C. Mayer

Artifizielle Störungen – Zwischen Täuschung und Selbstschädigung Konsiliarpsychiatrische Erfahrungen an einem Universitätsklinikum

ZusammenfassungWährend eines 18-Jahres-Zeitraums wurden im psychiatrischen Konsiliardienst eines Universitätsklinikums 93 Patienten (w=76, m=17) mit einer artifiziellen Störung identifiziert (Inzidenz: 0,62%). 50% der Frauen waren in medizinischen/pflegerischen Berufen tätig gegenüber nur 6% der Männer. Es handelte sich mehrheitlich um chronische Krankheitsverläufe, wobei aber bei ca. einem Viertel der Patientinnen ein intermittierender Verlaufstypus vorlag. In 11% imponierte ein klassisches „Münchhausen-Syndrom”. An psychiatrischer Komorbidität bestand bei 10% bzw. 4% der Frauen eine depressive bzw. eine Angststörung. In je ca. der Hälfte der weiblichen und männlichen Patienten wurden eine relevante Sexualstörung sowie ein Suchtproblem berichtet. Bei ca. einem Viertel der Patienten bestand neben der artifiziellen Störung auch eine genuine somatische Krankheit; ca. ein Drittel der Frauen zeigten zudem eine psychosomatische Krankheit, speziell Eßstörungen. In der Krankheitsanamnese fiel der hohe Prozentsatz von früheren somatoformen Störungen, offenen Selbstbeschädigungen und Suizidversuchen auf. Eine traumatisierende frühe Biographie mit emotional depravierenden Heimaufenthalten, hoch konflikthaftem häuslichem Milieu, körperlichem und sexuellem Mißbrauch, frühen Objektverlusten, prägenden Krankheitserfahrungen war häufig. Eine vielschichtige aktuelle Auslösesituation konnte für eine Mehrzahl der Patienten eruiert werden. Eine Diskussion der Ergebnisse erfolgt hinsichtlich Epidemiologie, klinischer Phänomenologie und Entwicklung der artifiziellen Störungen, Psychodynamik und Psychopathologie von Täuschung und Selbstschädigung sowie konsiliarpsychiatrischen Interventionsmöglichkeiten.SummaryDuring a 18-year-period 93 patients (f=76, m=17) with a factitious disorder were identified in the psychiatric consultation service of a university hospital (incidence: 0.62%). 50% of women were working in medical professions whereas only 6% of men. Chronic courses of illness were prevailing, but at least one quarter of female patients showed an intermittent type. There was a classical Munchhausen syndrome in 11% of patients. Depressive and anxiety disorders (10%, 4%) were to be respected as psychiatric comorbidity. Ca 25% of the patients suffered from a somatic illness in addition to the factitious disorder, and one third of the women had symptoms of psychosomatic, especially of eating disorders. Previous somatoform disorders, deliberate self harm and attempts of suicide were to be noted in the psychiatric history of many patients. There were frequent traumatizing events (foster home, disturbing family disharmony, physical and sexual abuse, early losses, serious illnesses) in the early biography. Various psychosocial stressors could be identified in the actual eliciting situation. The results are discussed in respect of epidemiology, development and clinical phenomenology of factitious disorders, psychodynamics and psychopathology of deception and self harm, and therapeutic options in the psychiatric consultation service.

Differences in the sensitivity to purinergic stimulation of myelinating and non‐myelinating Shwann cells in peripheral human and rat nerve

Schwann cells of the peripheral nervous system are distinguished by morphological and functional criteria in myelinating and non‐myelinating subtypes. We and others have previously reported that Schwann cells in isolated peripheral human and rat nerve respond to extracellular application of ATP with a rise in the intracellular free calcium concentration [Ca2+]i. In the present study, the receptors mediating these Ca2+ transients have been investigated in myelinating and non‐myelinating Schwann cells of intact fascicles of isolated human sural nerves, rat ventral roots, and rat vagus nerves. Microfluorometry and confocal laser scanning was used on preparations stained with the Ca2+‐sensitive dyes Calcium Green‐1 and Fura Red. In myelinating Schwann cells of human and rat nerves, the ATP‐induced rise of [Ca2+]i resulted from the activation of a P2Y2 purinoceptor subtype (rank order of potency: UTP ≥ ATP ≫ 2‐MeSATP = ADP). In contrast, in non‐myelinating Schwann cells, Ca2+ transients were produced by activation of a P2Y1 purinoceptor subtype (rank order of potency: 2‐MeSATP > ATP > ADP ≫ UTP). The P1 agonist adenosine and α,β‐meATP did not evoke Ca2+ signals. Ca2+ transients in both types of Schwann cells were found to be due to Ca2+ release from cyclopiazonic acid‐sensitive intracellular stores. However, inhibition by suramin was only found in non‐myelinating Schwann cells. These findings indicate that mammalian Schwann cells express phenotype‐specific P2Y receptor subtypes. GLIA 23:374–382, 1998.

Confocal calcium imaging reveals an ionotropic P2 nucleotide receptor in the paranodal membrane of rat Schwann cells

1 The paranodal Schwann cell region is of major importance for the function of a myelinated axon. In the present study we searched for a possible ionotropic effect of extracellular ATP in this Schwann cell compartment. 2 Whole‐cell patch‐clamp recordings from cultured rat Schwann cells revealed that ATP and 2′–3′‐O‐(4‐benzoylbenzoyl)‐adenosine 5′‐triphosphate (BzATP) induced a non‐specific cation current. The effect of ATP was much enhanced in a Ca2+‐ and Mg2+‐free solution. ADP, UTP and α,β‐methylene adenosine 5′‐triphosphate (α,β‐meATP) had no effect. 3 Confocal Ca2+ imaging of myelinating Schwann cells in isolated rat spinal roots showed a BzATP‐induced rise in the free intracellular Ca2+ concentration in the paranodal Schwann cell cytoplasm whereas α,β‐meATP and 2‐(methylthio)‐adenosine 5′‐triphosphate were without effect. In contrast to the known metabotropic effect of UTP on these Schwann cell regions, the BzATP‐induced Ca2+ signal was not transient, was unaffected by depletion of intracellular Ca2+ stores and dependent on the presence of extracellular Ca2+. 4 These results suggest that an ionotropic ATP receptor with electrophysiological and pharmacological characteristics of the P2X7 subtype of nucleotide receptors is functionally active in myelinating Schwann cells of peripheral nerves. Such a receptor might contribute to Schwann cell reactions in nerve injury or neuropathy.

Fast excitatory postsynaptic potentials in AH (Type 2) neurons of guinea pig myenteric plexus.

Intracellular studies of electrical activity from myenteric ganglion cells were reported first by Hirst et al. 2 and Nishi and North 4. These authors distinguished two types of myenteric neurons. The first type was referred to as S-neurons by Hirst et al. 2 and as Type 1 by Nishi and North 4. The second type was referred to as AH-cells 2 or Type 2 cells 4. The first type of neuron discharged repetitively throughout intrasomatic injection of depolarizing current and electrical stimulation of presynaptic fibers elicited nicotinic cholinergic excitatory postsynaptic potentials (EPSPs) in these cells ~,4. The second type of neuron was reported to have a higher resting potential, a lower input resistance, to discharge only a single spike at the onset of a depolarizing current pulse and to not receive synaptic input. Action potentials of this second type of neuron were followed by a prolonged hyperpolarizing after-potential which was associated with a decrease in input resistance. Both groups of investigators suggested that the second type of neuron was a sensory neuron because of the apparent absence of synaptic input to the ce111,2, 4. We now present evidence that the second type of neuron (AHor Type 2 cells) does receive synaptic input, and that the earlier suggestion that these cells are sensory neurons is not very likely. Conventional methods, which are described in detail elsewhere 5, were used to record intracellularly from and inject electrical current into myenteric neurons of guinea pig jejunum in vitro. Presynaptic fibers to the neurons were activated by electrical stimulation of interganglionic fiber tracts with electrodes that were fabricated from 20 #m diameter teflon-insulated Pt wire. Stimulus strength was monitored as voltage output from the stimulator. The distance between impaled neurons and the stimulating electrode was 200-500 #m. Drugs to block smooth muscle contractions in response to fiber tract stimulation were not used. Low amplitude EPSPs which were sometimes buried within the noise level of the recording system (0.5-1 mV) were averaged with an Ortec Signal Averager (Model 4623, 4620A), analyzed with a Hewlett Packard 9821A calculator and plotted with a Hewlett Packard 9862A plotter.

Prognostic value of 2D echocardiography in patients presenting with acute chest pain and non-diagnostic ECG for ST-elevation myocardial infarction

The purpose of the present study was to test the hypothesis that early detection of regional wall motion abnormalities (WMA) by 2D echocardiography (ECHO) accurately predicts further cardiac events in patients presenting with acute chest pain. A prospective analysis was performed in subjects admitted with the first presentation of acute chest pain and a non-diagnostic ECG for acute ST-elevation myocardial infarction. Patients with known coronary artery disease were excluded. All subjects were contacted by phone for a 30days follow-up regarding cardiac events defined as PCI/CABG, AMI, and death. In 132 consecutive patients (89 male, 43 female) complete data sets consisting of case history (H; abnormal: typical angina), ECG (abnormal: ST-depression, T-inversion, atypical ST-elevation, LBBB), serum markers (TnI; abnormal: elevation of troponin I=0.5 ng/ml), ECHO (abnormal: WMA) and follow-up were available. In 45 patients, 60 cardiac events occurred (three deaths, 24 AMI, 33 PCI/CABG). Positive (PPV; %) and negative predictive values (NPV; %) of ECHO were superior to all other diagnostic tests (P<0.05 each) for adverse cardiac events, evolving AMI or death, and superior to history and ECG for later need of revascularisation (PCI/ACVB). Multivariate analysis revealed that WMA in ECHO predict cardiac events independently of age, gender, and the common combination of investigations (H/ECG/TnI). A significant independent impact of ECHO was also determined for the prediction of AMI/death or PCI/CABG. The study shows that early 2D echocardiography provides superior prognostic information concerning the risk of subsequent complications in patients with acute chest pain and a non-diagnostic ECG for ST-elevation-AMI.

Intracellular calcium transients mediated by P2 receptors in the paranodal Schwann cell region of myelinated rat spinal root axons.

Receptors for neuroligands in the paranodal Schwann cell region of a myelinated nerve fiber could have important functions. We have used confocal laser scanning microscopy in combination with Ca(2+)-sensitive fluorescent dyes to study the possible effects of purinergic agonists on the free intracellular calcium concentration ([Ca2+]i) in paranodes of isolated rat spinal roots. Application of ATP in concentrations of 100 and 300 microM resulted in a transient rise in [Ca2+]i in about 57% of the paranodal Schwann cell regions studied. UTP was equipotent to ATP whereas adenosine, beta,gamma-methylene ATP, and elevation of the extracellular K+ concentration by 10 mM had no effect on [Ca2+]i. These data indicate the presence of the P2Y2 (previously termed P2U) subtype of P2 receptors in the paranodal Schwann cell membrane of rat spinal root myelinated nerve fibers.

Glucose availability alters ischaemia-induced changes in intracellular pH and calcium of isolated rat spinal roots.

Peripheral nerves in diabetic patients show an enhanced liability to ischaemic lesions. Using an in vitro model, we have now analysed the possible role of intracellular proton (pHi) and calcium concentrations ([Ca2+]i) for the pathophysiology of this phenomenon. Isolated rat spinal roots were preincubated for 3 to 6 h in either 5 or 25 mM of D-glucose before transient exposure to gaseous hypoxia or cyanide. Intracellular pH and Ca2+ concentrations were measured photometrically by means of the fluorescent dyes carboxy-SNARF-1 and a combination of Calcium Green-1 and Fura Red, respectively. The following observations were made. (a) The presence of 25 mM D-glucose resulted in stronger intracellular acidification and much slower post-hypoxic recovery of pHi as compared to 5 mM D-glucose. (b) Intracellular calcium increased during hypoxia and recovered quickly on reoxygenation. There were no statistically significant differences between the Ca2+ signals in either high or normal concentrations of D-glucose, although on average less rise was seen in high glucose. (c) Inhibition of glycolysis with iodoacetate reduced the acidification but amplified the rise in [Ca2+]i seen during transient hypoxia. These data suggest that hypoxia-induced nerve acidification rather than a rise in [Ca2+]i might contribute to ischaemic lesions found in diabetic neuropathy.

P2 purinoceptor-mediated intracellular Ca2+ transients in human sural nerve

Segments of biopsied human sural nerve were stained with the Ca(2+)-sensitive fluorescent dyes Calcium Green-1 and Fura Red. The emission ratio was used to follow changes in the intracellular free Ca2+ concentration ([Ca2+]i). Application of ATP and analogues in concentrations between 0.3 and 300 microM via the bathing solution resulted in a transient rise in [Ca2+]i. The rank order of agonist potency, 2-methylthioATP > ATP > UTP, and the failure of adenosine, alpha,beta-MeATP and beta,gamma-MeATP to evoke rises in [Ca2+]i indicate the presence of P2Y/U subtypes of purinoceptors in this preparation. ATP-induced Ca2+ transients in biopsied human nerve preparations might serve as a diagnostic tool in neuropathies.

Hydrophilic intraocular lens opacification after posterior lamellar keratoplasty - a material analysis with special reference to optical quality assessment

BackgroundLaboratory analysis and optical quality assessment of explanted hydrophilic intraocular lenses (IOLs) with clinically significant opacification after posterior lamellar keratoplasty (DMEK and DSAEK).MethodsThirteen opacified IOLs after posterior lamellar keratoplasty, 8 after descemet stripping automated endothelial keratoplasty (DSAEK), 3 after descemet membrane endothelial keratoplasty (DMEK) and 2 after both DSAEK and DMEK were analysed in our laboratory. Analyses included optical bench assessment for optical quality, light microscopy, scanning electron microscopy (SEM) and energy dispersive X-Ray spectroscopy (EDS).ResultsIn all IOLs the opacification was caused by a thin layer of calciumphosphate that had accumulated underneath the anterior optical surface of the IOLs in the area spared by the pupil/anterior capsulorhexis. The calcifications lead to a significant deterioration of the modulation transfer function across all spatial frequencies of the affected IOLs.ConclusionsThe instillation of exogenous material such as air or gas into the anterior chamber increases the risk for opacification of hydrophilic IOLs irrespective of the manufacturer or the exact composition of the hydrophilic lens material. It is recommended to avoid the use of hydrophilic acrylic IOLs in patients with endothelial dystrophy that will likely require procedures involving the intracameral instillation of air or gas, such as DMEK or DS(A)EK.

Vasoproliferative retinale Tumoren

ZusammenfassungVasoproliferative retinale Tumoren (VPRT) sind gutartige Retinatumoren, deren Ursprung bisher unbekannt und oft mit einer vitreoretinalen Entzündung verbunden ist. Wir stellen den Fall einer 21-jährigen Patientin mit einer akuten einseitigen Visusverschlechterung vor. Inferiortemporal stellte sich eine solide vaskularisierte hellgelbliche Läsion mit begleitender lokalisierter Netzhautablösung und Akkumulation von harten Exsudaten dar. Es lag lediglich ein erhöhter Bartonella-henselae-Titer vor. Bei persistierender Uveitis führten die Antibiose mit Makroliden und die Kryotherapie zu einer erfolgreichen Regression des Tumors.AbstractVasoproliferative retinal tumors are benign tumors of unknown origin often accompanied by vitreoretinal inflammation. A 21-year-old female patient presented with acute reduced unilateral visual acuity. A solid yellow vascularized lesion was present in the inferior temporal retina accompanied by localized retinal detachment and accumulation of hard exudations. The only finding was an increased Bartonella henselae titer. Persistence of uveitis and blurred vision led to therapy for Bartonella henselae with macrolide antibiotics and successful tumor regression was achieved by cryotherapy.