted, and withdrawn before the beginning of their psychotic state.

[Trichinosis outbreak in Purranque County, X Region, Chile. October-November, 1992]

An outbreak of trichinosis occurred in Purranque County, X Region, Chile, between october and november of 1992, which involved 36 persons. The incubation period, determined by the clinical picture and laboratory assays, fluctuated between 10 and 12 days. Myalgias (88.9%) and palpebral oedema (86.1%), were the most important symptoms, followed by fever (44.4%) and headache (33.3%). Eosinophils count ranged from two to 42% the first week, and this value raised to 55% the second week of the outbreak. Anti-Trichinella spiralis antibodies were determined by some serological tests such as: precipitin test (PT), bentonite flocculation test (BFT) and indirect hemagglutination test (IHAT) in sera from 28 patients at the beginning of the outbreak. PT was positive in 46.4% of the cases, followed by IHAT (21.4%) and BFT (3.6%). After 15 days, the three tests were performed in sera from 12 patients. At that time, the positivity was elevated in all of them: PT (100.0%), BFT (66.7%) and IHAT (91.7%). It is believed that the outbreak had its origin in infected pork meat that was consumed raw or insufficiently cooked without a previous veterinary inspection.

Evidence that fluoride therapy increases trabecular bone density in a peripheral skeletal site

We measured the spinal bone density (SBD) and femoral condyle bone density (FCD) in normal and osteoporotic females (n = 219) both before and during fluoride therapy. SBD and FCD in untreated osteoporotics were significantly lower (P < 0.05) than those in the age-matched controls. SBD and FCD were correlated in the untreated (r = 0.62; P < 0.0001) as well as in the fluoride-treated osteoporotics (r = 0.42; P < 0.0001). SBD and FCD were significantly increased (P < 0.05) in response to fluoride therapy. The average rates of increase in FCD and SBD were similar (1.3 +/- 1.3 vs. 1.24 +/- 1.4 mg/cc.month). We conclude that the osteogenic action of fluoride is not limited to the axial skeleton. An increase in trabecular bone density also occurs at peripheral weight-bearing sites such as the femoral condyle.

Spontaneous consecutive Brown syndrome following superior oblique palsy

A 28-year-old female presented with a left trochlear nerve palsy, after indirect head trauma, with no fracture or orbital lesion. She had diplopia, a hypertropia and excyclotropia on right downgaze. Three months later the trochlear palsy had been replaced by Brown's syndrome: a deficit of elevation in adduction, with diplopia, incyclotropia and hypertropia in up-gaze. The Brown syndrome remained the same over a period of 18 months. A 31-year-old male suffered from severe brain contusion with intracerebral haemorrhage and bilateral trochlear nerve palsy. Three years later, he had a bilateral trochlear palsy with bilateral severe Brown's syndrome, with a right hypertropia and 10° to 25° incyclotropia in upgaze and 5° to 10° excyclotropia in downgaze. The field of binocular vision was shifted to left gaze. Orbital CT scan was normal. At surgery, the forced duction test was positive for Brown's syndrome on both sides and the tendon of the superior oblique muscle of the right eye was thickened. The field of binocular vision was centralized after surgery but torsional diplopia in upgaze and downgaze was present as before. Secondary Brown's syndrome after (persisting or vanishing) trochlear nerve palsy without any direct trauma to the superior oblique muscles or the orbit could be caused by a fibrotic reaction of the superior oblique tendon or adjacent structures. This could be due to inactivity or to indirect trauma.

[Renal cell cancer in childhood]

Renal cell carcinoma is a rare disease in children and difficult to distinguish from Wilms-tumor before surgery. We present case histories of two children with renal cell carcinoma and discuss the problems of differential diagnosis versus nephroblastoma, therapy and prognosis. In contrast to Wilms-tumors, the most common kidney-tumor in children occurring mostly in young infants, renal cell carcinoma is rare in childhood and predominantly manifests in school-age. Only a few cases of renal cell carcinoma in younger children are described in the literature. Diagnostic imaging cannot reliably distinguish renal cell carcinoma from other neoplasm of the kidney. However, hematuria in patients with small tumors or no response to preoperative chemotherapy may indicate the presence of renal cell carcinoma rather than nephroblastoma. The determination of "tumor-associated trypsin inhibitor" (TATI) might give further contribution of differential diagnosis. It was measured only in one of our patients and was markedly elevated. Complete surgical resection (nephrectomy with lymphadenectomy) is a curative therapy in patients with tumors limited to the kidney. Chemotherapy and irradiation show no convincing effect. In metastatic tumors therapy with interleukin 2 may be successful.

[A drug evaluation and classification program in the USA--also a model for Germany]

The question of recognition and possibilities of proof regarding impairment by narcotics and drugs is gaining significance also in Germany. Therefore, it is necessary to deal more closely with the United States "Drug Evaluation and Classification Program" and consider its application in Germany as well. The American program is based on standardized education of drug recognition expert trainees and well-tested methods of examination. The results are convincing. The expert reports prepared by the examiners and the chemical-toxicological results correlate in 80 to 97% of the cases. As long as no definite findings regarding dose/concentration effect relationships exist, the classification of behavior, appearance and medical examination plays a significant role. To a great extent, the program makes allowance for the existing possibilities in Germany as well. The authors of this article would consider it to be wrong if, in Germany extensive, time-consuming field studies were undertaken to obtain further knowledge prior to introduction of such a program. On the other hand, despite the existing difficulties, it should be endeavored to find dose/concentration effects.

Leukotriene release from neutrophils of patients on hemodialysis with cellulose membranes

The role of cytokines in patients with chronic renal failure is currently under investigation. We therefore studied the release of leukotriene B4 (LTB4) from polymorphonuclear leukocytes (PMN) in stable dialysis patients treated with two different cellulose membranes, Cuprophan and Hemophan, a modified cellulose with less complement activation. Six patients were treated for four weeks with Cuprophan then switched to Hemophan for another four weeks. Before and after the last treatment of each period, PMN were separated from 20 ml heparinized blood by FICOLL density gradient centrifugation. Portions of 5 x 10(6) PMN were resuspended in Hanks' buffer and stimulated for 5 minutes with calcium ionophore A23187 (5 micrograms/ml). LTB4 in cell supernatants was determined by specific radioimmunoassay. PMN from dialysis patients before HD released significantly (p less than 0.01) more LTB4 than healthy donors. No significant difference between pre- and post-dialysis values was observed with Cuprophan or Hemophan dialyzers. Our data suggest that the acute effects of blood membrane interaction with either complement activating or non-activating dialyzers do not lead to changes in post-dialysis leukotriene metabolism, but leukotriene production is enhanced chronically in dialysis patients.

An autoimmuno-dominant thyroglobulin epitope characterized by a monoclonal antibody

It has become evident in recent years that autoimmune thyroglobulin (Tg) antibodies of Graves disease and Hashimoto's thyroiditis show a restricted epitope repertoire compared to Tg heteroantibodies. We have produced monoclonal antibodies (Mab) against human Tg by the hybridoma technique and the epitope specificity was determined by crossblocking experiments. Six noncrossreactive Mabs were used in a double determinant IRMA system for plasma Tg measurements. Sensitivity of the assays was between 1 and 2 ng/ml, intraassay variation less than 5%. Recovery experiments with added Tg were performed in 25 Graves sera with elevated Tg autoantibodies. Monoclonal antibody Tg13 showed an unusual strong interference with autoantibodies resulting in a very low recovery in all sera (median: less than 10%). In further studies Tg was digested by trypsin and after Western blotting, the resulting fragments were incubated with different Mab antibodies, a polyclonal antibody and 10 different Graves sera with high Tg autoantibodies. In contrast to all other mabs only Mab Tg13 showed several low molecular weight bands between 17 and 50 KD. The major bands recognized by Mab Tg13 corresponded to bands obtained by the autoimmune sera, which showed a very homogeneous band pattern. We conclude that Mab Tg13 is specific for an autoimmunodominant B cell epitope of human Tg.

Bite injuries upon a newborn

A 2 1/2-year-old boy inflicted on his 7-day-old brother suction and bite injuries of the head with loss of tissue of nose and lips. Place of the incident was the parents' bed. The event motivated us to report on the assignment of such injuries and the reasons for sibling violence.

[Plaque and gingivitis reduction by an amine fluoride/stannous fluoride combination]

A clinical study on children has demonstrated that the accumulation of plaque and the development of experimental gingivitis can be reduced by a daily mouthrinse with AmF/SnF2. Low, reversible yellowish tooth staining can almost be prevented by mechanical oral hygiene. The efficacy of AmF/SnF2 was nearly the same as chlorhexidine and the F combination can be recommended for preventive plaque control, especially on high-risk patients.

Leukotriene B4 and tumor necrosis factor release from leukocytes: effect of peritoneal dialysate

The effect of peritoneal dialysate on the capacity of peripheral blood polymorphonuclear (PMNL) and mononuclear leukocytes (MNC) to release leukotriene B4 (LTB4) and tumor necrosis factor alpha (TNF alpha) was investigated in vitro. Following density gradient separation, aliquots of 5 x 10(6) PMNL or MNC were incubated in peritoneal dialysis fluid containing 1.5% glucose or Hanks' buffer (= control) for 1-2 h at 37 degrees C. TNF alpha and LTB4 production was stimulated with Escherichia coli lipopolysaccharide (LPS) and calcium ionophore A23187, respectively. MNC incubated in buffer and LPS produced (mean +/- SD) 1,006 +/- 522 pg TNF alpha/5 x 10(6) cells; no significant amounts of TNF alpha were detectable in the presence of dialysate. An inhibition of TNF alpha release was also observed in MNC exposed to bicarbonate-buffered dialysates (pH 7.40) and 4.25% and 1.5% glucose solution with physiologic osmolality. Incubation of PMNL in Hanks' buffer followed by A23187 stimulation led to production of 29.1 +/- 19.2 ng LTB4/5 x 10(6) cells, whereas glucose-incubated cells were refractory to ionophore stimulation (less than 0.1 ng LTB4/5 x 10(6) cells). The failure of dialysate-exposed leukocytes to release inflammatory mediators in response to adequate stimuli may contribute to the impairment of cellular host defense in the setting of continuous ambulatory peritoneal dialysis.

[The pharmacologic activity of p-substituted DL-2-phenylglycine octyl esters]

DL-2-phenylglycine octyl ester has antiphlogistic, analgesic and spasmolytic activities as shown in different animal models. The antiphlogistic effectiveness is changed only a little by the p-substitution at the phenyl ring, whereas the analgesic action is markedly influenced. Most of the substituted compounds are significantly more active than the unsubstituted ester. DL-2-(benzyloxyphenyl)glycine octyl ester is the most active compound, it has furthermore the highest therapeutic quotient. Using the i.p. application its efficacy exceeds that of acetylsalicylic acid, phenylbutazone and indometacin, respectively. The spasmolytic activity is differently changed by the substituents. The most active ester, DL-2-(p-methoxyphenyl)glycine octyl ester, is about two times more active than papaverine. In histamine induced spasm the effectiveness is low compared with the specific antagonist mepyramine. The results obtained show that the activities of the p-substituted DL-2-phenylglycine octyl esters are different with regard to the three investigated pharmacological properties.

[Multiple homicide. Forensic medicine and criminal aspects]

36 human beings, of whom the youngest was one and a half years and the oldest 76 years old, fell victims to 16 multiple homicides each committed by one perpetrator. 7 of the homicides were committed outside the family and other lasting relationships. 9 homicides can be assigned to the group of "family tragedies". As far as the victims of the first group are concerned, the course of events in committing the crimes is of particular medical-criminalistic interest. There is a more detailed description of the constellation of two homicides in the course of which the victims were either removed by burying their corpses or a fire was set in order to keep the crime secret. The way the weapon was used, the dependence on the situation of the crime as well as the perpetrator's behavior after committing the crime are discussed and compared in both case groups.

[Evaluation of instrument improvements in oculomotor muscle surgery]

Five improvements of surgical instruments for strabismus-surgery are introduced; these are a small muscle-hook, a broad, flat muscle-hook, two variants of a retractor and one instrument for the resection or tucking of a rectus-muscle. All instruments have proved to be less traumatic and seem much safer than others even in less experienced hands. Most of them have been used over a period of more than 10 years in a specialized department.