Absolute arrhythmia without an initially recognizable cause--prognosis and course

On the basis of a 10-year course examination of 21 patients with absolute arrhythmia (a. p.) should be tested whether it is justified to assume a purely functional cause of disturbances of rhythm in initially normal internal basis findings. In the period of the examinations no patient had died. Five patients showed an organic heart disease without any stronger functional effects (mitral insufficiency, coronary heart disease, hypertension, hypertrophic cardiomyopathy). In two of them complications had appeared (brain embolisms, myocardial infarction). The remaining patients were without any complaints and capable to work, apart from the intermittent or persisting disturbance of rhythm which continued to appear in all cases, and had again normal basis findings. However, in six of them echocardiographical deviations were found. In initially normal basis findings and a.p. at first a good prognosis is to be assumed. Regular control examinations are, however, necessary, that the manifestation of organic basic disease which appears among our patients in 1/4 of the cases is not overseen.     

Arterial hypertension in psychopathological states of an endogenous nature

The article describes the features and character of hypertension in certain psychopathological, mainly hypochondriac, states in an endogenous psychic disease. It is shown that the subjective pathopsychological state, the patients' complaints and functional vegetovascular disorders differ from those observed in patients suffering from true vascular diseases. The increase in arterial pressure in the patients studied follows earlier disturbances of the general condition. The dependence of the character of increase in arterial pressure and its tendency to stabilization on the acuity and urgency of senestopathy automatism is noted.     

The diagnosis of functional epigastric syndrome

The radiological examination of the stomach and the duodenum under functional aspects resulted in references of an irritative stomach in patients with epigastric complaints without conceivable organic findings lasting for many years. On the basis of simultaneously established peculiarities in the behaviour and the social situation of the patients concerned the disturbance of kinetics demonstrated is realized with great probability and explained as pathological by the patient. The results of the examination may be points of influence for the therapy of such disturbances.     

Behavioral Treatment of Intractable Chest Pain in a Patient with Vigorous Achalasia

Chest pain is a major symptom of patients diagnosed with esophageal motility abnormalities. Motility disorders of the esophagus are also associated with elevated scores on measures of somatic anxiety and depression. In spite of this relationship between psychological characteristics and esophageal motility disturbances, few attempts have been made to treat complaints of chest pain in patients with esophageal motility disorders using psychological methods. This report describes the successful use of a behavioral pain management program for the treatment of persistent chest pain in a patient diagnosed with vigorous achalasia who was previously treated with pneumatic dilatation and a long Heller myotomy. This is the first report on the use of psychotherapy in treating chest pain associated with vigorous achalasia, and suggests that, in the etiology and treatment of chest pain in patients with esophageal motility disturbances, psychological influences may be more important than has generally been recognized. No long-term relationship between esophageal motility disturbances and complaints of chest pain was found.     

Prevalence of lactose malabsorption among patients with functional bowel disorders

To investigate the prevalence of lactose malabsorption among patients with functional gastrointestinal disturbances we prospectively evaluated all patients referred to a gastrointestinal outpatient clinic over a period of 18 months. All patients had a breath hydrogen test following oral lactose in addition to the standard diagnostic procedures. In 37 of the total of 64 patients no organic cause of the gastrointestinal complaints was found. In 9 of these 37 patients (24%) the breath hydrogen test indicated lactose malabsorption. Three to 6 month later most of the patients with lactose malabsorption showed a significant reduction of gastrointestinal complaints after they had maintained a lactose-poor diet. In comparison, patients with functional disturbances but without lactose malabsorption reported nor or only minor improvement of symptoms; most of these patients had consulted another physician since the last visit in the clinic.     

Clinical course of 470 patients with mitral valve prolapse

The clinical relevance of the echocardiographic finding of mitral valve prolapse (MVP) is largely unclear. Therefore we made a prospective study of 470 patients with MVP established by M-mode echocardiography (63.7% holosystolic, 36.3% late systolic) over an average period of 2.7 years, corresponding to an observation period of 1,269 patient years. Patients with hemodynamically relevant mitral insufficiency were excluded from the study, as were patients with additional cardiac disorders. Three patients died, two of non-cardiac causes, but one probably in sudden cardiac death. 54.8% complained of angina pectoris, 15.6% of dyspnea. 14.4% suffered from non-orthostatic vertigo. 23.3% had one or more syncopes, 14.9% for the first time during the period of observation. 43.4% suffered from rhythm disturbances, 10.2% for the first time during the period of observation. Patients with rhythm disturbances experienced non-orthostatic vertigo (p less than 0.01) and syncopes (p less than 0.01) more frequently than patients without rhythm disturbances. During the study none of the patients developed endocarditis and none had an arterial embolism. Patients with late systolic MVP and a click experienced syncopes more frequently than those with holosystolic MVP without a click (p less than 0.05). Further correlations between the echocardiographic picture, auscultatory findings, age, sex and weight on the one hand and clinical progress on the other hand, were not found. Thus prognosis for MVP with regard to survival seems to be good. Nonetheless, complaints, even potentially threatening syncopes, are frequent. Neither clinical nor echocardiographic findings permit a prognostic statement.     

Obstructive sleep apnea syndrome as an uncommon cause of fibromyalgia: a case report

Fibromyalgia syndrome (FMS) is characterized by chronic widespread musculoskeletal pain, stiffness and tenderness at multiple points. Sleep disturbances are common in FMS and patients usually complain about nonrestorative sleep. Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive pharyngeal collapse during sleep. Recurrent arousals from sleep occurs to restore pharyngeal patency in OSAS and this results in increased sympathetic activity and fragmentation of sleep. Sleep disturbances may lead to musculoskeletal pain and some studies suggest a relation between OSAS and FMS. Since OSAS is strongly associated with increased risk of myocardial infarction, cerebrovascular accidents and congestive heart failure, its diagnosis and treatment are of particular importance. Herein we present a female patient with diagnosis of FMS for 10 years who had complaints of morning fatigue, restless sleep, sleepiness during day and snoring besides musculoskeletal symptoms. Severe OSAS was diagnosed after polysomnographic analysis and FMS symptoms were totally improved with nasal continuous positive airway pressure treatment.     

Behavioral problems associated with dementia: diagnosis and treatment

The more common behavioral disturbances associated with dementia in elderly patients include depression, psychosis, and agitation. Diagnosis of the underlying cause of these behavioral disturbances begins with a careful investigation of possible medical or toxic disturbances, followed by a careful diagnostic assessment for co-morbid psychiatric syndromes. Treatment of the psychiatric syndromes is often beneficial to the demented patient, improving functional status and reducing the potential for additional morbidity. Patients receiving psychoactive drugs require close monitoring for side effects.     

Memory complaints in 200 subjects meeting the diagnostic criteria for age-associated memory impairment: psychoaffective and cognitive correlates

We studied 200 subjects recruited by general practioners and meeting the seminal criteria for the age-associated memory impairment construct (AAMI). These criteria did not allow to select an homogeneous population. Three groups could be distinguished. First, 18 subjects had apparent psychoaffective disturbances, mainly related to anxiety. Second, 41 subjects had lower memory performance than the other subjects and could be classified as severe AAMI or late-life forgetfulness, former constructs similar to the present construct of mild cognitive impairment (MCI). A large majority of subjects (n -/+ 141) had no apparent psychoaffective disturbances and normal memory performance. They could correspond to the proper AAMI construct. Actually, two subgroups could be distinguished in these subjects. Half of them had low cognitive complaints, assessed by the cognitive difficulties scale, compared to those formerly found in a population of 1349 subjects aged over 50, studied by GP, but not specifically recruited on the presence of memory complaints. These subjects could be considered as quite normal subjects. The other half of AAMI subjects had higher scores of memory complaints and more psychoafective disturbances than the subjects of the first group. No relationship was found between subjective complaints and memory performance in the total population as well as in any subgroup. The main correlate of memory complaints was the score on the Zung anxiety scale in the total population, the LLF and the AAMI groups. This study do not support the existence of a specific category of aged subjects intermediate between normal subjects without subjective memory decline and patients with MCI or incipient Alzheimer's disease. Memory complaints appear to be related to psychoaffective disturbances even in subjects with low memory performance.     

Behavioral and physiological sleep characteristics in women with irritable bowel syndrome

OBJECTIVES: The goal of this study was to investigate behavioral (self-reported) and physiological sleep characteristics in irritable bowel syndrome (IBS) patients with and without concurrent dyspeptic symptoms, as compared to control subjects. METHODS: A total of 31 women with IBS were stratified into two groups: 15 with bowel symptoms only (IBS-only) and 16 with both lower and upper dyspeptic symptoms (IBS+D). In addition, 23 healthy women served as controls. For 4 consecutive days, subjective sleep quality, insomnia symptoms, alertness, state anxiety, perceived daytime stress, and daytime and nighttime GI symptoms were assessed. On night 4, subjects underwent polysomnographic (PSG) monitoring for an objective assessment of sleep quality including microarousals and respiratory parameters. Saliva samples were collected for cortisol analyses each morning and evening across the 4 days of the study. Psychological disturbances were assessed with the SCL. RESULTS: Patients reported significantly more dissatisfaction with their sleep quality and increased daytime fatigue as a result of both insomnia-type symptomatology and nonrestful sleep. These complaints were significantly greater in IBS+D compared to IBS-only for some measures. A significant proportion of patients, particularly IBS+D patients, reported nighttime GI symptoms. Patients reported significantly greater average anxiety across the 4 days, which was greatest in IBS+D. Although both patient subgroups showed normal levels and circadian changes in cortisol compared to controls, IBS+D had significantly increased morning salivary cortisol levels compared to IBS-only. PSG data showed no significant differences between the patient groups and controls. Significant correlations were found between psychological distress and retrospective subjective sleep complaints for patients. CONCLUSIONS: This study confirms the importance of sleep complaints and nighttime GI symptoms in women with IBS that are not substantiated by any objective, physiological evidence. Rather, there is a reporting bias regarding sleep disturbances, which appears to be related to symptom severity and psychological disturbances.     

Colonic spasm and pseudo-obstruction in an elongated colon secondary to physical exertion: diagnosis by stress barium enema

Anatomic and functional abnormalities of the colon are known to cause a variety of abdominal complaints, including constipation, diarrhea, and pain. We describe a patient with dolichocolon (elongated colon) with transient spasm (pseudo-obstruction) associated with exertion. The diagnosis in this case rested with a novel approach and less invasive evaluation of the colon.     

Multiple cognitive functional assessments used to modify the disturbed behavior of an elderly woman with dementia from the viewpoint of psychoeducation for the patient and her family

We report a case of a patient with dementia for whom a psychoeducational intervention based on a cognitive functional assessment by multiple cognitive functional tests was useful. She was an 82-year-old woman with hypertension and hyperlipidemia. She often asked about the date, scorched pans several times, and bought large amounts of the same items over 2 years. Her family worried that she might have dementia and hospitalized her. Mixed type dementia was diagnosed from the results of a cognitive functional assessment and magnetic resonance imaging findings. A psychoeducational program was conducted based on the findings of retained and impaired cognitive abilities derived from the above assessment. Her daily life disturbances were modified by an external compensation method. For example, her son told her repeatedly when it was not necessary to make supper, and made use of a block calendar. To consider how to cope appropriately with daily life disturbances derived from the symptoms of dementia, it is important to understand retained and impaired cognitive abilities, by comparing multiple cognitive functional assessments with the type of disturbances, and to deepen understanding of patients' psychological profiles, from the viewpoint of psychoeducation for the patient and family.     

GI problems in the elderly, Part II: Prevalent diseases and disorders

When ambulatory geriatric patients present with gastrointestinal (GI) complaints, a complete workup is necessary to determine whether the cause is a functional problem or organic disease. Some of the more common organic diseases found in the elderly GI patient include peptic ulcer disease, neoplasms, inflammatory bowel diseases, and diverticular disease. Special considerations that must be given the geriatric patient during workup, diagnosis, and treatment are discussed.     

Funktioneller Herzschmerz

Functional heart symptoms, especially chest pain, are very widespread and, according to the International Classification of Diseases (ICD-10), are described as "somatoform autonomous functional disorders of the cardiovascular system". Although they are very often accompanied by considerable anxiety about having a heart attack, for example, they are initially not recognizable as such and have to be distinguished from somatic complaints. The most prevalent of these symptoms (Table 2) are chest pains, followed by feelings of weakness, a tendency to become easily fatigued and breathing difficulties. The perception of changes in cardiac activity, such as tachycardia, heart palpitations, irregular heartbeat or arrhythmias, is also extremely unsettling and thus anxiety-provoking. Therefore, although a responsible cardiac diagnosis is the basis for every further step taken, it is advisable to carry out a brief anamnesis immediately, if possible, to determine the prior history (Table 1). For example, previously conducted clarification of somatic causes, consultations with more than one physician in parallel or repeated medical emergency calls can be helpful for orientation. Moreover, in the interview during the diagnostic measures, the possibility of functional causes should always be pointed out in order to counteract a somatic fixation early on. The health-care policy role that lies in early diagnosis of functional cardiac complaints has to be regarded as highly relevant.Following exclusionary diagnosis, the patients should not be discharged as "healthy" from the cardiological practice without a more in-depth anamnesis of their complaints, because differentiated questioning of the patient not only about typical physical and psychic symptoms, but also about behavior patterns (Table 3) that can accompany functional cardiac complaints, works in favor of a doctor-patient relationship that is based on trust. Since, in addition to anxiety disorders, above all depressive states accompany functional heart complaints, and can also cause them in the sense of a comorbidity, a knowledge of characteristics related to depression (Table 4), such as a depressed mood, loss of interest or low motivation, is very helpful for a better understanding of the patients. The "vicious circle" that rapidly develops precisely in the case of this group of patients, consisting of physical symptoms, avoidance behavior and psychological as well as interpersonal difficulties, is described and possible solutions are pointed up.In summary, the following recommendations can be formulated for day-to-day clinical practice: 1. From the very beginning, a holistic approach should be conveyed in the interview by addressing psychological and social aspects as well, and taking them into account as possible causes. 2. The somatic diagnosis should, if possible, not go beyond that which is urgently necessary from a cardiological standpoint and presented in guidelines. One should, above all, not give in to pressure from the patients if it is a matter of repeated examinations within a short period of time. 3. A differentiated and focused anamnesis helps the patients to feel understood and taken seriously. 4. A relationship based on trust enhances the chances for a successful transfer to psychosomatic examination and treatment.     

Elements of fibromyalgia in an open population

OBJECTIVE: To examine the nosological concept of fibromyalgia in the general population. METHODS: A postal survey of rheumatic pain and non-specific bodily complaints was sent to all 3174 German female residents of Bad S?ckingen, Germany, aged 35 to 74 yr. A stratified random sample of 653 subjects was further examined in a clinical survey. RESULTS: On the population level the point prevalence of chronic widespread pain was 13.5%. In the clinical survey, tender point count was associated not only with the extent of rheumatic pain, but also independently with the extent of bodily complaints. Subjects with no history of rheumatic pain but with non-specific bodily complaints had as many positive tender points as subjects without bodily complaints but with a history of rheumatic pain. Subjects could be identified who met the tender point criterion of the ACR without a history of widespread pain. Multivariate analyses demonstrated that some symptoms carry a risk for positive tender points (low physical mobility, pain, bodily complaints) and some for chronic widespread pain (poor health status, catastrophizing, emotional reactions, low energy level, sleep disturbances) that are independent of each other and of age. CONCLUSIONS: The results do not only question the relevance and specificity of a history of widespread pain in diagnosing fibromyalgia, but also the concept of fibromyalgia as a distinct rheumatological disorder. The results support the concept of fibromyalgia as part of a wider spectrum of dysfunctional syndromes.     

The role of free fatty acids in the pathogenesis of arteriosclerosis

Several diseases and functional disturbances (e.g. diabetes mellitus, obesity, phaeochromocytoma, chronic renal functional disturbances, psychosocial stress) marked by a disturbed metabolism of free fatty acids (FFA) and a hyperlipacidaemia correlate with a premature occurrence of arteriosclerotic alterations of the vessels. The FFA do not play an unimportant role as a link in the causal chain between the above-mentioned diseases or functional disturbances on the one hand and the atherogenesis on the other. Therefore an overview is given of the influence of a hyperlipacidaemia on important partial processes of the atherogenesis. In this connection the role of FFA in the lesion of the endothelium and in the formation of foam cells is depicted.     

Endoscopic perfusion manometry: diagnosis of functional biliary disorders

During the last years the endoscopic perfusion manometry developed many new recognitions about the courses of pressure and motility at the sphincter Oddi. The clinical and experimental application of the method concentrated itself to the proof of functional disturbances. Many results are contradictory and a whole series of questions is unsolved. The own investigations concentrated themselves on pressure measurements in the common bile duct in patients with removed gallbladder, in whom by comprehensive diagnostic measures no organic disease of the biliary tract could be found. Two groups of patients were compared. Patients of group 1 (n = 14) had no biliary symptoms after cholecystectomy. The patients of the second group (n = 20) continued to have biliary complaints after cholecystectomy, or they again occurred after symptom-free interval. At the beginning of the investigation the pressure in the common bile duct was the same in the two groups. In group 1 the pressure remained constant also during the manometry and the patients remained without any complaints. However, in group 2 a gradual increase of pressure and biliary complaints developed during manometry. These occurred after an average pressure increase of 8 Torr. The velocity of the increase of pressure well correlated with the intensity of the complaints. The symptoms during manometry were identical with those cited in the anamnesis. The pressure increase in the common bile duct is regarded as an expression of a functional disturbance of the sphincter of Oddi. The constant perfusion rate (1.3 ml/min) in this group of patients is sufficient as volume load, in order to detect a disturbed drainage capacity of the papilla. On its part the increase of the pressure is responsible for the evocation of the complaints.     

Sleep disturbances in caregivers of patients with end-stage congestive heart failure: Part I--The problem

Up to 90% of caregivers report sleep disturbances, particularly congestive heart failure (CHF) caregivers. Sleep disturbances have numerous consequences that can negatively impact a wide domain of outcomes in both the caregiver and the patient for whom they care. Ultimately, these disturbances can lead to caregiver morbidity and CHF patient morbidity, readmission, and mortality. Nurses play a central role in patient education, especially with caregivers. Therefore, nurses can help to educate caregivers on the consequences of stress-related sleep disturbances, which are very prevalent in CHF caregivers.     

Sleep disturbances in caregivers of patients with end-stage congestive heart failure: Part II--assess and intervene

Sleep disturbances in caregivers of patients with congestive heart failure is common. The consequences of sleep disturbances are dire and have potential to seriously impact caregiver health and patient outcomes. Therefore, it is imperative that the health care team, especially nurses, assess and intervene. Basic assessment of caregiver sleep disturbance can be quick and simple and can be performed while assessing the congestive heart failure patient's health. If a more complex sleep disorder is suspected, other assessments can be conducted if time and money permit. The benefits to properly assessing sleep disturbance and subsequent treatment far outweigh the minimal time spent by the health care team or caregiver.     

A questionnaire for the detection of psychiatric and somatic complaints in the elderly

A questionnaire of psychic and somatic complaints for the elderly is presented. This questionnaire assesses with 8 factors the following symptoms cluster: depression, anxiety, cognitive disturbances, somatic complaints, social problems, sleep problems, psychotic experiences, and sexual disturbances. These subscales are reliable and valid measures. This measure is helpful in particular in epidemiological research and also in clinical day-to-day practice.