Olanzapine- and clozapine-induced stuttering. A case series

Drug-induced stuttering has been described in association with several drugs, in particular antidepressants and low-potency neuroleptics. Here we describe a case series of stuttering induced by the atypical neuroleptics olanzapine and clozapine. Patients receiving neuroleptic treatment were carefully screened for stuttering as a possible side effect. We have studied all patients in the outpatient department (800 per year) as well as most inpatients (1300 per year) within 3 years. Seven cases of drug-induced stuttering were observed. Six patients suffered from stuttering in association with olanzapine treatment, and one received clozapine. Stuttering arose on average 2-21 days after initiation of treatment and ceased 2-5 days after discontinuation. Most patients suffered from additional diseases, such as brain pathology due to cortical atrophy or celiac disease, or received concomitant medication (i.e. intrathecal morphine pump). Our case series suggests that the atypical neuroleptic olanzapine can induce stuttering in the absence of a history of stuttering without accompanying akathisia or general decline of function. It appears that preexisting brain pathology or concomitant anti-depressant medication might predispose some patients to this side effect.

Nongenetic pathologic developments of brain-wave patterns in monozygotic twins discordant and concordant for schizophrenia

Evidence from previous studies has suggested that the inter-individual differences in human brain-wave patterns (EEG) are predominantly determined by genetic factors. In particular, the within-pair EEG concordance of monozygotic (mz) twins was found to be typically as high as r = 0.81 across channels and frequency bands, thus being comparable to that between repeated assessments on the same individual with typically r = 0.83. Yet our investigations into mz twins discordant and concordant for schizophrenia yielded a significantly reduced within-pair EEG concordance for both, the pairs discordant for schizophrenia and the pairs concordant for schizophrenia (with concordance for schizophrenia assessed through a syndrome-oriented approach). A multivariate discriminant function of EEG parameters distinguished in a reproducible way between affected and unaffected subjects at an overall performance of >75% correctly classified subjects, while the severity of illness, as derived from EEG-differences between affected and unaffected subjects, was closely related to the severity of illness as provided by psychopathology syndrome scores. Consequently, EEG anomalies associated with schizophrenia and manifested differently in the mz co-twins concordant for schizophrenia are likely the effect of nongenetic, pathologic processes that evolved independently in the co-twins' genetically identical brains once the illness began to progress. The existence of such nongenetic processes would suggest a modification of the standard phenotype-to-genotype search strategies of molecular-genetic studies that aim to link the schizophrenia phenotype to genetic vulnerability factors.

Comparison of necrosis in human ovarian tissue after conventional slow freezing or vitrification and transplantation in ovariectomized SCID mice

This paper examines and compares necrosis in human ovarian tissue after conventional slow freezing or vitrification and ensuing xenotranplantation. Slow cryoconserved or vitrified ovarian tissue samples and fresh controls from nine patients were subcutaneously transplanted into SCID mice. The tissue samples were explanted after 6 weeks and the necrotic areas were examined by staining with Lucifer yellow SV. The size of the necrotic areas in parallel cultivated ovarian tissue samples was compared, as was necrosis in cultivated prostate tumour spheroids where the emergence of necrosis and its pathophysiological correlation have been described. Examinations showed no significant rise in the proportion of necrotic areas after slow cryoconservation/transplantation and in the controls (transplanted fresh tissue, not transplanted fresh tissue, long-term culture). The proportion of necrotic areas in the tumour spheroids was significantly higher than in the ovarian tissue. Vitrification could, after these results, be presented as an alternative to conventional slow cryoconservation.

Comparison of breast and rectal cancer patients' quality of life: results of a four year prospective field study

This paper compares quality of life in breast and rectal cancer patients. The Munich Cancer Registry records clinical details of all cancer patients in the region. Over a 2-year period, cooperating clinicians recruited patients who were sent quality of life questionnaires, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - C30 over 4 years. Breast cancer patients were compared to both male and female rectal cancer patients. A total of 1315 patients returned questionnaires (988 breast cancer, 327 rectal cancer). More breast cancer patients were under 70 years old, received adjuvant therapy, had a good prognosis, took medication and rated psychological support as important. Breast cancer patients reported poorer quality of life than rectal cancer patients in more than half the variables. In particular, they suffered significantly worse emotional functioning, fatigue, pain and sleeplessness. Female rectal cancer patients did not suffer the same problems. Both age groups and those with or without adjuvant therapy indicated the same trend, with breast cancer patients reporting lower scores. Breast cancer patients, despite better prognoses, appear to suffer more psychological problems than rectal cancer patients. Gender, age and therapy did not seem to explain these differences. The negative public perception of breast cancer may play a role.

The process of metastasisation for breast cancer

To investigate the process of metastasis, primary clinical data and disease events such as metastases, local recurrence and survival (median follow-up 9.4 years) from the Munich Cancer Registry from 1978 to 1996 were analysed. Since metastases, even from small tumours, may be initiated before the diagnosis of the primary tumour, the growth of the primary tumour and metastasisation may be two autonomous processes. In our data, survival following metastases was almost unrelated to primary tumour size. However, the number of M1 cases and the time to metastasisation depended on the tumour diameter at diagnosis. The time from initiation of metastases to its diagnosis was estimated as 5.8 years. The growth of metastases was almost homogeneous. However, the growth time following metastasisation-depending on the metastases-free time, receptor status and histological grade-only varied by approximately a factor of 2. Local recurrence, above all, was an indicator of metastases. Furthermore, local recurrence may also have the potential to metastasise. Excess mortality due to local recurrence was estimated up to 9.3 years after diagnosis. Our hypothesised metastases model illustrates the importance of early detection, the concept of breast-conserving therapy and additional metastases from local recurrence. It highlights the benefits of optimal local therapy of the primary tumour and the limitations of systemic therapy. It also questions the use of axilla dissection and lymph node irradiation. Its generalisation to solid tumours may help to clarify many of the current controversial debates.

Influence of gender and hemispheric lateralization on heat pain perception in major depression

Increased incidence of clinical pain complaints from patients with major depression, as well as increased experimental pain thresholds have been reported. The basis of this phenomenon remains unclear, as well as its relation to medication, clinical recovery, gender and lateralization of hemispheric function. We aimed to further elucidate heat pain perception in depression applying a testing battery including assessment (on both arms) of warmth perception, heat pain perception and heat pain tolerance, and the jaw opening reflex (duration of ES2 component) as a putative indicator of descending pain inhibition. The battery was applied to 20 patients and 20 age- and sex-matched controls. Patients were assessed: on admission (acutely depressed, off-medication), few days after admission (depressed, on medication), and after clinical recovery (mostly on medication), and controls at corresponding intervals. Significant elevated heat pain thresholds were found off and on medication in the acute stage (mainly in women) and after recovery on the right arm only. Elevated heat pain tolerance (on the right arm only) was seen in medicated patients in the acute and recovered stage. Significant prolongation of ES2 duration was only found in acutely depressed patients off medication. While confirming hypalgesia to heat pain in major depression, our findings demonstrate a close relation to gender and strong influence of lateralization after recovery. Altered pain processing at brain stem level might only partially be responsible for the observed finding.

Communication, quality of life and age: results of a 5-year prospective study in breast cancer patients

BACKGROUND

Previous studies have employed short follow-up periods or examined only certain aspects of quality of life (QoL). This study aimed to examine the effect of communication on breast cancer patients' QoL and to investigate the role of age in this relationship.

PATIENTS AND METHODS

In a prospective, observational study breast cancer patients were sent questionnaires, including the European Organisation for Research and Treatment of Cancer QLQ-C30, over 5 years.

RESULTS

Forty-five per cent of the sample reported that some aspect of the communication they received was unclear and 59% wanted to speak with medical staff more. Patients under 50 years rated social and psychological help as more important, they were more aware of such services, had greater contact with support groups but were less satisfied with the information they received. Seventeen of the 27 QoL variables were significantly worse (P <0.01), up to 4 years after diagnosis, for those patients reporting unclear information. For patients over 50 years, QoL was significantly (P <0.001) worse when communication was unsatisfactory. Operation method or arm problems did not mitigate the association between communication and QoL.

CONCLUSIONS

Communication is clearly a vital clinical skill that may play a role in patient QoL.

Pentosidine and N(epsilon)-(carboxymethyl)-lysine in Alzheimer's disease and vascular dementia

Increasing evidence suggests an interaction of oxidative stress and the formation of advanced glycation end products (AGE) in the onset and progression of Alzheimer's disease. We studied levels of pentosidine and N(epsilon)-(carboxymethyl)-lysine (CML) in serum and cerebrospinal fluid (CSF) of 15 patients with probable Alzheimer's disease (AD), 20 patients with vascular dementia (VD), and 31 control subjects (14 matched for age, and 17 younger patients). AGE protein concentrations in CSF did not differ within controls when divided into two subgroups by age. We found significantly elevated levels of CML in CSF of AD patients and of pentosidine in CSF of patients suffering from vascular dementia when compared to controls. The concentrations of pentosidine and CML in serum apparently did not relate directly to CSF values, suggesting influence of extra-cerebral factors in serum samples. It is concluded that AGE proteins are differentially affected in these types of dementia, depending on the specific neuropathology. Furthermore, measurements of AGE products in vivo should rely on CSF rather than blood samples.

Stimulus duration influences the dipole location shift within the auditory evoked field component N100m

The equivalent source of the neuromagnetic auditory evoked field (AEF) component N100m shifts systematically within its latency range. In the current study, possible effects of stimulus duration on this shift were analysed. 15 subjects were stimulated monaurally with tones of different duration (50, 100, 200 ms) and AEFs were recorded successively over both hemispheres. Dipoles were calculated in 5-ms-steps from 15 ms before to 15 ms after the N100m peak maximum. A dipole location shift within the N100m latency from posterior to anterior and from superior to inferior was observed. The shift in anterior-posterior direction was found to be larger in the right compared to the left hemisphere. Stimulus duration significantly affected the degree of dipole shift in this direction. It was found to be shorter the shorter the stimulus.

Platelet-derived growth factor activates production of reactive oxygen species by NAD(P)H oxidase in smooth muscle cells through Gi1,2

Recent findings indicate that platelet-derived growth factor (PDGF) plays a role in the generation of reactive oxygen species (ROS) as second messengers in smooth muscle cells (SMC). To identify the source and signal transduction pathway of ROS formation in SMC, we investigated PDGF-induced ROS formation. Stimulation of SMC with PDGF resulted in a rapid increase of ROS production. Using an inactivating antibody, we identified the increase to be dependent on p22phox, a NAD(P)H-oxidase subunit. ROS release was completely inhibited by the Gi protein inhibitor PTX as well as an antibody against Galphai1,2, however, not by antibodies against Galphai3/0, Gas, and Gbeta1beta2. The effect of PDGF on ROS production in SMC membranes could likewise be mimicked by the use of a recombinant Galphai2 subunit but not by Galphai3, Galphai0, Gas, and Gbetagamma subunits. Immunoaffinity chromatography demonstrated coupling of Galphai1,2 to the PDGF a-receptor, which, after preincubation of the SMC membranes with PDGF, was increased in the absence of GTPgammaS but decreased in the presence of GTPgammaS and prevented by PTX treatment. These data define a novel G protein-dependent mechanism by which PDGF signaling is transduced through direct coupling of the Gai1,2 subunit of the trimeric G proteins to the PDGF tyrosine kinase receptor.

Plague and other human infections caused by Yersinia species

With an estimated 100 million victims, pandemically and epidemically occurring plague has been looked upon as a classical scourge of mankind during the last two millenia. Without treatment at least 50% of the affected individuals die from infection with Yersinia pestis, a bacterium belonging to the family of Enterobacteriaceae. The disease takes a fulminant course. After an incubation period of 2-6 days, bubonic plague primarily attacks one group of lymph nodes. The onset of pulmonic plague, transmitted by droplet infection, takes place within several hours and causes bronchopneumonia. Early recognition facilitates a promising antibiotic therapy with tetracycline, streptomycin or chloramphenicol. Human beings acquire the bacteria through bites of fleas from domestic rats in densely populated cities of countries with low hygienic standards, or sporadically in the open country from infected wild rodents. Laboratory procedure includes microscopy supplemented by immunofluorescence and cultivation of the bacterium from clinical material. Direct serology and PCR result in a fast detection of specific antigens or nucleotide sequences. Determination of serum antibodies is principally used for epidemiological investigation. Today, physicians in the civilized western world lack experience for the recognition of plague, and analytical techniques for diagnosis are only available in some specialized laboratories. Yersiniosis becomes primarily manifest as gastroenteritis caused by Yersinia enterocolitica or as pseudoappendicitis caused by Yersinia pseudotuberculosis and requires antibiotics only in severe septic cases. Different extraintestinal symptoms may be observed in dependence on the patient's HLA type and gender. The ubiquitous germ is mainly transmitted by the fecal-oral route via infected domestic or farm animals and contaminated food. The relevant virulence factors are encoded on a 70 kB plasmid common to all Yersinia species and strains that are human pathogens. The most important tools for laboratory diagnosis are culture from suitable body fluids and serological detection of specific antibodies. The infection rate among healthy individuals in Europe in terms of percentage of elevated IgA or IgG titers has been quoted to be 3-40% in different investigations but does not significantly correlate to direct bacteriological detection.

Brown's syndrome diagnosed following repair of an orbital roof fracture: a case report

The upgaze deficit of Brown's syndrome differs from the upgaze deficit of an orbital floor fracture with entrapment. In Brown's syndrome, the upgaze limitation is most evident in adduction of the eye. This difference may be difficult to establish at times, particularly beneath the periorbital edema of an acute traumatic injury. Nevertheless, it is important to recognize this differentiation, since the approach to management of these two clinical entities is distinctly dissimilar. Brown's syndrome is produced by restriction of the superior oblique muscle tendon, usually in the region of the trochlea. In the course of describing a case of Brown's syndrome, recognized following the repair of an orbital roof fracture, issues related to etiology, diagnosis, and management are discussed. In the case presented, surgical repair of the left eye was performed.

Electroconvulsive Therapy: A German Perspective

A survey was undertaken in 1986 to provide reliable information on the present status of electroconvulsive therapy (ECT) in the Federal Republic of Germany (FRG). ECT was used in 26% of the state mental hospitals, 40% of the psychiatric departments of general hospitals, and in 78% of university hospitals. The number of treatment courses applied was low, with about 500 patients receiving ECT in 1985. The indications for ECT and patterns of administration appeared similar to those of other countries, although unilateral electrode placement was prescribed infrequently. The low use of ECT in the FRG (0.08/10,000 population) cannot be related to the attitudes of senior psychiatrists toward ECT, because the attitudes appear to be rather favorable. The majority maintained that indications for ECT exist and that every psychiatric hospital with comprehensive treatment facilities should offer this treatment. ECT usage seems to be partly determined by nonmedical factors, in particular, the recent attacks against psychiatry and ECT in the media. To correct the consequences of such attacks, the merits of ECT should become better known.