Course of illness and pattern of recurrences in patients with affective disorders during long-term lithium prophylaxis: a retrospective analysis over 15 years.

We analysed the recurrences of 86 patients with monopolar and bipolar mood and schizoaffective disorders treated with lithium over a period of 8.2 years on average in a specialized out-patient clinic. Lithium medication was discontinued by 24% of patients. Diagnosis, age and gender had no influence on the mean morbidity index. Bipolar and schizoaffective patients suffered from more severe recurrences, resulting in hospital admissions, than monopolar patients. A significant decrease in intensity of manic episodes and a significant shortening of depressive episodes was observed over a 10-year treatment period. However, the percentage of manic episodes among all episodes remained constant. There was no indication of a loss of the prophylactic effect in a subgroup of 30 patients who had been treated for a minimum of 10 years. The morbidity index also remained constant over 10 years in the whole sample. Furthermore, the mean lithium blood levels as well as the additional medication in this subgroup could be lowered in the second half of the treatment decade as compared to the initial 5 years.

[The behavior of plasma histamine levels following peridural morphine administration]. / Untersuchungen zum Verhalten der Plasmahistaminspiegel nach periduraler Morphinapplikation.

One of the frequently reported side effects following epidural morphine administration in clinical trials is a generalized pruritus of several hours duration. Since histamine can elicit pruritus we investigated the plasma histamine levels following epidurally applied morphine (0.05 mg/kg) in 10 urological patients. Plasma histamine levels were determined as an indicator of histamine release. Indeed, in 2 of 10 patients plasma histamine concentrations rose to 2 ng/ml. 5 of 6 criteria for establishing histamine release were fulfilled in both cases. Minor clinical symptoms appeared only in one patient (one single wheal of 1 cm diameter, metallic taste), but no symptoms at all in the other. Considering the low dose of the analgesic and the relatively high incidence of histamine release (2/10) the result of this prospective study seems worth to be emphasisized and followed-up in further studies. Pruritus did not occur in any of the patients, the role of histamine in its pathogenesis is now becoming more doubtful.

[Catheter peridural anesthesia with bupivacaine HCI and bupivacaine CO2. A comparison and the effects of premedication]. / Katheterperiduralanaesthesie mit Bupivacain HCI und Bupivacain CO2. Vergleichende Untersuchung und Auswirkung der Prämedikation.

A controlled prospective randomized study was carried out to compare the action of 0.5% bupivacaine-CO2 and 0.5% bupivacaine-HCI both with and without diazepam premedication. Those patients given an epidural with 0.5% bupivacaine-CO2 and diazepam premedication showed both the briefest time to onset of action and the greatest degree of motor block. In contrast to the other three groups, none of these patients had missed segments. Despite the fact that no significant differences could be calculated, the difference in intensity of action observed in this investigation may well be of clinical relevance.

[Post-traumatic metabolism--bases and clinical aspects]. / Posttraumatischer Stoffwechsel--grundlagen und klinische aspekte.

In order to rationalize the nutritional therapy of polytraumatized patients we have developed a concept to explain the humoral response and subsequent metabolic reactions to trauma, which is based on current reports in the literature and our own investigations. Three separate phases should be defined. a) The acute phase: catecholamines dominate in the initial phase following severe trauma. Insulin secretion is suppressed, and the levels of the anti-insulin hormones glucagon, cortisol and growth hormone are increased. Under modern conditions of treatment this phase lasts between 12-24 h. Nutritional therapy cannot be carried out during this phase of maximal glycogenolysis, lipolysis and gluconeogenesis because of the danger that a major metabolic imbalance might develop. b) The intermediate phase: This phase can be said to occur when after 12-24 h the primary stabilisation of the acute phase is complete. Insulin secretion can now be stimulated, but the levels of anti-insulin hormones remain high. This phase lasts for a number of days. The gradual introduction of nutritional therapy is now possible, but the danger of metabolic imbalances arising when abrupt substrate increases are made is nevertheless present. Should complications arise this phase can at any time revert to the acute phase. Patients who are only slightly injured or have undergone moderately extensive surgery are from the onset in this phase. c) The repair phase: In uncomplicated cases the intermediate phase passes after a number of days into the repair phase. This stage lasts for a number of weeks and is dominated by the presence of insulin. The levels of the anti-insulin hormones have returned to normal values.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparative studies on the side effects of morphine after peridural, spinal and intravenous administration]. / Vergleichende Untersuchungen der Nebenwirkungen von Morphin nach periduraler, spinaler und intravenöser Applikation.

A prospective randomized study was carried out on 29 patients undergoing transurethral prostatectomy. In addition to the regional anaesthetic given for the operation, the patients received either: 1 mg morphine intrathecally (spinal group), 0.05 mg/kg body weight of morphine i.v. (i.v. group), or 0.05 mg/kg body weight epidurally (PDA group). Two of the intrathecal group patients had to be given an antagonist because of clinically relevant respiratory depression. In one of these cases, this depression could be documented by a continuous fall in respiratory minute volume, and an increase in PCO2. In the other, bradypnoea and vomiting developed within a few minutes of injection. The presence of a central action of intrathecal and epidural opiates was indicated by the significant increase in reaction time found. In the two instances of respiratory depression, the CSF morphine concentration 24 hrs after injection was markedly lower (0 and 18 ng/ml respectively) than in unaffected patients. It must therefore be assumed that the respiratory depression was caused by a more rapid cephelad transport than that occurring in normal cases.

[Peridural morphine analgesia: effects and pharmacokinetics. A double-blind study in vaginal hysterectomy patients]. / Peridurale Morphinanalgesie: Wirkung und Pharmakokinetic. Eine Doppelblindstudie bei vaginalen Hysterektomien.

In a controlled prospective double-blind-study we were able to show that the analgesic duration of epidurally applied morphine is more than four fold longer lasting than intravenous morphine. We found similar pharmacokinetics in both groups, suggesting a rapid absorption of epidurally applied morphine into the vascular system. The identical pharmacokinetics of intravenous and epidurally applied morphine suggest that only small amounts of morphine diffuse across the dura to the spinal cord, where it produces a long lasting analgesia at the opiate receptors. The comparison of serum morphine levels in patients who reported a very short lasting and very long lasting analgesia gave us no pharmacokinetic explanation for this difference.

[Serum bupivacaine concentrations in patients with continuous peridural anesthesia administered by thoracic catheter]. / Bupivacainkonzentrationen im Serum von Patienten mit kontinuierlicher thorakaler Katheterperiduralanaesthesie.

Continuous infusion of a 0.2% solution of bupivacaine via a peridural catheter in a rate of 0.2 ml/kg x h is sufficient to make a patient pain-free for any time required following upper abdominal or abdomino-thoracic surgery. The zone of analgesia extends segmentally from T4 to T12/L1 so that the patient can be mobilized. If necessary an insufficient blockade can be completed by bolus injection of 10 to 15 ml of 0.2% solution. Using this technique over a period of four days after surgery, serum concentrations of bupivacaine were measured in 20 patients. The following values were found (median, range): at the end of the operation 0.85, 0.26-1.72 mg/1, after 24 h 1.70, 0.58-4.04 mg/1, after 48 h 3.46, 1.22-7.62 mg/1, after 72 h 2.80, 0.73-12.15 mg/1 and after 96 h (end of the investigation) 2.39, 0.34-9.92 mg/1. Moderate excitation was sometimes observed, while the patient was in the recovery room (shivering, restlessness) but disappeared completely within 10 h. Later on no signs of intoxication were observed, even when serum bupivacaine concentrations exceeded 6 mg/1. During continuous epidural anaesthesia, when serum bupivacaine concentrations increase gradually this level does not seem to be toxic. We consider this method to be suitable for keeping a patient pain-free following upper abdominal surgery, provided that adequate monitoring is available.

[Postoperative analgesia with epidural morphine injection after urologic operations (author's transl)]. / Untersuchungen zur postoperativen Schmerztherapie mit periduralen Morphingaben nach urologischen Operationen.

Eleven patients were given morphine 5 mg via an epidural catheter to provide analgesia after urologic surgery. Morphine levels were determined in serum and urine by radioimmunoassay. Cardiovascular reactions (heart rate, blood pressure) and arterial pO2 were recorded. Analgesia ensued very rapidly and lasted 29 hours on the average. For 4 hours after epidural administration, the serum morphine levels were within the range required for analgesia after intravenous injection. Side effects on the cardiovascular system and the respiratory system were not observed. Epidural morphine application is recommended as a good method for postoperative analgesia.

[Prospective studies on the pathologic mechanism of post-spinal headache in a select group of patients (author's transl)]. / Prospektive untersuchungen zum pathomechanismus des postspinalen kopfschmerzes an einem ausgewählten krankengut.

In this prospective study 613 patients on whom a total of 783 spinal anaesthetics had been performed, all for urological operations, were questioned and examined. Subjective complaints occured in 102 cases (13%) and were found to be more frequent amongst the female patients. 23 cases (2.9%) developed a typical post-spinal headache, this being more likely to occur if the patient was a woman, was young, and if a 22-Gauge needle was used. The headache usually began on getting up on the day of operation or the first post-operative day, and rarely lasted longer than four days. The pathophysiological changes indicate that the headache is caused by a fall in CSF pressure. The therapy and various methods of preventing this complication are discussed, and the other potential neurological symptoms and signs mentioned.