Changes in self-reported eating patterns after laparoscopic sleeve gastrectomy: a pre-post analysis and comparison with conservatively treated patients with obesity.

BACKGROUND: Patients with severe obesity need to adapt to surgically induced changes in their eating behaviors to maintain treatment success. OBJECTIVES: This study examined the effects of laparoscopic sleeve gastrectomy (LSG) on weight loss and on 3 dimensions of eating behavior, namely, cognitive restraint, disinhibition, and hunger. Outcomes of the LSG group were compared with a group of conservatively treated (CT) patients, who underwent a 1-year multimodal weight-reduction group program that included dietary advice, physical exercise, psychoeducation, cognitive-behavioral therapy, training in Jacobson's progressive muscle relaxation, and social group support. SETTING: The study setting was a multidisciplinary obesity center located in a university hospital. METHODS: A sample of 102 patients with obesity were investigated using the Three-Factor Eating Questionnaire before and, on average, 19 (±5) months after weight loss intervention. Of the 102 patients, 62 (age 45.8±10.8 years, 71% females) underwent LSG, and 40 patients (age 50.6±11.3 years, 77.5% females) underwent the CT program. Patients were assigned to either the surgical or the nonsurgical intervention group following clinical guidelines and patient preference. RESULTS: In the LSG group, total weight loss was 25.9±11.0%, excess weight loss was 52.8±24.1%, and body mass index decreased from 51.4±8.1 to 38.0±7.8 kg/m². In the CT group, total weight loss was 5.4±10.6%, excess weight loss was 13.9±27.1%, and body mass index decreased from 40.3±6.7 to 38.0±7.2 kg/m². Significant improvements in self-reported eating behaviors were observed in both groups, that is, an increased cognitive restraint of eating, a decreased disinhibition of eating control, and a reduced degree of perceived hunger. In contrast, whereas Three-Factor Eating Questionnaire scores before weight loss intervention did not differ between groups, LSG patients reported significantly greater reductions in disinhibition and hunger than CT patients did after weight loss intervention. In both groups, greater weight loss was associated with decreased hunger sensations. CONCLUSION: In the second follow-up year, LSG was associated with greater weight loss and greater improvements in self-reported eating behaviors compared with conservative treatment.

Plasma kisspeptin and ghrelin levels are independently correlated with physical activity in patients with anorexia nervosa.

While physical hyperactivity represents a frequent symptom of anorexia nervosa and may have a deleterious impact on the course of the disease, the underlying mechanisms are poorly understood. Since several food intake-regulatory hormones affect physical activity, the aim of the study was to investigate the association of physical activity with novel candidate hormones (kisspeptin, ghrelin, oxyntomodulin, orexin-A, FGF-21, R-spondin-1) possibly involved in patients with anorexia nervosa. Associations with psychometric parameters and body composition were also assessed. We included 38 female anorexia nervosa inpatients (body mass index, BMI, mean ± SD: 14.8 ± 1.7 kg/m2). Physical activity was evaluated using portable armband devices, body composition by bioelectrical impedance analysis. Blood withdrawal (hormones measured by ELISA) and psychometric assessment of depressiveness (PHQ-9), anxiety (GAD-7), perceived stress (PSQ-20) and disordered eating (EDI-2) were performed at the same time. Patients displayed a broad spectrum of physical activity (2479-26,047 steps/day) which showed a negative correlation with kisspeptin (r = -0.41, p = 0.01) and a positive association with ghrelin (r = 0.42, p = 0.01). The negative correlation with oxyntomodulin (r = -0.37, p = 0.03) was lost after consideration of potential confounders by regression analysis. No correlations were observed between physical activity and orexin-A, FGF-21 and R-spondin-1 (p > 0.05). Kisspeptin was positively correlated with BMI and body fat mass and negatively associated with the interpersonal distrust subscale of the EDI-2 (p < 0.01). Depressiveness, anxiety, and perceived stress did not correlate with kisspeptin or any other of the investigated hormones (p > 0.05). In conclusion, kisspeptin is inversely and ghrelin positively associated with physical activity as measured by daily step counts in anorexia nervosa patients suggesting an implication of these peptide hormones in the regulation of physical activity in anorexia nervosa.

Phoenixin is negatively associated with anxiety in obese men.

Phoenixin was recently identified in the rat hypothalamus and initially implicated in reproductive functions. A subsequent study described an anxiolytic effect of the peptide. The aim of the study was to investigate a possible association of circulating phoenixin with anxiety in humans. We therefore enrolled 68 inpatients with a broad spectrum of psychometrically measured anxiety (GAD-7). We investigated men since a menstrual cycle dependency of phoenixin has been assumed. Obese subjects were enrolled since they often report psychological comorbidities. In addition, we also assessed depressiveness (PHQ-9) and perceived stress (PSQ-20). Plasma phoenixin levels were measured using a commercial ELISA. First, we validated the ELISA kit performing a spike-and-recovery experiment showing a variance of 6.7±8.8% compared to the expected concentrations over the whole range of concentrations assessed, while a lower variation of 1.6±0.8% was observed in the linear range of the assay (0.07-2.1ng/ml). We detected phoenixin in the circulation of obese men at levels of 0.68±0.50ng/ml. These levels showed a negative association with anxiety scores (r=-0.259, p=0.043), while no additional associations with other psychometric parameters were observed. In summary, phoenixin is present in the human circulation and negatively associated with anxiety in obese men, a population often to report comorbid anxiety.

Improvement in self-reported eating-related psychopathology and physical health-related quality of life after laparoscopic sleeve gastrectomy: A pre-post analysis and comparison with conservatively treated patients with obesity.

OBJECTIVE: The present study examined the effects of laparoscopic sleeve gastrectomy (LSG) on self-reported eating-related psychopathology and health-related quality of life (HRQoL). Outcomes of the LSG group were compared with a group of conservatively treated (CT) patients, who underwent a 1-year multimodal weight reduction group program that included dietary advice, physical exercise, psychoeducation, cognitive-behavioral therapy, training in Jacobson's progressive muscle relaxation, and social group support. The setting was a multidisciplinary obesity center. METHOD: A sample of 103 patients with obesity were investigated using the Eating Disorder Inventory and the Short Form Health Survey before and, on average, 19 (±5) months after weight loss intervention. Thereof, 63 patients (age 45.6±10.9years, 71.4% females) underwent LSG, and 40 patients (age 50.6±11.3years, 77.5% females) underwent the CT program. Patients were assigned to either the surgical or the nonsurgical intervention group following clinical guidelines and patient preference. RESULTS: In the LSG group, excess weight loss (%EWL) was 53.0±24.0%, and body mass index (BMI) decreased from 51.5±8.1 to 38.0±7.7kg/m2. In the CT group, %EWL was 13.9±27.1%, and BMI decreased from 40.3±6.7 to 38.0±7.2kg/m2. Significant improvements in eating-related psychopathology were observed in both groups. Although both groups had a similar BMI after the respective interventions, LSG patients reported significantly greater body satisfaction and substantial improvement in perceived physical health from a lower baseline level than CT patients. DISCUSSION: In the second follow-up year, LSG was associated with greater weight loss from a higher baseline weight, and greater improvements in self-reported eating-related psychopathology and physical HRQoL compared with conservative treatment.

Associations of physical activity with depressiveness and coping in subjects with high-grade obesity aiming at bariatric surgery: a cross-sectional study.

BACKGROUND: Reduced physical activity is supposed to be associated with depressiveness and more passive coping patterns. For further evaluation of this assumed relation we studied energy expenditure due to physical activity - usually referred to as activity thermogenesis (AT) - together with depressiveness (clinical diagnosis, depression module of the Patient Health Questionnaire), and coping behaviours (Brief COPE Inventory) in 50 patients with high-grade obesity (42 ± 12 years; 9 with II° and 41 with III° obesity) aiming at bariatric surgery. METHODS: AT was assessed with a portable armband device (SenseWear™ armband). Depressiveness and coping were assessed using validated questionnaires. RESULTS: Weight-adjusted non-exercise AT and intensity of physical activity (metabolic equivalent) correlated inversely with body mass index (non-exercise AT: r = -0.32, P < 0.05; mean metabolic equivalent: r = -0.37, P < 0.01) but not with depressiveness. The coping strategies "support coping" and "active coping" showed significant inverse correlations to a) weight-adjusted non-exercise AT ("support coping": r = -0.34, P < 0.05; "active coping": r = -0.36, P < 0.05), b) weight-adjusted exercise-related AT ("support coping": r = -0.36, P < 0.05; "active coping": r = -0.38, P < 0.01) and c) intensity of physical activity (for mean metabolic equivalent: "support coping": r = -0.38, P < 0.01; "active coping": r = -0.40, P < 0.01; for duration of exercise-related AT: "support coping": r = -0.36, P < 0.05; "active coping": r = -0.38, P < 0.01). CONCLUSIONS: AT was not associated with depressiveness. Furthermore, supposed adaptive coping strategies of individuals aiming at bariatric surgery were negatively associated with AT.

Surgically and conservatively treated obese patients differ in psychological factors, regardless of body mass index or obesity-related co-morbidities: a comparison between groups and an analysis of predictors.

OBJECTIVE: For the treatment of obesity, both conservative and surgical procedures are available. Psychological factors are likely to influence the choice of treatment; however, to date, systematic studies that investigate these factors are few in number. The aim of our study was to analyze whether patients who undergo a surgical treatment differ from those who require a conservative treatment in regard to psychological factors, regardless of their somatic conditions. Furthermore, predictors of treatment choice will be examined. METHODS: A total of 244 patients (189 women), with a mean body mass index of 45.1 kg/m2, underwent a weight reduction treatment, with 126 patients undergoing bariatric surgery and 118 patients participating in a conservative, multimodal outpatient weight reduction program. Differences in the results of the psychological questionnaires between conservatively and surgically treated patients were evaluated through the use of t-tests, χ2-tests and an ANCOVA. For the analysis of the predictors, logistic regression models were calculated. RESULTS: Surgically and conservatively treated obese patients differ in psychological, somatic, and socio-demographic factors. The psychological differences between the groups are independent of obesity-related co-morbidities, such as body mass index (BMI), type 2 diabetes mellitus, hypertension and coronary heart disease. The following psychological and somatic factors equally predict the choice of bariatric surgery: apathy, delegated active coping, a sense of coherence, complaints, type 2 diabetes mellitus, BMI, and age. CONCLUSION: Longitudinal studies are required to assess the predictive value of the psychological factors in regard to the postsurgical weight course to improve the pre-surgical screening and treatment selection process. The pre-surgical identification of psychological predictors should result in a more personalized medicine course and may ensure long term outcomes.

Biological correlates of tinnitus-related distress: an exploratory study.

During the process of tinnitus diagnostics, various psychometric instruments are used to measure tinnitus-related distress. The aim of present work was to explore whether candidates for biological correlates of the tinnitus-related distress could be found in peripheral blood of patients and if so, whether there was association between them and psychometric scores that reflect tinnitus-related distress. The concentrations of interleukin-1ß (IL1ß), interleukin-6 (IL6), tumor necrosis factor-α (TNFα) and a brain-derived neutrotrophic factor (BDNF) were measured in serum of 30 patients diagnosed with chronic tinnitus and tested for correlation with psychometric scores collected on the same day. Spearman's correlation analyses detected significant positive association between the concentrations of tumor necrosis factor α and tinnitus loudness, total perceived stress, tension and depression and a negative association between tumor necrosis factor α and a psychometric score "joy". Concentrations of interleukin-1ß correlated with the awareness grade of tinnitus. The correlation between visual analogue scale (VAS) "loudness" and tumor necrosis factor α as well as between "joy" and tumor necrosis factor α retained their significance (p < 0.00167) after the application of Bonferroni correction for multiple testing. Partial correlations removing the effects of age, hearing loss and the duration of tinnitus verified the results obtained using Spearman correlation. We conclude that measuring the concentrations of selected circulating cytokines could possibly become an additional objective element of tinnitus diagnostics in the future.

Obese patients have higher circulating protein levels of dipeptidyl peptidase IV.

Dipeptidyl peptidase IV (DPPIV) is a protease with broad distribution involved in various homeostatic processes such as immune defense, psychoneuroendocrine functions and nutrition. While DPPIV protein levels were investigated in patients with hyporectic disorders, less is known under conditions of obesity. Therefore, we investigated DPPIV across a broad range of body mass index (BMI). Blood samples from hospitalized patients with normal weight (BMI 18.5-25 kg/m(2)), anorexia nervosa (BMI <17.5 kg/m(2)) and obesity (BMI 30-40, 40-50 and >50 kg/m(2), n = 15/group) were tested cross-sectionally and DPPIV concentration and total enzyme activity and the DPPIV targets, pancreatic polypeptide (PP) and glucagon-like peptide (GLP-1) were measured. DPPIV protein expression was detected in human plasma indicated by a strong band at the expected size of 110 kDa and another major band at 50 kDa, likely representing a fragment comprised of two heavy chains. Obese patients had higher DPPIV protein levels compared to normal weight and anorexics (+50%, p<0.05) resulting in a positive correlation with BMI (r = 0.34, p = 0.004). DPPIV serum activity was similar in all groups (p>0.05), while the concentration/activity ratio was higher in obese patients (p<0.05). Plasma PP levels were highest in anorexic patients (∼ 2-fold increase compared to other groups, p<0.05), whereas GLP-1 did not differ among groups (p<0.05). Taken together, circulating DPPIV protein levels depend on body weight with increased levels in obese resulting in an increased concentration/activity ratio. Since DPPIV deactivates food intake-inhibitory hormones like PP, an increased DPPIV concentration/activity ratio might contribute to reduced food intake-inhibitory signaling under conditions of obesity.

Balanced levels of nerve growth factor are required for normal pregnancy progression.

Nerve growth factor (NGF), the first identified member of the family of neurotrophins, is thought to play a critical role in the initiation of the decidual response in stress-challenged pregnant mice. However, the contribution of this pathway to physiological events during the establishment and maintenance of pregnancy remains largely elusive. Using NGF depletion and supplementation strategies alternatively, in this study, we demonstrated that a successful pregnancy is sensitive to disturbances in NGF levels in mice. Treatment with NGF further boosted fetal loss rates in the high-abortion rate CBA/J x DBA/2J mouse model by amplifying a local inflammatory response through recruitment of NGF-expressing immune cells, increased decidual innervation with substance P(+) nerve fibres and a Th1 cytokine shift. Similarly, treatment with a NGF-neutralising antibody in BALB/c-mated CBA/J mice, a normal-pregnancy model, also induced abortions associated with increased infiltration of tropomyosin kinase receptor A-expressing NK cells to the decidua. Importantly, in neither of the models, pregnancy loss was associated with defective ovarian function, angiogenesis or placental development. We further demonstrated that spontaneous abortion in humans is associated with up-regulated synthesis and an aberrant distribution of NGF in placental tissue. Thus, a local threshold of NGF expression seems to be necessary to ensure maternal tolerance in healthy pregnancies, but when surpassed may result in fetal rejection due to exacerbated inflammation.

Surgeons' work engagement: influencing factors and relations to job and life satisfaction.

BACKGROUND: Work engagement has become a topic of great interest in recent years. However, clinicians' work engagement has rarely been studied and relatively little is known about its predictors and consequences. Therefore the objective of this cross-sectional questionnaire study was to test a model of possible institutional and personal predictors and significant relations to job and life satisfaction. METHODS: 123 clinicians specializing in Surgery Medicine participated in the study. Self-administered questionnaires, including the Copenhagen Psychosocial Questionnaire, the Utrecht Work Engagement Scale, the Brief Resilient Coping Scale and the Questionnaire for Self-efficacy, Optimism and Pessimism, were administered. Bivariate analyses and a stepwise regression analysis were performed. RESULTS: The whole sample of surgeons rated work engagement with a high mean of M = 4.38; SD = .91. Job satisfaction and perceived quality of life have been rated with moderate scores. The results show that job resources have a greater impact on surgeons' work engagement than their job demands. Significant correlations between surgeons' work engagement, their job satisfaction and quality of life were found. Moreover, work engagement mediated the relation between institutional factors and surgeons' job satisfaction. CONCLUSION: Our research suggests that strengthening surgeons' work engagement will contribute to a more sustainable workplace, in terms of both individual and hospital performance. Therefore, increasing work engagement among surgeons should be of concern for supervisors and hospital managers. Future research should focus on further predictors that may have an influence on health professionals' work engagement. Another field for future research is to study potential effects of interventions on work engagement.

Surgeons' work ability and performance in surgical care: relations between organisational predictors, work engagement and work ability.

BACKGROUND: The aim of this study was to examine relations and influences between work-related factors, personal resources, work engagement and work ability of surgeons working in German hospitals. METHODS: The study was conducted as a cross-sectional survey investigation. We used the Utrecht Work Engagement Scale, the Copenhagen Psychosocial Questionnaire and the Work Ability Index to evaluate surgeons' work engagement, working conditions and work ability. Bivariate analyses and a stepwise regression analysis were performed. RESULTS: Surgeons reported a moderate work ability and work engagement. The results indicated significant associations between surgeons' sources of work engagement, work ability and work-related factors (e.g. job resources). Significant differences regarding these variables were also detected between males and females and the various age groups. CONCLUSION: The study results reflect the positive effect of supportive working conditions and work engagement on the preservation of work ability, indicating their importance in promoting surgeons' work ability. Due to the elderly population and the continuing development of health care in Germany, the demand for surgeons increases. These circumstances give reasons for a strong need to preserve and restore surgeons' work ability. New strategies for training and improving the capacity and performance of surgeons are necessary.

The CCKB antagonist CI988 reduces food intake in fasted rats via a dopamine mediated pathway.

Studies have shown a reduction of food intake following peripheral and brain injection of CCK. However, it remains to be established whether endogenous central CCK is involved in the regulation of food intake. We investigated the role of central CCK in the regulation of food intake by pharmacological manipulation of the CCK(B) (CCK(2)) receptor system. Intracerebroventricularly (ICV) cannulated male Sprague Dawley rats were fasted for 24h and received an ICV injection of the CCK(B) receptor antagonist CI988 at a dose of 10 nmol or 49 nmol or vehicle. Another group received two consecutive ICV injections consisting of the corticotropin-releasing factor (CRF) receptor-1 (CRF(1)) antagonist, CP376395 (3 nmol) or the CRF(2) receptor antagonist, K41498 (2 nmol) alone, or followed by CI988 (49 nmol). Lastly, another group of rats received an intraperitoneal (IP) injection of the dopamine antagonist, flupentixol (~197 and ~493nmol/kg) alone, or followed by CI988 (49 nmol, ICV). Cumulative food intake was assessed for 11h. Vehicle injected rats showed a robust feeding response. CI988 at 49 nmol reduced food intake by 30% starting at 2h post injection. CP376395 and K41498 had no effect on food intake. Flupentixol injected IP at a dose of 197 and 493 nmol/kg alone did not modulate food intake whereas the higher dose blocked the CI988-induced reduction of feeding. During the dark phase, CI988 had no effect on food intake in unfasted rats. In summary, CCK(B) signaling is involved in the regulation of food intake after a fast likely by downstream dopamine signaling.

Exposure of Wistar rats to 24-h psycho-social stress alters gene expression in the inferior colliculus.

Recently, we have demonstrated that the exposure of Wistar rats to psycho-social stress results in a transient auditory hypersensitivity. Here, to learn more about modifications occurring in auditory brainstem, we have analyzed gene expression pattern in inferior colliculus using quantitative RT-PCR. As targets, we have chosen genes associated with: neural activity (FBJ osteosarcoma viral oncogene, cFos), hypoxia (nitric oxide synthase inducible, iNos; superoxide dismutase 2, Sod2), neuroprotection (nerve growth factor beta, Ngfb; heat shock factor 1, Hsf1; heat shock protein 70, Hsp70) and inflammation (tumor necrosis factor alpha, Tnfa; tumor necrosis factor alpha receptor, Tnfar; substance P, Sp; cyclooxygenase 2, Cox2). We found that the expression of all genes was modified following stress, as compared to the controls. Immediately after stress, the number of transcripts encoding iNos, Sod2, Hsf1, Ngfb, Tnfa, Tnfar and Sp was significantly increased, suggesting possible modulation during exposure to stressor. Interestingly, we found that expression of Hsf1 and Ngfb at this particular time was left-right asymmetrical: there were more transcripts of both genes found in the left colliculi, as compared to the right colliculi. Three hours post-stress, iNos, Hsf1, Tnfa and Tnfar were still upregulated, Sod2, Ngfb and Sp went back to baseline and Cox2 was upregulated. Six hours post-stress, cFos mRNA became downregulated. The number of Hsp70 mRNA increased 24h post-stress. Except for the reduced number of cFos transcripts, expression of all other genes tested reached the baseline seven days post-stress. Presented results corroborate the concept of auditory system responding to the psycho-social stress. Post-stress changes in the IC gene expression could likely indicate shift from allostasis to homeostasis in the auditory brainstem.

The neuroimmune connection interferes with tissue regeneration and chronic inflammatory disease in the skin.

Research over the past decades has revealed close interactions between the nervous and immune systems that regulate peripheral inflammation and link psychosocial stress with chronic somatic disease. Besides activation of the sympathetic and the hypothalamus-pituitary-adrenal axis, stress leads to increased neurotrophin and neuropeptide production in organs at the self-environment interface. The scope of this short review is to discuss key functions of these stress mediators in the skin, an exemplary stress-targeted and stress-sensitive organ. We will focus on the skin's response to acute and chronic stress in tissue regeneration and pathogenesis of allergic inflammation, psoriasis, and skin cancer to illustrate the impact of local stress-induced neuroimmune interaction on chronic inflammation.

Improving quality of medical treatment and care: are surgeons' working conditions and job satisfaction associated to patient satisfaction?

BACKGROUND: Over the last decades, surgeons, researchers, and health administrators have been working hard to define standards for high-quality treatment and care in Surgery departments. However, it is unclear whether patients' perceptions of medical treatment and care are related and affected by surgeons' perceptions of their working conditions and job satisfaction. The aim of this study was to evaluate patients' satisfaction in relation to surgeons' working conditions. METHODS: A cross-sectional survey with 120 patients and 109 surgeons working in Surgery hospital departments was performed. Surgeons completed a survey evaluating their working conditions and job satisfaction. Patients assessed quality of medical care and treatment and their satisfaction with being a patient in this department. RESULTS: Seventy percent of the patients were satisfied with performed surgeries and services in their department. Surgeons' job satisfaction and working conditions rated with moderate scores. Bivariate analyses showed correlations between patients' satisfaction and surgeons' job satisfaction and working conditions. Strongest correlations were found between kindness of medical staff, treatment outcome and overall patient satisfaction. CONCLUSION: This study demonstrates strong associations between surgeons' working conditions and patient satisfaction. Based on these findings, hospital managements should improve work organization, workload, and job resources to not only improve surgeons' job satisfaction but also quality of medical treatment and patient satisfaction in Surgery departments.

Early expression of pregnancy-specific glycoprotein 22 (PSG22) by trophoblast cells modulates angiogenesis in mice.

Mouse and human pregnancy-specific glycoproteins (PSG) are known to exert immunomodulatory functions during pregnancy by inducing maternal leukocytes to secrete anti-inflammatory cytokines that promote a tolerogenic decidual microenvironment. Many such anti-inflammatory mediators also function as proangiogenic factors, which, along with the reported association of murine PSG with the uterine vasculature, suggest that PSG may contribute to the vascular adaptations necessary for successful implantation and placental development. We observed that PSG22 is strongly expressed around the embryonic crypt on Gestation Day 5.5, indicating that trophoblast giant cells are the main source of PSG22 during the early stages of pregnancy. PSG22 treatment up-regulated the secretion of transforming growth factor beta 1 and vascular endothelial growth factor A (VEGFA) in murine macrophages, uterine dendritic cells, and natural killer cells. A possible role of PSGs in uteroplacental angiogenesis is further supported by the finding that incubation of endothelial cells with PSG22 resulted in the formation of tubes in the presence and absence of VEGFA. We determined that PSG22, like human PSG1 and murine PSG17 and PSG23, binds to the heparan sulfate chains in syndecans. Therefore, our findings indicate that despite the independent evolution and expansion of human and rodent PSG, members in both families have conserved functions that include their ability to induce anti-inflammatory cytokines and proangiogenic factors as well as to induce the formation of capillary structures by endothelial cells. In summary, our results indicate that PSG22, the most abundant PSG expressed during mouse early pregnancy, is likely a major contributor to the establishment of a successful pregnancy.

Time and motion study of anesthesiologists' workflow in German hospitals.

BACKGROUND: The purpose of this study was to investigate anesthesiologists' workflow in real time. METHODS: Anesthesiologists were observed for a total of 60 workdays. All tasks performed during this time were recorded in real time. RESULTS: The anesthesiologists were shadowed for a total of 517:16:36 hours. The average workday lasted 08:37:17 hours. Overall they spent 28.5% of each workday on indirect patient care, 14.7% on direct patient care and 18.8% on administrative work. Communication took up 19.9% of anesthesiologists' time, breaks and disruptions 15.2% and other job tasks 2.9%. CONCLUSIONS: The results comprise objective data about the workflow and working conditions in anesthesiology. We found support of the large imbalance between the direct patient care and the heavy administrative workload reported by physicians. These results may be useful in future efforts to improve anesthesiologists' working conditions and workflow optimization.

Neutralization of LPS or blockage of TLR4 signaling prevents stress-triggered fetal loss in murine pregnancy.

Maternal stress can cause loss of both histocompatible (syngeneic) and histoincompatible (semiallogeneic) embryos in pregnant mice. Stress increases abortogenic Th1 cytokines and reduces levels of anti-abortogenic Th2 cytokines, progesterone levels, and T regulatory cell activity. While physiological levels of interferon-γ promote vascular remodeling at the feto-maternal interface, an overshooting Th1 cytokine response requires a Toll-like receptor (TLR)-mediated "danger signal" such as lipopolysaccharide (LPS). Interestingly, stress can enhance permeability of mucosal membranes to entry of bacterial products and promote transmucosal migration of commensal bacteria. We hypothesized that bacterial component such as LPS may provide the danger signal through which stress triggers maternal immune activation, subsequently resulting in fetal rejection. Blocking the TLR4 receptor for LPS or neutralization of LPS using bactericidal permeability increasing protein abrogate fetal loss due to sonic stress challenge in DBA/2J-mated CBA/J mice. These treatments prevented stress-triggered immune responses in the decidua, upregulated Treg cells, and reduced the frequency of mature dendritic cells in uterine-draining lymph nodes but not in the uterus. Interestingly, anti-TLR4 treatment only partly ameliorated stress-induced endocrine responses, such as increased hypothalamic corticotropin releasing hormone and vasopressin mRNA expression but not decrease of serum progesterone. Galectin-1 knock-out mice were more susceptible to stress-triggered complete implantation failure rather than fetal loss, which was also abolished by LPS neutralization. Insights provided in this paper shed new light on the mechanisms by which stress affects pregnancy outcome and introduce microbial-derived LPS as a mediator within the cascade of stress-triggered immune and endocrine events during pregnancy.

Real time analysis of psychiatrists' workflow in German hospitals.

BACKGROUND: The increasing administrative workload of German psychiatrists has led to rising dissatisfaction among physicians. Previous studies have assessed job satisfaction by conducting surveys among medical professionals. However, to date, no objective work task analysis has been conducted to investigate the workflow of psychiatrists in Germany. AIM: The objective of this study was to evaluate physicians' workflow, to assess the level of work efficiency of German psychiatrists in a real time analysis. METHOD: A trained observer accompanied 24 psychiatrists throughout complete shifts. A mobile computer was used to record all tasks. All psychiatrists were observed for total of 980:04:15 h. RESULTS: The average psychiatrist's workday lasted 09:03:19 h (standard deviation, s=01:01:20 h). Internal communication was the most frequently observed main activity (mean=2:58:15 h; s=0:48:10 h). Psychiatrists spent on average 0:52:12 h a day on indirect patient care (s=0:32:50 h; 5.60%). All administrative tasks accounted for roughly 1 h of the average workday (s=0:17:58 h; 10.75%). During the wobservation period, physicians were interrupted 17.37 times a day on average (s=5.81). During the observational period, simultaneous activities were recorded for a total of 17:27:54 h. CONCLUSION: This research is the first to investigate workflow of psychiatrists in German hospitals. Their work was found to be mostly communicative, although administrative work also demanded much of their time. High rates of multitasking and interruptions in the workflow, as seen for the psychiatrists in this study, could lead to possible medical errors, making further investigation of current working conditions necessary.

Depression, mood, stress, and Th1/Th2 immune balance in primary breast cancer patients undergoing classical massage therapy.

PURPOSE: Cancer patients frequently suffer from psychological comorbidities such as depression and elevated stress. Previous studies could demonstrate that cancer patients benefit from massage therapy on the physical and psychological level. This pilot study investigates the effects of massage on depression, mood, perceived stress, and the Th1/Th2 ratio in breast cancer patients. METHODS: Thirty-four breast cancer patients were randomly assigned to a massage group (n=17) and a control group (n=17). Patients of the massage group received two 30-min classical massages per week for 5 weeks. At baseline, at the end of the intervention period, and 6 weeks after the end of intervention, patients of both groups completed the Perceived Stress Questionnaire (PSQ), the Patient Health Questionnaire (PHQ), and the Berlin Mood Questionnaire (BFS) and blood was withdrawn for determining cytokine concentrations and the Th1/Th2 ratio. RESULTS: Twenty-nine patients were included in the statistical analysis. Depression (PHQ) and anxious depression (BSF) were significantly reduced immediately after massage compared to the control group. Stress (PSQ) and elevated mood (BSF) did not show significant alterations after massage therapy. Changes of cytokine concentrations and Th1/Th2 ratio were insignificant as well, although there was a slight shift towards Th1 in the massage group over time. CONCLUSIONS: Massage therapy is an efficient treatment for reducing depression in breast cancer patients. Insignificant results concerning immunological parameters, stress, and mood indicate that further research is needed to determine psychological and immunological changes under massage therapy.