Retroperitoneal Leiomyosarcoma Associated with an Elevated beta-HCG Serum Level Mimicking Extragonadal Germ Cell Tumor

Patient. A 65-year-old man was admitted with a large primary retroperitoneal tumor and an increased β-human chorionic gonadotropin (β-HCG) serum level. A germ cell tumor was suspected; however, a computed tomography-guided biopsy failed to enable tumor classification. After two courses of chemotherapy, the β-HCG serum level had returned to the normal level and a diagnostic laparotomy with incisional biopsy was performed. The immunohistochemical examination of the specimen identified the tumor as a retroperitoneal pleomorphic leiomyosarcoma.

Discussion. Tumor markers play only a marginal role in the work-up of patients with soft tissue sarcomas. In men with suspected retroperitoneal sarcomas, however, the determination of germ cell tumor markers occasionally enables a preoperative distinguishing of primary retroperitoneal germ cell tumors with considerable consequences for management. In this setting, a retroperitoneal tumor associated with a moderately elevated β-HCG is a diagnostic dilemma, and surgeons should be aware of the pitfall of a β-HCG-producing leiomyosarcoma in the differential diagnosis.

Durable complete remission of metastatic sarcomatoid carcinoma of the bladder with cisplatin and gemcitabine in an 80-year-old man

A patient with a durable, complete, local and pulmonary remission of a metastatic sarcomatoid carcinoma of the bladder treated with gemcitabine and cisplatin is presented. Sarcomatoid carcinoma arising in the bladder is a rare and notoriously aggressive variant of urothelial carcinoma for which an effective systemic treatment has not been reported up to now.

Malignant fibrous histiocytoma of the ileum at a site of previous surgery: report of a case

Sarcomas rarely arise in the intestinum, and leiomyosarcoma represents the majority of cases. With only seven cases reported in the available English literature up to now, malignant fibrous histiocytoma of the small intestine is exceedingly rare. Moreover, follow-up data are almost completely unavailable. We present herein the unique case of a malignant fibrous histiocytoma arising in a postoperatively adherent intestinal loop. To the best of our knowledge, this is the first such case ever to be described. The clinical history and the intraoperative findings suggested that chronic postoperative repair processes might have been a promoting factor in the tumorigenesis of this neoplasm, on the analogy of malignant fibrous histiocytoma arising at different sites. The patient recovered well but 9.5 years after surgical removal, a solitary recurrent tumor developed in the urinary bladder and progressed rapidly, highlighting the need for long-term, possibly life-long, surveillance of patients with this rare type of intestinal cancer.

Therapeutic drug monitoring of clozapine in relapse prevention: a five-year prospective study

Twenty-three outpatients with schizophrenia (ICD-10 F20.xx) treated with clozapine (CZ) as monotherapy entered a prospective study on relapse prevention. Every 4 weeks, psychopathology was assessed by the Brief Psychiatric Rating Scale (BPRS), and plasma CZ and norclozapine levels were measured. Patients were enrolled after complete remission of positive symptoms for at least 4 months according to the psychosis cluster of the BPRS and at a mean of 3.3 years after their last hospitalization. At the time of enrollment, the median BPRS total score was 29 points (range, 19-48). Within 4 months, the baseline CZ plasma level was established as the mean of CZ levels from at least four subsequent measurements. These baseline plasma levels were considered as the optimal relapse-preventing plasma CZ levels in the individual patients. When the patients were enrolled, they were considered to be prone to relapse. Relapse was defined as clinical deterioration, hospitalization, or both. Plasma levels were considered a prognostic factor, and patients were defined as at increased risk if plasma levels decreased by more than 40% from baseline CZ plasma level. The effect of plasma CZ levels on clinical outcome was evaluated by a Cox regression with plasma level as a time-dependent covariate. Within 46 months of enrollment, 32 episodes of relapse events in 10 patients were available for evaluation. Seventeen patients had a plasma level decrease of more than 40% at some point. In 12 of these, the decrease was present for more than 12% of the observation period. Eight patients of this group relapsed, and three of these had to be rehospitalized. Two patients relapsed, although their plasma levels decreased by more than 40% for less than 12% of the observation period. Within the first 2 years, relapse-free survival curves illustrate that both groups (episodes under elevated risk and episodes not under elevated risk) had identical relapse patterns, but from then on the relapse risk increased rapidly in the group with longer exposure to elevated risk. In a Cox model with a 40% decrease of plasma CZ levels as a dichotomous time-varying explanatory covariate, the risk ratio is 6 (95% confidence interval = 2-19, p = 0.003). The 10 patients who relapsed exhibited safe plasma levels (less than a 40% decrease from their baseline levels) for only 210 months, and 13 nonrelapsing patients had plasma levels defined as safe for 426 months.

Relevance of liver enzyme elevations with four different neuroleptics: a retrospective review of 7,263 treatment courses

Data on liver enzyme elevations were collected in a retrospective study of 7,263 treatment courses with haloperidol, clozapine, perphenazine, and perazine. Charts of 233 patients hospitalized between 1980 and 1992 at Tübingen University Psychiatric Clinic were selected because clinically relevant increases of liver enzymes had been detected during monotherapy with one of the four examined neuroleptics. At least one hepatic enzyme (mostly alanine aminotransferase [ALAT]) exceeded the established reference range of 3-fold elevations of ALAT, aspartate aminotransferase, gamma-glutamyl transpeptidase, and glutamate dehydrogenase and 2-fold elevations of alkaline phosphatase (AP) during monotherapy with clozapine in 15%, perazine in 7.6%, perphenazine in 4%, and haloperidol in 2.4% of the cases. If all liver enzyme abnormalities with any elevation greater than the conventional upper limits are considered, incidences were as follows: clozapine, 78%; perphenazine, 62%; perazine, 59%; and haloperidol, 50%. Testing for overall differences within the four neuroleptics resulted in significantly different incidences of liver enzyme elevations (chi2 test,p < 0.0001). Threefold increases of AP (>540 U/L) were seen in three patients receiving haloperidol (0.3%) only. Twofold increases of AP (>360 U/L) were distributed as follows: clozapine, 1%; haloperidol, 0.8%; perazine, 0.3%; and perphenazine, 0.1%. Only in the group with 1-fold elevations of AP (>180 U/L) were the differences within the drug regimens significant (clozapine, 40.3%; haloperidol, 33.2%; perphenazine, 23.4%; and perazine, 23.1%; chi2 test, p < 0.0001). In the period under study, no instance of icterus occurred.

[Secondary high-grade MALT lymphoma of the stomach in a 69-year-old patient with gastrocolic fistula]

A 69-year-old man was referred to our department with an exorbitant foetor ex ore, dysphagia and dyspepsia. Upper endoscopy had been performed prior by an outpatient gastroenterologist and the patient had received an eradication therapy for a Helicobacter pylori-induced gastritis. At admission upper endoscopy showed a gastric ulcer which drained a stinking fluid. Endosonography, computed tomography and an upper gastrointestinal series with water soluble media revealed a gastrocolic fistula. Multiple biopsies showed a low-grade gastric MALT lymphoma. Therefore, a surgical reconstruction with Roux-en-Y esophagojejunostomy and transverso-descendostomy was performed. The histology of the completely removed stomach revealed a high-grade Non Hodgkin Lymphoma (NHL) with parts of a low-grade NHL. 3 weeks after surgery chemotherapy was started with the CHOP-regime which was well-tolerated by the patient.

Ectopic submandibular thyroid tissue with a coexisting active and normally located thyroid gland: case report and review of literature

Ectopic thyroid tissue in the submandibular space with the thyroid gland in its normal location is an extremely rare phenomenon. We present a case of a 75-year-old woman who had painless swelling in the left submandibular space and was referred to our hospital with the suspicion of having a malignant tumor originating from the submandibular gland. Histologic examination showed normal follicular thyroid tissue without any sign of malignancy. In general there are 3 explanations for the presence of ectopic thyroid tissue found in the submandibular region: (1) displacement during the course of embryonal development, (2) spread of tissue during surgery on a normally located thyroid gland, and (3) metastasis of a highly differentiated papillary thyroid carcinoma. We reviewed the literature with respect to the embryological background and the clinical management of such cases.

[An unusual picture of insulinoma in type-2 diabetes mellitus and morbid obesity]

HISTORY AND CLINICAL FINDINGS

Marked hyperinsulinism was demonstrated in the course of an oral glucose tolerance test (oGTT) in a 63-year-old woman with severe obesity (height 1.59 m, body weight 123 kg, body-mass index 46.4 kg/m2). The diabetic metabolic state, first diagnosed 12 years ago, had been replaced by a low plasma glucose level: she often had attacks of ravenous hunger. A reducing diet of 800 kcal had not been tolerated. She had not had any syncopes. She had continually gained weight since puberty, but her weight had remained relatively constant for the past 5 years during which she had been treated with L-thyroxine for a diffuse goitre (stage II).

INVESTIGATIONS

In the course of an oGTT (75 g glucose) the basal insulin concentration (146 pmol/l) had risen to 1663 pmol/l at 30 min. The basal proinsulin level was 50 times normal (66 pmol/l vs. 1.418 pmol/l), while the initial plasma glucose level had fallen from 4.3 mmol/l to 3.8 mmol/l. Spiral computed tomography of the pancreas showed a 3 x 2.5 cm mass in the region of the tail of the pancreas.

TREATMENT AND COURSE

At laparoscopy a 4 cm tumor was palpated in the region of the pancreatic tail. Left resection of the pancreas was performed. Histopathological examination of the surgical specimen confirmed an insulinoma. A repeat of oGTT 6 months postoperatively demonstrated a markedly diminished insulin level compared with the preoperative results, as well as a diabetic metabolic state.

CONCLUSION

In case of dramatic improvement of diabetes mellitus in an obese patient without drug treatment or weight reduction an insulin-producing tumour should be considered in the differential diagnosis. There may be no typical hypoglycaemic symptoms because of insulin resistance associated with the obesity.

Spontaneous regression of hepatocellular carcinoma confirmed by surgical specimen: report of two cases and review of the literature

Two cases with spontaneous regression of a histologically confirmed hepatocellular carcinoma (HCC) are presented. This rarely seen phenomenon of a spontaneous tumor involution is discussed and compared with the current literature. The clinical symptoms were very similar to that of a liver abscess. A 56-year-old male suffered from a multicentric, highly differentiated, trabecular HCC. First symptoms were epigastric pain, septic fever and arthritis. The tumor marker AFP was constantly normal and no hepatitis could be verified. A resection of the tumor was performed. In patient 2, a 74-year-old male, a multicentric, clear cell HCC was found. The patient had completely recovered from hepatitis type B and within the liver tissue no viruses could be identified. Clinical symptoms were mainly characterized by upper abdominal pain and septic fever. AFP was excessively elevated (3850 ng/ml) but returned to normal preoperatively. In both cases, the specimen showed a subtotal necrotic HCC with insignificant amounts of vital tumor cells. Neither patient had a liver cirrhosis macroscopically, however patient 2 had local periportal fibrosis histologically. After 24 and 41 months of follow-up, respectively, both patients are in good health

Pharmacokinetics of clozapine and its metabolites in psychiatric patients: plasma protein binding and renal clearance

AIMS

N-Desmethylclozapine and clozapine N-oxide are major metabolites of the atypical neuroleptic clozapine in humans and undergo renal excretion. The aim of this study was to investigate to what extent the elimination of these metabolites in urine contributes to the total fate of clozapine in patients and how they are handled by the kidney.

METHODS

From 15 psychiatric patients on continuous clozapine monotherapy, blood and urine samples were obtained during four 2 h intervals, and clozapine and its metabolites were assayed in serum and urine by solid-phase extraction and h.p.l.c. Unbound fractions of the compounds were measured by equilibrium dialysis.

RESULTS

The following unbound fractions in serum were found (geometric means): clozapine 5.5%, N-desmethylclozapine 9.7%, and clozapine N-oxide 24.6%. Renal clearance values calculated from unbound concentrations in serum and quantities excreted in urine were for clozapine on average 11% of the creatinine clearance, whereas those of N-desmethylclozapine and clozapine N-oxide amounted to 300 and 640%, respectively. The clearances of unbound clozapine and N-desmethylclozapine increased with increasing urine volume and decreasing pH. All renal clearance values exhibited large interindividual variations. The sum of clozapine and its metabolites in urine represented on average 14% of the dose.

CONCLUSIONS

Clozapine, N-desmethylclozapine and clozapine N-oxide are highly protein-bound in serum. Clozapine is, after glomerular filtration, largely reabsorbed in the tubule, whereas the metabolites undergo net tubular secretion. Metabolic pathways alternative or subsequent to N-demethylation and N-oxidation must make major contributions to the total fate of clozapine in patients.

Elevated norharman plasma levels in alcoholic patients and controls resulting from tobacco smoking

Plasma norharman and harman levels were measured by solvent extraction and HPLC with fluorescence detection in alcohol-dependent patients undergoing in-patient abstinence treatment and in control subjects. In both groups, randomly collected samples from smokers contained higher mean norharman levels than those from non-smokers. In three volunteers norharman concentrations rose sharply after smoking of one or two cigarettes and declined to near-basal levels within one hour after one cigarette. When 12 patients kept a smoking-free interval of at least 6 h, they had similarly low plasma norharman concentrations (20 +/- 8 pg/ml) as 18 non-smoking control subjects (17 +/- 8 pg/ml) or as 13 smoking controls who had abstained from smoking (20 +/- 6 pg/ml). Ten of the patients smoked one cigarette and within 5-10 min attained norharman levels of 177 +/- 147 pg/ml plasma. The high prevalence of smokers among chronic alcoholics probably explains the previous finding of elevated norharman plasma levels in these patients.

Haloperidol and lorazepam combined: clinical effects and drug plasma levels in the treatment of acute schizophrenic psychosis

In 61 acute schizophrenic patients the effects of haloperidol (HPL) and lorazepam combined vs. HPL alone and the interaction between these drugs were evaluated. Patients were assigned to groups randomly. The study design was open. Study duration was 28 days. Psychopathology was evaluated on the basis of BPRS scores. Extrapyramidal side-effects were rated according to Simpson and Angus (1970). Pharmacological parameters included serum levels of lorazepam, HPL, and reduced HPL. Mean daily lorazepam dosage was 0.05 mg/kg, mean HPL dosage 0.5 mg/kg. None of the patients treated with lorazepam and HPL achieved better BPRS total or subscores, nor did their condition improve faster than in patients treated with HPL alone. A significant linear relationship between lorazepam serum levels and oral dosage was found, but none between lorazepam serum levels and BPRS total score, subscore reduction, or extrapyramidal side-effects. The authors conclude that beneficial effects of lorazepam in the treatment of acute psychosis are scant and may not justify the risks incurred with routine comedication of lorazepam.

Haloperidol and reduced haloperidol serum levels: correlation with psychopathology in acute schizophrenia

Serum levels of haloperidol (HPL) and reduced haloperidol (RHPL) as well as the RHPL/HPL ratio were determined in 55 acute schizophrenics on oral haloperidol medication and correlated over 28 days with psychopathology and extrapyramidal symptom scores. Linear and nonlinear models of serum concentration and psychopathology were tested at several time points. No single consistent model could be established for either HPL or RPHL. However, when non-parametrical methods are used HPL levels between 10 and 25 ng/ml can be shown to be significantly associated with better outcome during the first three weeks of treatment. RHPL is unsuitable for therapy monitoring, since equilibrium is not reached in the first four weeks of treatment. The RHPL/HPL ratio was found to rise continuously during the study, and it neither separated responders from nonresponders nor did it correlate with clinical outcome.

[Contribution to hypochondrogenesis]

Hypochondrogenesis is one of non-viable skeleton dysplasiae which recently has been delimited as an entity of its own and with its classification between spondylo-epiphysary dysplasia and achondrogenesis. An accurate differential diagnosis requires specialised histo-pathological investigations of the patient's cartilage tissue. Five new observations compared to a classical case of dysplasia spondylo-epiphysaria congenita are added to the references made in literature.

Urinary dolichol--a doubtful marker of alcoholism

The purpose of this study was to replicate the results of Pullarkat and Raguthu and Roine et al. who found elevated levels of urinary dolichol (long-chain 2,3-dihydropolyprenols) in chronic alcoholic patients. We investigated a sample of 21 alcohol-dependent inpatients voluntarily entering detoxification treatment. Urinary dolichol was only slightly increased as compared to 21 healthy controls. When dolichol was related to urinary creatinine no differences between alcoholic patients and controls could be found. Under conditions of confirmed abstinence the slightly elevated levels of dolichol returned to normal within 2 weeks. Compared with the sensitivity of gamma-glutamyltransferase which ranges from 72-85%, the value of urinary dolichol (sensitivity 9-19%) as a biochemical marker of alcoholism must be doubted.

Tolerability and antidepressive effect of brofaromine, a short-acting reversible MAO inhibitor--an open study

The tolerability and antidepressive effect of brofaromine, a selective MAO-A inhibitor was tested in 14 depressive patients. None of the patients showed blood pressure or pulse frequency changes after ingesting tyramine-enriched meals. Four instances of agitation were observed as side effects. In two of these cases, the appearance of paranoid thinking and suicidal tendencies led to premature termination of the study. In 3 cases sleep disturbances, in particular difficulties in falling asleep, were observed. In the test of antidepressive effectiveness (measured on the HAMD-scale) significant improvement was observed from day 14 onwards.

Amisulpride versus haloperidol in treatment of schizophrenic patients--results of a double-blind study

In a double-blind study, 41 schizophrenic patients (ICD, 9th rev.) were divided into two groups. With a flexible dose, twenty patients were treated with haloperidol, twenty-one with amisulpride. With respect to relevant criteria such as age, sex, length and degree of illness, the two groups were comparable. The study was conducted over 42 days. As early as within the first 14 days, both groups showed significant improvement with respect to their psychotic symptoms. When the two groups were compared on the basis of the BPRS subscore for the anxiety-depression syndrome, and the AMDP system subscores for the somatic-depressive syndrome and the hypochondriac syndrome, the amisulpride group showed significantly better results than the haloperidol group. The ratings on the EPS scales of Webster and Simpson revealed significantly fewer extrapyramidal side-effects in the amisulpride group. Psychotic symptoms were improved after both types of treatment. Amisulpride treatment showed better results with regard to depressive symptoms, and less tendency to generate extrapyramidal side-effects.

Validation of a therapeutic plasma level range in amitriptyline treatment of depression

In the course of a double-blind study, 29 depressed patients received amitriptyline 150 mg/day for 4 weeks. Scores on the Hamilton Depression Rating Scale were assessed before treatment and after 2 and 4 weeks, and plasma levels of amitriptyline, nortriptyline, and (E)-10-hydroxynortriptyline were monitored weekly. Response reflected by percent reduction of Hamilton Depression Rating Scale score and by final score was better at steady-state amitriptyline + nortriptyline concentrations of 125-210 ng/ml than at lower and higher plasma levels. This applied to the total group and to the subgroup of 22 female patients. The data confirm the results of a previous study performed in the same hospital. An influence of the (E)-10-hydroxynortriptyline concentration in plasma on therapeutic outcome was not discernible. The results suggest that plasma level monitoring may be helpful when patients do not respond to conventional amitriptyline doses.

Side effects of clozapine

In addition to the low risk of agranulocytosis, several more frequent side effects are associated with clozapine therapy. We tried to estimate the incidence of these side effects. We analysed 391 treatments in 315 inpatients, who received clozapine alone or combined with other neuroleptic and antidepressant drugs. Two thirds were combined treatments, one third were treatments with clozapine alone (i.e., no other neuroleptic, antidepressant or anticonvulsive drugs were allowed). The numbers in brackets show the incidence based on the analysis of the treatments with clozapine alone. In 49% (61%) of the treatments a rise in the liver enzyme values was observed. However, counting only the cases in which a two-fold increase over the normal values was observed, the incidence was reduced to 20% (31%). Increase in temperature was observed in 4% (6%) and leukopenia (leukocyte count under 3500/microliters) was recorded in 2% (2%). Hypotensive dysregulation (systolic blood pressure under 90 mm Hg) was observed in 25% of all treatments and pharmacogenic delirium in 8%. No cases of agranulocytosis were observed. Mean treatment duration was 56 days, mean daily dosage 257 mg. The mean age of the patients was 34 years. In the overall evaluation 71% of the treatments were classified as successful; clozapine therapy was continued after discharge in 68% of the treatments. Adverse reactions (delirium, rise in temperature, hypotension, fatigue, rise in liver enzymes) necessitated a change of medication in 17% of the treatments. Changeover to another neuroleptic drug due to ineffectiveness of clozapine was necessary in 7% of the treatments.(ABSTRACT TRUNCATED AT 250 WORDS)

Single-dose kinetics of the neuroleptic drug perazine in psychotic patients

Eight male and two female unmedicated psychotic patients received 100 mg perazine orally and seven blood samples were taken within 25 h. Plasma levels of perazine and its demethylated metabolite were analyzed by HPLC with electrochemical detection. They exhibited large interindividual variations, with maximal concentrations as well as AUC values of perazine differing more than 10-fold. From the decay of plasma levels during the last 12-18 h half-lives were estimated to be between 7.5 and 10 h; they did not correlate with AUC. There was a significant positive correlation between AUC and age. Desmethylperazine was consistently present at lower concentrations than the parent drug during the first 12 h.

[The anxiolytic action of phenoxypropanolamine derivatives in comparison with propranolol, diazepam and placebo]

The hypothesis that the phenoxypropanolamine derivative CGP 361 A possesses anxiolytic activity was examined in 80 female healthy volunteers. Each volunteer received the treatment under double-blind conditions as part of a 1-way analysis of variance design. The medication factor had 4 levels (CGP 361 A, propranolol, diazepam and placebo). Stress was induced by asking subjects to deliver a free speech in front of a video camera. The anxiety was measured using adjectives list, state-trait-anxiety inventory and visual analogue scales. The physiological equivalents observed were pulse rate and skin resistance. The results support the hypothesis that a single dose of 10 mg CGP 361 A has a higher anxiolytic effect than 10 mg propranolol, 5 mg diazepam and placebo, with the peripheral beta-blocking effects (established by pulse rate) being no stronger than with propranolol. No subjective or objective sedation has been determined under the different drug conditions.

[Serum levels of pyridostigmine in myasthenia gravis: methods and clinical significance]

Correlation studies on patients with myasthenia gravis are reported in which clinical assessment of fatigue and neurophysiological findings are compared to blood levels of pyridostigmine. Measurements using a high-pressure liquid chromatography method (HPLC), give reproducible results. The levels of pyridostigmine in the serum or plasma of healthy controls and of patients show no essential differences. Components of coffee, tea, chocolate and cigarettes can markedly disturb the chromatography by adding additional peaks, so that interpretation becomes difficult or impossible. Blood levels can be measured approximately one hour after oral intake of 60 mg pyridostigmine. Concentrations rise for two to four hours and then decline exponentially. The half-life of pyridostigmine was between 156 and 210 minutes. Despite identical oral dosages, the concentration differed intraindividually and interindividually among patients. While the blood level does not reach its maximum value for 1-1 1/2 to 3 hours, the maximum clinical and neurophysiological effect of pyridostigmine appears 30-60 minutes after ingestion. Variable distribution of cholinesterase inhibitors over the different compartments (blood, synaptic region) is assumed to cause this temporal lag. If the total amount of pyridostigmine is divided into 4-5 doses, the concentration profiles over the course of a day are relatively stable. There is no significant correlation between the variations in blood level throughout one day, and changes in myasthenic symptomatology. Effects of pyridostigmine can be measured at levels as low as 5 ng/ml; at levels above 40 ng/ml further improvement can be detected only rarely. Blood levels were lower if corticosteroids were administered simultaneously; azathioprine had no influence on blood levels. Blood levels assays allow better differentiation of cholinergic and myasthenic crises and the identification of disturbed absorption and interactions with other medications.

[Perazine-induced agranulocytosis--case report and discussion]

A 22-year-old female patient developed agranulocytosis 26 days after starting single agent treatment with perazine. In accordance with the clinical and hematological picture this agranulocytosis is classified as antibody mediated with destruction of peripheral neutrophils. After cessation of perazine treatment and proper therapy of infection the patient recovered within two weeks. The diagnosis of agranulocytosis should be suspected in anyone on neuroleptic treatment who develops fever, malaise or objective evidence of an infection and in neutropenic patients the adequate treatment should be started immediately.

Amisulpride--an open clinical study of a new benzamide in schizophrenic patients

In pharmacological screening amisulpride produces no catalepsy, no inhibition of stereotypic movements, yet a blockade of drug-induced vomiting. During an open clinical trial lasting 4 weeks, 14 patients (13 schizophrenics) were treated with the compound. The (BPRS-) syndromes anxiety/depression, thought disorder, activity, hostility and the global score showed significant improvement. With the AMDP system significant changes were seen in the paranoid-hallucinatory, manic, depressive and hostility syndromes as well as in the global score. No changes were revealed in anergia (BPRS) and apathia (AMDP). In the EEG a significant decrease in the frequency of alpha-rhythms was found. The scores of the Simpson-scale for extrapyramidal side effects were low, but there was an acute dystonic reaction in one patient. In three cases akathisia occurred; biperiden administration was necessary three times. In conclusion, amisulpride showed good antipsychotic efficacy without sedation. Contrary to expectations based on the pharmacological screening, we did find extrapyramidal side effects.

[Effects of neuroleptics on liver function, the hematopoietic system, blood pressure and temperature regulation. Comparison of clozapine, perazine and haloperidol by evaluating medical records]

The frequency of disturbances of the liver function, of leucopoiesis, blood pressure and temperature regulation under clozapine in comparison with perazine and haloperidol in 478 patients (partly being treated repeatedly) was investigated by means of case histories of the Psychiatric Clinic of Tübingen from October 1974 up to June 1978. Within the time of the investigation no case of jaundice arose, however non-symptomatic increases of the liver values could be observed. The three drugs did not differ in this respect. Within the time of the investigation no case of agranulocytosis was observed. Only one leucopenia under clozapine, one under perazine, and six under haloperidol occurred. Concerning cardio-vascular effects of the neuroleptic medication, in 4.1% of the patients under clozapine therapy, 4.3% under haloperidol therapy and 10.3% under perazine therapy hypotension could be observed. Under clozapine 15.2% of the patients showed a rise of temperature, under perazine 3.2% and under haloperidol 2.8% of the patients. 83.3% of cases with elevated temperature under clozapine occurred during the first two weeks of treatment.

Diurnal variation of urinary MHPG in unipolar and bipolar depressives

In eight bipolar depressives, 11 unipolar depressives, and 15 healthy controls urinary excretion of MHPG was measured at 3-h intervals over one 24-h period. Bipolars excreted smaller amounts of MHPG than unipolars and controls, especially at night. MHPG excretion was significantly dependent on time of day in the control group only. In the patients maximum excretion showed a tendency to occur earlier in the day than in controls. Minima were unaffected. There were indications that tricyclic antidepressants advance MHPG phases.

Response to maprotiline treatment in depressive patients relationship to urinary MHPG excretion and plasma drug level

In 20 patients with primary depression the urinary excretion of 3-methoxy-4-hydroxyphenylglycol (MHPG) was determined prior to a 4-week treatment with maprotiline 125 mg/day. Reliable data were available from 16 patients and averaged 1.35 mg/24 h. There was a trend towards a negative relationship between MHPG excretion and clinical improvement as reflected by the percent reduction in Hamilton scale scores. Responders, defined as those patients with a final score of less than or equal to 6, excreted less MHPG than partial or non-responders. Plasma maprotiline levels exhibited a significant increase between treatment days 14 and 28. They did not show a significant relationship to the reduction of total Hamilton scale scores. However, final scores of symptoms pertaining to depressive retardation were significantly higher in patients with low (less than 75 ng/ml) or high (greater than 150 ng/ml) plasma levels than in those with levels in an intermediate range.

Circadian course of body temperature and the excretion of MHPG and VMA in a patient with bipolar depression

A 38-year old woman with a bipolar affective disorder was examined for 10 days during a serious retarded depression phase and for 10 days during the subsequent symptom -free interval. During depression the MHPG-excretion showed a significantly shorter circadian periodicity of 20.5 hours, whereas the periodicity of body temperature and VMA amounted to 24 hours. During the symptom-free interval the circadian periodicity of all parameters was 24 hours. These results indicated that the depression phase of a bipolar affective disorder in this patient is related to a desynchronization of central NA function with peripheral NA activity and body temperature.

Plasma levels, psychophysiological variables, and clinical response to amitriptyline

Hamilton depression scale ratings and physiological measurements were made for 37 patients with primary depression before treatment with amitriptyline (150 mg/day) and again after 2 and 4 weeks of treatment; plasma drug levels were determined weekly. Improvement was maximal at mean amitriptyline + nortriptyline concentrations of 125-200 ng/ml (14 patients), while at lower levels the outcome was significantly poorer (12 patients). Highly variable results were seen in 11 patients with levels between 200 and 301 ng/ml, with lesser improvement occurring in those patients who exhibited poor habituation of the skin resistance response before treatment. Other psychophysiological variables showed significant changes during treatment, but no correlation with clinical results or drug levels.

Plasma protein binding of perazine and amitriptyline in psychiatric patients

The free fraction of amitriptyline (AT), measured by equilibrium dialysis in plasma from 29 AT-treated depressed patients, was 5.4-9.8% (mean 7.7%), which was the same as the values in 26 healthy controls (4.9-9.6%, mean 7.6%). The plasma levels of lipoproteins, as reflected by total cholesterol, and of alpha 1-acid glycoprotein (alpha 1-AGP) did not differ between the two groups. the free fraction of AT in both exhibited a significant negative correlation with the concentrations of those two proteins. The unbound fraction of perazine (PER) was the same (3.1-5.9%, mean 4.4%) in plasma from 22 schizophrenic patients and from 24 healthy volunteers (2.9-6.0%, mean 4.5%). However, in patient plasma alpha 1-AGP was significantly higher (mean 1.07 vs 0.81 mg/ml) and total cholesterol tended to be lower (mean 173 vs 201 mg/100 ml) than in plasma from normals. In consequence, the free fraction of PER was negatively correlated with the alpha 1-AGP concentration in plasma from patients and with the cholesterol level in plasma from control subjects; the other correlations were not significant. In 7 patients, the alpha 1-AGP level was normal prior to Per treatment. Serial blood samples from 6 patients revealed a consistent elevation of alpha 1-AGP above its pretreatment level during 4 weeks of PER administration in 5 of the subjects and a transient increase in one other. while low lipoprotein levels in schizophrenics seem to be a disease-related trait, the increase of alpha 1-AGP may be a drug effect.

Antidepressive effect and pharmacokinetics of amitriptyline with consideration of unbound drug and 10-hydroxynortriptyline plasma levels

In 27 inpatients with primary affective disorder the urinary excretion of 3-methoxy-4-hydroxyphenylglycol (MHPG) was measured prior to a 4-week treatment with 150 mg amitriptyline (AT)/day. Ratings according to the Hamilton depression scale were performed before therapy and repeated after 2 and 4 weeks. Plasma levels of AT, nortriptyline (NT), and E-10-hydroxynortriptyline (OHNT) were assayed weekly, and binding of AT to plasma proteins was determined in one sample. Better therapeutic results were obtained at intermediate, as compared to low and high concentrations of AT or AT plus NT. Independent evaluation of AT and metabolite levels revealed that patients with AT of 50--125 ng/ml responded particularly well when NT did not exceed 95 ng/ml or when NT plus OHNT was below 150 ng/ml. Outside this "therapeutic window' the outcome was markedly poorer. Interindividual variation of AT binding was much smaller than variation of total concentrations. Evaluation of free, instead of total levels did not help to clarify the relationship between clinical and pharmacokinetic variables. Plasma levels within the optimal ranges were found in more patients with high than with low MHPG excretion. The free fraction of OHNT in plasma of healthy subjects was about 35%.

Do urinary MHPG and plasma drug levels correlate with response to amitriptyline therapy?

Twenty-nine inpatients with primary affective disorder were treated with 150 mg amitriptyline (AT) daily for 28 days. Pretreatment urinary excretion of 3-methoxy-4-hydroxyphenylglycol (MHPG) was measured in two or three 24-h urine samples. Plasma levels of AT and nortriptyline (NT) were determined after 14, 21, and 28 days of treatment. MHPG excretion was significantly correlated with clinical response to treatment. Responders defined by two different methods showed higher pretreatment MHPG excretion than nonresponders. Correspondingly, high MHPG excretors (median split) showed significantly more improvement than low excretors. These relationships were even more apparent when possibly incomplete urine samples (creatinine excretion below 1000 mg/24h) were excluded. The high and low MHPG subgroups did not significantly differ from each other in their plasma levels of AT, NT, or AT plus NT. A significant rank correlation between clinical response and plasma levels of AT and/or NT did not exist, but there was a trend towards lower levels in responders.

Acathisia-syndrome: involvement of noradrenergic mechanisms

The involvement of noradrenergic mechanisms in patients suffering from acathisia was investigated by determination of urinary night-time 3-methoxy-4-hydroxy-phenyl glycol (MHPG)-excretion and was compared both with control patients matched according to age and sex and healthy individuals. A significantly reduced MHPG excretion was found among the acathisia patients. It is suggested that a supersensitivity of the spinal noradrenergically innervated receptors caused by their long-term blocking is responsible for occurrence of the symptoms.

4-methoxy-3-hydroxyphenylglycol as an internal standard for the determination of 3-methoxy-4-hydroxyphenyglycol in urine: results obtained in depressed patients and healthy controls

A modification of the method developed by Dekirmenjian & Maas (1970) Anal. Biochem. 35, 113-122) is described for the determination of 3-methoxy-4-hydroxyphenylglycol in urine. The use of 4-methoxy-3-hydroxyphenylglycol as an internal standard improves the accuracy, simplicity and reproducibility. Therefore, the method is suitable for routine determination in laboratories without gas chromatography/mass spectrometry equipment. Some results obtained in depressed patients and healthy controls are presented.

Tissue metabolites of trifluorperazine, fluphenazine, prochlorperazine, and perphenazine. Kinetics in chronic treatment

Repeated oral treatment of male rats with piperazine-substituted phenothiazine drugs in doses of 25 mg/kg or more daily led to an accumulation of metabolites containing an ethylenediamine group instead of the piperazine ring. These products of ring degradation with and without removal of the N-alkyl group were found, together with the parent drugs and their N-dealkylated metabolites, in liver, lung, kidney, and spleen, as well as in brain when high doses were administered. After termination of treatment, the ethylenediamine derivatives were eliminated more slowly than were their congeners containing the intact piperazine ring. Parallel observations were made in dogs given fluphenazine in daily doses of up to 40 mg/kg. Quantitative differences were observed in the relative amounts of mono- and disubstituted ethylenediamine metabolites accumulated in rat tissues during treatment with the various drugs; the proportion of the monosubstituted product formed by N-dealkylation and ring cleavage declined in the following order: perazine, prochlorperazine, trifluoperazine, fluphenazine, perphenazine. Condensation products of the ethylenediamine derivatives with formaldehyde were split in the extraction procedure used.