[Somatic disorders in outpatient psychiatry: the added value of a standard physical examination during the intake of outpatients]. / Somatiek in de ambulante psychiatrie: de toegevoegde waarde van een standaard lichamelijk onderzoek tijdens de ambulante intake.

BACKGROUND: It is well-known that psychiatric patients often suffer from severe somatic problems, such as diabetes mellitus and cardiovascular disease. Up till now, research has concentrated almost exclusively on the inpatient setting, but there is strong evidence that the correlation also exists in psychiatric patients who are outpatients. In the Netherlands there are, as yet, no clear recommendations regarding a standard form of somatic screening for the outpatient population. A pilot study performed by GGz Breburg has shown that somatic screening (without a physical examination) gave substantial additional value to treatment planning. AIM: To investigate the added value that a physical examination can provide when new psychiatric patients are screened for aspects of somatic concern (ASC). METHOD: Newly referred outpatients (n = 70) were screened somatically by means of a questionnaire and supplementary medical interview, and by laboratory tests and physical examination. If a somatic problem was found which had not been detected previously, the patient was referred back to to the general practitioner. RESULTS: At least one ASC was found in 81,4% of all patients. In 45,7% of all patients the asc had not been detected. 12% of all the newly discovered somatic problems were found exclusively via the physical examination. CONCLUSION: A physical examination provides substantial information and adds value to the somatic screening of psychiatric outpatients.

Reproducibility of ambulatory blood pressure monitoring in daily practice.

The reproducibility of ambulatory blood pressure monitoring (ABPM) was investigated in 45 untreated hypertensive patients in an out-patient clinic. Subjects with symptoms or diseases which could probably give rise to an increase in blood pressure (BP) variability were excluded. Patients underwent office BP (OBP) measurements and ABPM measurements with the Oxford Medilog device twice. The data were edited following previous set standards. Reproducibility of ABPM was good for the group: 24 h ABPM difference 0/2 mm Hg, standard deviation of the difference (SDD) 12/6 mm Hg for systolic BP and diastolic BP respectively. For OBP the difference between the two visits was 5/2 mm Hg with a SDD of 15/8 mm Hg. Intra-individual reproducibility was poor; almost half of the patients had a systolic difference of more than 10 mm Hg between both ABPM recordings. Reproduciblity of the day-night difference with a BP fall of at least 10% (dipper status) was moderate. About 60% of the subjects were dippers at one of the ABPM recordings but only 42% had a reproducible dip. Possible factors playing a role in the disappointing reproducibility of the ABPM recordings are the difference in daily activities between both recording days, decreased accuracy at higher BP, quality of sleep and the probable lower accuracy of the device during real ambulant conditions. In daily practice ABPM has no better reproducibility than OBP measurements, despite the larger number of measurements.

Aortic graft infection by Lactobacillus casei: a case report.

A 65-year-old man with an abdominal aortic endoprosthesis presented with fever without other symptoms. Investigations revealed Lactobacillus casei bacteraemia. The Lactobacillus graft infection was at first successfully treated by antibiotic therapy. However, during follow-up a relapse occurred, and after surgical replacement of the graft the patient was cured. At surgery an aortoenteric fistula was found as source of the infection.

Chronic meningococcaemia: a case report.

Chronic meningococcaemia (CM), caused by the bacterium Neisseria meningitidis is reported in a 27-year-old Indonesian man. The main symptoms were intermittent fever, skin rash and arthralgia. The pathogenesis, symptoms, differential diagnoses and treatment of CM are discussed.

[Extrapulmonary tuberculosis in 3 Dutch patients]. / Extrapulmonale tuberculose bij drie Nederlandse patiënten.

In three patients, two women aged 71 and 59 years and a man aged 49 who had been living in the Netherlands for a long time and who were admitted because of vague symptoms, extrapulmonary manifestations of tuberculosis were diagnosed: tuberculosis of the lumbar spine with psoas abscess, tuberculous peritonitis and adrenal tuberculosis with Addison's disease in a patient with open pulmonary tuberculosis. All three recovered with tuberculostatic therapy (isoniazid, streptomycin, pyrazinamide and rifampicin).

Forskolin-stimulated adenylyl cyclase activity is decreased but beta 2-adrenoceptor function is unchanged in primary hypertension.

beta 2-Adrenoceptor function may be decreased in primary hypertension, resulting in increased peripheral resistance. To study the beta 2-adrenoceptor function, we used circulating mononuclear leukocytes (MNL) as a model system. Twenty untreated hypertensive subjects [(HT) 10 men and 10 women] and 20 age- and sex-matched healthy normotensive (NT) volunteers were studied. The beta 2-adrenoceptor density was not significantly different between HT and NT, but the dissociation constants for the high- and low-affinity agonist binding states, studied by isoprenaline competition assays, were significantly higher in HT. Stimulation of adenylyl cyclase with isoprenaline (10 microM, beta 2-adrenoceptor-mediated stimulation) was not significantly different between the two groups. Forskolin-mediated direct stimulation of adenylyl cyclase was significantly higher in women than in men. For both sexes, the forskolin-induced cyclic AMP production was lower in the HT group, reaching statistical significance in the men. No major abnormalities were observed in beta 2-adrenoceptor function in mononuclear leukocytes. The putative relation between the decreased forskolin-mediated adenylyl cyclase activity and primary hypertension requires further study.

Adrenoceptors on blood cells in patients with primary hypertension: correlation with blood pressure and related variables.

OBJECTIVE: Alterations in platelet alpha 2-adrenoceptor and mononuclear leucocyte beta 2-adrenoceptor characteristics in primary hypertension have been extensively studied. The results of the reports have not been consistent, possibly because of the small number of subjects in most of the studies. We therefore studied the blood-cell adrenoceptor characteristics in a relatively large group of primary hypertensive and normotensive subjects. DESIGN: Platelet alpha 2-adrenoceptor characteristics were compared in 65 hypertensive and 51 normotensive subjects. Mononuclear leucocyte beta 2-adrenoceptor characteristics were compared in 72 hypertensives and 67 normotensives. Untreated hypertensive subjects were selected from the outpatient clinic and the normotensive controls were recruited by a newspaper announcement. METHODS: Platelets and mononuclear leucocytes were isolated from blood samples obtained after at least 10 min supine rest. The alpha 2- and beta 2-adrenoceptor characteristics were determined with [3H]-rauwolscine and [125I]-(-1)cyanopindolol, respectively. Correlations between the adrenoceptor characteristics and clinical parameters of the subjects were studied. RESULTS: No differences in alpha 2- or beta 2-adrenoceptor densities were observed between the two groups. However, a significantly lower equilibrium dissociation constant for [3H]-rauwolscine was observed in the hypertensive group. The correlations between the adrenoceptor characteristics and clinical parameters were weak and mostly not statistically significant. The results were compared with the most relevant studies in the literature. CONCLUSIONS: From our study and the literature, we conclude that blood-cell adrenoceptor characteristics are unchanged in primary hypertension.

Does treatment with beta-adrenergic blocking agents cause a decrease in beta 2-adrenoceptor affinity?

The effect of beta-adrenoceptor antagonists (BAAs) differing in lipophilicity and partial agonist activity (PAA), and a full agonist, on the dissociation constant for [125I]-(-)- iodocyanopindolol binding to beta 2-adrenoceptors (KD) has been investigated. Twelve healthy, normotensive male volunteers (mean age 22.3 y) were treated with different BAAs according to a cross-over design. The drugs used were propranolol (highly lipophilic BAA, no PAA), pindolol (moderately lipophilic BAA, strong PAA), dilevalol (highly lipophilic BAA, weak PAA) and salbutamol (full agonist). Before and after a single dose and an 8 day course of one of the drugs, blood pressure and the beta 2-adrenoceptor characteristics of mononuclear leukocytes (MNL) were determined. Between the treatment periods, there was a washout interval of 14 days. All BAAs decreased the blood pressure, but only propranolol lowered heart rate. Treatment with salbutamol decreased the diastolic and increased the systolic blood pressure and heart rate. Three hours after the single dose of any of the BAAs, a more than 2-fold increase in KD was observed, and the increase became larger after 8 days of administration (up to 3.7-fold increase). In contrast, no effect on KD was observed after treatment with salbutamol. BAAs with PAA and salbutamol induced a 30% decrease in beta 2-adrenoceptor density. It is concluded that treatment with BAAs, irrespective their lipophilicity or PAA, induces a decrease in the affinity of MNL beta 2-adrenoceptors for antagonists. This phenomenon may help to explain the contradictory relationship between the kinetics and dynamics of BAAs.

Adrenoceptors on blood cells from patients with primary Raynaud's phenomenon.

1. alpha 2-Adrenoceptors on platelet membranes and beta 2-adrenoceptors on lymphocytes were studied in 24 patients with primary Raynaud's phenomenon and in 24 age- and sex-matched control subjects. In two subgroups, a standardized mental arithmetic test and a finger-cooling test were performed. 2. Baseline blood pressure, heart rate and forearm blood flow did not differ between the two groups. 3. Baseline skin microcirculation (laser Doppler flux) was decreased in primary Raynaud's phenomenon (19 +/- 15 arbitrary units) compared with control subjects (33 +/- 14 arbitrary units) (P less than 0.01). 4. Baseline plasma noradrenaline concentration (2.00 +/- 1.44 versus 1.16 +/- 0.36 nmol/l) and alpha 2-adrenoceptor density (301 +/- 119 versus 210 +/- 82 fmol/mg) were increased in patients with primary Raynaud's phenomenon in comparison with the control subjects. The alpha 2-adrenoceptor density/beta 2-adrenoceptor density ratio in patients with primary Raynaud's phenomenon was, with a value of 0.37 +/- 0.04, higher than in the control subjects, where a value of 0.25 +/- 0.02 was measured (P less than 0.001). Plasma adrenaline concentration, beta 2-adrenoceptor density and the antagonist affinity to both receptor subtypes did not differ between both groups under baseline conditions. 5. Whereas during the finger-cooling test no differences were seen in the responses of the parameters measured, the mental arithmetic test induced an increase in laser Doppler flux in patients with primary Raynaud's phenomenon and a decrease in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased bronchial hyperresponsiveness after inhaling salbutamol during 1 year is not caused by subsensitization to salbutamol.

Recently, it was suggested that long-term administration of an inhaled beta 2-agonist might increase bronchial hyperresponsiveness (BHR) to histamine, possibly as a consequence of subsensitization to the inhaled beta 2-agonist. To test this hypothesis, we studied two groups of patients with asthma or with chronic obstructive pulmonary disease. An experimental group of 15 patients, inhaling 400 micrograms of salbutamol four times daily during 1 year and subsequently 40 micrograms of ipratropium bromide four times daily for 6 months, and a control group, consisting of 22 patients with the opposite treatment regimen. The BHR, the response in FEV1 to cumulative doses of salbutamol, and the number of beta 2-adrenoceptors and antagonist affinity of these receptors on circulating lymphocytes were assessed at the start of the study and at 6-month intervals for 1 1/2 years. The BHR increased significantly (p = 0.001) during the year salbutamol was inhaled and returned to about the value at the start of the study after inhaling ipratropium bromide for 6 months. No change occurred in the bronchodilating responses to cumulative doses of salbutamol, nor was any change observed in the number and the affinity of beta 2-adrenoceptors on lymphocytes. It was concluded that long-term use of salbutamol caused a small but significant increase in BHR. The increase in BHR was not caused by subsensitization of beta 2-adrenoceptors to salbutamol.

The relationship between adrenaline and beta 2-adrenoceptors on human lymphocytes.

To study the relation between plasma adrenaline (AD) and noradrenaline (NA) and the beta 2-adrenoceptor number (Bmax) on lymphocytes these variables were measured in the following three groups: a) In 67 normotensive volunteers after a rest period of at least 15 min. b) In 10 essential hypertensive (HT) and 10 age and sex matched normotensive (NT) subjects before and after a standardized bicycle exercise test (BE). c) In 10 bilaterally adrenalectomized females (AF) and 10 healthy age matched females (NF) before and after a mental arithmetic test (MA). Significant correlations were found between AD and Bmax in NT (r = 0.30, P = 0.015) and between the proportional increase in AD and the proportional increase in Bmax after BE (r = 0.60, P less than 0.005). The MA induced elevation of Bmax was blunted after adrenalectomy. All these findings point to a relation between AD and beta 2-adrenoceptor regulation.

Beta 2-adrenoceptor up-regulation in relation to cAMP production in human lymphocytes after physical exercise.

The effect of isotonic bicycle exercise on beta 2-adrenoceptors and cAMP production in lymphocytes was studied. The origin of the newly exposed receptors was studied by measuring radioligand binding in the presence of hydrophylic or lipophylic 'cold' ligands. During exercise beta 2-adrenoceptor density increased from 1207 +/- 144 to 1776 +/- 152 sites/cell (56 +/- 14%). Isoprenaline induced an increase in cAMP synthesis, which was 68 +/- 15% higher than those values measured before the test. Forskolin did not induce a higher increase in cAMP production after exercise. The increase in receptor density seems not to be due to a transfer of internalized receptors to the membrane surface. We conclude that physical exercise induces an up-regulation of beta 2-adrenoceptors on lymphocytes and that these adrenoceptors are functional.

Effects of isometric exercise on blood cell adrenoceptors in essential hypertension.

The effect of handgrip (HG) isometric exercise on plasma catecholamines, alpha 2-adrenoceptors on platelets and beta 2-adrenoceptors on lymphocytes was studied in normotensive subjects (NT) and essential hypertensive subjects (HT). Whereas systolic blood pressure (SBP) increases were similar in NT and HT subjects, diastolic blood pressure (DBP) and heart rate (HR) increased more in the former group. Baseline values and changes in plasma epinephrine (E) and norepinephrine (NE) did not differ between both groups. No differences were apparent in alpha 2-adrenoceptor density and affinity between NT and HT subjects before or after the test. HG isometric exercise induced a similar increase in beta 2-adrenoceptors on lymphocytes of 22 +/- 7 and 13 +/- 5% in NT and HT subjects, respectively. Affinity to the beta 2-adrenoceptors under baseline conditions was somewhat lower in HT (8.1 +/- 0.4 pM) than in NT subjects (6.5 +/- 0.5 pM), and this difference persisted during the test. Our results indicate that there are no differences in alpha 2- and beta 2-adrenoceptor densities either at baseline conditions or after HG isometric exercise between NT and HT subjects. Small differences noted in affinity to the beta 2-adrenoceptors require further investigation.

Adrenoceptors on blood cells in patients with essential hypertension before and after mental stress.

The effect of mental arithmetic (MA) on alpha 2- and beta 2-adrenoceptors on platelets and lymphocytes, respectively, and on plasma catecholamines was studied in normotensive (NT) and essential hypertensive (HT) subjects. There were no significant differences in responses of blood pressure, forearm blood flow (FBF) and heart rate to MA between the two groups. Baseline values and changes in adrenaline and noradrenaline levels during MA were similar in NT and HT. Alpha 2-adrenoceptor density and antagonist affinity did not differ between NT and HT and was not influenced by MA. Baseline values of beta 2-adrenoceptor density also did not differ between NT and HT and increased similarly after MA in both groups. Antagonist affinity to the beta 2-adrenoceptors under baseline conditions was lower in HT and did not change during MA in either group. Our results indicate that there are no differences between NT and HT in alpha 2- and beta 2-adrenoceptor density, either under baseline conditions or after mental stress.

Role of adrenaline in the short-term upregulation of beta-adrenoceptors in essential hypertensive and adrenalectomized females.

The effect of mental arithmetic on beta 2-adrenoceptors on lymphocytes, as measured by (-)125I-iodocyanopindolol binding, was studied in normotensive and essential hypertensive females. To determine the role of adrenaline, mental arithmetic was also carried out in bilaterally adrenalectomized females. There were no significant differences in the blood pressure and heart rate responses to mental arithmetic among the three groups. Baseline values or changes in adrenaline levels during mental arithmetic were similar in normotensives and hypertensives, whereas levels of adrenaline remained undetectable throughout the test in adrenalectomized females. Baseline values of beta 2-adrenoceptors did not differ among the three groups. In normotensive and hypertensive females the increase in beta 2-adrenoceptor density was, respectively, 27 and 20%. Baseline values of beta 2-adrenoceptors were not related to the percentage changes in the receptor densities. In adrenalectomized females, in contrast to normotensives and hypertensives, there was no change in receptor density. These findings suggest that adrenaline plays a role in the short-term upregulation of beta 2-adrenoceptors after mental arithmetic.

Kinetics of (-)125iodocyanopindolol binding to intact human mononuclear cells.

In association experiments of (-)125Iodocyanopindolol (125ICYP) with human mononuclear cells (MNC) at 70 pM and a temperature of 37 degrees C equilibrium was reached within 30 min. However, when the same experiments were performed at a concentration of 4 pM 125ICYP, equilibrium was only reached after 3 hours. The consequences of incomplete equilibrium for the interpretation of binding experiments under the incorrect assumption that equilibrium has been reached, was investigated at equilibration times of one, two and three hours. The dissociation constant, Kd, decreased from 7.4 +/- 0.2 pM after one hour to 2.5 +/- 0.4 pM after three hours of incubation while the receptor density, RO, decreased from 970 +/- 170 to 713 +/- 58 sites/cell. Analysis of computer simulated binding curves confirmed the decrease in Kd and RO at prolonged incubations. We conclude that in 125ICYP binding in intact MNC one hour of incubation is not sufficient to obtain equilibrium at the lower concentrations. This leads to an overestimation of Kd- and to a lesser extent of RO-values. Extending the incubation time to three hours on the other hand may lead to a loss of cells and therefore to an underestimation of RO.