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The structure and drivers of Southern Ocean meiofauna and macrofauna were investigated together in one extensive study. From the tip of the Antarctic Peninsula to the southeastern Weddell Sea, we classified the investigated stations into 5 categories according to their summer sea-ice cover: (I) none (Drake Passage), (II) irregular (Bransfield Strait), (III) seasonal (northwestern Weddell Sea), (IV) high (South Filchner Trough), and (V) constant (North Filchner Trough). The categories differed significantly in primary-production-related characteristics in the water column and food availability at the seafloor. Almost all ice-cover categories differed significantly in meiofauna communities (32-500 µm, 20 taxa, 585 825 individuals). Fewer regions differed significantly in macrofauna (>500 µm, 19 taxa, 3974 individuals) or the combined meiofauna and macrofauna communities. Environmental drivers explained >66% of the variation among different communities and differed for the faunal size classes: for meiofauna (84.2%), sea-ice cover (1 yr) and availability of fresh food (chlorophyll a [chl a]) were most important, whereas 1 yr ice cover, chl a, and total organic carbon were decisive drivers for macrofauna (66.6%). Grain size, water depth, water-column chl a, long-term ice cover, seafloor temperature, and the carbon/nitrogen ratio influenced communities to a lesser extent. We demonstrated a stronger relationship with sea-ice cover in meiofauna communities than in macrofauna communities, and we recommend including meiofauna in future assessments of the influence of environmental changes on Southern Ocean ecosystems.

We review anatomy of the thoracic, lumbar, and sacral spine. Knowledge of normal anatomy is vital when reviewing imaging of the spine because it allows for the detection of abnormal findings. We emphasize the normal appearance of the thoracic and lumbosacral spine on imaging, focusing on the most common imaging techniques of computed tomography and magnetic resonance imaging, as well as highlighting a few less common and emerging imaging techniques that can evaluate the spine.

Background/Introduction Cardiac fibrosis is a central pathophysiological process accompanying most cardiac diseases including heart failure, and is a predictor of poor outcomes. The fibrotic process is mediated by activated cardiac fibroblasts (CFBs), so-called myofibroblasts, which produce excessive amounts of type I collagen and other ECM molecules. The ADAMTSL family of glycoproteins is upregulated in the cardiac extracellular matrix (ECM) during heart failure, but their function in the heart is unknown. Some ADAMTSL proteins are suggested to regulate the TGFβ, a major driver of myofibroblast activation and cardiac fibrosis. Purpose The purpose of this study was to examine the role of ADAMTSL3 in TGFβ-regulation and heart failure. Methods ADAMTSL3 expression was analysed in failing hearts of patients and mice. To study the functional role of ADAMTSL3 in the failing heart, an Adamtsl3 knock-out (L3-KO) mouse was generated, and WT and L3-KO littermates were subjected to experimental heart failure by aortic banding (AB), or sham surgery, for a total of six weeks. The mice were followed with echocardiography and MRI, and the left ventricles (LVs) were harvested one and six weeks after AB or sham surgery, with molecular analyses performed. To elucidate molecular functions of ADAMTSL3 in vitro, we overexpressed ADAMTSL3 in CFBs producing an extensive ECM. Results We determined that ADAMTSL3 was produced by CFBs and upregulated in failing hearts of patients and mice. The L3-KO mice had a normal cardiac phenotype at baseline, but upon increased LV afterload developed a dilated cardiomyopathy phenotype with increased LV dilation and reduced systolic function from one week post-AB. Furthermore, high mortality was observed in the L3-KO mice post-AB, with 60% vs. 96% survival of WTs over six weeks. At one week post-AB RNA sequencing of LVs revealed 233 differentially expressed genes in L3-KO vs. WT, with Col1a1 and Postn among the most upregulated, suggesting increased fibrosis and TGFβ signalling. Increased canonical TGFβ signalling was confirmed by increased SMAD2/3 phosphorylation and increased Lox expression in L3-KOs six weeks post-AB. In vitro, ADAMTSL3 overexpression in cultured CFBs resulted in reduced collagen synthesis and reduced expression of COL1A1, LOX, CTGF and POSTN, indicating anti-fibrotic properties. Furthermore, ADAMTSL3 inhibited the expression of ACTA2 and SPP1, reduced α-SMA protein by 25%, and reduced proliferation and CFB contraction, suggesting attenuated TGFβ signalling and inhibited myofibroblast differentiation. Conclusions ADAMTSL3 was upregulated in human and mouse heart failure, and served an anti-fibrotic and cardio-protective role in failing mouse hearts. Mechanistically, ADAMTSL3 was produced by CFBs and inhibited myofibroblast differentiation and collagen synthesis through TGFβ in cultured CFBs. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Research Council of Norway

Several healthcare organizations across Minnesota have developed formal pharmacogenomic (PGx) clinical programs to increase drug safety and effectiveness. Healthcare professional and student education is strong and there are multiple opportunities in the state for learners to gain workforce skills and develop advanced competency in PGx. Implementation planning is occurring at several organizations and others have incorporated structured utilization of PGx into routine workflows. Laboratory-based and translational PGx research in Minnesota has driven important discoveries in several therapeutic areas. This article reviews the state of PGx activities in Minnesota including educational programs, research, national consortia involvement, technology, clinical implementation and utilization and reimbursement, and outlines the challenges and opportunities in equitable implementation of these advances.

Zusammenfassung Patienten mit der Hauptdiagnose einer Intelligenzminderung führen ein Schattendasein im deutschen Maßregelvollzug nach § 63 StGB. Zahlenmäßig stellen sie eine Minderheit dar, weisen jedoch im Vergleich zu anderen Diagnosegruppen eine überlange Verweildauer auf. Der bis dato persistierende Umstand mangelnder wissenschaftlicher Grundlagenkenntnisse über diese Patientengruppe hält deren Abseitsposition aufrecht. Dadurch werden Unsicherheiten bei der Diagnostik sowie Beurteilung der strafrechtlichen Verantwortlichkeit und Legalprognose sowohl auf Seiten der Juristen als auch der Sachverständigen und Therapeuten geschürt. Das dritte Eingangsmerkmal des § 20 StGB, unter das Patienten mit einer angeborenen Intelligenzschwäche ohne nachweisbare Ursache subsumiert werden, ist gleichsam ein Abbild dieses Daseins. Abgesehen von der noch bis Ende 2020 despektierlichen und antiquierten Bezeichnung (Schwachsinn), birgt dieser Rechtsbegriff Unklarheiten und erschwert ein sicheres, transparentes Vorgehen in der forensischen Beurteilung. Dabei sind gerade diese Patienten, allein aufgrund ihrer mangelnden intellektuellen Fertigkeiten, auf die Expertise und auch Fürsorge Anderer (Sachverständiger/Juristen) angewiesen. Anhand der Ergebnisse einer aktuellen empirischen Untersuchung über 102 im Maßregelvollzug des Landes NRW (gemäß § 63 StGB) untergebrachten intelligenzgeminderten Patienten soll versucht werden, einige der offenkundig gewordenen wissenschaftlichen Lücken zu schließen, um ein höheres Maß an Sicherheit im Umgang mit dieser Patienten- und Straftätergruppe zu erreichen. Im Besonderen ist darauf hinzuweisen, dass bei mehr als jedem fünften Urteil (21,5 %) erhebliche Defizite festzustellen waren, die beide Stufen der Schuldfähigkeitsbeurteilung betrafen. So ließ sich in den Urteilen bei 13 % keine Angabe zu einem Eingangsmerkmal des § 20 StGB entnehmen; in den restlichen Fällen fehlten konkrete Ausführungen zur Einsichts- und/oder Steuerungsfähigkeit. Bei kritischer Analyse der Einweisungsgutachten lag der Anteil an fehlerhaften Ausführungen zur Schuldfähigkeit noch etwas höher (27 %).

To describe and compare the delivery of medication therapy management (MTM) between Medicare beneficiaries with and without mental health conditions.Nationally representative cross-sectional study that used a 20% random sample of 2014 Medicare Parts A, B, and D data merged with a 100% sample of 2014 MTM data.Medicare beneficiaries continuously enrolled in Parts A, B, and D in 2014 were included in this study. Comprehensive medication review (CMR) use and MTM delivery were examined among a subset of 825,003 MTM-enrolled beneficiaries.Predisposing, enabling, and need characteristics were selected on the basis of the Andersen Behavioral Model of Health Services Use. Descriptive, bivariable, and multivariable logistic regression statistics were used to determine associations between beneficiary characteristics and MTM delivery.A total of 3,016,620 (43%) and 3,997,105 beneficiaries (57%) were categorized into mental health and nonmental health cohorts, respectively. MTM enrollment in the mental health cohort was significantly higher than that in the nonmental health cohort (17.4% vs. 7.5%, P0.001). However, once enrolled, a greater proportion of beneficiaries in the nonmental health cohort received CMRs (19.3% vs. 17.7%, P0.001). Patients in the mental health cohort were more likely to have hospitalization (22% vs. 9.2%, P0.001) or emergency department visit (25.2% vs. 11.5%, P0.001) and used more medications in 2014 (16 % vs. 12%, P0.001). The proportion of patients in the mental health cohort receiving a CMR in 2014 that had at least 1 medication-related problem (MRP) identified and resolved was higher than that of patients in the nonmental health cohort (24.8% vs. 20.6%, P0.001).Although patients with mental health conditions are more often enrolled into MTM, they are less likely to receive a CMR once enrolled. Given that this population has higher medical complexity and a higher MRP burden following a CMR, opportunities exist for pharmacists to enhance MTM delivery in this population.

A 67-year-old male presented to the hospital for lower back pain and left lower extremity radiculopathy. Although the patient was afebrile and white blood cell count was normal, MRI was concerning for discitis/osteomyelitis at L4-L5. Subsequently, the patient developed a right knee joint effusion and underwent an arthrocentesis that was notable for the presence of urate crystals. A systemic urate crystal arthropathy was proposed as a potential etiology for the patient’s back pain and radiculopathy. Dual energy CT of the lumbar spine was performed, a technique which determines material composition by comparing the photon attenuation of the substance from two different x-ray energy levels. Results revealed the presence of monosodium urate crystals in the intervertebral discs. This technique is proposed as a noninvasive way to evaluate for gout in atypical locations or those difficult to sample and may replace an invasive intervertebral disc/endplate aspiration and/or biopsy. Dual energy CT should be considered in patients with elevated serum uric acid and concern for spinal involvement of gout.

Background Antibodies to the aquaporin-4 (AQP4) water channel in neuromyelitis optica spectrum disorder (NMOSD) are reported to trigger the complement cascade, which is implicated in astrocyte damage and subsequent neuronal injury. The PREVENT study demonstrated that the terminal complement inhibitor eculizumab reduces adjudicated relapse risk in patients with anti-AQP4 immunoglobulin G-positive (AQP4+) NMOSD. The objective of this analysis was to evaluate the efficacy of eculizumab in reducing relapse risk and its safety in AQP4+ NMOSD across clinically relevant subgroups in PREVENT. Methods In the randomized, double-blind, time-to-event, phase 3 PREVENT trial, 143 adults received eculizumab (maintenance dose, 1200 mg/2 weeks) or placebo (2:1), with stable-dose concomitant immunosuppressive therapy (IST) permitted (except rituximab and mitoxantrone). Post hoc analyses of relapses and adverse events were performed for prespecified and post hoc subgroups based on concomitant IST and prior rituximab use, demographic and disease characteristics, and autoimmune comorbidity. Results The significant reduction in relapse risk observed for eculizumab versus placebo in the overall PREVENT population was consistently maintained across subgroups based on concomitant IST and previous rituximab use, age, sex, region, race, time since clinical onset of NMOSD, historical annualized relapse rate, baseline Expanded Disability Status Scale score, and history of another autoimmune disorder. The serious infection rate was lower with eculizumab than placebo regardless of rituximab use in the previous year, concomitant IST use, or history of another autoimmune disorder. Conclusion Across a wide range of clinically relevant AQP4+ NMOSD patient subgroups in PREVENT, eculizumab therapy was consistently effective versus placebo in reducing relapse risk, with no apparent increase in serious infection rate. Trial registration NCT01892345 (ClinicalTrials.gov).

Menschen, die infolge einer schwerwiegenden psychischen Storung straffallig geworden sind und infolge dieser Storung weiterhin gefahrlich sind, konnen zur Besserung und Sicherung in den Masregelvollzug nach §§ 63 und 64 des Strafgesetzbuches (StGB) untergebracht werden. In Deutschland werden gegenwartig etwa 9000 Patienten in Kliniken fur forensische Psychiatrie und Psychotherapie auf Grundlage des § 63 StGB und in Entziehungsanstalten auf Grundlage des § 64 StGB stationar behandelt. Die Behandlung der Patienten im Masregelvollzug ist landerrechtlich geregelt, sodass sich die Rahmenbedingungen der Behandlung in den einzelnen Bundeslandern unterscheiden. Wahrend fur die Erstellung von Gutachten zur Schuldfahigkeit und zur Legalprognose bereits Mindestanforderungen publiziert worden sind, liegen konsentierte Standards fur die Behandlung im psychiatrischen Masregelvollzug bislang nicht vor. Vor diesem Hintergrund beauftragte die DGPPN 2014 eine interdisziplinare Arbeitsgruppe damit, fachliche Standards fur die Behandlung in der forensischen Psychiatrie zu erarbeiten. Dabei sollten die rechtlichen, ethischen, strukturellen, therapeutischen und prognostischen Standards nach dem aktuellen Stand der Wissenschaft beschrieben werden. Nach dreijahriger Bearbeitungsphase wurden die Ergebnisse der interdisziplinaren Arbeitsgruppe im Fruhjahr 2017 vorgelegt und vom Vorstand der DGPPN konsentiert. Die Standards fur die Behandlung im psychiatrischen Masregelvollzug wollen eine Diskussion anstosen mit dem Ziel, die Behandlungsbedingungen zu vereinheitlichen und fachlich begrundete Empfehlungen zu verankern.

Many current models which "violate Lorentz symmetry" do so via a vector or tensor field which takes on a vacuum expectation value, thereby spontaneously breaking the underlying Lorentz symmetry of the Lagrangian. One common way to construct such a model is to posit a smooth potential for this field; the natural low-energy solution of such a model would then be excepted to have the tensor field near the minimum of its potential. It is shown in this work that some such models, while appearing well-posed at the level of the Lagrangian, have a Hamiltonian which is singular on the vacuum manifold and are therefore ill-posed. I illustrate this pathology for an antisymmetric rank-2 tensor field, and find sufficient conditions under which this pathology occurs for more general field theories., Comment: 11 pages

Purpose: The purpose of this article is to describe how an innovative partnership between a rural community mental health center, community independent pharmacy and College of Pharmacy and integration of a mental health pharmacist lead to identification of medication therapy problems (MTP’s) and interprofessional team partnerships with center mental health professionals. Methods: A contractual arrangement was initiated between Northern Pines Mental Health Center (NPMHC), GuidePoint Pharmacy Services GPS) and the University of Minnesota College of Pharmacy (UMN CoP) to place a PGY1 resident at NPMHC. The resident was assigned to work closely with the Chief Medical Officer and provide initial comprehensive medication management (CMM) services to individuals who were enrolled in Assertive Community Treatment (ACT). A retrospective chart review was conducted to evaluate the impact of services provided. Patient inclusion criteria included ACT enrollees 18 years or older, a diagnosis of SPMI, taking at least one psychotropic medication, and participation in at least one resident-led CMM visit. Additional findings included the relationship between the pharmacist, the psychiatric physician, and other members of the ACT team. Descriptive statistics were used to document the findings. Findings: N = 30 met the inclusion criteria: 18 males and 12 females, age ranged from 24 - 69 with average of 44 years old. 110 MTPs were identified ranging from no MTPs to 10 MTPs per patient, with a mean of 4 MTPs/patient. There was an uneven distribution of MTPs between psychiatric and medical conditions, with a disproportionately high occurrence of “Needs Additional Drug Therapy” in medical conditions and “Adverse Drug Reaction” in psychiatric conditions. In addition, the services were valued by members on the ACT team. Conclusion: Rural residents with SPMI in intensive community treatment have complex medication needs that require the training and skills of a clinical pharmacist. Despite the inclusion of a medication list as part of the ACT fidelity standards MTPs may go unrecognized and unresolved without the services of a clinical pharmacist conducting CMM. The pharmacist and psychiatric physician formed a collaborative partnership to address medication issues. We conclude that there is a need for integrating clinical pharmacist services into rural mental health centers. Article Type: Original Research

To describe and compare the delivery of medication therapy management (MTM) between Medicare beneficiaries with and without mental health conditions.Nationally representative cross-sectional study that used a 20% random sample of 2014 Medicare Parts A, B, and D data merged with a 100% sample of 2014 MTM data.Medicare beneficiaries continuously enrolled in Parts A, B, and D in 2014 were included in this study. Comprehensive medication review (CMR) use and MTM delivery were examined among a subset of 825,003 MTM-enrolled beneficiaries.Predisposing, enabling, and need characteristics were selected on the basis of the Andersen Behavioral Model of Health Services Use. Descriptive, bivariable, and multivariable logistic regression statistics were used to determine associations between beneficiary characteristics and MTM delivery.A total of 3,016,620 (43%) and 3,997,105 beneficiaries (57%) were categorized into mental health and nonmental health cohorts, respectively. MTM enrollment in the mental health cohort was significantly higher than that in the nonmental health cohort (17.4% vs. 7.5%, P0.001). However, once enrolled, a greater proportion of beneficiaries in the nonmental health cohort received CMRs (19.3% vs. 17.7%, P0.001). Patients in the mental health cohort were more likely to have hospitalization (22% vs. 9.2%, P0.001) or emergency department visit (25.2% vs. 11.5%, P0.001) and used more medications in 2014 (16 % vs. 12%, P0.001). The proportion of patients in the mental health cohort receiving a CMR in 2014 that had at least 1 medication-related problem (MRP) identified and resolved was higher than that of patients in the nonmental health cohort (24.8% vs. 20.6%, P0.001).Although patients with mental health conditions are more often enrolled into MTM, they are less likely to receive a CMR once enrolled. Given that this population has higher medical complexity and a higher MRP burden following a CMR, opportunities exist for pharmacists to enhance MTM delivery in this population.

In conventional gravitational physics, the so-called "bootstrap procedure" can be used to extrapolate from a linear model of a rank-2 tensor to a full non-linear theory of gravity (i.e., general relativity) via a coupling to the stress-energy of the model. In this work, I extend this procedure to a "Lorentz-violating" gravitational model, in which the linear tensor field and the matter fields "see" different metrics due to a coupling between the tensor field and a background vector field. The resulting model can be thought of as a generalized Proca theory with a non-minimal coupling to conventional matter. It has a similar linearized limit to the better-known "bumblebee model", but differs at higher orders in perturbation theory. Its effects are unobservable in FRW spacetimes, but are expected to be important in anisotropic cosmological spacetimes., Comment: 24 pages

Thomas Manns komplexe, zum Tode fuhrende Gefaskrankheit - Eine medizinische und literaturhistorische Betrachtung

Many current models which "violate Lorentz symmetry" do so via a vector or tensor field which takes on a vacuum expectation value, thereby spontaneously breaking the underlying Lorentz symmetry of the Lagrangian. To obtain a tensor field with this behavior, one can posit a smooth potential for this field, in which case it would be expected to lie near the minimum of its potential. Alternately, one can enforce a non-zero tensor value via a Lagrange multiplier. The present work explores the relationship between these two types of theories in the case of vector models. In particular, the na\"ive expectation that a Lagrange multiplier "kills off" one degree of freedom via its constraint does not necessarily hold for vector models that already contain primary constraints. It is shown that a Lagrange multiplier can only reduce the degrees of freedom of a model if the field-space function defining the vacuum manifold commutes with the primary constraints., Comment: 11 pages. v2: added discussion of previous work in Ref. [19]

People who have been convicted of a crime due to a severe mental disorder and continue to be dangerous as a result of this disorder may be placed in a forensic psychiatric facility for improvement and safeguarding according to § 63 and § 64 of the German Criminal Code (StGB). In Germany, approximately 9000 patients are treated in clinics for forensic psychiatry and psychotherapy on the basis of § 63 of the StGB and in withdrawal centers on the basis of § 64 StGB. The laws for treatment of patients in forensic commitment are passed by the individual States, with the result that even the basic conditions differ in the individual States. While minimum requirements have already been published for the preparation of expert opinions on liability and legal prognosis, consensus standards for the treatment in forensic psychiatry have not yet been published. Against this background, in 2014 the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) commissioned an interdisciplinary task force to develop professional standards for treatment in forensic psychiatry. Legal, ethical, structural, therapeutic and prognostic standards for forensic psychiatric treatment should be described according to the current state of science. After 3 years of work the results of the interdisciplinary working group were presented in early 2017 and approved by the board of the DGPPN. The standards for the treatment in the forensic psychiatric commitment aim to initiate a discussion in order to standardize the treatment conditions and to establish evidence-based recommendations.

Die Relevanz der Diagnostik sexuell ubertragbarer Infektionen („sexually transmitted infection“, STI) bei Verdacht auf sexuellen Kindesmissbrauch liegt in der Abklarung und ggf. Therapie ubertragener Erkrankungen sowie in der Uberfuhrung des Taters. Nicht alle STI bieten sich jedoch hierzu in gleicher Weise an. Der vorliegende Beitrag liefert eine Ubersicht uber STI, die dazu geeignet sind, den Verdacht des Missbrauchs durch Laboranalysen zu erharten. Hierzu wird auf die Bedeutung der Diagnostik und klinischen Relevanz von Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis, humanem Immundefizienz-Virus (HIV), Hepatitis-B-Virus (HBV), humanem Papillomavirus (HPV) und Herpes-simplex-Virus (HSV) bei sexuellem Kindesmissbrauch naher eingegangen. Der Stellenwert einzelner STI ist abhangig von der lokalen Pravalenz, der Moglichkeit anderer, nichtsexueller Ubertragungswege und der Qualitat der verfugbaren Testsysteme. Der Nachweis einer Humanen-Immundefizienz-Virus(HIV)- oder T.-pallidum-Infektion bei Kindern ist mit hoher Wahrscheinlichkeit auf einen Sexualkontakt zuruckzufuhren, sofern eine perinatale Infektion ausgeschlossen ist. Auch N.-gonorrhoeae-, C.-trachomatis- und T.-vaginalis-Infektionen sind hochverdachtig fur stattgefundene sexuelle Kontakte. Vor allem diese 5 Infektionen sind bei Verdacht auf sexuellen Kindesmissbrauch zur labordiagnostischen Abklarung geeignet. Im Hinblick auf die verheerenden Konsequenzen falsch-positiver Ergebnisse fur die Opfer und die putativen Tater sind dabei diagnostische Verfahren mit hoher Spezifitat erforderlich, deren Ergebnisse einen hohen positiven Pradiktivwert (PPV) aufweisen.

In der vorliegenden Studie wurde die ambulante Nachsorge forensischer Patienten, die im Bundesland Nordrhein-Westfalen in den Jahren 2002 bis 2006 aus einer Unterbringung gemas § 63 StGB in Freiheit entlassen (§§ 67d Abs. 2, 6 und 67b StGB) wurden, evaluiert. Dazu wurden an 21 Ambulanzstandorten umfangreiche Daten zum Nachsorgeverlauf von 115 forensischen Patienten erhoben. Fur weitere 110 Patienten, die ihre Zustimmung zur Teilnahme nicht erteilten, konnten anhand der Registereintragungen Daten zur Deliktruckfalligkeit ermittelt werden. Mittels eines Vergleichs der erfolgreich rehabilitierten mit den gescheiterten Patienten wurde schlieslich der Fragestellung nachgegangen, ob sich poststationare Prognosefaktoren extrahieren lassen, mit deren Hilfe das Risikomanagement und damit die Professionalisierung forensischer Nachsorge weiter verbessert werden konnten. Anhand zahlreicher Kasuistiken wurden typische Problemkonstellationen in der ambulanten Nachbetreuung heraus-gearbeitet und i.S. forensischer Lernfalle dargestellt. Als Ergebnis wurde eine geringe Rate strafrechtlich auffalligen Verhaltens der entlassenen Patienten festgestellt und als Hinweis auf eine hohe Effektivitat forensischer Nachsorge gewertet. Die 23 Patienten mit relevanten Auffalligkeiten in der Nachsorge wiesen bereits in anamnestischer Hinsicht eine wesentlich starkere psychosoziale und delinquente Vorbelastung auf. Auch wahrend der Unterbringung zeigte diese Gruppe signifikant haufiger (vielfaltig) regelwidriges Verhalten. Im poststationaren Verlauf erwies sich Substanzmissbrauch als hochsignifikanter Risikofaktor, der starkerer Beachtung bedarf. Eine gute Compliance des Patienten wirkte sich nicht nur auf das psychische Befinden stabilisierend aus, sondern machte auch erforderliche (freiwillige) Rehospitalisierungen mit hoher ruckfallpraventiver Wirkung moglich. Stabile und prosoziale Beziehungen liesen einen Schutz vor Ruckfalligkeit erkennen, Intimpartnerschaften dagegen nicht. Eine positiv erlebte Freizeitgestaltung erwies sich als protektiver Faktor, ein problematischer Umgang mit Geld korrelierte hingegen signifikant mit einem Scheitern der Wiedereingliederung. Haufige Veranderungen der Arbeit oder Verlust einer Beschaftigung stellten hohe Risikofaktoren dar. Aufsuchende Betreuung ,vor Ort’ und enge Vernetzung aller beteiligten Hilfesysteme gehorten zu den wesentlichen Arbeitsmethoden forensischer Ambulanzen; in diesem Bereich - auch bei der Fallkoordination – ergaben sich Verbesserungsvalenzen. Ein Ausbau der personellen Ressourcen der forensischen Ambulanzen ist eine notwendige Voraussetzung fur eine Optimierung der ambulanten Versorgung in Nordrhein-Westfalen.

August Gottlieb Richter (1742–1812) zahlt zu den bedeutendsten Chirurgen und medizinischen Schriftstellern der 2. Halfte des 18.Jh.s. In der Publikation werden sein Lebensweg und sein wissenschaftlicher Werdegang in einer Zeit standiger Kriege dargestellt. Diagnose und Therapie der Verletzungen hatten deshalb in seinem Werk einen besonderen Stellenwert. Die unterschiedlichen Aspekte der Brustverletzungen, die er in seinem wissenschaftspraktischen Journal Chirurgische Bibliothek und im 4. Band seines Alterswerks Anfangsgrunde der Wundarzneykunst ausfuhrlich dargestellt hat, werden referiert, bewertet und mit den Arbeiten anderer zeitgenossischer Autoren verglichen. Richters Ansichten zur Tracheotomie finden ebenso Berucksichtigung wie erste Erfahrungsberichte und Kasuistiken aus dem Gebiet der sich entwickelnden Kardiologie. Besonders hervorgehoben wird sein kritischer und selbstkritischer Ansatz, der auf Erfahrung und Reflexion beruht.

Theoretischer Hintergrund In Hamburg ist jahrlich von uber 1000 Straftaten gegen die sexuelle Selbstbestimmung auszugehen; rund ein Drittel der Opfer sind Kinder zwischen 0 und 14 Jahren. In der forensisch-medizinischen Praxis kommt dem Erstkontakt zu geschadigten Kindern eine besondere Bedeutung zu.

August Gottlieb Richter (1742–1812) zahlt sicherlich zu den bedeutendsten Operateuren in der zweiten Halfte des 18. Jahrhunderts. In der Publikation werden sein Lebensweg und sein wissenschaftlicher Werdegang im Spannungsfeld seines von Kriegen und Umbruchen geschuttelten Zeitalters beschrieben. Besondere Berucksichtigung finden seine Leistungen als Arzt, Lehrer und wissenschaftlicher Autor, die sich v. a. in der „Chirurgischen Bibliothek“, einem wissenschafts-praktischen Journal und in seinem Spatwerk „Anfangsgrunde der Wundarzneykunst“ niederschlagen. Dabei werden die urologischen Aspekte seiner Werke in den Mittelpunkt gestellt und mit zeitgenossischen Veroffentlichungen verglichen. Richters kritische Auseinandersetzung mit zeittypisch modischen Stromungen in der Medizin, seine Kultur der Kritik und Selbstkritik werden in besonderer Weise hervorgehoben.

The aim of our study was to determine the development of the number of patients with schizophrenia in detention (section 63 German Penal Code) in North Rhine-Westphalia and the characterization of these patients. Patients with schizophrenia are examined, by using a standardized questionnaire answered by the attending psychiatrist or psychologist (n = 531). During the last 12 years the number of patients with schizophrenia in forensic-psychiatric hospitals has increased three times, whereas the number of patients with other diagnoses heightened only twofold. The patients with schizophrenia showed high rates of psychiatric comorbidities (substance disorders 73.9 %, personality disorders 17.2 %), previous inpatient treatments (78.3 % with a mean of 7.5 stays) and previous convictions (63.4 %). Almost half of these convictions (46.6 %) were violent offences (e. g. assault, homicide). Possible explanations for this development are discussed. Language: de

Background:Focal neurological deficits following cardiopulmonary bypass surgery are usually thought to be the result of embolic stroke. Computed tomography (CT) is sometimes negative although severe deficits persist. Objectives: To describe a syndrome consisting of reduced postoperative vigilance, frequent epileptic seizures and focal neurological deficits in the presence of an apparently normal CT scan and often isolated cortical infarction on magnetic resonance imaging (MRI). Methods: We retrospectively collected data on all patients fulfilling the above-mentioned criteria, seen for neurological examination by the consultant between 2002 and 2006 in our heart center. Results: We found 39 patients, nearly all of whom had cortical hyperintense lesions on diffusion-weighted MRI in the right hemisphere with corresponding left-sided hemiparesis. Early seizures occurred in 31 patients. Clinical outcome was heterogeneous. Conclusions: Predominance of right hemisphere involvement and lesion pattern in MRI make air embolism the most probable cause for this postoperative syndrome.

BACKGROUND: Acute coronary syndrome (ACS) is caused by reduced perfusion of the myocardium and characterized by chest pain. The primary goals of treatment for ACS are to restore blood flow through occluded coronary arteries and prevent recurrent coronary events. Antiplatelet and anticoagulant therapies play a crucial role in the treatment of ACS by interrupting the thrombotic process. OBJECTIVES: To characterize the pathophysiology of ACS and to describe the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI); the use of antiplatelet and anticoagulant therapies for the treatment of STEMI, non-ST-segment elevation myo cardial infarction (NSTEMI), and unstable angina (UA), including patients who undergo percutaneous coronary intervention (PCI); and long-term antiplatelet therapy after an ACS episode. SUMMARY: The preferred reperfusion strategy in patients with STEMI is PCI if it can be performed within 90 minutes after arrival at the hospital. Patients with NSTEMI or UA also may undergo PCI. Thrombolysis is an alternative method of reperfusion for patients with STEMI but not for patients with NSTEMI or UA. Dual antiplatelet therapy with aspirin and the thienopyridine clopidogrel is recommended by the ACC/AHA for 12 months in patients with STEMI, NSTEMI, or UA, including patients with coronary stents. Platelet glycoprotein (GP) IIb/IIIa inhibitors are routinely used during PCI in patients with STEMI and NSTEMI. These agents should be used in addition to aspirin and clopidogrel in patients with NSTEMI and elevated troponin levels who undergo coronary intervention. Unfractionated heparin (UFH) or the low-molecular-weight heparin enoxaparin may be used in patients with STEMI undergoing reperfusion with thrombolytic agents or PCI and patients with NSTEMI or UA. There are substantial data on enoxaparin in the ACS arena, but UFH is preferred for patients who undergo coronary intervention because of greater ease of therapeutic monitoring and reversal of anticoagulant effects if bleeding complications arise. The pentasaccharide fondaparinux may become an alternative to UFH and enoxaparin for patients with STEMI and some patients with NSTEMI or UA. Fondaparinux is preferred for patients with NSTEMI or UA who are at increased risk for bleeding when a conservative approach is chosen, but it is not recom mended for patients when an early invasive approach is chosen because of the risk of catheter-related thrombi. The direct thrombin inhibitor bivalirudin may be used for anticoagulation in patients with NSTEMI who undergo early invasive procedures, and GP IIb/IIIa inhibitor use may be avoided in some patients; however, upstream antiplatelet therapy with clopidogrel is also needed if these patients undergo PCI. Patients undergoing coronary stenting must receive dual antiplatelet therapy. CONCLUSIONS: Antiplatelet and anticoagulant therapies for patients with ACS are complex. Evidence-based guidelines facilitate the therapeutic decision-making process for these therapies in patients with ACS. J Manag Care Pharm. 2008;14(6)(suppl S-a):S4-S13 Copyright © 2008, Academy of Managed Care Pharmacy. All rights reserved. PIOTR SOBIESZCZYK, MD, is Associate Director, Cardiac Catheterization Laboratory, Brigham and Women’s Hospital, Boston. AUTHOR CORRESPONDENCE: Piotr Sobieszczyk, MD, Associate Director, Cardiac Catheterization Laboratory, Brigham and Women’s Hospital, Cardiovascular Division, PBB-113, 75 Francis St., Boston, MA 02115. Tel.: 617.732.8898; Fax: 617.732.7122; E-mail: psobieszczyk@partners.org Author

BACKGROUND: Acute coronary syndrome (ACS) and venous thrombo­ embolism (VTE) are costly conditions, largely due to the high initial cost of treatment, patient nonadherence to prescribed antiplatelet therapy, avoidable rehospitalization in patients with ACS, and high rate of recurrence and long­term complications in patients with VTE. OBJECTIVES: To discuss the economic impact of ACS and VTE; factors that contribute to preventable morbidity, mortality, and costs associated with these conditions; and strategies that managed care pharmacists can use to improve clinician knowledge of evidence­based treatment guidelines and patient adherence to the treatment plan, thereby improving clinical and economic outcomes. SUMMARY: Premature discontinuation of antiplatelet therapy increases the risk of death and rehospitalization in patients with ACS. Factors associated with premature discontinuation include advanced age, lack of education, unmarried status, pre­existing cardiovascular disease, high cost of health care, failure to receive discharge instructions, and lack of referral for cardiac rehabilitation. Managed care plan benefit design should provide for the effective treatment of ACS and VTE by identifying the optimal type and duration of anticoagulant and antiplatelet therapy. In patients with VTE, the use of low­molecular­weight heparin (LMWH) in outpatients is as safe and effective and less costly than standard intravenous unfractionated heparin on an inpatient basis. Long­term LMWH treatment for acute deep vein thrombosis is safe and effective, and it is preferred over warfarin for patients with cancer. Managed care pharmacists can improve the quality of care for patients with ACS and VTE by using a variety of strategies to improve clinician knowledge of evidence­based treatment guidelines and patient adherence to the treatment plan. CONCLUSIONS: Efforts by managed care pharmacists to improve the quality of care for patients with ACS and VTE can improve patient outcomes and reduce health care utilization and costs.

A 42-year-old man who 16 years previously had had mediastinal radiotherapy (total focal dosage of 52 Gy) for a malignant lymphoma, developed chest pain on mild exertion. Coronary arteriography during a diagnostic cardiological work-up revealed a 50-70% stenosis of the right coronary artery near its origin and a 90% stenosis in the main left coronary artery. Except for being slightly over-weight (85 kg at a height of 181 cm) there were no risk factors for coronary heart disease and there was no evidence for arterial disease elsewhere. A double aortocoronary vein graft was placed to the right coronary artery and the interventricular branch of the left coronary artery. The postoperative course was unremarkable and the patient has resumed his occupation. This report emphasizes that, in case of atypical chest pain after mediastinal radiotherapy, coronary heart disease as a late complication should be considered.

The ability of the monoclonal antibody TU-20 and its scFv fragment to specifically bind to the C-end of the class III beta-tubulin makes these preparations useful as potential diagnostics for in vivo determination of neurodegenerative diseases that entail degradation of neuronal cytoskeleton. To examine this hypothesis, TU-20 and its scFv were labelled with 125I and their properties were extensively investigated. TU-20 and its scFv were labelled via chloramine-T with the yield 90–95% and 64–78%, respectively. Their quality control, performed by an ELISA and gel electrophoresis, determined adequate properties for further studies. The in vitro experiment, involving autoradiography and immunohistochemistry of mice’ brain slices, enabled confirmation of preserved immunospecificity of the radiolabelled substances. Finally, the in vivo biodistribution proved differences in elimination of either TU-20, scFv TU-20, or iodide from the mice.

The prediction of dangerousness in mentally disordered offenders is still as well complex as insufficiently empirically proven. So far more or less valid criteria for predicting recidivism have been determined concerning historical and clinical aspects. Whereas biological, neurological and neuropsychological variables that could be of importance for the development of chronic delinquent behavior have mostly been neglected. This article deals with the relevance of neurological soft signs (NSS) for the prediction of dangerousness in mentally ill offenders as one possible factor in a multidimensional model. 155 patients were examined after a minimum time at risk of 2 years (mean 4 years). The results showed that on the one hand there is no relevant and valid connection between neurological soft signs and recidivism for the general heterogeneous group of forensic patients. On the other hand similar results arose for the subgroup of patients with a personality disorder without intellectual deficits as for the homogeneous group of offenders in prisons [7,8]. Therefore a significant meaning of NSS for certain subgroups can be presumed.

Background Pharmacist participation in school medication management (MM) is minimal. School nurses are responsible for increasingly complex medication administration and management in schools. Objectives The purpose of this study was to 1) assess the MM needs of school nurses in Minnesota, and 2) determine if and how interprofessional partnerships between nurses and pharmacists might optimize MM for students. Methods Researchers from the University of Minnesota College of Pharmacy, School Nurse Organization of Minnesota, and Minnesota Department of Health conducted a 32-item online survey of school nurses. Results Nurses administered the majority of medications at their school (69.9%) compared with unlicensed assistive personnel (29%). Stimulants (37.7%), asthma medications (25.7%), over-the-counter analgesics (17.8%), and insulin (6.6%) were the most commonly administered drug therapies. A clear majority of school nurses were interested in partnering with pharmacists: 90.3% thought that a pharmacist could assist with MM, 80% would consult with a pharmacist, and 12.3% reported that they already have informal access to a pharmacist. Topics that nurses would discuss with a pharmacist included new medications (71.6%), drug–drug interactions (67.1%), proper administration (52%), and storage (39.4%). The top MM concerns included 1) availability of students' medications and required documentation, 2) health literacy, 3) pharmacist consultations, 4) lack of time available for nurses to follow up with and evaluate students, 5) family-centered care, 6) delegation, 7) communication, and 8) professional development. Conclusion Although the majority of school nurses surveyed indicated that partnerships with pharmacists would improve school MM, few had a formal relationship. Interprofessional partnerships focused on MM and education are high on the list of services that school nurses would request of a consultant pharmacist. Study results suggest that there are opportunities for pharmacists to collaborate with school nurses; further study is necessary to advance high-quality MM for students in Minnesota schools.