[Association of Deployment and Tobacco Dependence among Soldiers]. / Zusammenhang von Auslandseinsätzen und Tabakabhängigkeit bei Soldaten.

OBJECTIVE: Smoking is a highly preventable risk factor. The present study investigates whether military operations abroad, as compared to deployment preparation, increase the risk of starting to smoke, enhance tobacco dependence and moderator variables can be identified on smoking behavior. METHOD: The study was conducted at 2 mechanized infantry battalions with N=264 soldiers. The task force completed a deployment in Afghanistan, the control group performed a deployment training. Assessments of tobacco dependence, posttraumatic symptoms, depression and stress were done before (t1) and after (t3) deployment. In addition, one assessment was done at mid-point (t2) during deployment and during the pre-deployment training, respectively. RESULTS: The prevalence rate of smoking soldiers was 56,4%. 51,1% (n=135) of all examined soldiers smoked more than 20 cigarettes per day. The results show a significant increase of tobacco dependence in the task force from t1 to t3 (p=0,040) as compared to the control group. For both groups, there was no increase in starting to smoke during the period of investigation (χ²<1; n. s.). Moderator variables on smoking were not found, but there was a significant increase in posttraumatic stress symptoms in the deployed group (p=0,006). CONCLUSIONS: Perhaps the increase in tobacco dependence in the experimental group can be attributed to the specific burdens of deployment. If high smoking rates were to be found also in other branches of the armed services, effective smoking cessation programs should be offered more widely.

[When genetics spices up a severe flare of chronic inflammatory bowel disease]. / Quand la génétique pimente une poussée sévère de maladie inflammatoire chronique intestinale.

The simultaneous occurrence of pneumomediastinum, peridural emphysema, subcutaneous emphysema and pneumothorax is extremely rare. We report the case of a young man with severe chronic inflammatory bowel disease presenting with voluminous spontaneous pneumomediastinum complicated by subcutaneous emphysema as well as peridural emphysema and pneumothorax. A genetic disorder is suspected.

[Levels of evidence in drug therapy for alcohol use disorders and illicit drug use]. / Evidenzgrade in der Suchttherapie von alkoholbezogenen Störungen und illegalen Drogen.

Substance-related disorders are clinically and socially very important. In Germany over a million people of varying ages are affected. Depending on the substance and stage of treatment, drugs and different treatment methods are used. Through a literature search we examined the current knowledge of what drugs and therapies are used to date, and what randomised trials have been carried out to prove the efficacy of drug therapy. The aim was to define for each drug or pharmacological therapy a specific level of evidence. For the pharmacological treatment of alcohol, cocaine and opiate withdrawal syndromes and their relapses, prophylaxis or replacement therapy drugs are found to have a high level of evidence. Efficacy has been proven scientifically for processes such as behaviour therapy, contingency management or motivational interviewing.

Genetic polymorphisms in DNA repair and damage response genes and late normal tissue complications of radiotherapy for breast cancer.

Breast-conserving surgery followed by radiotherapy is effective in reducing recurrence; however, telangiectasia and fibrosis can occur as late skin side effects. As radiotherapy acts through producing DNA damage, we investigated whether genetic variation in DNA repair and damage response confers increased susceptibility to develop late normal skin complications. Breast cancer patients who received radiotherapy after breast-conserving surgery were examined for late complications of radiotherapy after a median follow-up time of 51 months. Polymorphisms in genes involved in DNA repair (APEX1, XRCC1, XRCC2, XRCC3, XPD) and damage response (TP53, P21) were determined. Associations between telangiectasia and genotypes were assessed among 409 patients, using multivariate logistic regression. A total of 131 patients presented with telangiectasia and 28 patients with fibrosis. Patients with variant TP53 genotypes either for the Arg72Pro or the PIN3 polymorphism were at increased risk of telangiectasia. The odds ratios (OR) were 1.66 (95% confidence interval (CI): 1.02-2.72) for 72Pro carriers and 1.95 (95% CI: 1.13-3.35) for PIN3 A2 allele carriers compared with non-carriers. The TP53 haplotype containing both variant alleles was associated with almost a two-fold increase in risk (OR 1.97, 95% CI: 1.11-3.52) for telangiectasia. Variants in the TP53 gene may therefore modify the risk of late skin toxicity after radiotherapy.

Good agreement between physician and self-reported hormone therapy data in a case-control study.

OBJECTIVE: In a population-based case-control study examining the effects of postmenopausal hormone therapy (HT) on breast cancer risk, the authors conducted a validation study comparing prescription data from gynecologists with self-reports. STUDY DESIGN AND SETTING: The study was conducted in the Rhein-Neckar and Hamburg regions of Germany from 2002 to 2005. A total of 224 cases and 225 controls, stratified by region, age, and hormone use were randomly selected for the validation study. RESULTS: For ever/never use 88.2% agreement was seen, and agreement for ever/never use by type of HT was 80.6%, 80.3%, and 90.5% for mono-estrogen, cyclical combined, and continuous combined therapy, respectively. The intraclass correlation coefficient (ICC) for duration of use was high, 0.82 (95% confidence interval [CI]: 0.77, 0.85), as were the ICCs for age at first and last use, 0.88 (95% CI: 0.85, 0.91) and 0.98 (95% CI: 0.97, 0.98). Despite the exceptionally high number of different HT prescriptions available in Germany, comparison of exact brand name resulted in perfect agreement for 50.2% of participants, partial agreement for 29.3%, and no agreement for 20.7%. In general, agreement was not differential by disease status. CONCLUSION: Overall, the self-reported HT of the study participants corresponded well with physicians' reports.

Alcohol related conditions represent a major psychiatric problem in emergency departments.

BACKGROUND: Alcoholism represents a huge socioeconomic burden in most developed societies. METHODS: In order to determine the impact of conditions associated with alcohol abuse on emergency care, in 2002 all patients with alcohol related pathology presenting to the emergency department (ED) of a large urban university hospital in Germany were assessed. RESULTS: Of 2194 patients seen by psychiatrists in the ED, the 613 cases associated with alcohol abuse represented the largest diagnostic group (30.7%). Within this group, alcohol intoxication was the most frequent diagnosis (71.4%). Patients with an alcohol related condition needed treatment by different medical specialities and required diagnostic procedures significantly more often and consequently stayed significantly longer in the ED than patients with other psychiatric presentations. CONCLUSIONS: The generally underestimated problem of alcohol abuse in Germany demands an excessive amount of manpower and resources in EDs, where a high yet expensive standard of care is provided. Against this background, how far this burden can be reduced, both in EDs and in society in general, is discussed.

A common polymorphism of the protein Z gene is associated with protein Z plasma levels and with risk of cerebral ischemia in the young.

BACKGROUND AND PURPOSE: The vitamin K-dependent protein Z (PZ) has been shown to possess anticoagulant as well as procoagulant properties. Plasma levels of PZ show a broad interindividual variation, but it is unknown to which extent this variation is under genetic control. Recent clinical studies revealed contradictory results on the association of PZ plasma levels and the risk of ischemic stroke. METHODS: We performed a case-control study including 200 patients with cerebral ischemia aged < or =50 years and 199 control subjects from the same South German region. We investigated a possible association of 2 common single nucleotide mutations in the PZ gene with the risk of cerebral ischemia. Furthermore, enzyme-linked immunosorbent assay measurements were done in control subjects without vascular disease to detect a potential association of different genotypes with PZ plasma (antigen) levels. RESULTS: In patients, the frequency of the A allele of the intron F polymorphism G79A was significantly lower than in controls (15.7% versus 24.4%; odds ratio, 0.58; 95% CI, 0.39 to 0.86; P=0.007; adjusted for age, sex, and conventional risk factors). The G allele of the promoter polymorphism A-13G tended to be less common in patients (4.2% versus 7.0%; adjusted odds ratio, 0.56; 95% CI, 0.28 to 1.13; P=0.105). In 42 control subjects, the A allele of the intron F polymorphism was associated with lower PZ antigen levels (P=0.0032; Spearman correlation coefficient rs=-0.48). CONCLUSIONS: The A allele of an intron F polymorphism of the PZ gene appears to be a novel protective genetic marker for the risk of cerebral ischemia in young adults. In the context of juvenile stroke, high PZ plasma levels may represent a prothrombotic condition.

The Heidenhain variant of Creutzfeldt-Jakob disease.

OBJECTIVE: To investigate whether typical neuropathological and radiological findings can be identified in patients with the clinical diagnosis of the Heidenhain variant of Creutzfeldt-Jakob disease (CJD). DESIGN: Case study. The clinical symptoms, neuropathological findings, electroencephalograms, magnetic resonance images, and cerebrospinal fluid samples of 14 Heidenhain cases were evaluated. Neuropathological changes were compared with those in a group of 14 patients with ataxia as the leading clinical sign. SETTING: A university hospital, base of the German National Creutzfeldt-Jakob Disease Surveillance Study. PATIENTS: Medical records of 169 neurologically examined patients with prospectively classified and neuropathologically confirmed CJD were analyzed. MAIN OUTCOME MEASURE: Difference in neuropathological and radiological findings between patients with the Heidenhain variant and other patients with CJD. RESULTS: Of 169 patients with confirmed CJD, 20% showed characteristic clinical findings such as blurred vision, visual field restriction, metamorphopsia, or cortical blindness. Disease course of the Heidenhain group, as compared with the group of all patients with definite CJD, was significantly shorter (5.7 months vs 7.5 months; P=.02, t test). Neuropathological examination of patients with the Heidenhain variant showed most pronounced changes in the occipital lobe but less damage in the cingulate gyrus and basal ganglia compared with 14 patients with CJD who had ataxia as the leading clinical sign. Eleven (92%) of 12 genetically analyzed Heidenhain cases were homozygous for methionine at codon 129 of the prion protein gene (PRNP). In 9 of 9 cases, the 14-3-3 protein was present. In 7 (78%) of 9 cases, the level of neuron-specific enolase was elevated, with a concentration above 35 ng/mL. Periodic sharp-wave complexes were observed in 11 (78%) of the 14 cases. In 7 (63%) of 11 patients, magnetic resonance images showed symmetric hyperintensities in the basal ganglia in the T2- and proton-weighted sequence. In 4 of 11 cases the T2- and proton density-weighted images showed a pronounced signal increase confined to the gray matter of the occipital and visual cortex. Isolated atrophy of the visual cortex was noticeable in 2 of 11 cases. CONCLUSIONS: The clinical presentation of the Heidenhain variant of CJD was shown to correlate with the neuropathological findings of gliosis and nerve cell loss. In patients with visual disorders of unclear origin and signs of dementia, the differential diagnosis of a Heidenhain variant of CJD must be taken into consideration.

Phenotypic variability in fatal familial insomnia (D178N-129M) genotype.

OBJECTIVE: To report the clinical and pathologic features of patients with the D178N-129M mutation living in Germany. METHODS: Patients with clinically suspected Creutzfeldt-Jakob disease (CJD) were seen in an ongoing, prospective epidemiologic study from June 1993 to August 1997 throughout Germany. Suspect patients were referred to the CJD unit by the participating hospitals or physicians. Patients were seen by a physician, and each patient underwent a detailed neurologic examination. Prion protein gene (PRNP) analysis was performed to distinguish patients with familial forms of CJD. RESULTS: The constellation D178N-129M was identified in eight individuals; in one patient, the diagnosis was made by neuropathologic examination. Four affected men and five women belong to eight unrelated families. A family history of a neurodegenerative disorder was recalled in only five patients. In contrast to the first reported fatal familial insomnia (FFI) patient, none of our patients complained of severe, untreatable insomnia in the early stages. Dysautonomia was observed in varying degrees in most patients. The clinical course of these patients resembled sporadic CJD. In six patients, brain tissue was available for neuropathologic study. In one patient, the neuropathologic examination showed changes that were more reminiscent of forms of sporadic CJD; in the remaining five, the histopathology was typical of FFI. CONCLUSIONS: The clinical presentation in patients with FFI may vary to a great extent. Genotyping of the patients was crucial in providing laboratory confirmation of the diagnosis of FFI, even when there was no family history of a prion disease.

Treatment of acute renal failure with urodilatin after unrelated bone marrow transplantation in an 18-month-old boy.

Acute renal failure was imminent in an 18-month-old male infant 20 days after unrelated BMT. The infant was treated with urodilatin (URO), a natriuretic vasorelaxant peptide. Diuresis increased 2 h after the commencement of URO infusion and the furosemide infusion was reduced from 5 mg/h to 2.5 mg/h. After seven days of URO treatment diuresis was normal, the serum creatinine level had decreased, and furosemide was reduced from 12 mg/kg bw/d to 1.8 mg/kg bw/d. No side effects were observed either during or following URO therapy. We consider URO to be a promising drug for the treatment, without any apparent side effects, of imminent or manifest acute renal failure in infants following BMT.

High frequency repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex in schizophrenic patients.

Repetitive transcranial magnetic stimulation (rTMS) has been tried therapeutically in major depression. In order to investigate the therapeutic efficacy of rTMS in psychotic patients, 12 participants (four women, eight men) with schizophrenia according to DSM-IV criteria, aged 25 to 63 years (mean (+/-s.d) 40.4+/-11.0), were enrolled in the study. Following a double-blind crossover design, patients were treated at random with 2 weeks of daily left prefrontal rTMS (20 2s 20 Hz stimulations at 80% motor threshold over 20 min, dorsolateral preforntal cortex) and 2 weeks of sham stimulation. The Brief Psychiatric Rating Scale decreased under active rTMS (p <0.05), whereas depressive symptoms (BDI) and anxiety (STAI) did not change significantly. Prefrontal rTMS might be effective in the non-pharmacological treatment of psychotic patients.

Assessment of alcohol and other drug disorders in the seriously mentally ill.

Brief assessment methods are needed to determine the presence of alcohol and drug problems in persons with severe mental illness. The purposes of this study were to determine the prevalence of alcohol and other drug problems in a rural population of 253 clients with severe mental illness and to determine the accuracy of case manager responses to specific alcohol and drug assessment questions about their clients. Clients were assessed for the presence of past and present alcohol and drug disorders by means of a face-to-face diagnostic interview. The specific questions the case managers were asked to complete were designed to assess the quantity and frequency of recent alcohol and drug use and the presence of three criteria for alcohol or drug dependence and to differentiate present versus past history of substance problems. On the basis of the Diagnostic Interview Schedule- Revised, 35 percent of the clients met current DSM-III-R alcohol or drug criteria for abuse, dependence, or both. There were differences between client and case manager reports on the clients' use of alcohol, marijuana, cocaine, narcotics, and unprescribed tranquilizers in the last year. The best predictor of a client's present alcohol or drug problem was whether the case manager thought that the client had substance use problems at some time in his or her life (sensitivity = 0.86, specificity = 0.75). This report provides additional evidence that case manager reports are a valid method of determining the prevalence of substance use problems in persons with severe mental illness.

Increase of neuron-specific enolase in patients with Creutzfeldt-Jakob disease.

Creutzfeldt-Jakob disease (CJD) is a rare neurodegenerative human disorder with an incidence of one case per 1000000 per year. Recently new diagnostic tests such as neuron-specific enolase (NSE), S-100, tau-protein and protein 14-3-3 have been established as markers in prion diseases. NSE is elevated in case of rapid nerve cell loss so quantitative measurement of NSE in cerebrospinal fluid (CSF) might correlate with the disease progression. To further evaluate this hypothesis we analysed longitudinal CSF samples from 16 CJD patients. The first spinal tap was taken two weeks after the first clinical signs of a neurodegenerative disorder. This showed an elevation of NSE which continued during the course of the disease. Longitudinal examination of neuron-specific enolase in cerebrospinal fluid therefore may be useful for differentiation between CJD and other dementias.

Medical education about substance abuse: changes in curriculum and faculty between 1976 and 1992.

PURPOSE: To examine changes in substance abuse education in U.S. medical schools between 1976 and 1992. METHODS: In 1991-92 the authors conducted a 16-year follow-up survey of six clinical departments in each of the 126 U.S. medical schools. Two previous surveys by scholars and surveys conducted by the Liaison Committee on Medical Education, Association of American Medical Colleges, and the National Center for Medical Fellowships in the Addictions provided baseline data for comparison. The statistical methods used in the comparisons were paired t-tests, one-way analyses of variance, and tests of differences between proportions. RESULTS: Significant increases were found in the numbers of required and elective curriculum units for medical students between 1986-87 and 1991-92. The number of medical schools requiring courses in substance abuse treatment increased from five to eight between 1986-87 and 1991-92. For residents, there were significant increases in the numbers of curriculum units for residents in family medicine and pediatrics. The average number of faculty in the 116 medical schools that reported units on substance abuse was 4.1. There were 45 fellowships in addiction medicine identified in 1991-92, with a total of 61 fellows in training. CONCLUSION: While the findings confirm positive changes, the amount of curricula time and the number of faculty having expertise in substance abuse education do not compare well with the amounts of time and numbers of faculty involved in clinical problems of similar prevalence, such as cancer and heart disease.

Characteristics of persons with severe mental illness and substance abuse in rural areas.

A cross-sectional study of 1,551 clients receiving care in ten community-based rural mental health care systems assessed problem behaviors and psychiatric symptoms among three groups of severely mentally ill clients: those with a current substance abuse problem, those with a history of substance abuse but no current problem, and those with no history of substance abuse problems. Clients with a current substance abuse problem were younger than clients who had no history of such problems and had more symptoms of anger, more trouble with the law, and more suicidal threats than clients in the other two groups.

Correlates of depression in primary care.

BACKGROUND: Depression is a significant health problem in the United States. This study examined the relationship between depression and substance use, substance problems, conduct disorders, and sociodemographic factors in primary care settings. METHODS: A survey of 1898 patients in 88 primary care offices was conducted using a self-administered health-habits questionnaire. Depression was assessed for both lifetime and for the past 30 days using the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised (DSM-III-R) criteria. RESULTS: A total of 21.7% of women and 12.7% of men met DSM-III-R criteria for depression in the 30 days prior to completing the survey. Lifetime rates of depression were 36.1% for women and 23.3% for men. Young women who smoke, drink, or use marijuana, and both men and women with antisocial personality disorder and a family history of mental health problems are particularly at high risk for depression. CONCLUSIONS: One in 5 women and one in 10 men who see their primary care physicians have recently been depressed.

[Drowning by aspiration of oral saline administration]. / Ertrinken durch Aspiration nach peroraler Salzwasserverabreichung.

A fatal case of salt water ingestion of a 35-year old drug addict is presented. Resuscitation by emergency doctor after first-aid was not successful. Autopsy revealed the classical signs of drowning. In the sphenoid sinus sodium-chloride could be detected. The diagnosis and differential diagnosis of drowning is discussed.

[Death caused by stomach rupture due to overinflation during oxygen administration via stomach tube]. / Tod nach Magenruptur durch Uberdehnung infolge Sauerstoffgabe über Magensonde.

Soon after transfer from an intensive care unit to a normal ward within a hospital a 59-year-old female patient died. The investigation revealed that oxygen was insufflated accidentally through a nasogastric tube into the stomach and the intestinum. Autopsy showed a distended abdomen and odorless free gas streaming out of the opened abdomen. In the gastric wall, a 12 cm long rupture and 5 more incomplete ruptures were found. A most possible mechanism of gastric rupture due to overstretching by insufflated gas is presented. Criminal responsibility was excluded as the cause of the death could not be stated without reasonable doubt. The problem of selecting patients for intensive care to the disadvantage of others who also might profit from this special treatment is discussed.

Alcohol dehydrogenase 1B (ADH1B) genotype, alcohol consumption and breast cancer risk by age 50 years in a German case-control study.

In a population-based study of 613 cases and 1082 controls, alcohol dehydrogenase 1B (ADH1B) genotype was not an independent risk factor for breast cancer, although the possibility was raised that it modifies risk associated with high levels of alcohol consumption (OR 1.1, 95% confidence interval (CI) 0.8-1.6 for ADH1B*1/*1 genotype vs 0.2, 95% CI 0.1-1.0 for ADH1B*2 carriers).

Pseudohallucinations associated with moclobemide: a case report.

The goal of the multicenter drug surveillance project AMSP ("Arzneimittelsicherheit in der Psychiatrie") is the monitoring, assessment and analysis of adverse drug reactions (ADR) of psychopharmalogical drugs. We report about a 23 year-old patient with a depressive episode. He developed severe pseudohallucinations under a treatment with moclobemide. The symptoms occur 6 days after starting the medication and decline within two days after stopping moclobemide. The term "pseudohallucinations" is discussed controversially but still of high interest.