[Depressive disorders and conduct disorders in childhood and adolescence. Prevalence, course, and risk factors]. / Depressive Störungen und aggressiv-dissoziale Störungen im Kindes- und Jugendalter. Prävalenz, Verlauf und Risikofaktoren.

Mental disorders belong to the most frequent disorders in the community and lead to noticeable functional impairments. The lifetime prevalence of clinical depression (ICD-10 diagnoses F33, F34) up to age 25 is 12.7%, showing a female-male ratio of 2:1. From adolescence onwards, persistence rates of depressive disorders are comparably as high as those found in externalizing disorders. Subclinical depression (ICD-10 subthreshold disorders) at ages 8 and 13 increases the risk for later clinically relevant mental disorders. Conduct disorders (ICD-10 diagnoses F91, F92) are the most frequent mental disorders in children and adolescents with lifetime prevalence rates of 22.4% up to age 25. Conduct disorders show unfavorable courses beginning at preschool age. Precursors of later disorders can be detected as early as toddlerhood. Adverse family factors in childhood and early externalizing problems of the child were most predictive for later conduct disorders. Therefore, the need for early prevention of conduct disorders is highlighted. The focus should be on families with low socioeconomic status (objective: strengthening family and child resources). For depressive disorders, we recommend testing and evaluating the indicated prevention programs in adolescence (objective: strengthening the resources of the adolescent).

Behavioral sequelae of perinatal insults and early family adversity at 8 years of age.

OBJECTIVE: This prospective longitudinal study investigated the simultaneous impact of early biological and psychosocial risk factors on behavioral outcome at school age. METHOD: A cohort of 362 children born between 1986 and 1988 with different biological (perinatal insults) and psychosocial risk factors (family adversity) was followed from birth to school age. When their children were aged 8 years, parents of 89.0% of the initial sample completed the Child Behavior Checklist (CBCL). RESULTS: More externalizing as well as internalizing problems were found in children born into adverse family backgrounds, whereas no differences at broad-band syndrome level were apparent between groups with varying obstetric complications. Children with family risk factors had higher scores on 5 of the 8 CBCL scales (including attention, delinquent, and aggressive problems), whereas children with perinatal risk factors had more social and attention problems than children in the nonrisk groups. With one exception, no interactions between risk factors emerged, indicating that perinatal and family risk factors contributed independently to outcome. The differences between risk groups applied irrespective of gender. CONCLUSIONS: The adverse impact of family adversity clearly outweighed the influence of obstetric complications in determining behavioral adjustment at school age.

A train passenger with pulmonary tuberculosis: evidence of limited transmission during travel.

In January 1996, smear- and culture-positive tuberculosis (TB) was diagnosed for a 22-year-old black man after he had traveled on two U.S. passenger trains (29.1 hours) and a bus (5.5 hours) over 2 days. To determine if transmission had occurred, passengers and crew were notified of the potential exposure and instructed to undergo a tuberculin skin test (TST). Of the 240 persons who completed screening, 4 (2%) had a documented TST conversion (increase in induration of > or = 10 mm between successive TSTs), 11 (5%) had a single positive TST (> or = 10 mm), and 225 (94%) had a negative TST (< 10 mm). For two persons who underwent conversion, no other risk factors for a conversion were identified other than exposure to the ill passenger during train and/or bus travel. These findings support limited transmission of Mycobacterium tuberculosis from a potentially highly infectious passenger to other persons during extended train and bus travel.

Transmission of Mycobacterium tuberculosis from tuberculosis patients with HIV infection or AIDS.

Contacts exposed to tuberculosis patients with acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection were compared with contacts of HIV-negative patients for evidence of Mycobacterium tuberculosis transmission, based on a review of records of tuberculin skin tests administered during routine health department follow-up investigations in Miami/Dade County, Florida, from 1985 through 1989. After an adjusted analysis designed to balance background prevalence, tuberculin positivity was 42.0% in 2,158 contacts of HIV-negative patients compared with 28.6% and 31.3% in 363 contacts of HIV-infected patients and 732 contacts of AIDS patients, respectively. Similar results were observed in a subset of 5- to 14-year-old contacts of United States-born black or white tuberculosis patients chosen to minimize the possibility of false-negative tuberculin tests in contacts due to undiagnosed HIV infection. Analysis of contacts as sets showed a more than expected number of sets with none or all contacts infected, but this did not differ by HIV/AIDS group. In this study, tuberculosis patients with AIDS or HIV infection were less infectious to their contacts and, in this community, exposed fewer contacts than HIV-negative tuberculosis patients.

[4 1/2 years later: Mannheim risk children of preschool age]. / Viereinhalb Jahre danach: Mannheimer Risikokinder im Vorschulalter.

The present investigation was concerned with the impact of prenatal and perinatal complications (biological risks) and of family adversity (psychosocial risks) on developmental status at age 4 1/2. In a prospective study the developmental course of 362 children (including 210 high-risk children) was followed from birth to age 4 1/2 years. A multilevel approach was used to assess all relevant domains of functioning (i.e. motor, cognitive and social-emotional development). The goal was to obtain information about the effects of biological and psychosocial risks alone and together on outcome in the different domains of functioning. The results show that psychosocial risk factors posed the greatest threat to normal development. Children with psychosocial risks were significantly behind those without such risks in all areas of functioning. Biological risks mainly affected motor development, their negative effects on cognitive and social-emotional functioning having been largely compensated for by age 4 1/2. The extent of an adverse outcome was related to both the degree of risk load and the number of risk factors, whereas interactions among risks were of only minor relevance. An adverse outcome is not inevitable, however: Despite the risks most of the at-risk children showed normal development at age 4 1/2.

Transmission of multidrug-resistant Mycobacterium tuberculosis during a long airplane flight.

BACKGROUND: In April 1994, a passenger with infectious multi-drug resistant tuberculosis traveled on commercial-airline flights from Honolulu to Chicago and from Chicago to Baltimore and returned one month later. We sought to determine whether she had infected any of her contacts on this extensive trip. METHODS: Passengers and crew were identified from airline records and were notified of their exposure, asked to complete a questionnaire, and screened by tuberculin skin tests. RESULTS: Of the 925 people on the airplanes, 802 (86.7 percent) responded. All 11 contacts with positive tuberculin skin tests who were on the April flights and 2 of 3 contacts with positive tests who were on the Baltimore-to-Chicago flight in May had other risk factors for tuberculosis. More contacts on the final, 8.75-hour flight from Chicago to Honolulu had positive skin tests than those on the other three flights (6 percent, as compared with 2.3, 3.8, and 2.8 percent). Of 15 contacts with positive tests on the May flight from Chicago to Honolulu, 6 (4 with skin-test conversion) had no other risk factors; all 6 had sat in the same section of the plane as the index patient (P=0.001). Passengers seated within two rows of the index patient were more likely to have positive tuberculin skin tests than those in the rest of the section (4 of 13, or 30.8 percent, vs. 2 of 55, or 3.6 percent; rate ratio, 8.5; 95 percent confidence interval, 1.7 to 41.3; P=0.01). CONCLUSIONS: The transmission of Mycobacterium tuberculosis that we describe aboard a commercial aircraft involved a highly infectious passenger, a long flight, and close proximity of contacts to the index patient.

The need for epidemic intelligence.

The past decade has witnessed an unprecedented upturn in tuberculosis morbidity and outbreaks of difficult- to-treat and highly lethal multidrug-resistant tuberculosis. In the early 1990s, a national consensus developed among public health officials to define more comprehensively the problem, and in January 1993, expanded tuberculosis surveillance was implemented nationwide. Carefully selected epidemiologic and case management variables were added to the Report of Verified Case of Tuberculosis form. Information is collected on the health status and treatment of patients, including human immunodeficiency virus status, drug susceptibility test results, and the initial drug regimen. Completion of therapy and use of directly observed therapy are also monitored. The new surveillance system allows a comparison of the quality of care of patients in the public and private sectors. Additional epidemiologic variables include membership in high-risk groups (the homeless, residents of correctional or long-term care facilities, migrant workers, health care workers, and correctional employees) and substance abuse (injecting drug use, non-injecting drug use, and excess alcohol use). The additional information derived from expanded tuberculosis surveillance is crucial to optimal patient management, policy development, resource allocation, as well as program planning, implementation, and evaluation at Federal, State, and local levels.

["Risk children": the importance of biological and psychosocial risks for child development in the first two years of life]. / "Risikokinder": Zur Bedeutung biologischer und psychosozialer Risiken für die kindliche Entwicklung in den beiden ersten Lebensjahren.

In a prospective longitudinal study the development of N = 362 children will be followed over four time points (T1-T4) from birth to school age utilizing a comprehensive battery of instruments. Aims of the study are the description of the developmental course of children born at differing degrees of biological and psychosocial risk, the identification of early predictors of developmental disorders and their compensation, as well as the analysis of the processes and mechanisms underlying differential developmental patterns. The results of waves 1 and 2 show that early development from 3 to 24 months is quite unstable. Depending on the examined domain of development up to 3/4 of the disturbances of infancy have remitted by the later age, whereas nearly a fifth of the hitherto well children developed new disturbances. Both risks have a marked negative effect on development. While biological risks go hand in hand with impaired motor functioning, psychosocial risks adversely affect cognitive and social-emotional competence. However, the relative weight of risk factors changes during the first two years with biological risks becoming less important and psychosocial risk factors gaining influence. Single risk factors identified as being prognostically very unfavourable are very low birth weight and neonatal seizures. Of the psychosocial risks a pattern of unfavourable family characteristics such as low educational level, history of broken home or mental health problems of parents and chronic difficulties is related most strongly to poor outcome.

[The effect of life change events on cognitive and socio-emotional development in early childhood]. / Die Wirkung von Lebensereignissen auf die kognitive und sozial-emotionale Entwicklung im frühen Kindesalter.

The present study investigates the role of life events of differing durations in the cognitive and social-emotional development of infants. A total of 354 children were examined at the ages of 3 and 24 months and the children's parents were interviewed about the occurrence of live events in this interval. The total number of life events was a significant predictor of changes in the level of cognitive and social-emotional functioning. Changes in the caregiver and marital discord were the best predictors of a child's social-emotional development, and serious illness in the child and changes in the caregiver were the best predictors of a child's cognitive development.

Psychosocial correlates of clinical depression after psychiatric in-patient treatment: methodological issues and baseline differences between recovered and non-recovered patients.

General methodological and design issues in research on psychosocial outcome predictors of clinical depression are discussed, and the first stage of a study of discharged depressed in-patients is presented. It involved 115 recovered and 75 non-recovered such patients who were compared regarding stress factors, social support, personality and coping styles. While there were few differences between recovered and non-recovered patients with respect to stable personality traits, recovered patients were less likely to have had severe long-term life difficulties, and their coping style differed: it was characterized by more negative appraisals of stressful situations, greater problem avoidance, less palliative activities, and a lesser inclination to solicit social support. Whereas among women without partners, as well as men, non-recovery was also associated with less support from friends, in particular psychological-emotional support in crises, non-recovered women with partners had much more such support. The results are discussed with reference to the existing literature on outcome correlates of clinical depression.

Perinatal events and further developmental outcome--assessment of a newborn's individual prognosis. 1. Neonatal period and results of an eight years' follow-up.

The aim of the prospective study described in this paper was to develop a prognostic screening method which permits to give an individual prognostic estimate for every newborn, with an accuracy acceptable for clinical purposes. In the following, the condensed data of the case histories as well as of the clinical and laboratory findings in 47 of initially 60 preterm and term newborns with and without cardiorespiratory distress were analyzed under two different aspects. In the first part, the general statistical relationships are presented in the followed up children, who were classified under various groups according to the clinical course during the first two years of life and to the developmental stage reached at the age of two and six years. It was shown that such a procedure will not suffice in clinical practice for the purpose of individual prognostic estimates. The analysis of the clinical classifications of the six-year-old children in comparison with their school performance at the age of eight years yielded a high accuracy of the previous clinical estimation.

Perinatal events and future developmental outcome--assessment of a newborn's individual prognosis. 2. Prediction of outcome on the basis of perinatological data--results of multivariate discriminant analysis.

The aim of the prospective study described in this paper was to elaborate a prognostic screening method which allows to give an individual prognostic estimate for every newborn, with an accuracy acceptable for clinical purposes. This second part informs about the results of multivariate discriminant analysis, using the data from case histories as well as from the clinical and laboratory findings in the neonates (including "criteria of hypoxia"). According to the kind and number of abnormalities found on the occasion of out-patient consultations during the course of the first two years of life, and according to the developmental status reached at the age of two and six years, the children were classified under two alternative groups. Satisfying results were achieved in the discrimination between the groups of six-year-old children. As compared with the literature, the prognostic method proposed in this paper yields a relatively high accuracy of individual predictions, and therefore promises to become a good tool for clinical practice.

[Intrauterine exchange transfusion in Rh immunization]. / Intrauterine Austauschtransfusion bei Rh-Immunisierung.

Intra-uterine exchange transfusion was performed on a patient in the 30th week of gestational age for Morbus haemolyticus fetalis. The indication for intra-uterine intervention resulted from spectrophotometric investigation of amniotic fluid which had revealed Zone III according to Liley as well as incipient hydropic development and development of ascites. The pregnancy had to be terminated for pathological CTG, four days after therapy. Postnatal neonatological intensive therapy included two exchange transfusions, before the child was dismissed in clinically intact condition.

Effect of early and late postnatal hypoxia on subcellular synaptosomal fractions from cerebral cortex of rats. I. An electron-microscopical and biochemical study.

Synaptosomal fractions of brain cortex of rats exposed to moderate intermittent hypobaric hypoxic conditions during the first or second decade of the postnatal life were investigated electron microscopically one day or up to one week after the hypoxia experiment. Mitochondria and synaptosomes with impaired morphology were observed to occur more frequently in fractions obtained from hypoxic animals. Synaptosomes showed lesions of the outer membrane and loss of the synaptoplasmatic content, or condensation of the synaptosomal content with increasing electron density, deformation of the synaptosomes in size and shape, disappearance of structural details, degeneration of intrasynaptosomal mitochondria in form of strong condensation and, finally, formation of intrasynaptosomal vacuoles with dense core inclusions. The mitochondrial reaction was characterized by two antagonistic configurations: condensation of the matrix with secondary enlargement of the intracistal spaces and of the outer compartment and, finally, the decay of the matrix condensate in several crumbs. On the other hand, swelling of the matrix with strong enlargement of the whole mitochondrium, later defects in the outer membrane and the degeneration into empty mitochondrial ghosts, appearing in the upper fractions. Some characteristic marker enzymes were tested in the fractions. The results hint at an elevated vulnerability of synaptosomes obtained from animals exposed to postnatal hypoxia, as indicated by the lowered quotient of LDH activities after and before addition of Triton X-100. Furthermore, there are clues to a decrease in the number of synaptic connections within the cortex of hypoxia exposed animals, as is concluded from the diminished AChE activity in the subcellular fractions of these animals. However, no different effect of early or late postnatal hypoxia exposition was evident in the biochemical parameters.

Effect of early and late postnatal hypoxia on subcellular synaptosomal fractions from cerebral cortex of rats. II. A quantitative ultrastructural study.

Synaptosomal subfractions were isolated by discontinuous sucrose gradient centrifugation from the P2-fraction of cerebral cortices of juvenile rats exposed to moderate intermittent hypobaric hypoxia from day 2-11 (early postnatal period) or from day 12-21 (late postnatal period) after birth. Ultrastructural investigations were carried out on fractions A and E of the preparation. Quantitative parameters of synaptosomes and mitochondria (volume density, numerical density, profile size frequency distribution) were estimated in a stereological analysis. Early postnatal hypoxia exposition strengthened the irreversible swelling of mitochondria. The effect on synaptosomes was less pronounced, very large synaptosomes showed significant condensation. Late postnatal hypoxia exposition resulted in strong condensation of synaptosomes in all size classes and similar reaction in mitochondria. Both hypoxia experiments produced an enhanced vulnerability of the synaptosomal membranes against the fractionation procedure and the appearance of monstrous large condensed synaptosomes. The results are discussed in view of hypothetical biochemical mechanisms underlying these changes.

Effect of chronic postnatal hypoxia on dopamine uptake by synaptosomes from striatum of adult rats.

The exposure of rats to an early postnatal hypoxia (pO2 11.3 kPa, 12 h daily, 2nd-11th day of life) causes not only long lasting changes in the dopamine (DA) release from striatum slices but also in the DA uptake by striatal synaptosomes. Adult controls have a synaptosomal DA uptake of about 5 pmoles per mg protein and per min (males 4.99, females 5.69). Rats which have been exposed to an early postnatal hypobaric hypoxia exhibit a DA uptake of 2.71 (males) and 4.53 (females) pmoles per mg protein and per min. This long-lasting effect on the dopaminergic system of the striatum must be caused by a hypoxic alteration of gene expression in a critical period of the neonatal rat brain development, with permanent effects on the DA-metabolism and/or on the function of synaptic membranes.

Dopamine release from striatum slices of rats at different age: influence of hypoxia.

During the maturation and aging of rats the dopamine release from striatum slices shows different dynamics in dependence on the stimuli used. Electrically evoked release is very constant. Amphetamine induced release is fully developed at the age of day 14 and declines after 9 months. The K+ stimulated release develops to a maximum at 10 weeks and decreases thereafter. The stimulus and age dependent inhibition of dopamine release after an 18 h hypoxic exposure may be the result of peroxidative reactions of membranous phospholipid components induced by free radicals. Adult rats exposed to a 200 h hypoxia reveal no change in dopamine release after the last exposure probably in consequence of adaptive processes of physiological protection, among other things, by scavenging of free radicals. Adult rats exposed to long term hypoxia postnatally during the growth spurt period of neuronal structures show an increased dopamine release and no posthypoxic release inhibition. Our data indicate that different mechanisms are operative during hypoxia in animals of different age.