[Bipolar disorders: the disease of extreme emotions]. / Bipolare Störung. Die Krankheit der extremen Emotionen.

Bipolar disorder is characterized by alternating phases of manic and depressive states that are separated by variably long and sometimes symptom-free intervals. Rapid changes in symptoms and mixed states during acute episodes can make diagnosis difficult. The risk of suicide is high. For diagnostic confirmation, the patient should be referred to a specialist as early as possible. The therapy should also be carried out in close collaboration with a neurologist or psychiatrist. The role of the family physician is to monitor the pharmaceutical phase prophylaxis and to attend to the patient's comorbidities.

Survival after pulmonary edema due to enterovirus 71 encephalitis.

BACKGROUND: A distinctive pattern of enterovirus 71 (EV71) infection, characterized by fever, exanthem, acute pulmonary edema (PE), brainstem encephalitis, and flaccid paresis, affects infants and young children. Most die rapidly owing to respiratory failure and fulminant PE. METHOD: The authors report short- and long-term outcome of six survivors of the acute illness. RESULTS: In the context of acute PE and widespread weakness, recognition of the underlying neurologic disorder was facilitated by the distinctive pattern of MRI signal abnormalities in posterior pons and medulla. EV71-specific PCR of clinical samples helped confirm the diagnosis. Acute PE was managed with mechanical ventilation, afterload reduction, and inotrope support, and resolved completely over days. One patient with minimal neurologic recovery died 9 weeks after disease onset. The other patients have residual neurologic dysfunction, varying from subtle monoparesis to severe bulbar dysfunction, central and peripheral respiratory failure, and flaccid quadriparesis. Faster neurologic recovery was associated with less long-term deficit. Long-term outcome was similar in patients treated with and without pleconaril or IV immunoglobulin. Three long-term survivors treated with IV corticosteroids had less severe long-term neurologic disability than two not treated with steroids. CONCLUSION: Acute pulmonary edema and encephalomyelitis occurs with EV71 infection in infants. Long-term neurologic outcome varied from minor, focal weakness to profound, global motor dysfunction with respiratory failure.

[Rare complication of a heparin-induced thrombocytopenia type II]. / Seltene Komplikation einer Heparin-induzierten Thrombozytopenie Typ II (HIT II).

HISTORY AND CLINICAL FINDINGS: A 63-year-old man was admitted to a surgery department with fracture of the acetabulum and luxation of the hip joint. Eight days after intracondylar nail-extension during subcutaneous heparin prophylaxis he developed a dramatic deterioration of his condition with severe abdominal pain and fever and was admitted to our hospital. INVESTIGATIONS: White cell count was 12,000/microliter, C-reactive protein 7.90 mg/dl. CT-scan, abdominal ultrasound, mesenteric angiography and exploratory laparotomy revealed no pathological findings. At day 13 abdominal ultrasound showed adrenal haemorrhages on the right. Together with a drop in platelet count below 50,000/microliter, adrenal haemorrhage caused by heparin-induced thrombocytopenia (type II; immunological [HIT II]) was suggested. THERAPY: After discontinuation of heparin and starting therapy with recombinant hirudin and hydrocortisone, a dramatic clinical recovery followed within 24 hours. One year after the initial diagnosis the patient is in a good condition. CONCLUSION: When abdominal pain, hypotension and fever occurs with a drop in platelet count during heparin therapy HIT II should be considered. An early diagnosis is essential for treatment of this life-threatening complication at an early stage.

Toxic shock syndrome associated with newly diagnosed type I diabetes.

Studies of two post-mortem pancreata of children at the onset of type I diabetes have suggested activation and expansion of islet infiltrating T cells by a superantigen. We present the first reported case of a superantigen mediated disease, toxic shock syndrome (TSS), occurring at the diagnosis of type I diabetes. A 12-year-old girl presented with TSS and newly diagnosed diabetes with ketoacidosis. At presentation she was unconscious, febrile and hypotensive, with a desquamating erythematous rash and Kussmaul breathing. During resuscitation, her renal impairment, diarrhoea, thrombocytopaenia and ketoacidosis resolved. Vaginal discharge and blood cultures grew Staphylococcus aureus. T cell studies at 2 weeks after diagnosis detected a high level of spontaneous and islet antigen-specific proliferation with associated interleukin-10 production compared to human leucocyte antigen DR matched controls.

Influence of 3-methylcholanthrene on the redox-state of liver and red muscles in vivo.

It was observed, that following an injection of 3-methylcholanthrene (MC), the tissue redox-state potential is modified expressively both in liver and in red muscles. In the liver in the first day an oxidosis develops, which is followed by redosis, but in the muscle a redosis can be observed already in the first day. It is a meaningful fact, that MC influences biochemical processes in the early phase of its effect not only in the liver but also in the red muscle. By reason of this data the possibility of a prevention of the MC influence by adequate redox agents might also be arised.

Model of redox regulation of hyper- or hypothyreoidism.

Since the triiodothyronine (T3) shifts the tissue metabolism to oxidative direction, one should await that in hyperthyreoidism caused by T3 an oxidosis will be formed, whilst in hypothyreoidism called forth by subtotal thyreoidectomy, redosis will be emerged. However, according to our experiments these interrelationships proved to be inverse. These "paradoxal" changes of redox-state are the consequences of the flowing redox compensations elicited by the tissue redox-buffer capacity (RBC). The pathomechanism can be modelled with differential equation (computer analysis). The redox-state changes are characteristics in each tissues. Between the RBC of the tissue and the shift of redox-state potential (E'0) there is a negative correlation. As an autoregulatory mechanims, the redosis formed in hyperthyreoidism will increase the hormone synthesis in the thyroid gland, while the oxidosis after hypothyreoidism will decrease the synthesis. In other words, these processes strengthen each other. Changes of the heart frequency show correlation with the E'0, and can be described by differential equation. Our theoretical model for the redox regulation might answer also the question of the reversibility-irreversibility range of the autoregulation in the pathomechanism.

Correlations between positive and negative aeroions, tissue redox-state potential and heart frequency in rats.

It was observed in rats that following positive aeroionization the redox-state potential (E'0) in skeletal muscles and liver was decreased, and the heart frequency increased. After negative ionization these interrelationships took place inversely. It was also established that upon adding an oxidant (menadione) i.v., the E'0 was decreased (compensatorily) in the organs mentioned above, parallel with the increment of heart frequency. Following injection of reductants (cysteine, thiamine) a reverse image was observed. Applying simultaneously positive ionization and reducing agents, the E'0 change and the heart frequency alteration failed to appear. The phenomenon was the same after simultaneous application of negative ionization and oxidant (menadione) injection. Because the heart effect of positive and negative ionization could readily be prevented by a respective redox agent, it seemed that actions of aeroions are exerted through shifts in tissue E'0. The most probable site of action of E'0, is the pacemaker mechanism, but an action on serotonin liberation may also be assumed.

[Intra-arterial DSA of the pelvic/leg vasculature using a 57 cm image intensifier]. / Intraarterielle DSA der Becken-/Beingefässe mit einem 57-cm-Bildverstärker.

100 consecutive intraarterial DSA's of the lower extremities obtained with a 57 cm image intensifier were evaluated retrospectively by 2 radiologists and 3 surgeons. The studies were considered diagnostic in 95% of the cases. The results, advantages and possible disadvantages are presented and compared to those associated with conventional film angiography and with i.v. DSA.

[Digital image intensifier radiography: imaging qualities and initial use in the gastrointestinal area]. / Digitale Bildverstärkerradiographie: Abbildungseigenschaften und erste Anwendung im Gastrointestinalbereich.

We determined the quality of digital radiographs delivered by a large image intensifier (diameter 54 cm) and by a conventional fluoroscopic unit with a 33 cm image intensifier, and compared them to that of 100 mm spot films obtained from the same units. A special image processor was available allowing 25 images/s using a 512/512 matrix or 7.5 images/s with a 1024 X 1024 matrix. The spatial resolution of digital radiographs was well below that of the spot films, while no difference was found in contrast resolution. Images of colon specimens and gastrointestinal studies demonstrate that digital radiography does not imply a loss in diagnostic information inspite of the lower spatial resolution. Gastrointestinal studies using digital radiographs will reduce the amount of irradiation exposure of the patient and could represent an additional use for an existing equipment for DSA.

Computer processed fluoroscopic images for digital intravenous renal angiography.

We investigated intravenous digital angiography using computer processed fluoroscopic images. Computer processed fluoroscopy (CPF) was compared to conventional digital subtraction angiography (DSA) in 39 patients referred for renal vessel evaluation. For assessment of CPF the anterior-posterior images were compared with the corresponding digital subtraction angiograms. 79% percent of DSA and 71% of CPF studies were diagnostic. Peripheral injection of contrast medium caused deterioration of CPF images. Skin dose measurements were obtained in 24 patients. The median dose for DSA was 8.2 rad, compared to 1.1 rad for CPF. It is concluded that sophisticated algorithms should be investigated for digital angiography, so that high image quality can be achieved with a reduced radiation exposure.

[Possibility of erroneous diagnosis with digital subtraction angiography and its causes]. / Möglichkeiten der Fehldiagnose mit der DSA und ihre Ursachen.

In digital subtraction angiography (DSA) motion artifacts, artifacts due to overshoot, high contrast enhancement, and long exposure time may result in erroneous evaluation of the vessels. Examples are given to demonstrate and analyse the causes of possible misdiagnoses.

[Contribution of digital subtraction angiography to the diagnosis of rejection reactions after kidney transplantation]. / Beitrag der digitalen Subtraktionsangiographie zur Diagnostik von Abstossungsreaktionen nach Nierentransplantation.

The ability to diagnose rejection changes in renal transplants using DSA was evaluated retrospectively taking intrarenal vascular changes into consideration. The findings obtained with DSA were compared to those of scintigraphy in 26 graft recipients, on whom both methods had been performed within a narrow time period for evaluation of hypertensive disease. The scintigraphic diagnosis was based on function and perfusion studies. The intrarenal vascular tree was demonstrated on DSA better by intraarterial than by intravenous contrast media injection, however both techniques delivered useful diagnostic information. The status of the graft was evaluated with comparable results by DSA and scintigraphy in 73% of the cases. In our experience, functional effects produced by morphological changes demonstrated by DSA, can be defined better with the help of scintigraphy. On the other hand, by performing DSA it is possible to clarify morphologically functional findings, which may be detected by scintigraphy but often are diagnostically nonspecific. The availability of both morphological and functional data increases the diagnostic accuracy which can be obtained with these two low invasive procedures in the assessment of vascular changes in renal transplants.

[Results of transvenous digital subtraction angiography with a 57 cm image intensifier in circulatory disorders of the lower extremities]. / Ergebnisse der transvenösen digitalen Subtraktionsangiographie mit einem 57-cm-Bildverstärker bei Durchblutungsstörungen der unteren Extremitäten.

The size of conventional image intensifiers is a limiting factor in performing transvenous digital subtraction angiography of the lower extremities. The results of transvenous digital subtraction angiography using a 57 cm image intensifier on 205 patients with vasoocclusive disease of the legs are presented. Two exposed fields sufficed in most cases for demonstration of all arteries, from the aortic bifurcation to the trifurcation at the lower leg. The principal advantages were the reduction of the contrast medium volume and the decrease in examination time. The reduced resolving power was a limiting factor in evaluating discrete wall lesions and of small vessels, but this did not induce diagnostic difficulties. The studies were evaluated retrospectively by an experienced vascular surgeon and in 85% of the cases were considered to be of diagnostic value.

[1 year's experience with a 57-cm image intensifier in a universal roentgen work station]. / Einjährige klinische Erfahrungen mit einem 57-cm-Bildverstärker in einem Universal-Röntgenarbeitsplatz.

3342 patients were examined by means of a 57 cm image intensifier during one year. The installation permits examination with the patient standing or lying. The resolution was measured with a lead grid under conditions resembling actual practice and were found to be similar to those obtained with angiographic equipment. Using a medium format technique for examining the gut and vascular system resulted in radiographic quality which was not significantly different from the use of a large format technique. For examination of the skeleton, radiographic quality, using the intensifier, was markedly poorer than that resulting from Bucky examinations. There was no diagnostic difference when carrying out lymphograms. The large intensifier window of 53 cm was particularly advantageous for DSA of the pelvic and lower limb vessels when compared with smaller intensifiers. Possible savings of film and contrast medium costs are discussed.

[Experimental and clinical determination of renal size after intravenous and intra-arterial administration of ionic and non-ionic contrast media]. / Nierengrössenbestimmung im Tierexperiment und am Menschen nach intravenöser und intraarterieller Applikation von ionischen und nicht-ionischen Kontrastmitteln.

A quantitative comparison of changes in renal size after the intravenous injection of contrast media showed no difference between ionic and non-ionic contrast medium. Contrast media of similar osmolarity (Metrizamide and Ioxaglate with 470 and 490 mosn/kg H2O) did show significant variations. Evidently properties of the contrast medium, other that their osmotic behaviour, are of significance (chemical structure, viscosity, iodine content, specific toxicity, and the effect on the permeability of biological membranes, calcium-binding activity, effect on coagulation). Changes in renal size could be reproduced by repeating the contrast injection at 24 to 48 hours.

Effect of redox agents on the non-electrolyte isotonic concentrations and on the equivalent pore radius of skeletal muscles of the frog.

Oxidizing and/or reducing agents inversely influence the alterations in the speed of mass changes (dw/dt) due to osmotic perturbations: an oxidizing agent increases while a reducing agent decreases it. The values for isotonic concentration (Ciso) increased for all of the tested non-electrolytes in the presence of an oxidizing agent, while decreased in the presence of a reducing one. The Staverman's reflection coefficient values (sigma) showed changes opposite in direction, so that the direct correlation between the size of test molecules and sigma values remained unchanged. An oxidizing agent increases and a reducing agent decreases the equivalent pore radius (EPR).

[Causes of hypertension following kidney transplantation with special reference to arterial stenoses]. / Ursachen der Hypertonie nach Nierentransplantation unter besonderer Berücksichtigung arterieller Stenosen.

Hypertension is regarded as a significant complication in renal transplant recipients. Its frequency was 48,1% after cadaver donor and 40,6% after living donor transplantation. The etiology is multifactorial. A correlation could be demonstrated between blood pressure and graft function or presence or absence of the diseased kidneys while no influence was found with regard to steroid dosage in patients with long term graft function. After 575 renal transplantations with 147 angiographies arterial stenoses were observed in nine patients (1,6%) and corrected surgically.