Der Nervenarzt
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In the final stage of amyotrophic lateral sclerosis (ALS) the majority of patients develop chronic respiratory failure due to respiratory muscle weakness. The interaction between the patient with ALS and the physician should be characterized by continuous communication, especially with respect to the prospect of ventilatory failure and for support. The patient and his family must be informed thoroughly about the natural history and the prognosis of ALS, depending on the individual disease process. ⋯ Mechanical ventilation should only be initiated in the exceptional case. However, if dyspnea occurs in the early stage of the disease, when there is no bulbar paralysis and peripheral muscle function is intact, then noninvasive mechanical ventilation via mask may improve the quality of life substantially. Nevertheless, invasive mechanical ventilation via a tracheostomy should be avoided.
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Review Comparative Study
[Schizophrenia concepts in Soviet and Russian psychiatry].
Concepts of schizophrenia of the Soviet Russian school are presented. They are historically based upon the broad concepts of schizophrenia by Kraepelin and Bleuler. ⋯ Differential-diagnostic criteria of sluggish schizophrenia and neurosis, such as positive psychopathological symptoms, thought disturbances and changes in personality, will be delineated. Furthermore, recent developments in Russian psychiatry and modifications in Russian schizophrenia concepts will be exemplified by the concept of "psychic diathesis."
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The new occurrence of epileptic disorders increases continuously above the age of 60 years. The most frequent etiology of epilepsy in the elderly is vascular (32-54%). Tumors are the cause of epilepsy in the elderly in 11 to 33 per cent of cases, with a peak around the age of 60. ⋯ It is important to recognize confusional states, for they may be symptoms of a psychomotor status or a prolonged postical phase. Occasional seizures occur more often in the elderly. Due to altered pharmacokinetics and problems of compliance in old age, the titration period of antiepileptic drugs should be planned with particular care and patients given simple drug regimens.
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Incidence and clinical significance of cardiopulmonary complications of acute cerebral lesions are still unclear. Neurogenic pulmonary edema (NPE) is characterized as an acute, protein-rich lung edema occurring shortly after cerebral lesions associated with an acute rise of intracranial pressure. NPE is infrequently diagnosed, usually in association with head trauma. ⋯ Pathological examination reveals myofibrillar necrosis. Cardiac complications are explained with overactivity of the sympathetic innervation and high levels of circulating catecholamines. For adequate treatment, close cardiac monitoring is required in all patients with acute cerebral lesions.
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Given the relentless progression of amytrophic lateral sclerosis (ALS) and the lack of causative therapy, breaking the news to ALS patients and their families is a daunting task for any physician. Obviously, such a task cannot be standardized. However, it is now recognized to be the first and one of the most sensitive and important steps in palliative care. ⋯ All questions from the patient should be discussed openly, with emphasis on the positive aspects. Available therapeutic options should be reviewed, pointing out the fact that all symptoms of ALS can be alleviated by palliative therapy. At the onset of dyspneic symptoms, the terminal phase of the disease and the option of mechanical ventilation should be discussed.