[Provision of palliative care for people with advanced dementia]. / Palliativversorgung von Menschen mit fortgeschrittener Demenz.

As a result of a literature-based expert process, this review provides an overview about the principles of palliative care for people with advanced dementia that are relevant for clinical practice. In particular, the indications, impact and aims of palliative care for advanced dementia are described. Life-prolonging measures and management of symptoms at the end of life are discussed. Furthermore, the overview focuses on the legal basis of decision making.

[Shared decision-making in acute psychiatric medicine : Contraindication or a challenge?] / "Shared decision-making" in der Akutpsychiatrie : Widerspruch oder Herausforderung?

BACKGROUND: The concept of shared decision-making (SDM) has existed since the 1990s in multiple fields of somatic medicine but has only been poorly applied in psychiatric clinical routine despite broad acceptance and promising outcomes in clinical studies on its positive effects. MATERIALS AND METHODS: The concept itself and its practicability in mental health are carefully assessed and strategies for its future implementation in psychiatric medicine are presented in this article. Ongoing clinical studies probing some of those strategies are further outlined. RESULTS AND DISCUSSION: On top of the ubiquitous shortage of time in clinical routine, psychiatrists report their concern about patients' limited abilities in sharing decisions and their own fear of potentially harmful decisions resulting from a shared process. Misinterpretation of shared decision-making restricting the health care professional to rather an informed choice scenario and their own adhesion to the traditional paternalistic decision-making approach further add to SDM's underutilization. Those hurdles could be overcome by communication skill workshops for all mental health care professionals, including nursing personnels, psychologists, social workers and physicians, as well as the use of decision aids and training courses for patients to motivate and empower them in sharing decisions with the medical staff. By this, the patient-centered treatment approach demanded by guidelines, carers and users could be further facilitated in psychiatric clinical routine.

National climate policies across Europe and their impacts on cities strategies.

Globally, efforts are underway to reduce anthropogenic greenhouse gas emissions and to adapt to climate change impacts at the local level. However, there is a poor understanding of the relationship between city strategies on climate change mitigation and adaptation and the relevant policies at national and European level. This paper describes a comparative study and evaluation of cross-national policy. It reports the findings of studying the climate change strategies or plans from 200 European cities from Austria, Belgium, Estonia, Finland, France, Germany, Ireland, Italy, Netherlands, Spain and the United Kingdom. The study highlights the shared responsibility of global, European, national, regional and city policies. An interpretation and illustration of the influences from international and national networks and policy makers in stimulating the development of local strategies and actions is proposed. It was found that there is no archetypical way of planning for climate change, and multiple interests and motivations are inevitable. Our research warrants the need for a multi-scale approach to climate policy in the future, mainly ensuring sufficient capacity and resource to enable local authorities to plan and respond to their specific climate change agenda for maximising the management potentials for translating environmental challenges into opportunities.

Over-the-counter-drugs for the treatment of mood and anxiety disorders--the views of German pharmacists.

INTRODUCTION: Depression, anxiety, agitation and sleep disorders are highly prevalent in the general population, but few persons receive psychiatric care. METHODS: Our aim was to study the views of 690 German pharmacists on "over-the counter" (OTC) drugs for these indications. RESULTS: They reported dispensing OTC medication to an average of 12 customers per day, and this corresponded to almost one quarter of the medications provided for these indications. Herbal drugs and complex homeopathic formulations were used most frequently. Patients preferring OTC substances were described as being younger, with shorter durations of illness and less severe symptoms, and more skeptical regarding psychopharmacology. While genuine pharmacological effects were considered as most relevant, pharmacists were highly aware of placebo and interpersonal factors. Symptoms, comorbidity and advice on drug intake were prominent topics during pharmacy consultations. CONCLUSION: German pharmacists report dispensing large amounts of OTC drugs for anxiety, agitation, sleep disturbances or depression. It is unclear whether this constitutes a rational and cost effective method to deal with mild courses of high prevalence diseases or must be seen critically.

[Understanding the term burnout in psychiatry and psychotherapy]. / Verständnis des Begriffs Burnout in Psychiatrie und Psychotherapie.

BACKGROUND: Currently there is much debate about the concept of burnout and its use as a diagnostic entity. The aim of the present survey was to present the view of mental health professionals towards the concept of burnout. METHODS: A total of 300 mental health professionals were surveyed using a structured questionnaire. RESULTS: The majority of participants see burnout as a state of exhaustion which constitutes a risk factor for later developing a mental disorder. Participants reported that from their point of view typical triggers for burnout exist while symptoms overlap to a great extent with depression. Psychotherapy as well as interventions at the workplace are regarded as promising interventions; however, in the clinical routine only a minority of participants actually contacted the patients' workplace. In the participants workplace settings most Burnout-Patients suffered from a diagnosis defined in ICD 10 but judged themselves to be suffering from burnout. DISCUSSION: Burnout-Patients in mental health settings differ from the picture currently drawn in the media, probably because Burnout-Patients reach the mental health sector only after already having developed a manifest psychiatric disorder.

Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses.

BACKGROUND: Diagnostic errors can have tremendous consequences because they can result in a fatal chain of wrong decisions. Experts assume that physicians' desire to confirm a preliminary diagnosis while failing to seek contradictory evidence is an important reason for wrong diagnoses. This tendency is called 'confirmation bias'. METHOD: To study whether psychiatrists and medical students are prone to confirmation bias and whether confirmation bias leads to poor diagnostic accuracy in psychiatry, we presented an experimental decision task to 75 psychiatrists and 75 medical students. RESULTS: A total of 13% of psychiatrists and 25% of students showed confirmation bias when searching for new information after having made a preliminary diagnosis. Participants conducting a confirmatory information search were significantly less likely to make the correct diagnosis compared to participants searching in a disconfirmatory or balanced way [multiple logistic regression: odds ratio (OR) 7.3, 95% confidence interval (CI) 2.53-21.22, p<0.001; OR 3.2, 95% CI 1.23-8.56, p=0.02]. Psychiatrists conducting a confirmatory search made a wrong diagnosis in 70% of the cases compared to 27% or 47% for a disconfirmatory or balanced information search (students: 63, 26 and 27%). Participants choosing the wrong diagnosis also prescribed different treatment options compared with participants choosing the correct diagnosis. CONCLUSIONS: Confirmatory information search harbors the risk of wrong diagnostic decisions. Psychiatrists should be aware of confirmation bias and instructed in techniques to reduce bias.

The seven-span transmembrane receptor CD97 has a cellular ligand (CD55, DAF).

CD97 is an activation-induced antigen on leukocytes with a seven-span transmembrane (7-TM) region homologous to the secretin receptor superfamily. However, in contrast to this group of peptide hormone receptors, CD97 has an extended extracellular region with three EGF domains at the NH2 terminus, two of them with a calcium binding site. By demonstrating that lymphocytes and erythrocytes specifically adhere to CD97-transfected COS cells we here show that CD97 in parallel with its molecular evolution has acquired the ability to bind cellular ligands. A mAb selected on its capacity to block the adhesion between CD97 transfectants and red cells was found to be directed to the NH2-terminal short consensus repeat (SCR) of decay accelerating factor (DAF, CD55), a regulatory protein of the complement cascade. The specificity of the interaction of CD97 with CD55 was established by the observation that erythrocytes that lack CD55, obtained from patients with paroxysmal nocturnal hemoglobinuria (PNH) or the CD55, phenotype Inab, failed to adhere to CD97 transfectants. This is the first demonstration of a cellular ligand for a 7-TM receptor.

Effect of CT scan protocols on x-ray-induced DNA double-strand breaks in blood lymphocytes of patients undergoing coronary CT angiography.

AIMS: To compare in vivo DNA lesions induced during helical and sequential coronary computed tomography angiography (CTA) and to evaluate the effect of CT parameters on double-strand break (DSB) levels. METHODS: Thirty-six patients were examined with various CT protocols and modes (helical scan, n = 27; sequential scan, n = 9) either using a 64-slice dual-source or a 128-slice CT system. Blood samples were obtained before and 30 min after CT. Lymphocytes were isolated, stained against the phosphorylated histone variant γ-H2AX, and DSBs were visualised by using fluorescence microscopy. RESULTS: DSB yields 30 min after CTA ranged from 0.04 to 0.71 per cell and showed a significant correlation to DLP (ρ = 0.81, p < 0.00001). Median DSB yield and median DLP were significantly lower after sequential compared to helical CT examinations (0.11 vs. 0.37 DSBs/cell and 249 vs. 958 mGy cm, p < 0.00001). Additional calcium scoring led to an increase in DLP (p = 0.15) and DSB levels (p = 0.04). DSB levels normalised to the DLP showed a significant correlation to the attenuation of the blood (ρ = 0.53, p = 0.01) and a negative correlation to the body mass index of the patients (ρ = -0.37, p = 0.06). CONCLUSION: γ-H2AX immunofluorescence microscopy allows one to determine dose-related effects on x-ray-induced DSB levels and to consider individual factors which cannot be monitored by physical dose measurements.

Absence of flow-mediated vasodilation in the rabbit femoral artery.

The purpose of this study was to determine if there is flow-mediated vasodilation of the femoral artery in response to progressive increases in flow within a physiological range observed in the in vivo experiments. Femoral artery blood flow was determined in conscious rabbits (n = 5) using chronically implanted flowprobes. Resting blood flow was 8.3 +/- 0.6 ml/min and increased to 39.9 +/- 5.4 ml/min during high intensity exercise. Femoral arteries (n = 12, 1705 +/- 43 microm outer diameter) harvested from a separate group of rabbits were mounted on cannulas and diameter was continuously monitored by video system. Functional integrity of the endothelium was tested with acetylcholine. The arteries were set at a transmural pressure of 100 mm Hg and preconstricted with phenylephrine to 73 +/- 3% of initial diameter. Using a roller pump with pressure held constant, the arteries were perfused intraluminally with warmed, oxygenated Krebs' solution (pH = 7.4) over a physiological range of flows up to 35 ml/min. As flow increased from 5 ml/min to 35 ml/min, diameter decreased significantly (p < 0.05) from 1285 +/- 58 microm to 1100 +/- 49 microm. Thus, in vessels with a functional endothelium, increasing intraluminal flow over a physiological range of flows produced constriction, not dilation. Based on these results, it seems unlikely that flow-mediated vasodilation in the rabbit femoral artery contributes to exercise hyperemia.

Caregiver involvement in psychiatric inpatient treatment - a representative survey among triads of patients, caregivers and hospital psychiatrists.

AIMS: Studies on the frequency of caregiver involvement in representative inpatient samples are scarce. The aim of our study was to conduct a representative survey on caregiver involvement in routine inpatient care involving all three parties (patients, caregivers, psychiatrists). Therefore, we performed face-to-face interviews consisting of open-ended questions to gain a deeper understanding of when and how caregivers are involved in care treatment and to identify which topics are mainly discussed. METHODS: This cross-sectional survey included inpatients from 55 acute psychiatric wards across ten psychiatric hospitals, their treating psychiatrists and, when possible, their caregivers. In total, we performed semi-structured face-to-face interviews with 247 patients, their treating psychiatrists and 94 informal caregivers. Each psychiatrist named the next two to three patients to be discharged. After a patient had given informed consent, the interview was performed by a researcher. In addition, the psychiatrist and, when possible, the primary caregiver identified by the patient, were also interviewed. RESULTS: It was perceived by both patients and psychiatrists that contact between caregiver and psychiatrist had taken place in one-third of the patient cases. Predictors for psychiatrist-caregiver-contact were revealed in the patient's diagnosis (schizophrenia), a lower history of inpatient stays, and the respective hospital. According to psychiatrists the most frequent subjects of discussion with caregivers involved therapeutic issues and organisational and social-psychiatric topics (e.g. work, living and social support). Patients and caregivers stated that psychiatric treatment and the diagnostic classification of the mental illness were the most frequent topics of conversation. For all three groups, the most often cited reason for missed caregiver involvement was the subjective perception that a caregiver was not in fact needed. CONCLUSIONS: Whether or not caregivers were contacted and involved during an inpatient stay strongly depended on the individual hospital. The frequency of involvement of caregivers can certainly be increased by changing processes and structures in hospitals. All three parties (patients, caregivers and psychiatrists) most often stated that the caregiver was not involved in the treatment because they thought it was unnecessary. Evidence demonstrates the positive effect of caregivers' involvement on the therapeutic process but also on the well-being of the caregiver, therefore it is necessary to increase awareness of this evidence among all three interest groups.

Implementing shared decision-making on acute psychiatric wards: a cluster-randomized trial with inpatients suffering from schizophrenia (SDM-PLUS).

AIMS: Although shared decision-making (SDM) has the potential to improve health outcomes, psychiatrists often exclude patients with more severe mental illnesses or more acute conditions from participation in treatment decisions. This study examines whether SDM is facilitated by an approach which is specifically adapted to the needs of acutely ill patients (SDM-PLUS). METHODS: The study is a multi-centre, cluster-randomised, non-blinded, controlled trial of SDM-PLUS in 12 acute psychiatric wards of five psychiatric hospitals addressing inpatients with schizophrenia or schizoaffective disorder. All patients fulfilling the inclusion criteria were consecutively recruited for the trial at the time of their admission to the ward. Treatment teams of intervention wards were trained in the SDM-PLUS approach through participation in two half-day workshops. Patients on intervention wards received group training in SDM. Staff (and patients) of the control wards acted under 'treatment as usual' conditions. The primary outcome parameter was the patients' perceived involvement in decision-making at 3 weeks after study enrolment, analysed using a random-effects linear regression model. RESULTS: In total, 161 participants each were recruited in the intervention and control group. SDM-PLUS led to higher perceived involvement in decision-making (primary outcome, analysed patients n = 257, mean group difference 16.5, 95% CI 9.0-24.0, p = 0.002, adjusted for baseline differences: ß 17.3, 95% CI 10.8-23.6, p = 0.0004). In addition, intervention group patients exhibited better therapeutic alliance, treatment satisfaction and self-rated medication compliance during inpatient stay. There were, however, no significant improvements in adherence and rehospitalisation rates in the 6- and 12-month follow-up. CONCLUSIONS: Despite limitations in patient recruitment, the SDM-PLUS trial has shown that the adoption of behavioural approaches (e.g. motivational interviewing) for SDM may yield a successful application to mental health. The authors recommend strategies to ensure effects are not lost at the interface between in- and outpatient treatment.Trial registration: The trial was registered at Deutsches Register Klinischer Studien (DRKS00010880).

How psychiatrists inform themselves and their patients about risks and benefits of antipsychotic treatment.

OBJECTIVE: In order to choose the best treatment option, physicians have to inform themselves and their patients about both the benefits and risks of available treatment options equally. Our study aims to investigate whether psychiatrists actually do conduct such a balanced information search and presentation. METHOD: Psychiatrists' information search and information presentation to a patient with schizophrenia were studied using two separate experiments. In both, participants were presented with hypothetical case vignettes and descriptions of fictitious antipsychotics. RESULTS: When searching for information, psychiatrists looked more for risks than benefits of antipsychotic treatment options (t = -3.4, df = 74, P = 0.001). However, when informing a patient, they named more benefits than risks (t = 17.1, df = 224, P < 0.001). CONCLUSION: The risk-biased information search presumably follows the principle of 'primum non nocere'. The benefit-biased information presentation might be motivated by the wish to persuade patients to accept the proposed therapy.

Audit of nasendoscope disinfection practice.

INTRODUCTION: Several options exist with regard to flexible pharyngo-laryngoscope sterilisation. We audited the use of disposable sheaths in our department over a six-month period. METHODS: A cost-analysis was performed and the advantages and disadvantages of this system were compared with several alternative options. RESULTS: We found that the overall cost of disposable sheaths averaged l4008 per month over a six-month period. We subsequently introduced chlorine dioxide (ClO2) wipes as a means of disinfection. Chlorine dioxide wipes have enabled a monthly saving of l3145 over sheath usage. Additionally, they meet health regulation requirements and are a convenient, cost-effective alternative to sheaths. DISCUSSION: The limiting factors, including time and financial issues, involved in nasendoscope disinfection are discussed. CONCLUSIONS: We have found chlorine dioxide wipes to be a satisfactory alternative means of nasendoscope disinfection. Possible time constraints aside, there are no advantages of sheath use over our current method. Chlorine dioxide wipes are also preferable from a financial point of view.

Managers' reactions towards employees' disclosure of psychiatric or somatic diagnoses.

AIMS: To study whether employees who disclose a psychiatric diagnosis, such as depression risk stigmatisation and discrimination at the workplace. METHODS: Randomised experimental study with 748 managers from German companies incorporating four case vignettes displaying an employee with different 'diagnoses' (depression, burnout, private crisis and thyroid dysfunction), but identical unspecific complaints. Main outcome measures were the managers' attitudes and their impact on stigmatisation with respect to job performance. RESULTS: In nearly all aspects of job performance, the diagnosis depression (psychiatric disorder) was seen as more critical than the diagnosis of a thyroid dysfunction (somatic disease). The diagnosis 'burnout' did not prove to be less stigmatising than 'depression'. Likewise 'private crisis' was rated less favourably than thyroid dysfunction. CONCLUSIONS: Therefore, employees have to evaluate if they disclose their psychiatric disorder or if they conceal it as a somatic illness.

Sevenspan transmembrane molecules: novel receptors involved in leukocyte adhesion.

CD97 is a member of a new subgroup of seven-span transmembrane (7-TM) molecules which belong to the secretin receptor superfamily. Different from other members of the secretin receptor family, these recently characterized molecules have extended extracellular regions comprising several EGF domains near the NH2 terminus. We recently demonstrated that the extracellular part of CD97 is involved in intercellular adhesion since it specifically binds to CD55 (decay accelerating factor), a regulatory protein of the complement cascade. To our knowledge this is the first demonstration of a cellular ligand for a 7-TM molecule.

Effect of epinephrine on net lactate uptake by contracting skeletal muscle.

The purpose of this study was to determine the effect of epinephrine on net lactate (La(-)) uptake at constant elevated blood La(-) concentration and steady level metabolic rate (O(2) uptake) in the canine gastrocnemius-plantaris muscle in situ. Infusion of La(-)/lactic acid (pH 3.5) established a mean arterial blood La(-) concentration of ~10 mM while normal blood-gas and pH status were maintained as the gastrocnemius-plantaris was stimulated with tetanic trains at a rate of one contraction every 4 s. After steady-state control measures, epinephrine was infused for 35 min at rates that produced a high physiological concentration with (Pro; n = 6) and without (Epi; n = 6) beta-adrenergic-receptor blockade via propranolol. Net La(-) uptake values during the control conditions were not significantly different between trials (Epi: 0.756 +/- 0.043; Pro: 0.703 +/- 0.061 mmol. kg(-1). min(-1)). Steady level O(2) uptake averaged approximately 69.5 ml. kg(-1). min(-1) for both control conditions and did not significantly change over the course of the experiments in either set of trials. Epi experiments resulted in a significantly reduced net La(-) uptake (0.346 +/- 0.088 mmol. kg(-1). min(-1) after 5 min of infusion) compared with control value at all sample times measured. However, net La(-) uptake was not significantly different from control at any time during Pro (0.609 +/- 0.052 mmol. kg(-1). min(-1) after 5 min of infusion). When the change from the respective control values for net La(-) uptake was compared across time for both series of experiments, Epi resulted in a significantly greater change from control than did Pro. This study suggests that epinephrine can have a profound effect on net La(-) uptake by contracting muscle and that these effects are elicited through beta-adrenergic-receptor stimulation.

Role of convective O(2) delivery in determining VO(2) on-kinetics in canine muscle contracting at peak VO(2).

A previous study (Grassi B, Gladden LB, Samaja M, Stary CM, and Hogan MC, J Appl Physiol 85: 1394-1403, 1998) showed that convective O(2) delivery to muscle did not limit O(2) uptake (VO(2)) on-kinetics during transitions from rest to contractions at approximately 60% of peak VO(2). The present study aimed to determine whether this finding is also true for transitions involving contractions of higher metabolic intensities. VO(2) on-kinetics were determined in isolated canine gastrocnemius muscles in situ (n = 5) during transitions from rest to 4 min of electrically stimulated isometric tetanic contractions corresponding to the muscle peak VO(2). Two conditions were compared: 1) spontaneous adjustment of muscle blood flow (Q) (Control) and 2) pump-perfused Q, adjusted approximately 15-30 s before contractions at a constant level corresponding to the steady-state value during contractions in Control (Fast O(2) Delivery). In Fast O(2) Delivery, adenosine was infused intra-arterially. Q was measured continuously in the popliteal vein; arterial and popliteal venous O(2) contents were measured at rest and at 5- to 7-s intervals during the transition. Muscle VO(2) was determined as Q times the arteriovenous blood O(2) content difference. The time to reach 63% of the VO(2) difference between resting baseline and steady-state values during contractions was 24.9 +/- 1.6 (SE) s in Control and 18.5 +/- 1.8 s in Fast O(2) Delivery (P < 0.05). Faster VO(2) on-kinetics in Fast O(2) Delivery was associated with an approximately 30% reduction in the calculated O(2) deficit and with less muscle fatigue. During transitions involving contractions at peak VO(2), convective O(2) delivery to muscle, together with an inertia of oxidative metabolism, contributes in determining the VO(2) on-kinetics.

New generation antipsychotics for first episode schizophrenia.

BACKGROUND: The new generation antipsychotics are associated with a lower risk of adverse effects compared with drugs such as haloperidol. Many treatment guidelines recommend the use of new generation ('atypical') antipsychotic drugs for people with a first episode of schizophrenia. OBJECTIVES: To examine the effects of the new generation antipsychotics for people with a first episode of schizophrenia or schizophrenia-like psychoses. SEARCH STRATEGY: The reviewers searched the Cochrane Schizophrenia Group's register (March 2002) and the included and excluded studies tables of relevant Cochrane reviews, references of all relevant studies, contacted industry and authors of relevant studies to identify further trials. SELECTION CRITERIA: Randomised clinical trials comparing new generation antipsychotics (amisulpride, clozapine, olanzapine, quetiapine, risperidone, sulpiride, ziprasidone, zotepine) with conventional antipsychotics for people with a first episode of schizophrenia or schizophrenia-like psychoses. DATA COLLECTION AND ANALYSIS: Citations and, where possible, abstracts were independently inspected by three reviewers, papers ordered, re-inspected and quality assessed. We independently extracted data but excluded them if loss to follow up was greater than 50%. For homogeneous dichotomous data, we calculated the relative risk (RR), the 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT), on an intention-to-treat basis. For continuous data, reviewers calculated weighted mean differences (WMD). MAIN RESULTS: We include two short-term studies (total n=266), one of which was a report of a sub-group of a larger study. One compared risperidone with an average of 6 mg/day haloperidol and the other olanzapine with an average of 11 mg/day haloperidol. Compared with olanzapine, significantly more people receiving haloperidol left the study early (n=83, 1 RCT, RR 0.43 CI 0.3 to 0.7, NNH 3 CI 2 to 8). This was not so for the risperidone versus haloperidol comparison (n=183, 1 RCT, RR=0.7 CI 0.4 to 1.1). In terms of global effects, studies reported no differences between risperidone and haloperidol (n=183, RR not much improved 1.0 CI 0.6 to 1.5), and olanzapine and the same control (n=83, RR needing at least one dose of benzodiazepine 0.8 CI 0.5 to 1.1). More people allocated to olanzapine had clinically significant improvement in mental state compared with those given haloperidol (n=83, RR no 'clinically significant improvement' 0.45 CI 0.3 to 0.7, NNH 3 CI 2 to 6). In the risperidone study, however, no such difference was apparent (n=183, RR 'no clinically significant improvement in mental state' 0.85 CI 0.6 to 1.2). Significantly more people given haloperidol (4-16mg) experienced at least one adverse event when compared with risperidone (4-16mg) (n=183, RR 0.9 CI 0.8 to 0.98, NNH 8 CI 4 to 50). Use of anticholinergic medication for extrapyramidal adverse events was less prevalent for people allocated either olanzapine (n=83, RR 0.3 CI 0.2 to 0.7, NNH 4 CI 2 to 14) or risperidone (n=183, RR 0.7 CI 0.5 to 0.9, NNH 4 CI 3 to 9) compared with those given haloperidol. There are no data at all on outcomes such as compliance, cost, social and cognitive functioning, relapse, rehospitalisation, or quality of life. There are no medium to long-term data. Eight ongoing studies may provide more information. REVIEWER'S CONCLUSIONS: The results of this review are inconclusive. Whether the use of new generation antipsychotics really makes the treatment less off putting and enhances long-term compliance is unclear. Pragmatic, well-designed and reported long-term trials would be useful to answer this question.

Relationship between teat tissue immune defences and intramammary infections.

The teat is the main entrance for pathogens into the mammary gland. It also acts as a sensory, motor and primary defence organ. This latter function is important in preventing intramammary infections while efficiency in preventing new infections is determined by teat tissue integrity. Machine milking may evoke mechanical and circulatory impairment in teat tissues. These local metabolic disorders may decrease the efficiency of the local immune defence mechanisms. Teat tissue changes can be estimated by measuring teat thickness before and after milking. Experimental and field studies showed a high correlation between changes in thickness and infection risk. Teats with > 5% change in thickness have significantly increased teat duct colonisation rates and intramammary infection rates. The link between changes in teat thickness and infections should be found in changes in local immune defences and measurable changes in cytological and biochemical immune factors are expected. Indeed, the application of experimental milking conditions (i.e. no pulsation milking and positive pressure milking) showed to have a significant influence on some non specific immune factors in teat secretion. Positive pressure milking increases PMNs content and decreases macrophages content of teat secretion. Some enzymes such as NAGase and lysozyme were decreased by positive pressure milking, the concentration of the same enzymes were higher after no pulsation milking. A better knowledge on the interaction between the teat apex immune defense mechanisms and the machine milking process is necessary to reduce the new infection rate of the bovine mammary gland.

Language bias in neuroscience--is the Tower of Babel located in Germany?

In internal medicine German authors tend to publish randomized controlled trials (RCTs) with non-significant findings in German journals, RCTs with significant findings in international journals. In the neurosciences a similar trend was seen but the findings were not statistically significant. The reason for this inconclusive finding might be the low number of RCTs published in German.