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Although asexuality became a growing research subject over the last decade, data on the mental health of individuals identifying as asexual is still rare. The key objective of the present study was to examine depressive symptoms among individuals identifying as asexual. Data of LGBTQIA+ (Lesbian, Gay, Bi-sexual, Trans*, Queer, Inter*, Asexual and/or + indicating others within the community) and cisgender heterosexual individuals was collected through an online survey during the COVID-19 lockdowns in Germany. The survey included questions about sexual and gender identity, depressive symptoms, and asexual identity. An analysis of N = 6601 participants was conducted. A total of n = 445 individuals identified as asexual. Regression results indicated identifying as asexual being significantly associated with higher depressive symptoms. Results suggest that individuals identifying as asexual represent a vulnerable group within the group of sexual minorities, one that fundamentally requires special psychosocial support, especially in times of pandemics., (© 2024. The Author(s).)

A Gram-negative, aerobic, pink-pigmented, and bacteriochlorophyll a -containing bacterial strain, designated B14 T , was isolated from the macroalga Fucus spiralis sampled from the southern North Sea, Germany. Based on 16S rRNA gene sequences, species of the genera Roseobacter and Sulfitobacter were most closely related to strain B14 T with sequence identities ranging from 98.15 % ( Roseobacter denitrificans Och 114 T ) to 99.11 % ( Roseobacter litoralis Och 149 T ), whereas Sulfitobacter mediterraneus CH-B427 T exhibited 98.52 % sequence identity. Digital DNA-DNA hybridization and average nucleotide identity values between the genome of the novel strain and that of closely related Roseobacter and Sulfitobacter type strains were <20 % and <77 %, respectively. The novel strain contained ubiquinone-10 as the only respiratory quinone and C 18 : 1  ω7 c , C 16 : 0 , C 18 : 0 , C 12 : 1  ω7 c , C 18 : 2  ω7,13 c , and C 10 : 0 3-OH as the major cellular fatty acids. The predominant polar lipids of strain B14 T were phosphatidylcholine, phosphatidylethanolamine, and phosphatidylglycerol. The genome of strain B14 T comprises a chromosome with a size of 4.5 Mbp, one chromid, and four plasmids. The genome contains the complete gene cluster for aerobic anoxygenic photosynthesis required for a photoheterotrophic lifestyle. The results of this study indicate that strain B14 T (=DSM 116946 T =LMG 33352 T ) represents a novel species of the genus Roseobacter for which the name Roseobacter fucihabitans sp. nov. is proposed.

Introduction: Measures against the COVID-19 pandemic led to restrictions in ambulatory health care in Germany. While the restrictions have been described from claims data, the patients' perspective has been missing. Lesbian, gay, bisexual, trans-, inter- and asexual persons (LGBTIA) might have been particularly affected by these restrictions because of their vulnerability. Thus, our research questions were: 1) How did the restrictions during the pandemic influence primary care and psychotherapy in Germany from the patients' perspective? 2) Are there differences between LGBTIA and cis-heterosexual persons regarding these restrictions?, Methods: We conducted an online survey with two survey waves in March/April 2020 and January/February 2021. Sampling was conducted via multiplicators and via snowball sampling. Amongst others, the survey contained open-ended questions regarding primary care and psychotherapy. From the answers of the first survey wave we constructed quantitative items for the second survey wave. Descriptive and inferential statistical analysis was conducted, including linear regression with R., Results: 6,784 participants took part in the survey (2,641 in the first survey wave), 5,442 of whom identified as LGBTIA. Categories of changes in primary care were: no health care utilization, no changes in primary care, insecurity regarding primary care, and changes in primary care which could be less frequent utilization, differing procedures or changes in ways of communication. In the second wave, LGBTIA participants rated the worsening of primary care during the pandemic as being more pronounced. Regarding psychotherapy, the change can be described as no change in care, changes in the form of therapy, treatment in emergencies only and a longer break from psychotherapy. There was no different rating by LGBTIA persons compared to cis-heterosexual persons in the second survey wave. Telephone and video consultations were more common in psychotherapy than in primary care., Discussion: LGBTIA persons were oversampled, so the sample included more people from urban areas than the German population. Due to the online survey form, older people were underrepresented relative to their numbers in the general German population., Conclusion: With respect to future pandemics general practitioners in primary care must be prepared that psychotherapy might be paused and delayed for some time. Video and telephone consultations should be offered to overcome pandemic-related restrictions in the future. General practitioners should know the gender identity and sexual orientation of their patients in order to proactively address health care barriers., (Copyright © 2023. Published by Elsevier GmbH.)

Purpose: There are only rough estimates of the worldwide incidence of pilonidal sinus carcinoma. The purpose of the study is to explore the demographic characteristics of this disease and to provide more precise information about its incidence., Methods: The study included questioning the surgeons and pathologists in Germany in addition to a literature research. The literature investigation included all published articles about pilonidal carcinoma in all languages. The questionnaire included 1050 pathologists and all 834 hospitals with a surgical division in Germany. The outcome measures included the total number of cases, the language of publication, gender, age, country of origin, interval until the diagnosis of carcinoma, and reported incidence based on local studies., Results: From 1900 to 2022, we found 140 cases of pilonidal sinus carcinoma in 103 articles. The investigation revealed two additional unpublished cases from Germany. The male-to-female ratio was 7.75:1. The countries with the most cases were the USA (35 cases, 25.0%), Spain (13 cases, 9.3%), and Turkey (11 cases, 7.6%). The average age was 54.0 ± 11.8 years and the interval between the diagnosis of the disease and the development of carcinoma was 20.1 ± 14.1 years. There was a parallel increase in reported cases of pilonidal sinus disease and pilonidal carcinoma over the last century. The reported incidence varied from 0.03% to 5.56%. The worldwide calculated incidence equaled 0.17%., Conclusion: Due to underreporting and other causes, the incidence of carcinoma emerging on the background of pilonidal sinus disease is higher than reported., (© 2023. The Author(s).)

Background: Intensive Care Resources are heavily utilized during the COVID-19 pandemic. However, risk stratification and prediction of SARS-CoV-2 patient clinical outcomes upon ICU admission remain inadequate. This study aimed to develop a machine learning model, based on retrospective & prospective clinical data, to stratify patient risk and predict ICU survival and outcomes., Methods: A Germany-wide electronic registry was established to pseudonymously collect admission, therapeutic and discharge information of SARS-CoV-2 ICU patients retrospectively and prospectively. Machine learning approaches were evaluated for the accuracy and interpretability of predictions. The Explainable Boosting Machine approach was selected as the most suitable method. Individual, non-linear shape functions for predictive parameters and parameter interactions are reported., Results: 1039 patients were included in the Explainable Boosting Machine model, 596 patients retrospectively collected, and 443 patients prospectively collected. The model for prediction of general ICU outcome was shown to be more reliable to predict "survival". Age, inflammatory and thrombotic activity, and severity of ARDS at ICU admission were shown to be predictive of ICU survival. Patients' age, pulmonary dysfunction and transfer from an external institution were predictors for ECMO therapy. The interaction of patient age with D-dimer levels on admission and creatinine levels with SOFA score without GCS were predictors for renal replacement therapy., Conclusions: Using Explainable Boosting Machine analysis, we confirmed and weighed previously reported and identified novel predictors for outcome in critically ill COVID-19 patients. Using this strategy, predictive modeling of COVID-19 ICU patient outcomes can be performed overcoming the limitations of linear regression models. Trial registration "ClinicalTrials" (clinicaltrials.gov) under NCT04455451., (© 2021. The Author(s).)

Background: Preliminary empirical data indicates a substantial impact of the COVID-19 pandemic on well-being and mental health. Individuals with minoritized sexual and gender identities are at a higher risk of experiencing such negative changes in their well-being. The objective of this study was to compare levels of well-being among cis-heterosexual individuals and individuals with minoritized sexual and gender identities during the COVID-19 pandemic., Methods: Using data obtained in a cross-sectional online survey between April 20 to July 20, 2020 (N = 2332), we compared levels of well-being (WHO-5) across subgroups (cis-individuals with minoritized sexual identities, individuals with minoritized gender identities and cis-heterosexual individuals) applying univariate (two-sample t-test) and multivariate analysis (multivariate linear regression)., Results: Results indicate overall lower levels of well-being as well as lower levels of well-being in minoritized sexual or gender identities compared to cis-heterosexual individuals. Further, multivariate analyses revealed that living in urban communities as well as being in a relationship were positively associated with higher levels of well-being. Furthermore, a moderation analysis showed that being in a relationship reduces the difference between groups in terms of well-being., Conclusion: Access to mental healthcare for individuals with minoritized sexual and gender identities as well as access to gender-affirming resources should be strengthened during COVID-19 pandemic. Healthcare services with low barriers of access such as telehealth and online peer support groups should be made available, especially for vulnerable groups., Competing Interests: Pichit Buspavanich received a research grant from Gilead. Sven Mahner reports Research support, advisory board, honoraria and travel expenses from AbbVie, AstraZeneca, Clovis, Eisai, GlaxoSmithKline, Medac, MSD, Novartis, Olympus, PharmaMar, Pfizer, Roche, Sensor Kinesis, Teva, and Tesaro. All other authors have no conflict of interest to declare We confirm that our Competing Interest statement does not alter the adherence to PLOS ONE policies on sharing data and materials.

Introduction:  Besides dyspnea a dry cough is one of the main symptoms in patients with pulmonary fibrosis. Little is known about the 24-hour-variability of this symptom. Moreover, it is unclear if other auscultation phenomena occur., Methods:  A long-term auscultation for 24-hours was performed in patients with fibrotic lung diseases (LEOSound, Löwenstein Medical GmbH & Co. KG, Medical-Electronics, Bad Ems, Germany). Coughing and wheezing sounds were recorded. For the following analysis the 24-hour period was divided into two intervals of 12 hours each (daytime and nighttime). Events were registered in epochs (at least one event in 30 seconds)., Results:  20 patients were included (6 with nonspecific interstitial pneumonia and 14 with idiopathic pulmonary fibrosis). On average 166 coughing epochs were recorded in a 24-hour-period (day/night 116/50; P  < 0.001). Moreover, 203 wheezing epochs were registered (day/night 84/119; P  = 0.273). Auscultation phenomena did not correlate with spirometric and bodyplethymographic data, nor with data of diffusion capacity., Discussion:  The study is showing the clinical potential of long-term auscultation in patients with fibrotic lung diseases. Especially the findings concerning the coughing symptoms were remarkable. It could be shown that there was a decrease of coughing during nighttime in comparison to daytime. In contrast to this, wheezing sounds were increasing at nighttime. The clinical relevance of this finding is yet to be assessed. Finally, there was no correlation between the severity of the disease measured by functional diagnostics and the amount of coughing., Competing Interests: M. B., M. W. S. und D. M. geben an, keinen Interessenkonflikt im Kontext der vorliegenden Arbeit zu haben.W. W. hat Vortragshonorare von Löwenstein Medical GmbH und Co. KG erhalten.S. B. S. und F. S. M. geben an, Reisekostenunterstützung von Löwenstein Medical GmbH und Co. KG erhalten zu haben., (Thieme. All rights reserved.)

A SARS-CoV2 super-spreading event occurred during carnival in a small town in Germany. Due to the rapidly imposed lockdown and its relatively closed community, this town was seen as an ideal model to investigate the infection fatality rate (IFR). Here, a 7-day seroepidemiological observational study was performed to collect information and biomaterials from a random, household-based study population. The number of infections was determined by IgG analyses and PCR testing. We found that of the 919 individuals with evaluable infection status, 15.5% (95% CI:[12.3%; 19.0%]) were infected. This is a fivefold higher rate than the reported cases for this community (3.1%). 22.2% of all infected individuals were asymptomatic. The estimated IFR was 0.36% (95% CI:[0.29%; 0.45%]) for the community and 0.35% [0.28%; 0.45%] when age-standardized to the population of the community. Participation in carnival increased both infection rate (21.3% versus 9.5%, p < 0.001) and number of symptoms (estimated relative mean increase 1.6, p = 0.007). While the infection rate here is not representative for Germany, the IFR is useful to estimate the consequences of the pandemic in places with similar healthcare systems and population characteristics. Whether the super-spreading event not only increases the infection rate but also affects the IFR requires further investigation.

Background: Few data are available on the characteristics of inpatient treatment and subsequent outpatient treatment for depression in Germany. In this study, we aimed to characterize the inpatient and outpatient treatment phases, to determine the rates of readmission and mortality, and to identify risk factors., Methods: We carried out a descriptive statistical analysis of routine administrative data from a large health-insurance carrier (BARMER). All insurees aged 18 to 65 who were treated in 2015 as inpatients on a psychiatry and psychotherapy service or on a psychosomatic medicine and psychotherapy service with a main diagnosis of depression were included in the analysis. Risk factors for readmission and death were determined with the aid of mixed logistic regression., Results: Of the 22 893 patients whose data were analyzed, 78% had been hospitalized on a psychiatry and psychotherapy service and 22% on a psychosomatic medicine and psychotherapy service. The median length of hospital stay was 42 days. Follow-up care in the outpatient setting failed to conform with the recommendations of the pertinent guidelines in 92% of the patients with a main diagnosis of severe depression during hospitalization, and in 50% of those with moderate depression. 21% of the patients were readmitted within a year. The mortality at one year was 961 per 100 000 individuals (adjusted for the age and sex structure of the German population), or 3.4 times the mortality of the population at large. In the regression model, more treatment units during hospitalization and subsequent treatment with psychotherapy were associated with a lower probability of readmission, while longer hospitalization with subsequent pharmacotherapy or psychotherapy was associated with lower mortality., Conclusion: The recommendations of the national (German) S3 guidelines for the further care of patients who have been hospitalized for depression are inadequately implemented at present in the sectored structures of in- and outpatient care in the German health care system. This patient group has marked excess mortality.

Background: Pollen allergies affect a significant proportion of the population globally. At present, Web-based tools such as pollen diaries and mobile apps allow for easy and fast documentation of allergic symptoms via the internet., Objective: This study aimed to characterize the users of the Patient's Hayfever Diary (PHD), a Web-based platform and mobile app, to apply different symptom score calculations for comparison, and to evaluate the contribution of organs and medications to the total score for the first time., Methods: The PHD users were filtered with regard to their location in Austria and Germany, significant positive correlation to the respective pollen type (birch/grass), and at least 15 entries in the respective season. Furthermore, 4 different symptom score calculation methods were applied to the datasets from 2009 until 2018, of which 2 were raw symptom scores and 2 were symptom load index (normalized) calculations. Pearson correlation coefficients were calculated pairwise for these 4 symptom score calculations., Results: Users were mostly male and belonged to the age groups of 21 to 40 years or >40 years. User numbers have increased in the last 5 years, especially when mobile apps were made available. The Pearson correlation coefficients showed a significant linear relationship above 0.9 among the 4 symptom score datasets and thus indicated no significant difference between the different methods of symptom score calculation. The nose contributed the most to the symptom score and determined about 40% of the score., Conclusions: The exact method of calculation of the symptom score is not critical. All computation methods show the same behavior (increase/decrease during the season). Therefore, the symptom load index is a useful computation method in all fields exploring pollen allergy, and Web-based diaries are a globally applicable tool to monitor the effect of pollen on human health via electronically generated symptom data., (©Katharina Bastl, Maximilian Bastl, Karl-Christian Bergmann, Markus Berger, Uwe Berger. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.02.2020.)

Objectives: Coal tar creosote oils are used as highly effective wood protectants for, e.g., railway sleepers, utility poles and marine pilings. For impregnation of wood, the hot creosote oil is mostly applied in vacuum processes and by hot-and-cold dipping. From the perspective of an occupational hygienist, creosote tar oils are problematic because they have a number of hazardous properties, including carcinogenicity. We have studied inhalation and dermal exposure in six and four impregnation plants, respectively, in Germany. Some plants were visited repeatedly, for up to five measurement campaigns conducted over several years. Inhalation and dermal exposure resulting from vacuum impregnation and from hot-and-cold dipping, as well as secondary exposure resulting from assembly of impregnated railway sleepers have been measured. Accompanying, human biomonitoring of the employees has been performed., Methods: Inhalation exposure was measured using personal air samplers, collecting particles and vapours simultaneously. Dermal exposure was investigated by whole body dosimetry using disposable chemical protective coveralls and split leather gloves. 18 polycyclic aromatic hydrocarbons (PAHs) have been determined separately by high performance liquid chromatography (HPLC) or gas chromatography-mass spectrometry (GC-MS), respectively. For human biomonitoring 1-hydroxypyrene (1-OHP) in urine related to creatinine has been measured using HPLC. Both, pre- and post-shift values have been determined for this metabolite., Results: Dermal exposure towards pyrene and the sum of the determined 18 PAHs as well as inhalation exposure to naphthalene, pyrene and the sum of the determined 18 PAHs are presented in this paper. The plants performing vacuum impregnation have employed different constructive, technical and organisational measures, and some measures have also changed between the different measurement campaigns. We have found that cooling the vacuum impregnation vessel before unloading can reduce inhalation exposure to about one-third. However, our data shows that installation of structural or technical risk management measures (RMM) did not always reduce the exposure as intended, and can even lead to increased exposure in adverse constellations. Dermal exposure was strongly affected by differences in the working procedures. Measurements performed during assembly of impregnated railway sleepers indicate that secondary exposure leads to lower inhalation, but similar dermal exposure compared to the impregnation processes. Also 1-OHP excretion rates are similar after impregnation process and after assembly of impregnated railway sleepers., Conclusion: Our recent data underlines that efficient reduction of the exposure resulting from impregnation with creosote requires sophisticated risk reduction strategies. Structural measures such as the enclosure of the loading area and technical measures like local exhaust ventilation shall be coordinated carefully with organisational measures and provision of personal protective equipment. The data presented here represents a broad bandwidth of current workplace situations in the creosote oil processing industry and is therefore suitable for risk assessment in related plants as well as under regulatory frameworks like the European Biocides Regulation. Each plant in this investigation was unique. Together they represent the whole width of this branch in Germany. Additionally, the number of plants and exposed workers is limited and relative low. Therefore, a comprehensive consideration and statistical analysis were not feasible., Competing Interests: Declaration of competing interest The authors declare no conflict of interest relating to the material presented in this article. Its contents, including any opinions and/or conclusions expressed, are solely those of the authors., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Today, antibiotics are essential for effective treatment of infectious diseases both in human and veterinary medicine. The increasing development and distribution of antibiotic-resistant microorganisms are subject of concern. In some sectors of animal agriculture, such as poultry feeding farms, the application of antibiotics and hence occupational exposure is inevitable. In the past, numerous studies focussed on the occurrence of antibiotic-resistant bacteria in livestock farming, but little attention was paid to the employees. The exposure of workers to antibiotics was the focus of the study detailed in this article. Four biomonitoring campaigns monitoring systemic exposure of workers to antibiotics were run at two farms over four fattening periods. Urine samples of potentially affected employees were sampled and analysed for the antibiotics of interest by liquid chromatography-mass spectrometry. The highest antibiotic concentrations detected in urine samples exceeded the minimum inhibitory concentration of some bacteria strains. In some cases, the amount of antibiotics excreted over a time-period of 24 h indicated the exceedance of the tolerable daily intake., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Occupational Hygiene Society.)

Mental health promotion programs (MHP) seek to reduce sub-syndromal symptoms of mental distress and enhance positive mental health. This study evaluates the long-term effects of a mindfulness-based MHP program ('Life Balance') provided by health coaches in a multi-site field setting on mental distress, satisfaction with life and resilience. Using a controlled design, propensity score matching was used to select a control group for participants of the MHP. The total study sample (N = 3624) comprised 83% women, with a mean age of 50 years. Data was collected via mailings 1 year after study entry. Results suggest participants experience reduced emotional distress at 12-month follow-up, with a medium between-group effect size (d = 0.40) for those participants who showed clinically relevant symptoms of mental distress at study entry. The effects of the program were more pronounced in participants with higher initial distress scores. New cases of psychopathological symptoms were prevented in 1 of 16 participants. Satisfaction with life and resilience were enhanced significantly. Our data suggest 'Life Balance' shows long-term effectiveness and indicate it is possible to design MHP programs that serve as both primary and indicated prevention, and that these programs can be applied on a population basis., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The highly virulent Escherichia coli O104:H4 isolate that caused a large outbreak in 2011 carries three plasmids. Out of these, only one, the IncI plasmid pO104&#95;90 that encodes two extended spectrum beta-lactamases, can transfer itself by conjugation. Considering its potential contribution to the emergence and virulence of the outbreak strain, we aimed to get a closer insight into pO104&#95;90 transfer efficiency and control. We tested the host spectrum of the plasmid and observed transmission into Enterobactericeae including clinically relevant enterobacterial pathogens like Salmonella typhimurium and Shigella flexneri. However, we found that this plasmid did not transfer into E. coli strains that kill the donor strain due to bacteriocin production, e.g. the probiotic E. coli Nissle 1917. Under the same conditions, the highly transmittable control plasmid RP4 was efficiently transferred into all these recipients. Therefore we hypothesized that the failure of transfer of pO104&#95;90 was simply due to the generally much lower transmission rates of this IncI plasmid and we decided to screen for factors that negatively affect the transfer of the plasmid by an in vivo deletion analysis. Our attempts to delete larger regions of the plasmid resulted in cells containing both a truncated plasmid (Δ50 kb and Δ75 kb) and a wild type copy of pO104&#95;90. When used as donors in conjugation experiments, these cells transferred the wild type plasmid at dramatically increased rates. This indicated that the relatively limited region shared by both plasmids contained an activator of transfer. We therefore analyzed its transcriptional organization, dissected the candidate region by subcloning and showed that additional copies of repY/INC were sufficient to increase the transfer frequency of pO104&#95;90 to the observed level. To our knowledge, this is the first evidence for a direct regulatory cross talk between core control elements of the vegetative replication and the transfer functions of an IncI1 plasmid., (Copyright © 2018 Elsevier GmbH. All rights reserved.)

Escherichia coli O104:H4 (E. coli O104:H4), which caused in 2011 a massive foodborne outbreak in Germany, is characterized by an unusual combination of virulence traits. E. coli O104:H4 contains a prophage-encoded Shiga toxin (Stx) gene, which is the cardinal virulence factor of enterohemorrhagic E. coli (EHEC). However, the outbreak strain shares highest DNA sequence similarity with enteroaggregative E. coli (EAEC) and displays the EAEC-characteristic tight adherence to epithelial cells. The virulence potential of the underlying EAEC background has not been investigated and it is therefore not clear whether E. coli O104:H4 displays distinct virulence characteristics in comparison to prototypical EAEC. In this study, we performed a detailed comparative phenotypic characterization of the Stx phage-cured E. coli O104:H4 strain C227-11φcu, the closely related EAEC strain 55989 and two other well-characterized EAEC strains 042 and 17-2 with focus on virulence traits. C227-11φcu displayed superior aggregative adherence phenotype to cultured HCT-8 epithelial cells, adhering with 3-6 times more bacteria per epithelial cells than the tested EAEC strains. Otherwise, C227-11φcu showed similar virulence characteristics to its closest relative 55989, i.e. strong acid resistance, good biofilm formation and cytotoxic culture supernatants. Furthermore, C227-11φcu was characterized by significantly weaker motility and pro-inflammatory properties than 55989 and 042, nevertheless stronger than 17-2. Taken together, C227-11φcu displayed mostly robust, but not outstanding virulence characteristics in comparison to the tested EAEC. Therefore, it appears likely that the combination of Stx production and EAEC characteristics in general, rather than an exceptionally potent EAEC background resulted in the unusual virulence of the E. coli O104:H4. Thus, the emergence of such hypervirulent strains in the future might be more likely than previously anticipated., (Copyright © 2018 Elsevier GmbH. All rights reserved.)

Objective: Examination of the attendance for using internet-based measures after inpatient treatment., Methods: Cross-sectional-survey in former inpatients (N = 247)., Results: 44.9 % are willing to use measures via videoconference, 34.7 % via Chat, 50.0 % via E-Mail and 38.0 % as onlinetherapy. Attendance is lower in older age groups. Benefits regarding the introduced measures are seen mainly in the flexibility and disadvantages in the impersonal character., Conclusions: A relevant share of especially younger patients is willing to use internet-based measures., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Enterohemorrhagic Escherichia coli (EHEC) are Shiga toxin (Stx) producing bacteria causing a disease characterized by bloody (or non-bloody) diarrhea, which might progress to hemolytic uremic syndrome (HUS). EHEC O104:H4 caused the largest ever recorded EHEC outbreak in Germany in 2011, which in addition showed the so far highest incidence rate of EHEC-related HUS worldwide. The aggressive outbreak strain carries an unusual combination of virulence traits characteristic to both EHEC-a chromosomally integrated Stx-encoding bacteriophage, and enteroaggregative Escherichia coli-pAA plasmid-encoded aggregative adherence fimbriae mediating its tight adhesion to epithelia cells. There are currently still open questions regarding the 2011 EHEC outbreak, e.g., with respect to the exact molecular mechanisms resulting in the hypervirulence of the strain, the natural reservoir of EHEC O104:H4, and suitable therapeutic strategies. Nevertheless, our knowledge on these issues has substantially expanded since 2011. Here, we present an overview of the epidemiological, clinical, microbiological, and molecular biological data available on the 2011 German EHEC O104:H4 outbreak.

Background: The financing of psychiatric psychotherapeutic care in Germany is determined by the German psychiatric staffing regulations which are unchanged since 1991. Psychotherapy was established after 1991 as an effective and indispensable treatment of mental and behavioral disorders., Aims and Objectives: The aim of this study was to empirically investigate the use of psychiatrists' and psychologists' working time for psychotherapy in guideline-adherent hospital care. A further aim was to compare these results to the resources defined by the German psychiatric staffing regulations and in the new prospective payment system for psychiatry and psychosomatics in Germany., Material and Methods: University hospitals for psychiatry and psychotherapy were asked to retrospectively provide data of patients for which guideline-adherent care was possible. Participating institutions provided both data describing the staff time utilization of psychotherapeutic services provided by psychiatrists and psychologists and patient classifications according to the German psychiatric staffing regulations and the new prospective payment system for psychiatry and psychosomatics., Results: Resources defined by the German psychiatric staffing regulations covered a mean of only 71 min of psychotherapy per patient and week while the actual mean intensity of psychotherapeutic care provided by the participating hospitals was 194 min per patient and week. The associated use of staff time was 102 min per patient and week. Both figures increased during an inpatient episode. The resources defined by the German psychiatric staffing regulations covered only 70 % of medical and psychological personnel. The current configuration of the new prospective payment system for psychiatry and psychosomatics covered only 59 % of staff time., Conclusion: The results of this study provide another unambiguous recommendation to adjust the out-dated German psychiatric staffing regulations to the current evidence and S3 guidelines for psychiatric psychotherapeutic hospital care. In particular, more resources are required for the provision of psychotherapeutic care.

Adult ADHD is a frequent psychiatric disorder affecting relevant aspects of an individual's life. The aim of our study group was to carry out the first randomized controlled multicenter study to evaluate the effects of psychotherapy compared to clinical management in combination with psychopharmacological treatment with methylphenidate (MPH) or placebo (Plac) in a factorial four-arm design. Here, we present the enrollment procedure and description of adult ADHD patients recruited for the trial. Four hundred and thirty-three adult patients with ADHD were randomized at seven study sites in Germany to four treatment conditions: manualized dialectical-behavioral-therapy-based group psychotherapy (GPT) plus MPH or Plac, or clinical management (CM) including supportive counseling plus MPH or Plac with weekly sessions in the first 12 weeks and monthly sessions thereafter. Assessment for eligibility included standardized scales and instruments. After prescreening of 1,480 patients, 518 were evaluated for trial participation and 433 were randomized. The main reasons for prescreening failure were lack of interest in participating (n = 205), difficulties in meeting the time and effort requirements for participation (n = 186), and contraindications for psychopharmacological treatment with MPH (n = 194). The full analysis set (FAS) comprised 419 adult ADHD patients (mean age 35.2 years, males/females 1:1). Fifty-seven percent of the patients suffered from the combined ADHD subtype. Prevalence of at least one current or lifetime axis-I comorbidity was 66 %. Axis-II comorbidity rates was 18 % (patients with comorbid borderline and antisocial personality disorders were excluded). Our network was able to recruit an adult ADHD sample essentially comparable to community samples. A selection bias was created by excluding patients unable or unwilling to participate, or who had somatic and psychiatric contraindications for stimulant treatment (Current Controlled Trials ISRCTN54096201, FUNDING: Federal Ministry of Education and Research 01GV0606).

The aim of this study was to analyze in detail the site of metastasis of stage 4 Wilms tumor (WT) and its correlation with outcome. The databases from 3 major European pediatric cancer institutions were screened for children with WT between 1994 and 2011. Of 208 children identified, 31 (14.9%) had metastases at diagnosis. The lung was affected in 29 children (93.5%) and the liver in 6 children (19.4%). Twenty-seven children (87.1%) had metastases isolated to 1 organ, with the lung being the most common site (80.7%). Five-year overall survival was significantly better in those children with distant disease in either lung or liver (95.8%) compared with those affected in both lung and liver (57.1%, P=0.028). Further, prognostic markers were the response of metastases to preoperative chemotherapy (P=0.0138), high-risk histology (P=0.024), and local stage (P=0.026). Five-year overall survival was 82.1% and 5-year event-free survival was 67.9%. The overall follow-up time was 74.1 and 87.2 (2 to 151) months among survivors, and the treatment-related complication rate was 16.7%. In conclusion, in our series of stage 4 WT, prognosis was excellent if histology was favorable, metastatic disease was isolated to either lungs or liver, and if metastases responded to preoperative chemotherapy.

In general work involves health promoting functions but can also have hazardous impacts on well-being. Due to a massive change in working conditions it has become increasingly more recognized that depressive disorders are highly prevalent at the workplace and that work stress belongs to the most common triggers of depressive disorders, particularly in men. It is relevant to differentiate between subjectively experienced burnout and clinical depression. The best investigated psychosocial work stressors include increased job demands in connection with low control possibilities and lack of gratification, interpersonal conflicts, role stress and social isolation. For the treatment of work-related clinical depression, an additional focus of interpersonal psychotherapy (IPT) of depression, namely "work-related stress and burnout experience" was conceptualized based on a vulnerability-stress model and the fact that work usually takes place in an interpersonal context. This new problem area focuses on role stress and conflicts at work and the reduction of stressful working conditions. Interpersonal psychotherapy has so far been useful for the treatment of depression due to problems at work; however, further studies are needed to evaluate the efficacy of this newly designed problem area.

Data from a pilot study suggest that naltrexone might reduce dissociative symptoms in patients with borderline personality disorder. However, the interpretation of these data is limited by the lack of a control group and by the nonblind nature of this study. Hence, we examined the effects of naltrexone using a more rigorous design that controlled for major confounders such as spontaneous reduction of dissociation over time and placebo effects. Unmedicated patients with BPD [according to Diagnostic and Statistical Manual of Mental Disorders-IVth edition (DSM-IV)] were included in two small double-blind placebo-controlled randomized trials (total n=29). Patients received both 3 weeks of naltrexone (50 or 200 mg/day) and 3 weeks of placebo in a randomized order. Twenty-five patients completed the study according to protocol. Dissociation under naltrexone and placebo, respectively, was compared by repeated-measures analyses of variance. In either trial, both the intensity and duration of dissociative symptoms were numerically lower under naltrexone than under placebo. However, the effects were too small to reach statistical significance. Our data provide the first estimate of the pure pharmacological antidissociative efficacy of naltrexone from a rigorously designed trial.

The general efficacy of psychotherapeutic approaches in the treatment of mental disorders has been demonstrated by meta-analyses. Disorder-specific methods are increasingly dominating the field. In the field of depression psychological interventions have proven to be as equally effective as pharmacotherapy in mild and moderate depressives but with longer lasting effects after termination of treatment. The combination of both methods is particularly relevant for the therapy of severe and chronic depression. The indications should be differentiated beyond the severity and course of the disorder, e.g. according to previous traumatization, comorbidity, patient difficulty and the empirical evidence of the different approaches.

Background: When assessing the function of the cardiovascular system, cardiac output (CO) is a substantial parameter. For its determination, numerous non-invasive techniques have been proposed in the recent years including inert gas rebreathing (IGR) and impedance cardiography (ICG). The aim of our study was to evaluate whether a novel ICG algorithm (electrical velocimetry) and IGR can be used interchangeably in the clinical setting., Methods: A total of 120 consecutive stable patients were included resulting in two pairs of repeated non-invasive cardiac output measurements., Results: The mean CO was 5.0 ± 1.2 l/min (range 2.6-8.6 l/min) using IGR and 4.4 ± 1.1 l/min (1.7-7.4 l/min) using ICG, respectively. Bland-Altman analysis revealed an acceptable agreement with a mean bias of 0.6 ± 1.2 l/min. We found a high reproducibility with a mean bias of 0.2 ± 0.7 l/min for IGR and 0.0 ± 0.3 l/min for ICG (p < 0.001), respectively. There was a statistically significant difference for unphysiological circulatory conditions represented by values of 2.6-4.1 l/min and 5.6-8.6 l/min., Conclusions: Both non-invasive techniques are associated with low operating costs and require only a few expendable items for the rapid determination of cardiac function. We found an acceptable agreement between IGR and ICG as well as a high reproducibility, which was statistically significant higher for ICG. For cardiac output states exceeding the physiological range, we found a statistically significant difference. Consequently, values of cardiac function determined by either method should not be used interchangeably in the clinical setting.

A substantial proportion of Borderline Personality Disorder (BPD) patients respond by a marked decrease of psychopathology when treated with Dialectical Behavioral Therapy (DBT). To further enhance the rate of DBT-response, it is useful to identify characteristics related to unsatisfactory response. As DBT relies on emotional learning, we explored whether dissociation-which is known to interfere with learning- predicts poor response to DBT. Fifty-seven Borderline Personality Disorder (BPD) patients (DSM-IV) were prospectively observed during a three-month inpatient DBT program. Pre-post improvements in general psychopathology (SCL-90-R) were predicted from baseline scores of the Dissociative Experiences Scale (DES) by regression models accounting for baseline psychopathology. High DES-scores were related to poor pre-post improvement (β = -0.017 ± 0.006, p = 0.008). The data yielded no evidence that some facets of dissociation are more important in predicting DBT-response than others. The results suggest that dissociation in borderline-patients should be closely monitored and targeted during DBT. At this stage, research on treatment of dissociation (e.g., specific skills training) is warranted.

Background: Inflammatory bowel disease (IBD) is a polygenetic disorder. Our group previously showed that a variant within the CXCL9 gene is associated with pediatric Crohn's disease. As CXCL9, CXCL10, and CXCL11 are the 3 ligands to the receptor CXCR3, the aim of this study was to investigate the colonic transcriptional activity of the CXCR3 axis and to perform SNP genotyping of a CXCL11 polymorphism in a large pediatric and adult IBD cohort., Methods: mRNA expression of CXCR3, CXCL9, CXCL10, CXCL11, and IL8 was analyzed in colonic biopsies using real-time PCR. CXCL11 rs6817952 nucleotide substitution was determined in 501 German individuals with IBD (336 CD, 165 UC) including 258 children and 243 adults as well as in 231 controls by a TaqMan SNP genotyping assay., Results: CXCR3 axis genes were significantly overexpressed in inflamed colonic tissue of pediatric CD and UC patients. The prevalence of hetero- and homozygous variants of the rs6817952 genotype was higher in pediatric but not in adult CD patients compared with that in controls (P = 0.04). Moreover, carriers of the hetero- and homozygous genotype variants of rs6817952 were at increased risk for UC in all age groups (P = 0.009)., Conclusions: Our study provides evidence of the significant overexpression of the CXCR3 axis in active IBD, suggesting it has a role in IBD pathogenesis. The rs6817952 A variant is a risk allele for pediatric CD and UC in all age groups. Therapeutic studies will have to show whether the blockade of chemokine receptors such as CXCR3 can modulate intestinal inflammation in a clinical application.

Background: Depressive disorders are among the most common illnesses and reasons for obtaining health care. Their diagnosis and treatment are still in need of improvement. In Germany, a new S3/National Clinical Practice Guideline has been developed for this purpose., Methods: The existing guidelines on unipolar depression from Germany and other countries were synoptically compared and supplemented with systematic literature searches. After 14 consensus conferences, a total of 107 evidence-based recommendations were issued., Results: Unipolar depression should be diagnosed in accordance with ICD-10 criteria. Screening questionnaires are useful aids to diagnostic classification. When a treatment is chosen, shared decision-making with the patient is essential. Mild depressive episodes can be treated initially by watchful waiting for 14 days. For moderate depressive episodes, pharmacotherapy and psychotherapy are equally effective treatment options. For severe depression, a combination of pharmacotherapy and psychotherapy is recommended. If 4 to 6 weeks of acute therapy are insufficiently effective, lithium augmentation is recommended, rather than combination antidepressant therapy or a switch to another antidepressant. After remission, maintenance therapy should be continued for 4 to 9 months. In recurrent depression, pharmacotherapy and/or psychotherapy, where appropriate, should be continued for at least two years. Specific recommendations are given for patients who have somatic or mental comorbidities or are acutely suicidal, and recommendations are also given for coordination of care., Conclusion: This guideline is a comprehensive set of evidence- and consensus-based recommendations for the diagnosis and treatment of unipolar depression. An improvement in the care of patients with unipolar depression will require broad implementation of the guideline, both in the inpatient and outpatient setting.

Unipolar depressive disorders are among the most frequent reasons for utilizing the health care system. Although efficacious treatments are available and further advances have recently been made there is still a need for improving diagnostic and therapeutic procedures. Alignment of treatment on evidence-based treatment guidelines establishes an essential mainstay. The new S3 and National Health Care guidelines on unipolar depression, the compilation of which was coordinated by the German Society of Psychiatry, Psychotherapy and Neurology (DGPPN) and which were approved by 29 scientific and professional associations, is the ambitious effort to present state of the art evidence and clinical consensus for the treatment of depression. For pharmacotherapy of depression differentiated recommendations can be given, also separate from and in addition to psychotherapy.

Investigation of the dichloromethane extracts from herbal and root parts of Mercurialis perennis L. afforded a mixture of 11 homologous n-alkylresorcinols (ARs) with saturated odd-numbered alkyl side chains (C15:0-C27:0). In addition to three predominant ARs (C19:0, C21:0 and C23:0), a number of minor ARs were identified by use of LC-MS/MS and GC-MS techniques. Among the compounds detected, four uncommon ARs with even-numbered alkyl side chain lengths were also determined. The overall AR concentration in herbal parts was 7 to 9 times higher compared to that of the roots. The results presented may open a new view on the phytochemistry and pharmacognosy of M. perennis and other members of the Euphorbiaceae family.

Schizophrenia clinical practice guidelines are developed to provide expert- and evidence-based advice to practicing psychiatrists in order to improve the management of this disorder. However, the application of these guidelines in everyday health care can still be described as nonsatisfying. Within the project "Guideline-supported quality management in outpatient treatment", we investigated whether guideline adherence and quality of outcome can be improved by implementing a computer-based, guideline-oriented decision-support system. Therefore, a disease-specific decision-support system was developed interactively presenting guidelines to support the physicians decision-making process during the treatment of schizophrenia patients. We evaluated the system in a control group design: An experimental group consisting of 15 psychiatrists in private practice used the decision-support system, thus documenting the treatment of schizophrenic patients. Guideline-based algorithms were interactively and case specifically displayed on the PC-screen as soon as predefined triggers were met. A first control group in Munich provided treatment-as-usual, documenting the treatment via paper-pencil. Two further physician groups served as additional comparison groups: one also documented electronically using the decision-support system, however without receiving electronic guideline support, the second group carried out traditional quality circles while also using the paper-pencil approach. As a result of the intervention, we observed a strong initial but time-limited improvement with respect to the core aspects of outpatient treatment in schizophrenia in the experimental group. The findings suggest that decision-support systems, despite their limitations, can be used to enhance treatment outcome in schizophrenia outpatient care.

Pharmacological neuroenhancement is an attempt to increase cognitive performance in healthy humans. Learning and memory, attention and vigilance or mood and social interaction are targeted by a modulation of brain plasticity. Firstly, an analysis of the current state of research shows that, until now, clinical trials of neuroenhancing drugs have demonstrated only limited efficacy and long-term side effects remain largely unexplored. Secondly, we argue that, from an ethical perspective, neuroenhancement differs from socially mediated methods of learning. Pharmacological neuroenhancement is based on notions of efficacy and control that threaten to undermine other important aspects of mental capacities.

The paper reflects central recommendations and methodological issues of the new German guidelines for the treatment of depression, as discussed in the article New German Guidelines for the Treatment of Depression - The Central Role of Psychotherapy (Schauenburg et al. 2009). Members of the steering group for these guidelines disagree with the authors' description in several points, especially with reference to the efficacy of pharmacotherapy with antidepressants and psychotherapy, as well as the relationship between both strategies of therapy and their combination in diverse phases of treatment (acute/maintenance). Furthermore, we try to clarify some misunderstandings in matters of the guideline's methodology which arose in the paper cited.

Objective: To analyze patient satisfaction in inpatient depression treatment depending on German language proficiency., Methods: Documentation of patients in 24 psychiatric hospitals in Baden-Württemberg (South Germany). The following three groups were matched according to age, gender, and education: native German speakers, non-native speakers with good German proficiency, and non-native speakers with limited German proficiency (67 in each group)., Results: The number of unsatisfied patients was four times higher in the group of non-native speakers with limited German proficiency (24 %) than in the native German speakers group (6,5 %) and more then twice as high as in the group of non-native speakers with good German proficiency (10.2 %). Patient satisfaction was lower in the group of non-native speakers with limited German proficiency independent of treatment outcome than in both other groups, whereas in both groups with good German proficiency, satisfaction was associated with treatment outcome., Conclusions: Good linguistic understanding is more important for patient satisfaction in inpatient depression treatment than treatment outcome.

Objective: This study analyzed whether quality of inpatient depression treatment was dependent on German language proficiency., Methods: Native German speakers and nonnative speakers with good or limited German proficiency (67 per group) hospitalized for depression in 24 psychiatric hospitals in Baden-Württemberg were matched by age, gender, and education., Results: Germans received more group psychotherapy than the other two groups (p=.003). No differences were found in regard to pharmacotherapy. Those with limited German proficiency were discharged an average of 18 days earlier than native German speakers and six days earlier than those with good proficiency (p=.02). Twice as many nonnative patients with good proficiency and nearly four times as many patients with limited proficiency were discharged with lingering depressive symptoms (p=.006)., Conclusions: Results confirmed the significance of linguistic factors for the effectiveness of treatment of patients with depression and showed a direct impact of linguistic factors on length of hospitalization.

Because of the new medical licensure act in Germany, much more bedside teaching than before is needed. For many of the relevant clinical pictures, few patients can be expected to undergo study lessons. That is why many universities use simulated patients (SP). In contrast to other disciplines such as internal medicine or surgery, there is not much literature about SP in psychiatry and psychotherapy. The objective of this pilot study was to evaluate if SP used for clinical teaching in addition to real patients are well accepted for simulation of psychiatric illnesses and clinical teaching. After randomization, one half of the 139 study medical students were taught using real patients and the other half using real patients and SP. The amounts of patient contact were equal in both groups. Using a questionnaire, pre- and postanalysis was carried out of answers about communication skills, the capability of addressing difficult subjects such as suicidality, and interest in psychiatry. The acceptance rate of SP was very high. Students' ratings of clinical teaching and their own performance, and their interest in future psychiatric work were significantly higher in the SP group. The results of this pilot study are very encouraging and indicate that the systematic use of SP in clinical psychiatric teaching is not only an appropriate alternative to real patients but also can lead to higher quality.

A suggestive locus on chromosome 8 could be shown to be associated with familial high factor VIII (FVIII) levels in venous thromboembolism. The ADAMDEC 1 gene is a candidate expressing an ectodomain sheddase. However, the ectodomain of the clearance receptor for FVIII, the low-density lipoprotein receptor-related protein (LRP), is subject to proteolysis by metalloproteases like ADAMDEC1. Other LRP-interacting proteins are lipoprotein lipase (LPL) and t-PA. For an association study, 165 thrombotic patients with high FVIII levels (from the MAISTHRO, i.e. Main-Isar-thrombosis register) were included. All patients with known causes for high FVIII levels had been previously excluded. The patients were compared with 214 healthy blood donors. Polymorphisms with usually a minor allele frequency >5%, i.e. 24 SNPs and two insertion/deletion polymorphisms of LPL gene, eight SNPs of the t-PA gene, and five SNPs of the ADAMDEC1 gene, were analyzed. Haplotype differences were calculated using PHASE. A new polymorphism in intron 7 of the t-PA gene with a minor allele frequency of 2.2% was identified. Analysis of each SNP by the Cochrane-Armitage trend test did not show any significant association between genotype and disease status. Interestingly, the ADAMDEC1 haplotype (rs12674766, rs10087305, rs2291577, rs2291578, rs3765124) differed between cases and controls (p = 0.04). In particular, the TGTGG haplotype showed a difference. In conclusion, the ADAMDEC 1 haplotype may indicate an underlying mechanism for high FVIII levels. The only moderate linkage disequilibrium may be due to a possible causal polymorphism in distant introns or the promoter region against a polygenic background.

Depressive disorders rank among the most frequent causes of consultation and diseases in health care. Although they are treatable, there is further need to optimize diagnostics and therapy, despite sizable progress in recent years. The implementation of evidence- and consensus-based guidelines is an appropriate measure to improve care for depressive patients. An evidence-based guideline for depression is currently being developed for Germany. In order to ensure its acceptance and a wide dissemination, this guideline will be adopted in consensus by all relevant health care providers in this field. According to this, it is a future challenge to anchor guideline-based diagnostics and treatment in routine care.

Objective: Having established the importance of compliance as a significant factor of a successful orthodontic treatment, the aim of the present study was to evaluate intrapersonal and interpersonal factors which could help predict patient compliance., Methods: The attributional style of 58 patients was assessed by a standardised questionnaire. An individual questionnaire was designed to determine attitudes concerning orthodontic treatment, the doctor-patient relationship, the wearing behaviour and control behaviour. The questionnaire was answered by the patient and by the orthodontist. The compliance was evaluated by the orthodontist on the basis of commonly used indicators for compliance: wearing time, oral hygiene and reliability of keeping the appointments., Results: The results showed a significant correlation between the compliance and the attributional style of the patients in positive situations, but not between the compliance and the wearing behaviour estimated by the patient. The interpersonal comparison revealed a lack of knowledge on the part of the orthodontist about the patients' daily activities and their ability to correctly wear their appliances., Conclusion: The questionnaire answers show compliance to be a subjective construct of the orthodontist demonstrating mostly social-emotional matters. There is no consistency with compliance and the patients' statement concerning their wearing behaviour but with a positive attitude on the part of the patients demonstrating independent responsibility.

Background: Inpatient treatment is the most costly sector of treatment for depressive disorders in Germany. However, little is known about which patient and hospital characteristics contribute to costs of inpatient episodes., Patients and Methods: To take part in this study, patients had to fullfill criteria for ICD-10 diagnosis of F31.3-F31.5, F32, F33, F34.1, F43.20, or F43.21. Episodes were recorded between September 9 2001 and March 3 2003 in ten hospitals in three German states. Inpatient records of 1,202 persons were analysed. Multiple regression analysis was performed to identify significant patient predictors of cost per inpatient episode, and the predictive function of hospital characteristics was analysed by applying hierarchical linear modeling., Results: Patient characteristics at admission could not explain a substantial part of the variance in episode costs. Better prediction was possible including variables from the whole treatment process. Also, conditions for admission and patient-related factors did not well explain cost differences between hospitals, but characteristics of the whole treatment were., Conclusion: For predicting costs of inpatient depressive episodes, the complete course treatment has to be considered. As in the physiologic sector, therapeutic and diagnostic procedures have a great effect on cost prediction.

Background and Objective: To assess the relation between body mass index (BMI) and the risk of death from various causes in a prospective cohort study., Methods: In 6,192 obese patients (BMI > or =25 kg/m(2)) with mean BMI 36.6 kg/m(2) (SD 6.1) and mean age 40.4 years (SD 12.9) who had been referred to the obesity clinic of the Heinrich-Heine-University Düsseldorf, Germany, between 1961 and 1994, there were 1,058 deaths from all causes during a median follow-up time of 14.8 years. We calculated standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) for death from predefined groups of diseases by using Germany as reference population., Results: In both sexes, risk of death from cardiovascular diseases (men: SMR = 2.2, CI 1.9-2.5; women: SMR = 1.6, CI 1.5-1.8), from diabetes (men: SMR = 5.4, CI 3.2-8.7; women: SMR = 3.5, CI 2.6-4.8), and in men from digestive diseases (SMR = 1.6, CI 1.01-2.3) was significantly increased. In contrast to other studies, an association between obesity and all-cancer mortality could not be found. Only in morbidly obese women (BMI > or =40 kg/m(2)), all-cancer mortality was significantly increased (SMR = 1.5, CI 1.1-1.9)., Conclusion: Obesity is associated with increased risk of death from cardiovascular diseases and diabetes in both sexes, and from diseases of the digestive system in men.

Issue: Depressive disorders are of great medical and political significance. The potential inherent in achieving better guideline orientation and a better collaboration between different types of care is clear. Throughout the 1990s, educational initiatives were started for implementing guidelines. Evidence-based guidelines on depression have been formulated in many countries., Purpose: This article presents an action programme for structural, educational, and research-related measures to implement evidence-based care of depressive disorders in the German health system. The starting points of the programme are the 'Guidelines Critical Appraisal Reports' of the 'Guideline Clearing House' and measures from the 'Competence Network on Depression and Suicidality' (CNDS) funded by the Federal Ministry of Education and Research. The article gives an overview of the steps achieved as recommended by the Guidelines Critical Appraisal Reports and the ongoing transfer process into the German health care system., Results: The action programme shows that comprehensive interventions to develop and introduce evidence-based guidelines for depression can achieve benefits in the care of depression, e.g. in recognition, management, and clinical outcome., Conclusion: It was possible to implement the German Action Programme in selected care settings, and initial evaluation results suggest some improvements. The action programme provides preliminary work, materials, and results for developing a future 'Disease Management Programme' (DMP) for depression.

Mandibles of two cats containing carious lesions were discovered among the previously published findings of feline dental resorptive lesions from materials examined at an archaeological museum. These lesions were too small to be noted on radiographs, and consisted of two inconspicuous enamel lesions in a mandibular left first molar tooth (309), a clinically visible white spot area containing an enamel lesion in a mandibular left fourth premolar tooth (308), and a root surface caries in the 308 of a different specimen. Histologic examination using special stains and polarized light revealed both initial and early initial stage enamel caries, as well as root surface caries. Knoop hardness measurements confirmed these findings, considered the first documented cases of feline caries.

Process and outcome quality of inpatient treatment of depression in Germany was described in a multicenter study of 10 hospitals in North-Rhine Westphalia, Baden-Württemberg and Bavaria. The treatment of more than 2000 depressive patients was assessed by quality indicators and outcome was compared between the hospitals (benchmarking). Results show great variance in length of stay between the hospitals. While in one hospital patients with depressive episodes were discharged after 36.8 days (average), the average length of stay in another hospital was 64.3 days. Furthermore the study revealed that hospitals differ strongly regarding their case-mix. Using stepwise multiple regression analyses potential confounding variables (sociodemographics, history of previous treatment, severity of depression) were identified and their influence on length of stay was calculated. After cross validation the regression analyses model explained 7% of the variance and included 5 predictors. Length of stay is prolonged by patients with a recurrent depressive disorder, by patients with impairment of social functioning and by severity of the depression. Length of stay is reduced if the indication of inpatient treatment was crisis intervention and if there was a previous suicide attempt. It was shown that differences in patient case-mix only account for a small percentage of hospital differences in length of stay. Method, effort and benefit of the regression analyses approach are discussed.

Background: Several quality assurance initiatives in health care have been undertaken during the past years. The next step consists of systematically combining single initiatives in order to built up a strategic quality management., Methods: In a German multicenter study, the quality of inpatient depression treatment was measured in ten psychiatric hospitals. Half of the hospitals received comparative feedback on their individual results in comparison to the other hospitals (bench marking). Those bench markings were used by each hospital as a statistic basis for in-house quality work, to improve the quality of depression treatment., Results: According to hospital differences concerning procedure and outcome, different goals were chosen. There were also differences with respect to structural characteristics, strategies, and outcome. The feedback from participants about data-based quality circles in general and the availability of bench-marking data was positive. The necessity of carefully choosing quality circle members and professional moderation became obvious., Conclusions: Data-based quality circles including bench-marking have proven to be useful for quality management in inpatient depression care.

In the outpatient treatment of depression, the potential of diagnostic and therapeutic methods is seldom exhausted resulting in variable quality of treatment and partly insufficient cost effectiveness. Implementation of a guideline-oriented reimbursement system seems to be an option to improve quality of treatment. Corresponding incentive systems have been outlined and evaluated for the health care of somatic diseases such as diabetes. Acting on these experiences, an attempt was made to utilize them for the area of psychiatric disorders. Taking depression as an example, a model for a quality-oriented, guideline-based reimbursement system for general and specialist practice is presented.

Patient outcome and guideline conformity in inpatient schizophrenia treatment was systematically evaluated and compared with 597 patients across seven psychiatric hospitals. Patient structure and treatment processes showed a great variability between hospitals. Patient characteristics, especially mental state, and the chronicity of the disease were the strongest predictors of clinical outcome. Outcome evaluation using quality indicators is only possible after case-mix adjustment taking into account prognostic factors. A poorer average clinical outcome was associated with lower guideline conformity in a variety of treatment domains. After case-mix adjustment, benchmarking is an opportunity to improve quality of treatment and promote guideline conformity.

During 1998-2000 a quality assurance program for diagnosis and treatment of depression was conducted in 24 hospitals for psychiatry and psychotherapy in Baden-Wurttemberg (southern Germany). Process and outcome quality of 3,000 depressive patients was documented at admission and discharge. The article focuses on therapeutic measures, duration, outcome, patient satisfaction, and their interactions. The results show that the patients' satisfaction with the care received is very high and the pre-post effect sizes of inpatient treatment for depression are high.

Service utilization and total direct cost of care was assessed in 270 patients suffering from depressive disorder. Patients were recruited from primary care physicians or family doctors (n = 43) or psychiatrists (n = 23) in office practice, from three different regions in Germany (county of Düren and city of Aachen, Lörrach-county, city of Munich). A detailed catalogue of unit costs (including inpatient, outpatient and rehabilitative services) was used for calculating total cost of care on an individual basis. Service utilization and costs referred to 2001. Mean cost of total medical care of the study patients was euro 3849 (excluding cost of drugs for physical illness). The cost for treating depressive disorders and additional psychiatric co-morbidity (which is included into the total cost of care) was euro 2073 per patient and year. When cross-checking with ICD-10 criteria for depressive disorders, the original diagnosis by family doctors or psychiatrists could be confirmed in 186 patients of the total sample (n = 270), suggesting that there is a high amount of falsely diagnosed patients in primary and specialized care of depressive patients in Germany. Direct cost of the 186 confirmed patients was higher (total care cost: euro 4715, cost for treatment of depression and psychiatric co-morbidity: euro 2541) than in the total group and should be considered as reference cost, when discussing cost of care in depressive patients in Germany. Results suggest to analyse cost of care in depressive patients further and to discuss a more efficient allocation of health budgets in the field.

Objectives: The majority of patients with chronic decompensated forms of tinnitus have comorbid psychological disorders, possibly accompanied by restricted quality of life and participation in everyday activities. There is no standardized tool to measure these clinically relevant dimensions., Sample and Method: Both the Hospital Anxiety and Depression Scale (HADS) and the Short Form 36 (SF-36) were administered to a consecutive sample of patients ( n=110) who were recruited from the tinnitus outpatient service in the department of psychiatry and psychotherapy. Using the Tinnitus Questionnaire (TF), associations of the HADS and SF-36 scales with tinnitus grading were determined and the classification of patients (mild-medium-severe-very severe) was evaluated., Results: A severe tinnitus grading is correlated to a high extent of anxiety and depression and a low quality of life. With the exception of the SF-36 subscale on physical functioning, all scales discriminated between the extreme groups (mild vs severe/very severe), but less between the two medium groups., Conclusions: Patients with severe decompensated tinnitus (grades III and IV) should be seen for diagnosis of psychiatric comorbidity and supportive psychotherapy/psychopharmacotherapy used when necessary.