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Non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) offer a promising alternative to psychotherapeutic and pharmacological treatments for depression. This paper aims to present a practical guide for its clinical implementation based on evidence from the literature as well as on the experience of a group of leading German experts in the field.The current evidence base for the use of rTMS in depression was examined via review of the literature. From the evidence and from clinical experience, recommendations for the use of rTMS in clinical practice were derived. All members of the of the German Society for Brain Stimulation in Psychiatry and all members of the sections Clinical Brain Stimulation and Experimental Brain Stimulation of the German Society for Psychiatry, Psychotherapy, Psychosomatics and Mental Health were invited to participate in a poll on whether they consent with the recommendations.Among rTMS experts, a high consensus rate could be identified for clinical practice concerning the setting and the technical parameters of rTMS treatment in depression, indications and contra-indications, the relation of rTMS to other antidepressive treatment modalities and the frequency and management of side effects.

Die chirurgische Therapie der Adipositas in Deutschland ist ein sich rasch entwickelndes Gebiet, welches streng an die Nationalen Leitlinien gebunden ist. Darstellung der Belastung der Adipositaszentren durch den exponentiellen Anstieg postbariatrischer Patienten In einer retrospektiven Studie haben wir deskriptiv die Entwicklung der ambulanten Patientenzahlen an unserem universitaren Adipositaszentrum (gegrundet 2007) untersucht. Die Patientenbesuche wurden jahrlich ausgewertet und in zwei Gruppen eingeteilt: Erstvorstellung und Wiedervorstellung. Die Anzahl der durchgefuhrten bariatrischen Operationen sowie deren Akzeptanz/Kostenubernahme durch die Krankenkassen wurden ebenfalls evaluiert. Im Jahr 2007 wurden insgesamt 318 Patienten gesehen: 156 waren Erstvorstellungen, 162 Wiedervorstellungen. Die Ablehnungsrate der Kostenubernahme durch die Krankenkassen betrug 16,8 %. 2016 gab es 1691 Patientenvorstellungen (2016 vs. 2007 + 532 %), hiervon 487 Erstvorstellungen (+312 %) und 1204 Wiedervorstellungen (+743 %). Die Ablehnungsrate seitens der Krankenkassen fiel auf 1,8 %, wahrend sich die Anzahl der Operationen nahezu verzehnfachte. Mit der steigenden Akzeptanz der bariatrischen Therapie muss sich eine vergleichsweise kleine Zahl an spezialisierten Zentren mit der exponentiell steigenden Nachsorgefrequenz auseinandersetzen. In Anbetracht des Ausmases der Adipositasepidemie stellt insbesondere eine adaquate Nachsorge ein soziookonomisches Problem dar, welches nur im interdisziplinaren Setting unter struktureller Integration in das komplexe Gesundheitssystem gelost werden kann.

Die repetitive transkranielle Magnetstimulation (rTMS) eroffnet neue therapeutische Optionen bei neuropsychiatrischen Erkrankungen. Die Anwendung der rTMS bei Depressionen ist bisher in Studien am besten untersucht worden. In Deutschland wird die rTMS auserhalb klinischer Studien nicht nur bei Depressionen bereits immer haufiger angewendet. Unsere bundesweite Umfrage an psychiatrischen Kliniken diente der Erfassung eines aktuellen Standes der Anwendung der rTMS im klinischen Alltag und soll als Grundlage fur die Entwicklung von Qualitatsstandards dienen.

Nodal status is a strong prognostic factor after resection of pancreatic cancer. The lymph node ratio (LNR) has been shown to be superior to the pN status in several studies. The role of log odds of the ratio between positive and negative nodes (LODDS) as a suggested new indicator of prognosis, however, has been hardly evaluated in pancreatic cancer. Prognostic factors for overall survival after resection for cancer of the pancreatic head were evaluated in 409 patients from two institutions (prospectively maintained databases). The lymph node status, LNR, and LODDS were separately analyzed and independently compared in multivariate survival analysis. The median numbers of examined and positive lymph nodes were 16 and 2, respectively. Actuarial 3- and 5-year survival rates were 29 and 16 %. All three classifications of nodal disease significantly predicted survival in the entire group (n = 409), in patients with free resection margins (n = 297), and in patients with

Pancreatic ductal adenocarcinoma (PDAC) is a disease with a poor prognosis. PDAC shows characteristic mutations within codon 12/13. Circulating tumor cells (CTC) detected in blood samples of patients with cancer are hypothesized as the means of systemic tumor spread. But less is known about morphological/molecular characteristics or the pathophysiological meaning of PDAC CTC.The aim of the study was a cytomorphological and genetic analysis of CTC from patients with PDAC followed by the correlation of the results with those of the corresponding tumor in the pancreas.Blood samples of 58 patients with PDAC and 10 "normal" control donors were processed through a size-based CTC isolation. KRAS-mutation analyses were performed for CTC and the primary tumor and the results were compared. Furthermore, their potential as a prognostic marker was evaluated.In patients with different UICC stages CTC were detected, but not in normal control patients. There was a trend for a worse median overall survival (OS) for patients with3 CTC/ml. Patients with a KRASDetection and characterization of CTC (for example by KRAS mutation analysis) may be useful for prognosis. Furthermore, it expands our knowledge of tumor biology and may detect possible tumor heterogeneity regarding the mutation profile of some cancer types.

Background Intestinal anastomotic insufficiency (AI) is a common problem in visceral surgery associated with overexpression of matrix metalloproteinases (MMPs). In some patients it occurs more than once. The etiology of recurring anastomotic insufficiency (RAI) is not understood yet and should be addressed as an independent disease entity. Materials and methods Thirty nine consecutive patients with AI were treated at our university center and were included in this prospective study. Clinical data were evaluated by correlative statistical analysis to identify independent risk factors for RAI. Patients were divided in two groups: 18 patients had a single operative revision until restoration (group SAI), and 21 patients had two or more revisions (group RAI). Anastomotic tissue samples as well as untouched bowel wall were collected during reoperations for analysis of MMPs and tissue inhibitor of metalloproteinases (TIMP2). Clinical data were correlated with pathological observations. Results Significant differences of clinical and molecular pathological data were found between the two groups. Transfusion of red blood cells until the first reoperation and alcohol abuse led to RAI and were the only independent risk factors for RAI in multivariate analysis. Overexpression of MMP-8, -9, and -13 in anastomotic tissue correlated with the administration of red blood cells during initial operation. Reduced expression of TIMP2 was frequent in nearly all patients without differences throughout the subgroups. Conclusions RAI seems to have an independent disease pattern. Transfusion of blood products is not only a known risk factor for AI but seems to significantly disturb the anastomotic healing process leading to RAI.

The surgical treatment of obesity in Germany is a rapidly developing field which is strictly controlled by national guidelines.Depiction of the burden on obesity centers by the exponential increase in numbers of patients following bariatric treatment.In a retrospective study the numbers of outpatients at this university obesity center (founded 2007) were descriptively analyzed. Outpatient visits were documented annually and divided into two groups: primary visit and follow-up visit. The frequency of bariatric operations as well as their acceptance/cost coverage by health insurances were evaluated.Overall 318 patients were seen in 2007: 156 primary and 162 follow-up visits. The health insurance rejection rate for cost coverage was 16.8%. There were 1691 outpatient visits in 2016 (2016 vs. 2007: +532%), of which 487 (+312%) were primary and 1204 (+743%) follow-up visits. The health insurance rejection rate dropped to 1.8%, while the frequency of operations increased nearly tenfold.With the increasing acceptance of bariatric surgery, a relatively low number of specialized centers have to deal with an exponentially rising follow-up frequency. In consideration of the extent of the obesity epidemic an adequate follow-up constitutes a socioeconomic problem, which can only be solved in an interdisciplinary setting under structural integration.

Bariatrische Operationen werden in Deutschland immer haufiger durchgefuhrt. Primareingriffe werden meist in spezialisierten Zentren durchgefuhrt. Es gibt jedoch spate Komplikationen, die Monate bis Jahre nach der Operation auftreten und mit denen jeder Allgemein- und Viszeralchirurg, unabhangig von der Grose und Spezialisierung seiner Klinik, konfrontiert werden kann. Der laparoskopische Roux-Y-Magenbypass ist weltweit die am haufigsten durchgefuhrte bariatrische Operation. Durch das antekolische Hochfuhren der alimentaren Schlinge zum Pouch entsteht dorsal der alimentaren Schlinge und unterhalb des Kolon transversum eine Mesenteriallucke, auch Petersen-Lucke genannt. Sowohl hier als auch im Bereich der Mesenteriallucke der Roux-Anastomose kann es zu einer inneren Hernie kommen, d. h. der Dunndarm kann sich hier um die eigene Achse drehen. Abdominelle Beschwerden durch Darmobstruktion sind unspezifisch, aber sehr ausgepragt. Patienten prasentieren klinisch entweder ein akutes Abdomen oder intermittierende abdominelle, unspezifische Schmerzen mit Ubelkeit und selten auch Erbrechen. Meistens zeigen die klinischen und die laborchemischen Untersuchungen keinen wegweisenden Befund. Im Zweifel bildet daher die kontrastmittelverstarkte Computertomografie des Abdomens die bildgebende Diagnostik der Wahl. Eine diagnostische Laparoskopie sollte bei jedem Patienten mit klinischem Verdacht auf eine innere Hernie auch bei unauffalligem CT erfolgen. Die diagnostische Laparoskopie sollte durch einen laparoskopisch versierten Operateur mit Erfahrung in der bariatrischen Chirurgie durchgefuhrt werden, da ohne genaue Kenntnis der Bruchpforten die Zuordnung der Darmschlingen sehr schwierig ist. Der primare Blick geht nach inframesokolisch unter Hochheben des Kolon transversum. Von hier aus bietet sich bei offener Petersen-Lucke die direkte Sicht von rechts auf das Treitz-Band. Falls man rechts davon Dunndarm vorfindet, besteht eine Petersen-Hernie. Nach dem inframesokolischen Blick sollte man die Gastroenterostomie aufsuchen und sich entlang der alimentaren Schlinge nach distal in Richtung Jejunojejunostomie vorarbeiten. Dort findet man die 2. mogliche Lucke. Nachdem beide Lucken aufgefunden und ggf. eine Hernie reponiert werden konnte, sollten die Lucken mit einer nicht resorbierbaren Naht verschlossen werden.

Background: Advances regarding perioperative mortality rates and oncological outcomes after esophagectomy have been reported extensively by specialized high-volume centers in Europe and the USA over the last decade. However, recent database analyses reveal that the perioperative mortality of esophagectomy remains high in these countries, indicating a discrepancy between surgical quality in baseline hospitals and specialized centers. Methods: This article provides an overview over the existing literature on the correlation between structural quality, procedural volume, and surgical outcome in e- sophageal surgery. Results: Structural, procedural and outcome measures can be used to assess the quality of surgical treatment and perioperative management. Surgical procedures on the esophagus for both benign and malignant diseases are rare and typically associated with high perioperative morbidity and mortality. Usually, direct outcome measures do not provide enough statistical power to actually identify differences in surgical quality between hospitals, making structural quality measures the only feasible parameter to compare the quality of e- sophageal surgery among different centers. Several analyses from different countries have shown a strong correlation between hospital volume and postoperative mortality. Data from countries in which esophageal surgery has been centralized indicate beneficial effects of a centralized health care system on postoperative mortality after esophagectomy. Additionally, only high-volume centers generally provide optimal preoperative and postoperative management and comprehensive access to modern multimodal treatment. In Germany, esophageal surgery is still decentralized, but hospitals performing complex esophageal procedures have to fulfill minimum caseload requirements of 10 cases per year. In practice, these requirements are not met by the majority of hospitals and a detrimental effect on the achieved surgical outcomes can be noted. Conclusion: Therefore, we conclude that structural quality assurance is crucial to further reduce postoperative morbidity after esophageal surgery and to improve long-term results.

Clinical data indicate that laparoscopic surgery has a beneficial effect on intestinal wound healing and is associated with a lower incidence of anastomotic leakage. This observation is based on weak evidence, and little is known about the impact of intraoperative parameters during laparoscopic surgery, e.g., temperature and humidity.A small-bowel anastomosis was formed in rats inside an incubator, in an environment of stable humidity and temperature. Three groups of ten Wistar rats were operated: a control group (G1) in an open surgical environment and two groups (G2 and G3) in the incubator at a humidity of 60 % and a temperature of 30 and 37 °C (G2 and G3, respectively). After 4 days, bursting pressure and hydroxyproline concentration of the anastomosis were analyzed. The tissue was histologically examined. Serum levels of C-reactive-protein (CRP) were measured.No significant changes were seen in the evaluation of anastomotic stability. Bursting pressure was very similar among the groups. Hydroxyproline concentration in G3 (36.3 μg/g) was lower by trend (p = 0.072) than in G1 (51.7 μg/g) and G2 (46.4 μg/g). The histological evaluation showed similar results regarding necrosis, inflammatory cells, edema, and epithelization for all groups. G3 (2.56) showed a distinctly worse score for submucosal bridging (p = 0.061) than G1 (1.68). A highly significant increase (p = 0.008) in CRP was detected in G3 (598.96 ng/ml) compared to G1 (439.49 ng/ml) and G2 (460 ng/ml).A combination of high temperature and humidity during surgery induces an increased systemic inflammatory response and seems to be attenuating the early regeneration process in the anastomotic tissue.

The repetitive transcranial magnetic stimulation (TMS) opens new therapeutic options in neuropsychiatric disorders. The use of rTMS in depressive disorders has been most preferably investigated in clinical trials. In Germany, the application of rTMS outside of clinical trials is already increasingly common, not only for depression. Our nationwide survey in psychiatric hospitals was used to detect the current state of the application of rTMS in clinical practice, and should serve as a basis for the development of quality standards.

Einleitung: Das Pankreaskarzinom (PDAC) ist eine der todlichsten Krebserkrankungen uberhaupt. Sowohl fruh-diagnostische als auch therapeutische Verfahren fehlen. Beim Mammakarzinom werden zirkulierende Tumorzellen (CTCs) bereits erfolgreich zur erweiterten Diagnostik und als prognostische Marker eingesetzt. Beim PDAC ist die Bedeutung von CTCs bisher unklar. Ziel: Die Isolation und genetische Charakterisierung von CTCs bei Patienten mit PDAC sowie deren Evaluation als prognostischer Marker. Methodik: Blutproben von Patienten mit PDAC wurden vor Therapie auf das Vorhandensein von CTCs untersucht. Hierfur wurde die „isolation by size of epithelial cells“ (ISET) Methode eingesetzt. Parallel wurden Filter fur die zytologische und genetische Untersuchung verwendet. Das Zell-Lysat wurde mittels wild-typ KRAS PNA-Clamping PCR auf KRAS Mutationen untersucht und sequenziert. Die Ergebnisse wurden mit demografischen und klinischen Daten sowie dem Uberleben korreliert. Ergebnis: Bei 56 Patienten mit PDAC wurden Blutproben auf CTCs untersucht.10 Proben (17.9%) hatten weder eine KRAS Mutation noch ein positives zytologisches Ergebnis und waren CTC negativ, 46 Proben (82,1%) waren CTC positiv. Diese Proben hatten entweder maligne Zellen in der Zytologie (n = 9), oder eine KRAS Mutation (n = 21) in den CTCs oder beides (n = 16). CTCs wurden bei Patienten der UICC Stadien IIA-IV gefunden, nicht jedoch bei IA oder IB Tumoren. Sie waren nachweisbar sowohl bei lokalisiertem Tumor als auch bei Vorliegen von Metastasen. Das pure Vorhandensein von CTCs war dabei nicht signifikant mit dem medianen Uberleben korreliert (CTC negativ 9 vs. CTC positiv 10,5 Monate; p = 0,92). In den CTCs fanden sich verschiedene Typen von KRAS Mutationen. Patienten mit der Variante KRAS G12V (n = 14) zeigten ein besseres medianes Uberleben (24,5 Monate), als Patienten mit KRAS wild typ oder ohne detektierte CTC (n = 19; 8 Monate) oder andere KRAS Mutationen (n = 23; 10 Monate). Dies war jedoch nicht signifikant (p = 0,43). Fazit: CTCs konnen zuverlassig bei vielen Stadien des PDAC gefunden werden. Ihre klinische Bedeutung bleibt jedoch unklar – potenziell sind Subtypen der CTC oder bestimmte genetische Mutationen mit besserem Uberleben assoziiert. Weitere Studien – auch von Oberflachenmarkern – sind notwendig.

The frequency of bariatric operations has increased in Germany. Primary operations are usually performed at specialised centres. However, late complications may develop months or even years after the operation, and every general and visceral surgeon may be confronted with them, regardless of the size and specialisation of their clinics. The laparoscopic Roux-Y gastric bypass is the most frequently performed bariatric operation worldwide. During this procedure, the alimentary loop is lifted up in front of the colon to form a pouch, which creates a mesenteric space, also called the Petersen space, dorsal to the alimentary loop and below the transverse colon. Both here and around the mesenteric space of the Roux anastomosis, an internal hernia may develop, i.e. the small intestine can twist on its own axis. Abdominal discomfort due to intestinal obstruction is unspecific, but very pronounced. Clinically, patients either present with an acute abdomen or with intermittent unspecific abdominal pain with nausea, and rarely also with vomiting. Clinical examinations and lab chemistry tests usually do not reveal any indicative findings. In cases of doubt, therefore, contrast-enhanced computed tomography of the abdomen is the diagnostic imaging procedure of choice. A diagnostic laparoscopy should be performed in every patient with a clinical suspicion of an internal hernia, even if the CT scan is unremarkable. This should be done by a surgeon who is well-versed in laparoscopy and experienced in bariatric surgery, since classification of the intestinal loops is very difficult without knowledge of the hernial orifices. First, an inframesocolic view is obtained with the transverse colon being lifted. From here, the open Petersen space offers a direct view of the ligament of Treitz from the right side. If small intestine is found to the right of the ligament, there is a Petersen hernia. After the inframesocolic view, the gastroenterostomy should be located and the alimentary loop should be followed in distal direction towards the jejunojejunostomy, where the second possible space may be found. Once both spaces have been located and a hernia has been reduced as appropriate, the spaces should be closed with non-absorbable suture.

Das Magenkarzinom des alteren Patienten stellt eine Entitat mit vielen Ubereinstimmungen, aber auch mit Unterschieden im Vergleich zum Magenkarzinom des jungeren und mittelalten Patienten dar. Die onkologische totale oder subtotale Gastrektomie inklusive radikaler Lymphadenektomie ist heutzutage in der Regel flankiert von den perioperativen chemotherapeutischen Therapieprotokollen. Sie stellt die einzige kurative Therapieoption dar, obwohl die Therapie bei alteren Patienten insgesamt mit erhohten Raten postoperativer Morbiditat und Mortalitat behaftet ist. Vor dem Hintergrund der aktuellen Datenlage ist nichtsdestoweniger anzunehmen, dass auch alte Patienten mit Magenkarzinom ganz eindeutig in ihrer Lebensqualitat und Lebenserwartung von der kurativen Therapie profitieren.

BackgroundPostoperative pancreatic fistula (POPF) is regarded as the most serious complication of pancreatic surgery. The preoperative risk stratification of patients by simple means is of interest in perioperative clinical management.MethodsBased on prospective data, we performed a risk factor analysis for POPF after pancreatoduodenectomy in 62 patients operated between 2006 and 2008 with special focus on clinical parameters that might serve to predict POPF. A predictive score was developed and validated in an independent second dataset of 279 patients operated between 2001 and 2010.ResultsSeveral pre- and intraoperative factors, as well as underlying pathology, showed significant univariate correlation with rate of POPF. Multivariate analysis (binary logistic regression) disclosed soft pancreatic texture (odds ratio [OR] 10.80, 95% confidence interval [CI] 1.80–62.20) and history of weight loss (OR 0.15, 95% CI 0.04–0.66) to be the only independent preoperative clinical factors influencing POPF rate. The subjective assessment of pancreatic hardness by the surgeon correlated highly with objective assessment of pancreatic fibrosis by the pathologist (r=−0.68, P

Delusional parasitosis can occur as an isolated delusional syndrome, or it may be associated with an underlying psychiatric disorder or physical illness. The benefit of treatment with antipsychotics in the treatment of delusional parasitosis is well known. Because of their efficacy and side effects profile, atypical neuroleptics have been suggested as potential alternatives to classical neuroleptics. In the case presented, the positive experiences with the novel neuroleptic aripiprazole are described.

Tumor cell metaphases of classical Hodgkin's lymphoma (cHL) characteristically display highly rearranged karyotypes with chromosome numbers in the hyperploid range and marked intraclonal variability. The causes of this cytogenetic pattern remain largely unknown. An unusual type of chromosomal abnormality coined as segmental chromosomal aberration (SCA) has been recurrently observed in HL cell lines and was suggested to be associated with ribosomal DNA (rDNA) rearrangements. Moreover, centrosome abnormalities provoking deficient chromosome segregation have been reported in many solid tumors and also in cHL cell lines. Whether SCA, rDNA rearrangements or centrosome abnormalities also occur in primary cHL is not yet known. Thus, we performed extensive molecular cytogenetic and immunohistological studies in two cHL cases. Both cases presented SCA associated with genomic gains of the REL and JAK2 loci, respectively. The SCA involving JAK2 was associated with rDNA rearrangements. The absolute centrosome size of HRS cells in both cases was significantly larger than in non-HRS cells, but the relative centrosome size of HRS cells corrected for nuclear size was in the same range as that of the non-neoplastic cells. These findings demonstrate that the various mechanisms associated with chromosomal instability warrant a more detailed characterization in cHL.

The aim of the article is to investigate a new anastomotic technique compared with standardized intestinal anastomotic procedures.A total of 32 male Wistar rats were randomized to three groups. In the Experimental Group (n = 10), the new double 90 degrees inversely rotated anastomosis was used, in the End Group (n = 10) a single-layer end-to-end anastomosis, and in the Side Group (n = 12) a single-layer side-to-side anastomosis. All anastomoses were done using interrupted sutures. On postoperative day 4, rats were relaparotomized. Bursting pressure, hydroxyproline concentration, a semiquantitative adhesion score and two histological anastomotic healing scores (mucosal healing according to Chiu and overall anastomotic healing according to Verhofstad) were collected. Most data are presented as median (range). p0.05 was considered significant.Anastomotic insufficiency occurred only in one rat of the Side Group. Median bursting pressure in the Experimental Group was 105 mm Hg (range = 72-161 mm Hg), significantly higher in the End Group (164 mm Hg; range = 99-210 mm Hg; p = 0.021) and lower in the Side Group by trend (81 mm Hg; range = 59-122 mm Hg; p = 0.093). Hydroxyproline concentration did not differ significantly in between the groups. The adhesion score was 2.5 (range = 1-3) in the Experimental Group, 2 (range = 1-2) in the End Group, but there were significantly more adhesions in the Side Group (range = 3-4); p = 0.020 versus Experimental Group, p0.001 versus End Group. The Chiu Score showed the worst mucosal healing in the Experimental Group. The overall Verhofstad Score was significantly worse (mean = 2.032; standard deviation [SD] = 0.842) p = 0.031 and p = 0.002 in the Experimental Group, compared with the Side Group (mean = 1.729; SD = 0.682) and the End Group (mean = 1.571; SD = 0.612).The new anastomotic technique is feasible and did not show any relevant complication. Even though it was superior to the side-to-side anastomosis by trend with respect to functional stability, mucosal healing surprisingly showed the worst results. Classical end-to-end anastomosis still seems to be the best choice regarding structural and functional anastomotic stability.

Purpose: This investigation focuses on the physiological characteristics of gene transcription of intestinal tissue following anastomosis formation. Methods: In eight rats, end-to-end ileo-ileal anastomoses were performed (n = 2/group). The healthy intestinal tissue resected for this operation was used as a control. On days 0, 2, 4 and 8, 10-mm perianastomotic segments were resected. Control and perianastomotic segments were examined with an Affymetrix microarray chip to assess changes in gene regulation. Microarray findings were validated using real-time PCR for selected genes. In addition to screening global gene expression, we identified genes intensely regulated during healing and also subjected our data sets to an overrepresentation analysis using the Gene Ontology (GO) and Kyoto Encyclopedia for Genes and Genomes (KEGG). Results: Compared to the control group, we observed that the number of differentially regulated genes peaked on day 2 with a total of 2,238 genes, decreasing by day 4 to 1,687 genes and to 1,407 genes by day 8. PCR validation for matrix metalloproteinases-3 and -13 showed not only identical transcription patterns but also analogous regulation intensity. When setting the cutoff of upregulation at 10-fold to identify genes likely to be relevant, the total gene count was significantly lower with 55, 45 and 37 genes on days 2, 4 and 8, respectively. A total of 947 GO subcategories were significantly overrepresented during anastomotic healing. Furthermore, 23 overrepresented KEGG pathways were identified. Conclusion: This study is the first of its kind that focuses explicitly on gene transcription during intestinal anastomotic healing under standardized conditions. Our work sets a foundation for further studies toward a more profound understanding of the physiology of anastomotic healing.

Einleitung: Nur ein Teil aller alkoholabhangigen Patienten wird leitliniengerecht behandelt. In der Behandlung stellen chronische Verlaufe und haufige Rezidive oft hohe Anforderungen an die Beteiligten des Versorgungssystems. Eine Ausweitung vorhandener Angebote ist allein aus okonomischen Grunden kein Ausweg. Kostengunstige flexible ambulante telemedizinische Therapiesysteme konnten eine Alternative darstellen. Methode: Wir fuhren seit Mai 2012 eine DFG-geforderte multizentrische, kontrollierte, randomisierte Studie zur Wirksamkeit eines interaktiven SMS-basierten Kommunikationssystems zur Trinkmengenverminderung nach Alkoholentgiftung durch (www.controlled-trials.com/ISRCTN78350716). In 4 Studienzentren in Mecklenburg-Vorpommern (Rostock, Greifswald, Schwerin, Stralsund) sollen bis November 2013 insgesamt 462 Probanden eingeschlossen werden. Die Probenden erhalten uber 12 Monate automatische SMS mit einer Frage zum aktuellen Hilfebedarf. Bei Alkoholruckfallen oder signalisierten Notlagen erfolgt eine kurze bedarfs- und losungsorientierte telefonische Intervention. Alkoholkonsum und Psychopathologie werden in Katamnesen nach 3, 6, 9 und 12 Monaten erfasst. Diskussion/Ergebnisse: Eine vorgeschaltete Pilotstudie lieferte Hinweise fur Machbarkeit, Effizienz und Effektivitat. Bei Patienten mit Konsummengen im Dosisbereich vergleichbarer Therapiestudien zeigte sich, dass die SMS-Intervention innerhalb von 8 Wochen zu einer Erhohung des Anteils von Probanden mit “low-risk”-Konsum (WHO) fuhrte (Risk Difference: 0,27, 95% CI: -0,02 – 0,51; χ2= 4.893, p = 0,087; NNT = 3,7). Schlussfolgerung: In unserem Beitrag diskutieren wir Fragen des Studiendesigns und bisherige Erfahrungen in Hinblick auf eine mogliche Umsetzung des Projekts in die Regelversorgung. Hier beleuchten wir insbesondere okonomische Aspekte und die Auswirkungen verschiedener Anreize auf die beteiligten Mitspieler bei der Behandlung der Alkoholabhangigkeit.

Tumoren der kleinen SpeicheldrUsen des Gaumens gehOren zu den seltenen Erkrankungen im HNO-Bereich. An den UniversitAts-HNO-Kliniken Homburg/Saar und Rudolf Virchow, Berlin, wurden in den letzten 6 Jahren 13 Patienten mit einem Tumor des Gaumens behandelt. Bei 10 Patienten ging der Tumor von den kleinen SpeicheldrUsen aus (5 pleomorphe Adenome, 2 adenoidzystische Karzinome, 2 Adenokarzinome, 1 solides Adenom, das 8 Jahre spAter zu einem Adenokarzinom rezidivierte). Bei 3 Patienten lag ein Gaumentumor anderen Ursprungs vor (2 Non-Hodgkin-Lymphome, 1 Neurilemmom des weichen Gaumens). Aufgrund der Symptomatik und des klinischen Befundes kOnnen Tumoren der kleinen SpeicheldrUsen von VorwOlbungen des Gaumens anderer Ursache im allgemeinen nicht unterschieden werden, so dass eine unklare Schwellung des Gaumens nicht voreilig inzidiert werden sollte. Dies gilt besonders fUr VorwOlbungen im Bereich des weichen Gaumens, wenn differentialdiagnostisch auch ein Tumor im Innenlappen der Glandula parotis vorliegen kann. Die Computertomographie stellt hier ein wichtiges diagnostisches Verfahren dar, besonders aber die Kernspintomographie, um Weichteilprozesse voneinander zu unterscheiden. Auf Diagnostik und Differentialdiagnosen von Gaumentumoren wird eingehend eingegangen.

Background. Anastomotic insufficiency still remains an unsolved problem in digestive surgery. Little clinical data regarding the impact of perioperative volume management show less complications in intestinal surgery for restrictive volume regimes. The aim of our study was to examine the effect of the extent of the intraoperative volume substitution with cristalloids on the stability of intestinal anastomoses. Material and methods. 21 rats were randomly assigned to three groups (n = 7 rats/group): control group Co (9 ml/h*kgbw cristalloid infusion Iono Steril®), volume restriction group V (−) (3 ml/h*kgbw) and the group with volume overcharge V (+) (36 ml/h*kgbw). After midline incision all animals received the corresponding infusion for a 30 minutes period. The infusion was continued for further 30 minutes while performing the anastomosis. An end-to-end small bowel anastomosis 15 cm proximal to the Bauhin valve was performed with 8 interrupted inverting sutures (Ethilon® 8/0). At reoperation on 4th postoperative day the anastomotic segment was prepared and measurement of the bursting pressure [mmHg] was performed. As second parameter for the quality of the anastomotic healing hydroxyproline concentration was determined with a spectrophotometric method [µg/g dry tissue]. Data are given as mean ± SEM. P < 0.05. Results. An anastomotic insufficiency was not found in the groups. The bursting pressure of Co group was 102 ± 8 mmHg. In V (+) with high volume exposure bursting pressure was lowest with 77 ± 6 mmHg and significantly lower compared to V (−) (112 ± 9 mmHg; p = 0.01) while the difference compared to the control group did not reach significant values. Hydroxyproline concentration in V (+) was significantly lower compared to V (−) animals (p < 0.05). Conclusion. On the basis of our experimental data, we are the first to prove that the amount of the intraoperatively applied cristalloids has a significant impact on functional (bursting pressure) and structural (hydroxyproline) stability of intestinal anastomoses on 4th postoperative day. Since the stability and quality of an intestinal anastomosis have an impact on the insufficiency rate, this — at least in an animal model — seems to be significantly affectable by a restrictive volume management.

Delusional parasitosis can occur as an isolated delusional syndrome, or it may be associated with an underlying psychiatric disorder or physical illness. The benefit of treatment with antipsychotics in the treatment of delusional parasitosis is well known. Because of their efficacy and side effects profile, atypical neuroleptics have been suggested as potential alternatives to classical neuroleptics. In the case presented, the positive experiences with the novel neuroleptic aripiprazole are described.

In der ersten Halfte des 20. Jahrhunderts war die psychiatrische Grundlagenforschung stark neuroanatomisch und neuropathologisch orientiert. Methoden zur nichtinvasiven Darstellung des Gehirns am lebenden Menschen fehlten damals ganzlich. Mit der Einfuhrung neuerer Untersuchungsmethoden wie CT (erstes nichtinvasives Verfahren, was die morphologische Darstellung des Gehirns erlaubte), MRT, fMRT, SPECT und PET kam es zu einem Aufschwung neuromorphologischer Untersuchungen bei psychiatrischen Patienten.

Das maligne neuroleptische Syndrom (MNS) als gefurchtete Komplikation einer Therapie mit Neuroleptika ist in seinem Pathomechanismus weiterhin unverstanden. Die Auspragung des Vollbildes mit Hyperthermie, Hyperhidrosis, Verwirrtheit, Rigiditat, autonomer Dysregulation sowie gesteigerter Kreatininkinase zeigt eine Inzidenz zwischen 0,02 und 2,4%. Milde subsyndromale Verlaufsformen sollen in der Inzidenz um 12% liegen [3]. Oft ist die differenzialdiagnostische Unterscheidung von MNS und febriler Katatonie schwierig. Die perniziose oder febrile Katatonie gilt als Sonderform der katatonen Schizophrenie. Aufgrund erheblicher Uberschneidungen in der Symptomatik (Hyperthermie, Bewusstseinsstorungen, Stupor und autonome Dysregulationen bei beiden Syndromen) spricht man auch vom „katatonen Dilemma“. Diagnostische Unterschiede lassen sich, wenn uberhaupt, am Anfang der Symptomatik herausarbeiten. So beginnt die perniziose Katatonie mit typischen schizophrenen Symptomen. Ein MNS entwickelt sich dagegen meist innerhalb von 1–2 Wochen nach Beginn der Neuroleptikatherapie, wenn die psychotische Symptomatik haufig bereits abgeschwacht ist. Bei der perniziosen Katatonie findet sich typischerweise eine ausgepragte extrapyramidale Symptomatik mit Rigor, Akinese, aber auch Dys- und Hyperkinesen sowie Stupor [1,2,4].

In order to assess the functional integrity of motor pathways through the corpus callosum (CC) in patients with schizophrenia transcallosally mediated inhibition (TI) of voluntary tonic EMG activity of first dorsal interosseus muscle following ipsilateral focal transcranial magnetic stimulation (fTMS) was investigated. In addition thickness and length of CC were calculated.Twelve patients suffering from schizophrenia and 12 healthy controls were investigated. CC morphology was measured in mid-sagittal MRI-slices. Latency and duration of TI were calculated.In schizophrenics the duration of TI was significantly prolonged, whereas latencies were not. In addition, a lack of TI was found unilaterally in three patients. Measurements of CC revealed a significantly reduction of the length and thickness in the anterior part of CC in patients.These findings indicate that measurement of TI could be used to detect clinical silent affection of transcallosal motor pathways in schizophrenics. The effect of neuroleptic drugs has to be explored.