[Memorandum on sustainable reinforcement of prevention and health promotion: challenges at the federal, state and local level]. / Memorandum--Prävention und Gesundheitsförderung nachhaltig stärken: Herausforderungen auf Bundes-, Landes- und kommunaler Ebene.

Research-based evidence and practice-based experience are core requirements for the effective implementation of preventive interventions. The knowledge gained in the Prevention Research Funding Initiative of the German Federal Ministry of Education and Research (2004-2013) was therefore amalgamated, reflected and consolidated in the Cooperation for Sustainable Prevention Research (KNP) meta-project. In annual strategy meetings, researchers and practitioners from the field and other experts developed 3 memoranda providing recommendations for the further development of research and practice in the field of prevention and health promotion. Memorandum III is primarily aimed at decision-makers in politics and administration at the federal, state and local level, in civil society and in the workplace. Its recommendations show that structuring efforts are urgently needed to achieve sustainable policy, particularly in the fields of health, education, employment and social affairs. Memorandum III brings together the knowledge extracted and problems identified in research projects. More so than its 2 predecessors, Memorandum III abstracts knowledge from the individual projects and attempts to derive guidance for action and decision-making, as shown by the 7 recommendations that appear to useful for consensus-building in practice and research. Value judgments are inevitable. Prevention and health promotion are an investment in the future: of social health, social capital and social peace. Improvement of the framework conditions is needed to achieve the harmonized awareness and the sustained effectiveness of these structure-building efforts in different policy areas, spheres of life, fields of action, and groups of actors. This includes the implementation of an overall national strategy as well as the expansion of sources of funding, extension of the legal framework, overarching coordination, and the establishment of a National Center of Excellence to develop and safeguard prevention and health promotion. The memorandum is intended to stimulate a discourse resulting in structure-building and stabilizing measures designed to ensure the sustainability of prevention and health promotion.

[Deep brain stimulation for addiction, anorexia and compulsion. Rationale, clinical results and ethical implications]. / Tiefe Hirnstimulation bei Sucht, Anorexie und Zwang. Rationale, klinische Ergebnisse und ethische Implikationen.

BACKGROUND: As an established treatment for movement disorders, the application of deep brain stimulation (DBS) for psychiatric indications has been investigated for almost 15 years. A CE label (also FDA approval) has recently been obtained for treatment of refractory obsessive-compulsive disorder (OCD). OBJECTIVES: This article aims at illustrating the current state of DBS in the treatment of refractory OCD. In addition, initial experimental approaches to investigate the potential use of DBS in substance addiction and anorexia nervosa (AN) will also be outlined as both disorders share some common features with OCD. MATERIALS AND METHODS: The present review is based on a keyword literature search (PubMed) while taking into account relevant references and own investigations RESULTS: Although the number of clinical trials for treatment of refractory OCD is limited and sample sizes are small, there is some evidence for a substantial improvement, a so-called full response of OCD symptoms under DBS. However, not all patients benefit from the intervention. Regarding substance addiction and AN, data are scarce and are only indicative of a potential benefit at most. DISCUSSION: Present data regarding the clinical benefits of DBS in OCD are encouraging and open up new avenues for the treatment of therapy refractory patients. However, several aspects, such as mechanisms of action, predictors and long-term side effect profiles, are incomplete or even unknown. In the case of addiction and AN, DBS remains purely experimental, at least for the moment. Hence, clinical trials should remain the gold standard for all three indications.

[Interventional treatment of the acute and subacute vena cava superior syndrome]. / Interventionelle Behandlung des akuten und subakuten Vena-cava-superior-Syndroms.

BACKGROUND: Superior vena cava syndrome is defined as the lack of central venous inflow through the superior vena cava and can present a life-threatening situation. The acute situation is characterized by dyspnea and requires a fast and effective treatment. METHODS: Using two case reports, endovascular stent therapy for the treatment of acute and subacute superior vena cava syndrome is explained and discussed. RESULTS: In the first case, we introduce a patient with acute dyspnea due to decompensation of a chronic thrombosis of the superior vena cava. The second case displayed the same acute symptoms consisting of acute dyspnea and upper venous congestion due to a tumor-related compression of the superior vena cava. In both cases, the acute situation of superior vena cava syndrome was successfully treated by stent implantation. CONCLUSION: Endovascular treatment of superior vena cava syndrome is an effective option with a high technical success rate.

Pharmacological treatment of deep brain stimulation-induced hypomania leads to clinical remission while preserving motor benefits.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective treatment for Parkinson's disease, but can lead to adverse effects including psychiatric disturbance. Little is known about the risk factors and treatment options for such effects. Here, we describe a patient who reproducibly developed stimulation-induced hypomania when using ventrally located electrodes and responded well to pharmacological intervention while leaving the stimulation parameters unchanged to preserve motor benefits. In spite of clinical remission, [¹5O]-positron-emission-tomography (PET) demonstrated activation patterns similar to those reported during mania. This case, therefore, highlights an important treatment option of adverse effects of DBS, but also points toward the need for investigations of its risk factors and their underlying neurobiological mechanisms.

[Promoting instead of controlling health--lessons learned, lessons to learn]. / Gesundheit fördern statt kontrollieren - lessons learned, lessons to learn.

Health promotion, as laid down in the Ottawa Charta by the World Health Organisation, embraces the call for self-responsibility. Self-responsibility, however, is not merely directed towards apparently personal risk factors. The Ottawa Charta clearly puts health in a wider societal context and follows the line of early social medicine, which, as Virchow put it, understood politics as medicine on a large scale. With the increasing dominance of neoliberal thinking during the 1990s, this view of health in its societal context was pushed aside to make way for an individualistic understanding of self-responsibility. At the same time a resurgence of expert-led prevention strategies could be observed. Recently, however, the discussion on self-responsibility appears to be regaining societal aspects. The task on hand is, to support this societal approach to health whilst at the same time to ensure the field of health promotion does not overstretch itself.

[Tobacco prevention at the regional level, Bavaria as an example]. / Tabakprävention auf Landesebene. Das Beispiel Bayern.

Tobacco consumption is one of the most relevant behavior-based health risks. It has been estimated that there are 14,000-18,000 tobacco-related deaths each year in Bavaria, Germany. Thus, efficient tobacco prevention, which involves measures of behavior-oriented as well as of condition-oriented prevention at the Federal State level, is a priority objective of prevention politics in Bavaria. Measures of behavior-oriented prevention account for the fact that tobacco prevention affects private lifestyles, where statutory provisions may not be effectual. However, smoking bans have achieved the creation of smoke-free living spaces especially for children and adolescents. In the long term, it is essential to enhance evaluation of tobacco prevention, to pay more attention to sustainability of approved projects, and to ensure a smoke-free environment for children and adolescents. The Bavarian health program "Gesund.Leben.Bayern." is an important platform for this.

Observations on unaided smoking cessation after deep brain stimulation of the nucleus accumbens.

AIMS: We explore whether clinical research on deep brain stimulation (DBS) of the nucleus accumbens (NAc) to treat addiction is justified besides theoretical speculation. METHODS: Since 2004, 10 patients who were also smokers were treated at the University of Cologne for Tourette's syndrome (TS), obsessive-compulsive disorders (OCD) or anxiety disorders (AD) by DBS of the NAc. We assessed their smoking behavior after DBS and (in retrospection) before by the Fagerstrom Test for Nicotine Dependence (FTND) and additional items. RESULTS: Three male patients were able to quit smoking after DBS. They were less dependent and higher motivated compared to the rest of the sample. They are stimulated with a higher voltage. During 1-year, 2-year, and 30-month follow-ups, we found a higher rate of successful smoking cessation (20, 30 and 30%) compared to unaided smoking cessation in the general population (13, 19 and 8.7%). CONCLUSIONS: Albeit the results of the study are severely limited by the method of retrospective self-assessment of psychiatric patients, further research of DBS of the NAc to treat addiction seems justified. In addition to biological mediators, psychosocial factors should be assessed in further prospective studies.

[Secondhand smoke in hospitality venues. Exposure, body burden, economic and health aspects in conjunction with smoking bans]. / Tabakrauch in gastronomischen Einrichtungen. Exposition, innere Belastung, ökonomische und gesundheitliche Aspekte im Zusammenhang mit Rauchverboten.

Secondhand smoke was classified by national and international organisations as a known cause of cancer in humans and has many adverse health effects, especially cardiovascular diseases and lung tumours. Global studies have clearly shown that hospitality venues have the highest levels of indoor air pollution containing different substances that are clearly carcinogenic--such as tobacco-related chemicals--compared with other, smoke-free indoor spaces. Data from the human biomonitoring of non-smoking employees in the food service industry confirm this high exposure level. Non-smokers exposed to secondhand smoke in these environments are at increased risk for adverse health effects. The consistent protection of non-smokers in public places such as restaurants and bars through a smoking ban results in a significant reduction of the pollutants in the air (mostly > 90%) and clearly reduces the internal body burden for users and employees. Furthermore, health complaints by non-smoking employees are reduced and the higher risk for lung tumours of employees in the food service industry compared with the general population can be effectively reduced as well. According to current standards of knowledge, other measures such as spatial separation of smoking areas or the use of mechanical venting systems do not achieve a comparably high and effective pollutant reduction under field conditions. Studies concerning the economic effects of prohibiting smoking in public places conducted in various countries have shown that beverage-focused gastronomic enterprises experience a short-term down trend but that food-focused gastronomic enterprises do not experience any negative or even positive effects. The positive effects of a ban on smoking in public places on the general population are a decline in cigarette consumption and the reduction of secondhand smoke exposure by non-smokers. Smoking bans in hospitality venues are not necessarily linked with a shift of the tobacco consumption to private rooms and an associated increase of secondhand smoke exposure. A comprehensive smoking ban in public spaces without exemption is therefore an easy and targeted measure for gastronomic enterprises from a health perspective.

[Smoking bans in public places: current epidemiological evidence of cardiovascular health impacts at the population level]. / Rauchverbote in öffentlichen Räumen: Aktuelle epidemiologische Evidenz für kardiovaskuläre Gesundheitseffekte auf Bevölkerungsebene.

During the past years smoking bans in public places including hospitality venues have been introduced in several countries. Up to now, eight ecological studies on hospital admission rates due to acute myocardial infarction or coronary events after introduction of a smoking ban in the United States, Canada, and Italy have been published. This article reviews these studies and discusses their significance and potential sources of error from an epidemiological point of view. The chronological order of reduction in acute myocardial infarction rates following the smoking ban, the consistency of this association in several countries, and the biological plausibility because of the known acute cardiovascular effects of secondhand smoke suggest a causal association. Thus, if this turns out to be true public smoking bans will be a very effective public health measure.

[Ethical aspects of workplace health management]. / Ethische Aspekte des betrieblichen Gesundheitsmanagements.

Ethical issues have always been part of the debate around work and its relation to people. In the context of workplace health management, however, ethical considerations have received little attention to date. This paper discusses some examples of the ethical questions arising in the pursuit of workplace health management, such as issues around the organization of work procedures, double loyalties, the significance of occupational screening examinations or how people in precarious working conditions are being dealt with. Subsequently, two ethical codes commonly used in the field of work and health in German-speaking countries are introduced. They originate from the field of occupational medicine, but have meanwhile been opened to other professions in the field of work and health. Finally, some perspectives for further discussion are put forward.

A Phase I and pharmacological study of the glutamine antagonist acivicin with the amino acid solution aminosyn in patients with advanced solid malignancies.

Acivicin is a glutamine analogue antimetabolite that inhibits several glutamate-dependent synthetic enzymes. Previous studies of this agent administered on a 72-h continuous i.v. infusion schedule every 3 weeks demonstrated a high rate of severe, albeit reversible, central nervous system (CNS) toxicity at the 30 mg/m2/day dose level. Animal studies have shown that the CNS toxicity of acivicin can be prevented by a concomitant infusion of amino acids postulated to block drug uptake in the CNS by a saturable transport system that is common to endogenous amino acids. This study evaluated the feasibility of escalating acivicin doses in cancer patients by administering acivicin with a concomitant 96-h i.v. infusion of a mixture of 16 amino acids (Aminosyn, 10%). Twenty-three patients with advanced malignancies were treated with acivicin on a 72-h continuous infusion schedule at doses ranging from 25 to 60 mg/m2/day every 3 weeks. Reversible, dose-limiting CNS toxicity, characterized by lethargy, confusion, and decreased mental status, occurred in the two patients enrolled at the 60 mg/m2/day dose level, precluding further dose escalation. The maximum tolerated dose (MTD) and recommended dose for additional evaluation of acivicin on this schedule is 50 mg/m2/day. Other toxicities observed were dose-related neutropenia that was grade 4 in four patients (four courses), complicated with fever in three of those patients, and grade 3-4 thrombocytopenia in three patients (three courses). Pharmacokinetics studies performed in 15 patients revealed that the acivicin plasma Css increased from 0.44 microg/ml (range, 0.28-0.59 microg/ml) at the 25 mg/m2/day to 1.06 microg/ml (0.64-1.5 microg/ml) at the 50 mg/m2/dose level. Acivicin Css at the MTD was not significantly higher than previously reported values with single-agent acivicin on the same schedule of administration at the MTD of 25 mg/m2/day dose level (0.60 microg/ml; range, 0.43-0.81 microg/ml). Neurotoxicity did not correlate with acivicin Css, but relationships between exposure to acivicin and the occurrence of both neutropenia and thrombocytopenia were well described by a sigmoidal Emax model. This trial demonstrated that concomitant infusions of amino acid can prevent acivicin-induced CNS toxicity, which allows the dose of acivicin to be escalated 2-fold above previously tolerable doses; however, this effect did not translate in a significant increment in acivicin Css.

Effects of deep brain stimulation on prepulse inhibition in obsessive-compulsive disorder.

Owing to a high response rate, deep brain stimulation (DBS) of the ventral striatal area has been approved for treatment-refractory obsessive-compulsive disorder (tr-OCD). Many basic issues regarding DBS for tr-OCD are still not understood, in particular, the mechanisms of action and the origin of side effects. We measured prepulse inhibition (PPI) in treatment-refractory OCD patients undergoing DBS of the nucleus accumbens (NAcc) and matched controls. As PPI has been used in animal DBS studies, it is highly suitable for translational research. Eight patients receiving DBS, eight patients with pharmacological treatment and eight age-matched healthy controls participated in our study. PPI was measured twice in the DBS group: one session with the stimulator switched on and one session with the stimulator switched off. OCD patients in the pharmacologic group took part in a single session. Controls were tested twice, to ensure stability of data. Statistical analysis revealed significant differences between controls and (1) patients with pharmacological treatment and (2) OCD DBS patients when the stimulation was switched off. Switching the stimulator on led to an increase in PPI at a stimulus-onset asynchrony of 200 ms. There was no significant difference in PPI between OCD patients being stimulated and the control group. This study shows that NAcc-DBS leads to an increase in PPI in tr-OCD patients towards a level seen in healthy controls. Assuming that PPI impairments partially reflect the neurobiological substrates of OCD, our results show that DBS of the NAcc may improve sensorimotor gating via correction of dysfunctional neural substrates. Bearing in mind that PPI is based on a complex and multilayered network, our data confirm that DBS most likely takes effect via network modulation.

Pharmacokinetics and efficacy of a long-acting formulation of the new somatostatin analog BIM 23014 in patients with acromegaly.

The treatment of acromegalics with somatostatin analogs requires continuous sc infusion using pumps or several sc injections daily. Long-acting formulations (BIM-LA) of BIM 23014 (BIM) using delayed microcapsules may provide a more convenient form of therapy. Fourteen acromegalics whose GH secretion had not been normalized by transphenoidal surgery followed, in 10 cases, by pituitary radiotherapy (performed at least 2 yr before the study) were studied. Eight of these patients participated in an initial study of the pharmacokinetics of BIM-LA, after which a 6-month efficacy study was undertaken. The 8 patients in the pharmacokinetic study had an initial blood sample collected for measurements of plasma GH and insulin-like growth factor-I (IGF-I) levels before the im injection of 30 mg BIM-LA, and blood samples were subsequently taken 2, 4, 6, and 8 h after injection and then twice a week for a month. Plasma IGF-I levels were measured on days 4, 14, 20, and 30 after the injection. Assays of plasma GH, IGF-I, and BIM levels were performed by RIAs. The results showed that plasma GH levels were markedly reduced from 26.0 +/- 2.0 to 2.5 +/- 0.2 micrograms/L 2 h after BIM-LA injection and remained lower than 5 micrograms/mL for the 11 following days. Plasma GH levels increased to 5.5 +/- 1.2 micrograms/L on day 14 and returned to basal values 23 days after injection. Similarly, plasma IGF-I decreased from an initial level of 656 +/- 43 to 324 +/- 23 ng/mL on day 4 and remained close to the normal range for the following 10 days. Plasma BIM levels reached a peak 2 h after the injection (7.2 +/- 2.3 ng/mL) and remained higher than or close to 1 ng/mL until the 14th day after injection. This initial study showed that a single injection of 30 mg BIM-LA effectively suppressed GH and IGF-I secretion for at least 14 days, in accordance with the kinetics of the drug in plasma. Based on the results of this initial study, 30 mg BIM-LA were injected twice monthly for 6 months in all 14 patients. All of the subjects had a basal evaluation before treatment with BIM-LA and were then subjected to assessment of clinical, pituitary, and hormonal parameters. Patients were evaluated after 3 and 6 months of treatment on the same basis as that previously used when starting the BIM-LA therapy. Plasma BIM levels were measured monthly. Clinical signs of acromegaly improved during the treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

Localization of regional lymph nodes in melanomas of the head and neck.

OBJECTIVES: To study the efficacy of gamma-probe radiolocalization of the first draining (sentinel) lymph node (SLN) in stage N0 melanoma of the head and neck and to evaluate its potential role in the staging and treatment of this disease. DESIGN: Gamma-probe radiolocalization, a new alternative to blue-dye lymphatic mapping, uses a scintillation (gamma) probe to identify radiolabeled SLNs. In a consecutive sample clinical trial, gamma-probe radiolocalization of the SLN is compared with lymphoscintigraphy and blue-dye lymphatic mapping. Follow-ups ranged from 1.7 years to 4 years, with a mean follow-up of 2.5 years. SETTING: Tertiary and private care teaching hospital. PATIENTS: Between June 1993 and November 1995, 23 patients with stage N0 intermediate-thickness melanoma of the head and neck were enrolled in this volunteer sample. INTERVENTIONS: Twenty-four hours prior to surgery, a radioactive tracer was intradermally injected around the circumference of a primary melanoma. Twelve patients also had blue dye injected just prior to surgical resection. Using a handheld gamma probe, radiolabeled lymph nodes were identified and selectively removed with minimal dissection. In patients with nodes with histologic evidence of metastases, a regional lymphadenectomy was performed. MAIN OUTCOME MEASURES: The successful identification of radiolabeled SLNs, the correlation of SLN radiolabeling to lymphoscintigraphy and blue-dye mapping, and the long-term development of regional metastases. RESULTS: Surgeons successfully resected the radiolabeled SLNs in 22 (96%) of 23 patients. The success rate of blue-dye lymphatic mapping was 8 (75%) of 12 patients and lymphoscintigraphy was 20 (91%) of 22 patients. One hundred percent of blue-stained lymph nodes were radiolabeled. The one patient in whom no SLN could be identified developed regional disease at 17 months. CONCLUSIONS: Gamma-probe radiolocalization and resection of the radiolabeled SLN is a simple and reliable method of staging regional lymph nodes and determining the need for elective lymphadenectomy.

A nurse's right to refuse a patient care assignment.

Ethics is a set of moral principles or values--a guiding philosophy for behavior. Ethical dilemmas in the health care setting occur daily. Perioperative nurse managers need to consider basic ethical principles when resolving these dilemmas, and they must keep in mind that solutions need to serve the best interests of all people involved in given situations. This article discusses criteria by which a nurse can refuse a patient care assignment and those by which a nurse manager can require that a nurse perform a patient care assignment.

[Basics of Bavarian health assessment reporting]. / Grundzüge einer Bayerischen Gesundheitsberichterstattung (GBE).

Management information systems which support a demand-oriented, integrative and comprehensive decision-making in health care policy are of pre-eminent importance for the health care system. Present health care legislation in Bavaria underlines the importance of health reporting as a tool for periodical assessment of the situation and starting-point for decision-making in health care. Demands made on the Bavarian health report stem from both European and national levels and also from the regional structure within the state. It is intended that the health reporting should reach the local level. Single reports cannot cover all relevant aspects. Therefore, health reporting in Bavaria has a modular structure. There is a need for integrated, flexibly useful information. Following an evidence-based approach, health information may be subject to critical assessment. This approach enables decision makers to assess the grade of certainty of recommendations. Health reporting in Bavaria aims at following the people through time. The intelligent use of new media will have to play a key role.

[Iatrogenic Wernicke-Korsakow syndrome with unusual neurological deficits and MRI lesions]. / Iatrogenes Wernicke-Korsakoff-Syndrom mit ungewöhnlichen Symptomen und MRT-Veränderungen.

Wernicke-Korsakow Syndrome (WKS) is caused by thiamine (vitamin B1) deficiency and usually occurs in conjunction with chronic alcohol abuse. Our report concerns a 64-year-old, nonalcoholic, woman with no history of alcohol abuse, who became ill with WKS after 3 weeks of parenteral nourishment. As an unusual initial symptom she went blind in both eyes; this was followed a few days later by impaired consciousness and spastic tetraparesis. A cranial MRI examination showed symmetrical signal alteration (T2, FLAIR and diffusion weighting) in the medial thalamus, periaqueductal mesencephalon including the quadrigeminal plate, mamillary bodies and-most unusually-both paracentral gyri. Laboratory tests confirmed the diagnosis of WKS as significant thiamine deficiency was detected. Following several weeks of intravenous thiamine supplementation the MRI lesions were almost completely reversed but the neurological deficits regressed only partially.