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Regular moderate physical activity (PA) has been linked to beneficial adaptations in various somatic diseases (e.g. cancer, endocrinological disorders) and a reduction in all-cause mortality from several cardiovascular and neuropsychiatric diseases. This study was designed to investigate acute and prolonged exercise-induced cardio- and neurophysiological responses in endurance runners competing in the Munich Marathon. ReCaP (Running effects on Cognition and Plasticity) is a multimodal and longitudinal experimental study. This study included 100 participants (20–60 years). Six laboratory visits were included during the 3-month period before and the 3-month period after the Munich marathon. The multimodal assessment included laboratory measurements, cardiac and cranial imaging (MRI scans, ultrasound/echocardiography) and neurophysiological methods (EEG and TMS/tDCS), and vessel-analysis (e.g. retinal vessels and wave-reflection analyses) and neurocognitive measurements. The ReCaP study was designed to examine novel exercise-induced cardio- and neurophysiological responses to marathon running at the behavioral, functional and morphological levels. This study will expand our understanding of exercise-induced adaptations and will lead to more individually tailored therapeutic options. [ABSTRACT FROM AUTHOR]

Background: Physician-assisted suicide (PAS) and voluntary euthanasia remain highly debated topics in society, drawing attention due to their ethical, legal, and emotional complexities. Within this debate, the loss of a loved one through suicide may shape the attitudes of survivors, resulting in more or less favorable attitudes towards this topic., Aims: This study aims to explore and compare the attitudes towards PAS and voluntary euthanasia in a population of suicide loss survivors and the general population, while also considering socio-demographic factors., Methods: A total of 529 participants, 168 of whom were survivors of suicide loss, completed an online questionnaire on their attitudes (NOBAS) and opinions (open response format) towards PAS and voluntary euthanasia, as well as regarding their legalization in Germany. The analysis consisted of both quantitative and qualitative components., Results: The entire sample showed positive attitudes towards PAS and voluntary euthanasia in terminally ill persons. Participants were more divided in their attitudes towards PAS in the case of a mental health disorder. Individuals without experienced suicide loss were more liberal regarding legalization in Germany and were more likely to understand the wish for PAS. Survivors of suicide loss were mainly concerned about the consequences for relatives. However, differences between both groups are small., Discussion: The experience of a loss by suicide influences attitudes towards PAS and voluntary euthanasia. Both groups showed an accepting attitude towards PAS and voluntary euthanasia, but also expressed concerns and fears regarding easy accessibility and consequences for grieving relatives., (© 2024. The Author(s).)

Background: Cholangiocarcinoma (CCA) is a fatal cancer of the bile duct with a poor prognosis owing to limited therapeutic options. The incidence of intrahepatic CCA (iCCA) is increasing worldwide, and its molecular basis is emerging. Environmental factors may contribute to regional differences in the mutation spectrum of European patients with iCCA, which are underrepresented in systematic genomic and transcriptomic studies of the disease., Methods: We describe an integrated whole-exome sequencing and transcriptomic study of 37 iCCAs patients in Germany., Results: We observed as most frequently mutated genes ARID1A (14%), IDH1, BAP1, TP53, KRAS, and ATM in 8% of patients. We identified FGFR2::BICC1 fusions in two tumours, and FGFR2::KCTD1 and TMEM106B::ROS1 as novel fusions with potential therapeutic implications in iCCA and confirmed oncogenic properties of TMEM106B::ROS1 in vitro. Using a data integration framework, we identified PBX1 as a novel central regulatory gene in iCCA. We performed extended screening by targeted sequencing of an additional 40 CCAs. In the joint analysis, IDH1 (13%), BAP1 (10%), TP53 (9%), KRAS (7%), ARID1A (7%), NF1 (5%), and ATM (5%) were the most frequently mutated genes, and we found PBX1 to show copy gain in 20% of the tumours. According to other studies, amplifications of PBX1 tend to occur in European iCCAs in contrast to liver fluke-associated Asian iCCAs., Conclusions: By analyzing an additional European cohort of iCCA patients, we found that PBX1 protein expression was a marker of poor prognosis. Overall, our findings provide insight into key molecular alterations in iCCA, reveal new targetable fusion genes, and suggest that PBX1 is a novel modulator of this disease., (© 2024 The Author(s). Clinical and Translational Medicine published by John Wiley & Sons Australia, Ltd on behalf of Shanghai Institute of Clinical Bioinformatics.)

Background: During the COVID-19 pandemic and associated public health and social measures, decreasing patient numbers have been described in various healthcare settings in Germany, including emergency care. This could be explained by changes in disease burden, e.g. due to contact restrictions, but could also be a result of changes in utilisation behaviour of the population. To better understand those dynamics, we analysed routine data from emergency departments to quantify changes in consultation numbers, age distribution, disease acuity and day and hour of the day during different phases of the COVID-19 pandemic., Methods: We used interrupted time series analyses to estimate relative changes for consultation numbers of 20 emergency departments spread throughout Germany. For the pandemic period (16-03-2020 - 13-06-2021) four different phases of the COVID-19 pandemic were defined as interruption points, the pre-pandemic period (06-03-2017 - 09-03-2020) was used as the reference., Results: The most pronounced decreases were visible in the first and second wave of the pandemic, with changes of - 30.0% (95%CI: - 32.2%; - 27.7%) and - 25.7% (95%CI: - 27.4%; - 23.9%) for overall consultations, respectively. The decrease was even stronger for the age group of 0-19 years, with - 39.4% in the first and - 35.0% in the second wave. Regarding acuity levels, consultations assessed as urgent, standard, and non-urgent showed the largest decrease, while the most severe cases showed the smallest decrease., Conclusions: The number of emergency department consultations decreased rapidly during the COVID-19 pandemic, without extensive variation in the distribution of patient characteristics. Smallest changes were observed for the most severe consultations and older age groups, which is especially reassuring regarding concerns of possible long-term complications due to patients avoiding urgent emergency care during the pandemic., (© 2023. The Author(s).)

BackgroundThe COVID-19 pandemic expanded the need for timely information on acute respiratory illness at population level.AimWe explored the potential of routine emergency department data for syndromic surveillance of acute respiratory illness in Germany.MethodsWe used routine attendance data from emergency departments, which continuously transferred data between week 10 2017 and 10 2021, with ICD-10 codes available for > 75% of attendances. Case definitions for acute respiratory infection (ARI), severe acute respiratory infection (SARI), influenza-like illness (ILI), respiratory syncytial virus infection (RSV) and COVID-19 were based on a combination of ICD-10 codes, and/or chief complaints, sometimes combined with information on hospitalisation and age.ResultsWe included 1,372,958 attendances from eight emergency departments. The number of attendances dropped in March 2020 during the first COVID-19 pandemic wave, increased during summer, and declined again during the resurge of COVID-19 cases in autumn and winter of 2020/21. A pattern of seasonality of respiratory infections could be observed. By using different case definitions (i.e. for ARI, SARI, ILI, RSV) both the annual influenza seasons in the years 2017-2020 and the dynamics of the COVID-19 pandemic in 2020/21 were apparent. The absence of the 2020/21 influenza season was visible, parallel to the resurge of COVID-19 cases. SARI among ARI cases peaked in April-May 2020 (17%) and November 2020-January 2021 (14%).ConclusionSyndromic surveillance using routine emergency department data can potentially be used to monitor the trends, timing, duration, magnitude and severity of illness caused by respiratory viruses, including both influenza viruses and SARS-CoV-2.

At present, there are no German guidelines regarding suicidal behaviors in adulthood despite their relevance to public health and the well-established evidence about their prevention. This paper first describes the history and background of working with guidelines. The current status of guidelines for mental illness in Germany is presented and examined for suicide-preventive content. The need for evidence-based suicide prevention and a specific guideline for suicide prevention in adults is discussed.Only via targeted suicide prevention strategies and interventions for the respective risk groups, and by paying particular attention to age and gender specificity in the outpatient as well as inpatient sector, can a high level of care for all patients be ensured. Such strategies have to pay specific attention to the interface between the individual care sectors and need to take comprehensive, easily accessible, needs-based, and affordable sustainable medical care into account. This applies to the outpatient and inpatient sectors as well as to their interfaces. Suicidality is a cross-diagnosis syndrome that occurs in different care contexts and requires complex treatment; therefore, intersectoral and multiprofessional aspects must particularly be addressed in the guideline. Scientific evidence and interdisciplinary expert consensus on the management of suicidal behavior in medical care can help reduce morbidity and mortality associated with suicidality. In August 2021, the funding of an S3 guideline "Management of Suicidality" was approved by the Federal Joint Committee., (© 2021. The Author(s).)

Background: The occurrence of suicide attempts is a key indicator of the population's mental health and therefore belongs in the domain of Mental Health Surveillance at the Robert Koch Institute. No data source is currently being used systematically for the continuous observation of psychiatric emergencies (including suicide attempts) in Germany. Therefore, the use of routine data from emergency departments will be explored in this work., Methods: We included routine data from 12 emergency departments between 1 January 2018 and 28 March 2021. We developed syndrome definitions for suicide attempts, psychiatric emergencies based on combinations of chief complaints, and diagnoses from patients presenting with psychopathological symptoms. A descriptive analysis over time was presented and stratified by age and sex., Results: In total 1,516,883 emergency department attendances were included, among which we identified 5,133 cases (0.3%) as suicide attempts, 31,085 (2.1%) as psychiatric emergencies, and 34,230 (2.3%) as cases with psychiatric symptoms. Among psychiatric emergencies, 16.5% presented because of a suicide attempt. Of cases presenting with a suicide attempt, 53.4% were male and 20.2% were aged between 25 and 34 years. Cases identified by all 3 syndrome definitions and their temporal variations could be displayed over the entire observation period., Conclusion: Syndromic surveillance using emergency department data indicates a potential for continuous surveillance of suicide attempts and psychiatric emergencies and provides a basis for further validation and analysis. The display of changes in real time extends the current research opportunities for psychiatric emergencies in Germany. Systematic surveillance of suicide attempts can contribute to evidence-based suicide prevention., (© 2021. The Author(s).)

Subclinical effects of coffee consumption (CC) with regard to metabolic, cardiac, and neurological complications were evaluated using a whole-body magnetic resonance imaging (MRI) protocol. A blended approach was used to estimate habitual CC in a population-based study cohort without a history of cardiovascular disease. Associations of CC with MRI markers of gray matter volume, white matter hyperintensities, cerebral microhemorrhages, total and visceral adipose tissue (VAT), hepatic proton density fat fraction, early/late diastolic filling rate, end-diastolic/-systolic and stroke volume, ejection fraction, peak ejection rate, and myocardial mass were evaluated by linear regression. In our analysis with 132 women and 168 men, CC was positively associated with MR-based cardiac function parameters including late diastolic filling rate, stroke volume ( p < 0.01 each), and ejection fraction ( p < 0.05) when adjusting for age, sex, smoking, hypertension, diabetes, Low-density lipoprotein (LDL), triglycerides, cholesterol, and alcohol consumption. CC was inversely associated with VAT independent of demographic variables and cardiovascular risk factors ( p < 0.05), but this association did not remain significant after additional adjustment for alcohol consumption. CC was not significantly associated with potential neurodegeneration. We found a significant positive and independent association between CC and MRI-based systolic and diastolic cardiac function. CC was also inversely associated with VAT but not independent of alcohol consumption.

Background: Suicide bereavement is a significant risk factor for psychological and somatic disorders. However, to date there exists only a limited number of suicide bereavement interventions, and little is known about their efficacy., Methods: A computerized search in databases such as PsychINFO, PubMed, Medline was conducted. Randomized controlled trials (RCTs) that compared an intervention for suicide bereaved to a control condition were included after a quality assessment of two independent researchers. In total, six studies with N  = 473 participants were included. Cohen's d was used to calculate the effect sizes., Results: The results indicated small to medium effect sizes for within-group differences for the main outcomes in the intervention condition, while no significant between-group differences were revealed., Conclusions: Interventions for suicide bereavement can reduce mental health symptoms, however the results do not appear robust between group comparisons. Thus, it could not be demonstrated that an intervention following the suicide of a close relative is more effective than no intervention or an unspecific intervention. Future research should focus on high-quality intervention studies., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objectives: Management of incidental findings (IF) remains controversial but highly relevant. Our aim was to assess the frequency, management and psychosocial consequences of IF reporting in a population-based cohort study undergoing whole-body MR imaging., Methods: The study was nested in a prospective cohort from a longitudinal, population-based cohort (KORA-FF4) in southern Germany. All MR obtained on 3 T MR scanner were reviewed by board-certified radiologists regarding clinically relevant IF. A baseline and follow-up questionnaires including PHQ-9 were completed prior to and 6-month after to the scan., Results: Of 400 participants (56.3 ± 9.2years, 58 % male) undergoing whole-body MR, IF were found in 22 % of participants (n = 89); most frequently located in the abdominal sequences. In the pre-scan survey, most participants stated as the motivation that they wanted to "contribute to a scientific purpose" (91 %), while "knowing whether I'm healthy" was the most frequent motivation reported 6 months post-scan (88 %). The desire for IF reporting increased over time (pre- vs. 6-months-post-scan), also for clinically less important IF (72 % vs. 84 %, p = 0.001). Regarding psychosocial impact, a small portion (3.4 %) reported that awaiting the IF report added "definitely" or "very probably" additional stress burden. Of participants with reported IF, 56.8 % classified the results as "very helpful". In the post-scan survey moderate depression was observed in 3.3 % and severe depression in 1.2 %. This did not differ between participants with and without reported IF., Conclusion: In a cohort with whole-body MR imaging, the prevalence of IF was high. Participants considered reporting of IF highly important and added only minor psychological burden., (Copyright © 2020 Elsevier B.V. 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.

To identify the most important factors that impact brain volume, while accounting for potential collinearity, we used a data-driven machine-learning approach. Gray Matter Volume (GMV) was derived from magnetic resonance imaging (3T, FLAIR) and adjusted for intracranial volume (ICV). 93 potential determinants of GMV from the categories sociodemographics, anthropometric measurements, cardio-metabolic variables, lifestyle factors, medication, sleep, and nutrition were obtained from 293 participants from a population-based cohort from Southern Germany. Elastic net regression was used to identify the most important determinants of ICV-adjusted GMV. The four variables age (selected in each of the 1000 splits), glomerular filtration rate (794 splits), diabetes (323 splits) and diabetes duration (122 splits) were identified to be most relevant predictors of GMV adjusted for intracranial volume. The elastic net model showed better performance compared to a constant linear regression (mean squared error = 1.10 vs. 1.59, p < 0.001). These findings are relevant for preventive and therapeutic considerations and for neuroimaging studies, as they suggest to take information on metabolic status and renal function into account as potential confounders.

Background: Multiple system atrophy is a rare neurodegenerative disease characterised by aggregation of α-synuclein in oligodendrocytes and neurons. The polyphenol epigallocatechin gallate inhibits α-synuclein aggregation and reduces associated toxicity. We aimed to establish if epigallocatechin gallate could safely slow disease progression in patients with multiple system atrophy., Methods: We did a randomised, double-blind, parallel group, placebo-controlled clinical trial at 12 specialist centres in Germany. Eligible participants were older than 30 years; met consensus criteria for possible or probable multiple system atrophy and could ambulate independently (ie, were at Hoehn and Yahr stages 1-3); and were on stable anti-Parkinson's, anti-dysautonomia, anti-dementia, and anti-depressant regimens (if necessary) for at least 1 month. Participants were randomly assigned (1:1) to epigallocatechin gallate or placebo (mannitol) via a web-generated permuted blockwise randomisation list (block size=2) that was stratified by disease subtype (parkinsonism-predominant disease vs cerebellar-ataxia-predominant disease). All participants and study personnel were masked to treatment assignment. Participants were given one hard gelatin capsule (containing either 400 mg epigallocatechin gallate or mannitol) orally once daily for 4 weeks, then one capsule twice daily for 4 weeks, and then one capsule three times daily for 40 weeks. After 48 weeks, all patients underwent a 4-week wash-out period. The primary endpoint was change in motor examination score of the Unified Multiple System Atrophy Rating Scale (UMSARS) from baseline to 52 weeks. Efficacy analyses were done in all people who received at least one dose of study medication. Safety was analysed in all people who received at least one dose of the study medication to which they had been randomly assigned. This trial is registered with ClinicalTrials.gov (NCT02008721) and EudraCT (2012-000928-18), and is completed., Findings: Between April 23, 2014, and Sept 3, 2015, 127 participants were screened and 92 were randomly assigned-47 to epigallocatechin gallate and 45 to placebo. Of these, 67 completed treatment and 64 completed the study (altough one of these patients had a major protocol violation). There was no evidence of a difference in the mean change from baseline to week 52 in motor examination scores on UMSARS between the epigallocatechin gallate (5·66 [SE 1·01]) and placebo (6·60 [0·99]) groups (mean difference -0·94 [SE 1·41; 95% CI -3·71 to 1·83]; p=0·51). Four patients in the epigallocatechin gallate group and two in the placebo group died. Two patients in the epigallocatechin gallate group had to stop treatment because of hepatotoxicity., Interpretation: 48 weeks of epigallocatechin gallate treatment did not modify disease progression in patients with multiple system atrophy. Epigallocatechin gallate was overall well tolerated but was associated with hepatotoxic effects in some patients, and thus doses of more than 1200 mg should not be used., Funding: ParkinsonFonds Deutschland, German Parkinson Society, German Neurology Foundation, Lüneburg Foundation, Bischof Dr Karl Golser Foundation, and Dr Arthur Arnstein Foundation., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose:  Antepartal MR pelvimetry is used to assess the viability of vaginal breech delivery. We evaluated the reliability of MR pelvimetric measurements as well as incidental findings noted by different clinicians and assessed potential reference values., Methods:  In this monocentric study, the radiologic database was searched for obstetric MR pelvimetries with singleton breech pregnancies between 1999 and 2016. 99 consecutive MR pelvimetries were included. A structured, independent review was performed by six observers with three clinical experience levels (attending, fellow, junior resident from the departments of radiology and obstetrics). Image analysis entailed the quantitative assessment of conjugata vera (CV) and diameter transversalis (DT), image quality and incidental findings. Obstetric data was retrieved from the obstetric database for reference value assessment., Results:  Interobserver agreement was strong throughout (mean intraclass correlation coefficient range: 0.889 - 0.968). The individual measuring biases ranged between 0 - 2 mm, and the average limits of agreement were ± 3 mm. Regarding the mode of delivery, the recommended cesarean section (rCS) group showed significantly smaller CV measurements (CV: 11.37 ± 0.73, p-value < 0.0001) than any other delivery group. No statistical difference in CV between the vaginal delivery and unplanned cesarean section groups was found (p-value 0.902). DT measurements only showed a significant difference between rCS and elective cesarean section (p-value 0.039). 134 incidental findings were noted., Conclusion:  Strong interobserver agreement irrespective of the reader's experience level supports MR pelvimetry as a reliable method for identifying women with fetopelvic disproportion in breech presentation. For a comprehensive appraisal of incidental findings, radiologic expertise is vital., Key Points:   · MR pelvimetry is a reliable method irrespective of the reader's experience level.. · Conjugata vera measurements aid in the prepartal viability assessment of vaginal breech delivery.. · Incidental findings are relatively common.., Citation Format: · von Bismarck A, Ertl-Wagner B, Stöcklein S et al. MR Pelvimetry for Breech Presentation at Term- Interobserver Reliability, Incidental Findings and Reference Values. Fortschr Röntgenstr 2019; 191: 424 - 432., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Although polypharmacy is associated with a negative clinical outcome in various settings and commonly observed in patients receiving oral anticoagulation therapy, evidence on the relevance for the clinical outcome of anticoagulated patients is currently limited. The aim of the study was to investigate the effect of polypharmacy on the clinical outcomes among patients taking phenprocoumon., Design: Prospective cohort study., Setting: Regular medical care., Participants: Information on 2011 individuals receiving vitamin K antagonists was available for analysis from the prospective multicenter thrombEVAL study., Measurements: Data were obtained from clinical visits, computer-assisted interviews, and laboratory measurements. Information on clinical outcome was obtained during a 3-year follow-up period and subsequently validated via medical records., Results: The prevalence of polypharmacy (five drugs or more) was 84.1% (n = 1691). Quality of anticoagulation therapy assessed by time in therapeutic range was lower in individuals on five to eight drugs and nine drugs or more (70.7% and 64.7%, respectively) compared with subjects without polypharmacy (73.4%). In addition, a significantly higher variability of international normalized ratio measurements was found in the presence of polypharmacy. The cumulative incidence of bleeding, hospitalization, and all-cause mortality, but not for thromboembolic events, increased across groups of medication. In adjusted Cox regression analysis, polypharmacy is an independent risk factor for bleeding (hazard ratio [HR] ≥ 9 drugs vs 1-4 drugs = 1.62; 95% confidence interval [CI] = 1.04-2.52; p = .033); hospitalization (HR ≥ 9 drugs vs 1-4 drugs = 1.60; 95% CI = 1.26-2.03; p < .001; and all-cause mortality (HR ≥ 9 drugs vs 1-4 drugs = 2.16; 95% CI = 1.43-3.27; p < .001) in a dose-dependent relationship. Per additional drug, bleeding risk was increased by 4%., Conclusions: Polypharmacy influences the quality of anticoagulation therapy and translates into an elevated risk of adverse events in anticoagulated patients. This suggests that additional medication intake in such patients should be critically reviewed by physicians, and it highlights the importance of initiating investigations aimed at reducing multiple medication intake. J Am Geriatr Soc 67:463-470, 2019., (© 2018 The American Geriatrics Society.)

Objectives: The Suicide Behaviors Questionnaire-Revised (SBQ-R) was developed by Osman et al. (2001) to economically assess different aspects of suicidality. It consists of 4 items. There are several critical points concerning item construction: (1) temporal frame (e. g. retrospective vs. prospective) and (2) response labels of item 1 and 3 (e. g. 2 alternatives with the same scoring). Information about psychometric properties of the German version of the SBQ-R were not available until now. The SBQ-R is assumed to be a unidimensional measure and is evaluated using a total score, although its dimensionality has never been tested., Methods: The SBQ-R and several measures for convergent validity were assessed in a representative sample of the German general population (N=2497). Convergent validity was tested against symptoms of depression and anxiety (PHQ-4), as well as the core constructs of the Interpersonal Theory of Suicidal Behavior (IPTS) (INQ, ACSS-FAD). Unidimensionality of the SBQ-R was tested using confirmatory factor analysis and intercorrelations with the convergent measures were calculated., Results: The initial model fit of the unidimensional solution was unsatisfactory. After inclusion of a correlated error term of item 2 and item 4 based on modification indices, the model fit was very good. Moreover the SBQ-R showed satisfactory internal consistency (Cronbach's α=0.72). With the exception of the ACSS-FAD, all correlations with convergent measures were according to the theoretically proposed expectations., Conclusion: In principle the findings on the psychometric properties justify the use of the SBQ-R, although several critical points concerning item scoring remain unresolved. Moreover, sufficient unidimensional model fit was not possible without including correlated errors. Since suicidality is a frequently assessed construct in suicide research and as an exclusion criterion in clinical studies, it would be desirable to develop an economic, psychometrically sound and compelling instrument for the assessment of the different aspects of suicidality in future., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Clinically evidenced cardiac involvement in systemic sarcoidosis occurs in approximately 5% of patients, whereas post-mortem examinations identify cardiac sarcoidosis in over 60% of cases., Objective: Given the inconsistency of diagnostic approaches, we took aim at prospectively investigating the prevalence of cardiac sarcoidosis by cardiovascular magnetic resonance (CMR) in a primary Caucasian population and at correlating the results with standard clinical parameters., Methods: 188 patients with histologically proven sarcoidosis were included, provenient from the local pneumological department and a national sarcoidosis self-help association. All of them underwent CMR-imaging. Complementary 12-lead ECG, Holter monitoring, laboratory and pulmonary function testing were performed., Results: CMR-based diagnosis of cardiac sarcoidosis was made in 29 patients (15.4%), of whom 17 patients (9% of total cohort) exhibited increased relative gadolinium enhancement - reflecting acute inflammatory processes -, while 11 patients (5.9% of total cohort) showed late gadolinium enhancement as a marker for nonviable tissue damage. Both abnormalities were present in 1 patient (0.5%). Correlation analysis evinced significant association between CMR-diagnosed cardiac sarcoidosis and reduction in LVEF, increase in diastolic interventricular septal thickness, diastolic dysfunction as well as limited electrocardiographic abnormalities. Neither laboratory values nor pulmonary function parameters correlated with presence or activity of cardiac sarcoidosis., Conclusions: Among our predominantly Caucasian sarcoidosis study population, CMR-detected cardiac affection occurred in 15.4% and was missed by internationally valid standard clinical testing in all but one case. It reinforces CMR's diagnostic value as modality of choice to evaluate cardiac sarcoidosis. The estimation of its prognostic potential and its value in assessing the incidence of cardiac sarcoidosis however requires further longitudinal investigation.

Background: Reliable information on micronutrient status before bariatric surgery is needed to optimize preoperative nutritional status and postoperative nutritional therapy., Objective: To investigate the pro-/vitamin and mineral status and its association with nutrient intake in morbidly obese patients seeking bariatric surgery, Setting: Klinikum Vest, Recklinghausen, Germany., Methods: The cross-sectional study investigated retinol, ascorbic acid, tocopherol, and β-carotene (high-pressure liquid chromatography), 25-hydroxycholecalciferol (enzyme-linked immunosorbent assay), and calcium, phosphate, and magnesium (photometry) in serum/plasma in 43 patients (body mass index: 52.6±10.5 kg/m(2)) before sleeve gastrectomy. Albumin, parathyroid hormone, and alkaline phosphatase were analyzed. Data were compared with accepted cutoff values. Dietary intake was estimated by 3-day food records, and nutrient intake was compared with recommended values., Results: One third of participants had ascorbic acid concentrations<28 nmol/L. All patients had β-carotene levels≤.9 µmol/L, although retinol was below the cutoff value (<.7 µmol/L) in only 5%. Tocopherol/cholesterol-ratio was always>2.8 µmol/mmol. Of the patients, 84% had 25-hydroxycholecalciferol levels below 50 nmol/L. Parathyroid hormone was elevated in 23% (>6.5 pmol/L). Calcium, magnesium, and alkaline phosphatase were always, and phosphate was mostly (98%) above cutoff values. Intake of retinol (23%), ascorbic acid (55.8%), vitamin D (90.7%), tocopherol (48.8%), and β-carotene (<2.0 mg/d; 37.2%) were often below recommendations. Correlations between serum/plasma concentrations and nutritional intake and associations between low concentrations and inadequate intake were not observed., Conclusions: Many morbidly obese patients in Germany suffer from deficiencies in multiple micronutrients, particularly vitamin D, ascorbic acid, and β-carotene before sleeve gastrectomy. Measurement of preoperative micronutrient status will help supplement patients before, and optimize nutritional therapy after, surgery., (Copyright © 2015 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Recent studies have shown that smoking and alcoholism may be associated with altered DNA methylation and that alcohol consumption might induce changes in DNA methylation by altering homocysteine metabolism. In this monocenter study, we included 363 consecutive patients referred for hospitalization for alcohol detoxification treatment. Blood samples were obtained on treatment days 1, 3, and 7 for measurement of global DNA methylation in leukocytes by liquid chromatography tandem mass spectrometry. Genomic DNA was used for genotyping the following seven genetic variants of homocysteine metabolism: cystathionine beta-synthase (CBS) c.844&#95;855ins68, dihydrofolate-reductase (DHFR) c.594 + 59del19bp, methylenetetrahydrofolate-reductase (MTHFR) c.677C > T and c.1298A > C, methyltetrahydrofolate-transferase (MTR) c.2756A > G, reduced folate carrier 1 (RFC1) c.80G > A, and transcobalamin 2 c.776C > G. Multivariate linear regression showed a positive correlation of global DNA methylation with alcohol consumption and smoking on day 1 of hospitalization. DNA methylation was not correlated with homocysteine or vitamin plasma levels, nor with the tested genetic variants of homocysteine metabolism. This suggests a direct effect of alcohol consumption and smoking on DNA methylation, which is not mediated by effects of alcohol on homocysteine metabolism., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Previous research has shown an association between certain personality characteristics and suicidality. Methodological differences including small sample sizes and missing adjustment for possible confounding factors could explain the varying results. The aim of this study was to assess the impact of the Big Five personality dimensions on suicidality in a representative population based sample of adults., Method: Interviews were conducted in a representative German population-based sample (n=2555) in 2011. Personality characteristics were assessed using the Big Five Inventory-10 (BFI-10) and suicide risk was assessed with the Suicidal Behaviors Questionnaire-Revised (SBQ-R). Multivariate logistic regression models were calculated adjusting for depression, anxiety, and various sociodemographic variables., Results: Neuroticism and openness were significantly associated with suicide risk, while extraversion and conscientiousness were found to be protective. Significant sex differences were observed. For males, extraversion and conscientiousness were protective factors. Neuroticism and openness were found to be associated with suicide risk only in females. These associations remained significant after adjusting for covariates., Conclusion: The results highlight the role of personality dimensions as risk factors for suicide-related behaviors. Different personality dimensions are significantly associated with suicide-related behaviors even when adjusting for other known risk factors of suicidality.

Objective: A number of studies have revealed that the number of completed suicides decreases with increasing body mass index (BMI). However, only few studies have evaluated the association between suicidal behavior, suicide attempts, and the various BMI categories. The aim of this study was to determine whether obesity is positively associated with increased suicide attempts and suicidal behavior with consideration of gender differences., Methods: In a representative German population-based sample (N = 2436), interviews were conducted in 2011 to examine the prevalence of suicide attempts and suicidal behavior in participants in the different BMI categories. Logistic regression analyses were conducted for suicidal behavior and suicide attempts to examine the association between obesity status and suicidality, controlling for confounding variables. Suicidal behavior was assessed by the Suicidal Behaviors Questionnaire-Revised (SBQ-R), which is a four-item self-report measure of suicidal thoughts and past attempts. BMI was calculated from participants' self-reported height and weight., Results: Analyses revealed that extremely obese participants (BMI ≥ 40.0) had a prevalence rate of suicidal behavior of 33% for female respondents and 13% for male respondents and rates for suicide attempts of 27% for female and 13% for male respondents. No significant gender differences could be found for any of the weight categories. Furthermore, adjusted odd ratios (AOR) showed a significant difference in suicidal behavior in class I obesity (OR, 3.02 [1.50-6.08] and class III obesity (OR, 21.22 [6.51-69.20]. AORs for suicide attempts showed significantly greater odds for class I obesity (OR, 3.49 [1.76-6.90] and class III obesity (OR, 12.43 [3.87-39.86] compared to the normal weight group., Conclusion: These results support a positive relationship between suicidal behavior, suicide attempts, and obesity. However contrary to previous findings, no gender differences were found. The findings support the introduction of routine screening for suicidal behavior in extreme obese individuals., (© 2013 Wiley Periodicals, Inc.)

Purpose: To evaluate the intra- and inter-rater reliability of the quantification of blood and CSF flow rates by phase contrast MRI., Materials and Methods: Blood and CSF flows in the upper cervical region were imaged with velocity-encoded cine-phase contrast using 3T scanners from different manufacturers at two centers. Data of 6 subjects scanned in center A and of 5 subjects in center B were analyzed by six readers at two levels of training. Each data set was analyzed three times in a randomized order for a total of 33 data sets. Intra-class correlation coefficients (ICC) were calculated for the primary measurements of areas and flow rates through the main cervical arteries, veins and the CSF space, and for secondary parameters derived from the individual flow rates., Results: ICC ranged from 0.80 to 0.96 for the lumen area and from 0.97 to 0.99 for the volumetric flow rate. The ICC for the derived secondary measures ranged from 0.85 to 0.99. Differences due to operator level of training were not statistically significant., Conclusion: High intra- and inter-rater reliability of volumetric flow rate measurements is currently achievable across manufacturers and users' skill levels with a pulsatility based automated lumen segmentation., (Copyright © 2013 Wiley Periodicals, Inc., a Wiley company.)

Objective: Findings about the association between working alliance and therapy outcome in Internet-based treatments are contradictory. Evidence for the working alliance in Internet-based treatment for Binge Eating Disorder is still missing and can help to elucidate this question., Methods and Results: In an Internet-based cognitive-behavioral intervention, working alliance (WAI-S, mid n = 59; post n = 49) and eating disorder symptoms (EDE-Q, n = 49) as therapy outcome were assessed. A positive working alliance was reported by study participants. Working alliance had significant correlations with and EDE-Q-scales but not with binge eating episodes., Conclusions: Our study refers to the important role working alliance has for therapy outcome., (© Georg Thieme Verlag KG Stuttgart · New York.)

Clinical Issue: Causes and imaging patterns of hydrocephalus differ depending on the age of the patient. Traditionally, hydrocephalus was classified into non-communicating and communicating hydrocephalus but more recent classifications also take the site of occlusion and the etiology into account., Diagnostics: For the diagnostic work-up computed tomography (CT), sonography and magnetic resonance imaging (MRI) are available and MRI is the method of choice for children and adolescents as it allows determination of the cause and location of a possible obstruction. In the first 12-18 months sonography allows evaluation of the lateral ventricles and the third ventricle and CT is usually only chosen in children in emergency situations and/or if no other modality is available., Performance: We retrospectively evaluated a population of 785 children and adolescents (426 males aged 0-17 years) referred for MRI between April 2009 and March 2012 due to headaches, somnolence, concentration difficulties or developmental delay. Among these 80 (49 male) met the MRI criteria for hydrocephalus, 75 (46 male) had non-communicating hydrocephalus and 5 (3 male) communicating hydrocephalus. Of the patients 24 (15 male) had posthemorrhagic aqueductal stenosis, 16 (8 male) intracranial tumors, 9 (6 male) Chiari II malformations, 5 (4 male) other congenital malformations including malformations of the Dandy Walker spectrum, 9 (3 male) idiopathic aqueductal stenosis, 7 (5 male) arachnoidal cysts and 10 (8 male) other disorders, such as post-infections, macrocephaly cutis marmorata telangiectatica congenita (M-CMTC) syndrome, mesencephalic arteriovenous malformation (AVM), Langerhans cell histiocystosis., Practical Recommendations: It is important to take the age of the patient and the imaging pattern into account and to exclude tumors when reporting MR images of children with hydrocephalus.

Background: We wanted to compare the outcome following IV thrombolysis in our patients with ischemic stroke with the outcome reported from the phase 3 registration trials and other large trials., Patients and Methods: From January 2008 through December 2009 we treated 225 patients with ischemic stroke with IV thrombolysis. Retrospectively, we analyzed their clinical data upon admission, during their stay, and upon discharge with special reference to eligibility criteria for IV thrombolysis, symptomatic hemorrhage, and clinical outcome., Results: The average age of the patients was 74 years, with 34% being older than 80 years. The median time between stroke onset and initiation of treatment was 112 min. The initial median NIHSS was 11 points (Rankin score  ≥ 4 in 79% of patients). The rate of symptomatic hemorrhage was 3%. The median follow-up was 14 days. At the end of the observation period, clinical symptoms had improved in 73% of patients (Rankin score  ≤ 2 in 45% of patients). The mortality rate was 12%. In 55% of patients, IV thrombolysis was off label (age  > 80 years in 34% of patients)., Conclusion: The clinical results of IV thrombolysis in our stroke center are similar to the outcome reported from the registration trials and larger clinical series although we treated off label in more than half of the patients. Even larger studies have since shown that the age limit under 80 years for patients is not reasonable. The eligibility criteria should be adapted to reality at this point.

In the present study, comprehensive data on the seroprevalence of Corynebacterium (C.) pseudotuberculosis infections in goats are presented for Baden-Wuerttemberg, a Federal State of Germany, for the first time. As a prerequisite, ELISAs based on a recombinant phospholipase D (rPLD) and whole cell antigens (WCA) were designed and validated yielding sensitivity values of 81% and 97% and specificity values of 98% and 99%, respectively. Immunisation trials in goats demonstrated a significant production of antibodies to rPLD but an evidently lower antibody production to WCA as determined in the corresponding ELISA. Moreover, immunisation with rPLD resulted in the formation of antibodies, which were also detected in the WCA ELISA. In contrast, this phenomenon was not observed with the rPLD ELISA after immunisation with WCA. Implementation of the rPLD and WCA ELISAs in a broad-based seroprevalence study in Baden-Wuerttemberg revealed positive reactions in both ELISAs in 13.2% of the 1771 goat sera tested. In 53.7% of 121 herds of which five or more animals were tested per herd there was at least one animal that showed a positive reaction in both tests.

Life-review therapy has been recognized as an effective therapeutic approach for depression in older adults. Additionally, the use of new media is becoming increasingly common in psychological interventions. The aim of this study was to investigate a life-review therapy in a face-to-face setting with additional computer use. This study explored whether a six-week life-review therapy with computer supplements from the e-mental health Butler system constitutes an effective approach to treat depression in older adults aged 65 and over. A total of 36 participants with elevated levels of depressive symptoms were randomized to a treatment group or a waiting-list control group and completed the post-assessment. Fourteen individuals in the intervention group completed the follow-up assessment. Analyses revealed significant changes from pre- to post-treatment or follow-up for depression, well-being, self-esteem, and obsessive reminiscence, but not for integrative reminiscence and life satisfaction. Depressive symptoms decreased significantly over time until the three-month follow-up in the intervention group compared to the control group (pre to post: d = 1.13; pre to follow-up: d = 1.27; and group × time effect pre to post: d = 0.72). Furthermore, the therapy led to an increase in well-being and a decrease in obsessive reminiscence among the participants in the intervention group from pre-treatment to follow-up (well-being: d = 0.70; obsessive reminiscence: d = 0.93). Analyses further revealed a significant but small group × time effect regarding self-esteem (d = 0.19). By and large, the results indicate that the life-review therapy in this combined setting could be recommended for depressive older adults.

Background: Renal insufficiency is common after liver transplantation (LT). The use of creatinine (Crea) as a marker of the glomerular filtration rate (GFR) is limited in patients after LT. Beta-trace protein (BTP), an alternative marker of GFR, is independent of muscle mass and has not been evaluated in LT recipients., Aim: To evaluate BTP as an alternative tool to monitor renal function in LT recipients., Methods: We determined the diagnostic performance of BTP in comparison to Crea and cystatin C (CysC) in 52 patients, who concomitantly underwent (99m)Tc-DTPA-clearance measurements. Furthermore, we evaluated bias, precision and accuracy of five recently developed BTP-based equations to estimate GFR., Results: The average measured GFR was 51 (46.1; 56.0) ml/min/1.73 m(2). Using a cut-off of 30 ml/min/1.73 m(2) the area under the curve (AUC) was nearly identical for all markers. At a decision point of 60 ml/min/1.73 m(2) BTP showed only a trend towards a higher AUC compared with Crea and CysC (0.806 vs. 0.754 and 0.760, respectively; P>0.2). In comparison to the modification of diet in renal disease-formula (MDRD) only one of five BTP-based equations displayed a significantly higher accuracy within 30% of the measured GFR (84.6 vs. 59.6%; P=0.006). None of these equations showed a significant improvement compared with MDRD with respect to bias and precision., Conclusions: Beta-trace protein can be used as an alternative diagnostic tool to detect moderate or severe GFR reduction in patients after LT. Furthermore BTP-based equations are able to estimate GFR in LT recipients. However, these equations fail to perform constantly better than the MDRD formula., (© 2011 John Wiley & Sons A/S.)

Quality management (QM) cannot be successfully implemented and performed without audits. The PDCA (Plan-Do-Check-Act) cycle is the core component of QM systems. In this cycle an audit represents the crucial step "check". Audits verify whether the performed actions and their results conform to the requirements. It is especially important to verify whether the principles of QM are omnipresent and fully implemented in a department or institution. The announcement of an audit may cause mixed feelings or even anxiety among the personnel to be audited. Without previous information and training the audit may be perceived as an act of control and intrusion into departmental affairs. The colleagues often fear sanctions if lapses are found or consider the audit to be a cross-examination. However, an audit is rather meant to be a helpful aid and a chance to continuously improve the departmental QM system by means of a constructive communication among colleagues. In the year 2009 the European Commission published guidelines for the performance of clinical audits in medical radiology, including diagnostic radiology, nuclear medicine and radiation therapy (Council Directive 97 / 43 / EURATOM). The aim is an optimal protection of the individual from the hazards of ionizing radiation and the directive expects radiological departments to perform clinical audits in accordance with national procedures.

Purpose: The aim of this study was to identify and evaluate the work-related satisfaction of radiologists and its influencing factors in Germany., Materials and Methods: For this purpose an invitational letter for an online opinion survey was sent to all member physicians of the Deutsche Roentgengesellschaft in 2008. 1200 questionnaires were completed (response rate 21 %) and evaluated statistically., Results: 81.7 % of radiologists declared themselves as being "very" or "rather satisfied". The level of satisfaction was largely independent of age, gender, status, salary or family status. It increased over the last 5 years for 37.5 % of participants and decreased for 24.8 %. Nevertheless, 72 % of respondents indicated that they would not choose to specialize in radiology again. The main reason given was the workload. 65.6 % deemed it to be "considerably" or "rather too high". Concomitantly, more than 70 % of respondents indicated that the workload had increased "a lot" or "rather". Further reasons for not wanting to select the radiological profession again were "unfavorable working hours" and "unsatisfactory career perspectives"., Conclusion: The job satisfaction of radiologists in Germany is generally very high in spite of the perception of an extensive and frequently increasing workload. The high workload was the dominant factor against a renewed selection of the field of radiology. These data have to be interpreted in light of the current lack of residents and trained radiologists in Germany to counteract the trend toward emigration., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Complicated grief (CG) has been proposed as a distinct diagnostic category in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). However, few epidemiological studies to date have measured CG in the general population., Methods: Prevalence of CG, sociodemographic characteristics, and grief-related factors were examined in a representative population-based survey (N = 2520) through face-to-face contact. The sample included all bereaved subpopulations and all age groups from 14 to 95 years., Results: The conditional prevalence of developing CG after major bereavement was 6.7%; the prevalence of CG in the general sample was 3.7%. Predictors of higher risk for developing CG were female gender, lower income (< €1250/month), older age (> 61 years), having lost a child or a spouse, or cancer as the cause of death., Limitations: The sample of bereaved people was small, and some categories contained very few cases. Psychiatric comorbidities were not assessed in this study., Conclusions: The results indicate that CG is prevalent in the population, and risk factors were identified., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Determination of HbA1c values with high performance liquid chromatography (HPLC) occasionally reveals hemoglobin anomalies with no or minimal clinical evidence. We coincidentally detected two cases of Hb Hasharon, an alpha globin gene mutation, in two heterozygous patients and one case of Hb NYU, a delta globin gene mutation, in another patient. Both anomalies have not been described in subjects of German origin to date. Characterization was carried out with HPLC, hemoglobin electrophoresis, capillary zone electrophoresis, DNA sequencing, complete blood count and clinical chemical analysis.

In this study, 809 samples of ice cream from different sources were investigated by using cultural methods for the presence of presumptive Bacillus cereus. Isolates from culture-positive samples were examined with a real-time PCR assay targeting a region of the cereulide synthetase gene (ces) that is highly specific for emetic B. cereus strains. The samples were collected from ice cream parlors and restaurants that produced their own ice cream and from international commercial ice cream companies in different regions of Bavaria during the summer of 2008. Presumptive B. cereus was found in 508 (62.7%) ice cream samples investigated, and 24 (4.7%) of the isolates had the genetic background for cereulide toxin production. The level of emetic B. cereus in the positive samples ranged from 0.1 to 20 CFU/g of ice cream.

In addition to teleradiological reporting as a nighthawking or a regular service, teleradiological communication can be used for interdisciplinary expert consultation. We intended to evaluate an interdisciplinary consultation system based on a teleradiology platform with regard to its impact on therapeutic decision-making, directed patient referrals to an academic tertiary care center and the economic benefit for the hospital providing the service. Therefore, consultations from five secondary care centers and consecutive admissions to an academic tertiary care center were prospectively evaluated over a time period of six months. A total of 69 interdisciplinary expert consultations were performed. In 54 % of the cases the patients were consecutively referred to the university hospital for further treatment. In all acutely life-threatening emergencies (n = 9), fast and focused treatment by referral to the academic tertiary care center was achieved (average time to treat 130 min). The admissions to the academic tertiary care center led to improved utilization of its facilities with additional revenue of more than 1,000000 euro p. a. An interdisciplinary expert consultation via a teleradiology platform enables fast and efficient expert care with improved and accelerated patient management and improved utilization of the service providing hospital.

Neonatal hyperbilirubinemia (NHB) above 20 mg/dl (NHB20) has been shown to increase the risk of hearing impairments. Up to now, audiological findings based on behavioural audiometry (BA), otoacoustic emissions (TEOAE) and auditory brainstem responses (ABR) from children after being diagnosed with NHB20 have not been thoroughly compared to those with lower NHB-levels. We, therefore, aimed to assess the presence and characteristics of auditory dysfunction in children with NHB20. The audiological data of 15 children aged 11 months to 9 years with a NHB level between 22.6 and 45.6 mg/dl and/or MRI-confirmed bilirubin encephalopathy (NHBG) were compared retrospectively to 15 children with NHB levels between 12.5 and 19.4 mg/dl (CG). After matching by weeks of gestation at birth, BA, TEOAE and ABR were performed in all the children. Subsequently the groups were compared. Only two children of the NHBG had consistently normal audiologic findings. Hearing function disorders were detected in 87% (13/15) of the NHBG-children, ranging from total deafness to normal BA, including unilateral and bilateral deafness as well as cochlear hearing loss. Auditory neuropathy/dys-synchrony (AN) was found in a total of eight children (53%) of the NHBG. In addition, it was found that after the occurrence of NHB20, initially detected TEOAE can disappear in some cases. In the comparison group (CG) only two children demonstrated a hearing dysfunction, both of which were cochlear hearing impairments, whereas no child had AN. A bias towards hearing impairments has to be taken into account for both groups. Detailed pedaudiologic testing should be mandatory for all children after the occurrence of NHB20 including follow-up during the first 12 months. Audiological diagnostic work-up in the affected children requires objective investigations of hearing functions, while BA is recommended to evaluate the adequate therapeutic procedure.

In a representative epidemiological study (n=2426) with a broad age range of respondents (14-93 years), prevalence rates of traumatic life events, post-traumatic stress disorder (PTSD), and partial PTSD were estimated. A standardized interview using the trauma checklist of the Composite International Diagnostic Interview and a DSM-IV PTSD symptom checklist (Modified PTSD Symptom Scale) were applied. One-month prevalence rates were 2.3% for DSM-IV PTSD and 2.7% for partial PTSD. There were no gender differences but age-group differences did appear: among persons older than 60, the prevalence of PTSD was 3.4%, whereas the prevalence was estimated at 1.3% among persons aged 14-29 years and 1.9% among those aged 30-59 years. Partial PTSD exhibited the same age distribution, with 3.8% in the elderly, 2.4% in the middle-aged, and 1.3% in young adults. The results correspond with those of other international studies taking war-related consequences for older age groups into account. Our representative study provides the first evidence of higher PTSD prevalence rates among older age groups in the German population, which is assumed to be related to consequences of World War II.

The present study investigates the efficacy of an Internet-based cognitive-behavioral therapy program for bereaved people suffering complicated grief. The program combines established methods of psychotherapy with new technology--therapists and patients communicated exclusively by e-mail. Bereaved individuals diagnosed with complicated grief (n = 55) were randomly assigned to either the treatment group or a waiting list control condition. The 5-week intervention consisted of three modules: (1) exposure to bereavement cues; (2) cognitive reappraisal; and (3) integration and restoration. The Impact of Event Scale (IES), a failure to adapt scale, and the depression and anxiety subscales of the Brief Symptom Inventory (BSI) were used to assess treatment outcomes. Participants in the treatment group (n = 26) improved significantly relative to participants in the waiting condition on symptoms of intrusion, avoidance, maladaptive behavior, and general psychopathology, and showed a large treatment effect. Follow-up results show that this improvement was maintained after 3 months.

The child who presents with acute coma runs a high risk of cardiopulmonary insufficiency, direct brain injury or even cerebral herniation. The case-management of such child requires a coma-specific emergent evaluation, immediate treatment of any hypoxicischemic insults and of the underlying cause. The coma-specific examination includes performance of child-adapted Glasgow Coma Score, the evaluation of brain stem functions such as pupillary response to light, cough- and gag reflex, and determination of all vital signs including body temperature. Treatment of hypoxicischemic insults includes control of airways and ventilation in patient with coma defined as GCS <8; liberal treatment of impaired cardiovascular states with isotonic fluids such as 0.9% sodium chloride; and treatment of cerebral herniation with head elevation, mannitol, hypertonic sodium chlorid fluids, steroids and hyperventilation. Immediately treatable causes are hypoglycemia, meningitis/encephalitis, opioid overdose and status epilepticus. Exclusion of rapidly progressive intracranial lesions almost always requires referral to the tertiary centre with head CT-scan facilities. Finally, an extensive etiology search of the stable coma is performed by looking for disease or trauma of the brain, for metabolic causes, for intoxications and for cardiopulmonary problems.

German psychiatry has been using parent-child treatment for only a few years-in contrast to Anglo American countries. Now, however, similar modalities are now on the rise in Germany, and it is time to list experiences and considerations of possible quality standards for such treatment units. To account for the necessary broadening of perspectives including the whole family system, the term "parent-child treatment" is used instead of the frequently used "mother-child treatment."

Background: Up to now, reliable data has not been available on the actual costs of treating oncological patients. However, such data material is urgently required in view of the institution of the health service reform with the concomitant introduction of the G-DRG remuneration system., Patients: The medical services and their costs for 66 patients comprising several stays in hospital, part-time hospitalization and outpatient visits to the clinic categorized "establishment of the diagnosis", "stem cell therapy (SCT)" and "chemotherapy" were recorded in parallel to treatment over a time period of three months. It was thus possible to relate a cost volume of 2.7 million euro to more than 2800 nursing days (full and partial hospitalization) and more than 500 outpatient visits., Methods: All pertinent costs were collated with the various stays/movements of the patients over 100 calendar days. This was very largely possible thanks to a sophisticated costing and setting off of payments within the hospital on the part of the service providers in the hospital in direct allocation to patients and the third-party payers. Additionally, partial and full surveys as well as questionnaires enabling allocation to the individual case as far as possible, especially the staff requirement, were used. A breakdown of the costs in terms of the patient nursing days was only effected in marginal areas such as the "hotel function" or the general administrative costs. A further subdivision of the stays and movements as well as the phases of the stays applied to the service or the treatment progress above and beyond the areas of treatment. In the case of chemotherapy, a distinction was therefore made between "protocol blocks" and "stays due to complications" and in the case of SCT inter alia even individual phases such as "conditioning"., Results and Conclusions: It is problematical to represent these patients within an DRG case flat rate system because of frequent and very divergent residence periods with regard to services and costs. The multiplicity of treatment sessions is manifested in the compact "establishment of the diagnosis" to determine a therapy protocol which entails very elaborate inpatient measures under hospitalization, in the expensive and individual "stays due to complications" which usually take place between the "chemotherapy blocks", and the expensive long-term care of the SCT patients after the end of the residence limit (GVD). Owing to the small and divergent numbers of cases in Germany (2000 new patients in 50 centers and 330 SCT per year) and per center, this problem cannot be dealt with by means of a quantity compensation argumentation, as is doubtless justified elsewhere. The actual individual case costs of oncological patients would be 166,72 euro; per outpatient contact and covered by 459,30 euro; per day of hospital care and 808,20 euro; per inpatient treatment day (admission plus discharge day calculated separately and comprised stem cell transplantation patients beyond the residence limit) is covered. The level of the currently applicable case flat rate payments for stem cell transplantations and heterologous donors, mismatched heterologous donors and family donors appear appropriate in relation to the GVD. (The true costs of all oncological patients would indeed be even higher if the GOA payment of the ILV did not only relate to a house-internal low pricing of the GOA scoring value, but would also relate to HLA typing, unpaid physician overtime and the costs of the study centers to the individual cases. From 2002, there will be changes consequent on the judgment of the European Court that stand-by is working time, so that more physicians must be employed and there are expensive changes in the infrastructure owing to the need for a GMP clean area laboratory to process stem cells according to the medical products law.) The indeterminate bound-aries between the three treatment categories place in question the dual financing by the Panel Doctor's Association and the health insurance funds and indicate that a total-sum remuneration appears appropriate.

Regional population forecasts are on average even more uncertain than nationwide projections, due to the greater importance of migration and the unstable smaller absolute numbers. Other than national projections, local or regional calculations do normally have an explicit goal. In this paper, a projection of the population and age structure in the region of Augsburg is used to demonstrate some specific aspects of local population projections used for public health purposes. If institutions of childhood ages are to be projected the results are primarily determined by the assumptions on migration. If questions of old age are to be answered, the main factor of influence is the development in mortality. Depending on the specific alm of a local population projection, the principal insecurity about the future should be integrated by calculating confidence bands for those demographic parameters, that are most important for the specific question.