[Psychotherapy of depressive disorders: Evidence in chronic depression and comorbidities]. / Psychotherapie depressiver Störungen: Evidenz bei chronischer Depression und bei Komorbidität.

BACKGROUND: Psychotherapy has been shown to be an effective treatment option for depressive disorders; however, its effectiveness varies depending on patient and therapist characteristics and the individual form of the depressive disorder. OBJECTIVES: The aim of this article is to present the current evidence for psychotherapeutic antidepressive treatments for patients with chronic and treatment-resistant depression as well as for patients with mental and somatic comorbidities. MATERIAL AND METHODS: During the revision of the currently valid German S3- and National Disease Management Guideline (NDMG) on unipolar depression published in 2015, a comprehensive and systematic evidence search including psychotherapy for specific patient groups was conducted. The results of this search along with a systematic update are summarized. RESULTS: Psychotherapy has been shown to be effective in reducing depressive symptoms in patients suffering from chronic and treatment-resistant depression and in patients with mental and somatic comorbidities. The evidence is insufficient particularly for patients with mental comorbidities. CONCLUSION: Based on the current evidence and clinical expertise the NDMG recommends psychotherapy alone or in combination with pharmacotherapy to treat most of these depressive patient groups. Evidence gaps were identified, which highlight the need for further research.

[Psychotherapy of depressive disorders : Procedures, evidence and perspectives]. / Psychotherapie depressiver Störungen : Verfahren, Evidenz und Perspektiven.

BACKGROUND: Depressive disorders are associated with a high burden of suffering and significantly reduce the well-being and the self-esteem of affected patients. Psychotherapy is one of the main treatment options for depressive disorders. OBJECTIVE: The aim of this article is to present the current evidence for antidepressive psychotherapeutic treatments. MATERIAL AND METHODS: During the revision of the German S3- and National Disease Management Guideline (NDMG) on unipolar depression in 2015, a comprehensive and systematic evidence search was conducted. The results of this search along with a systematic update are summarized. RESULTS: The most intensively investigated psychotherapeutic method is cognitive behavioral therapy (CBT), which proved to be effective in many trials. Evidence also exists for psychodynamic psychotherapy and interpersonal therapy (IPT), followed by systemic therapy and client-centered psychotherapy; however, the evidence is less robust. CONCLUSION: Psychotherapy alone or in combination with pharmacotherapy was shown to be an effective treatment option. Psychotherapy represents a key element in the treatment of depressive disorders.

[Mental disorders in pregnancy and postpartum : Prevalence, course, and clinical diagnostics]. / Psychiatrische Erkrankungen in Schwangerschaft und Stillzeit : Häufigkeit, Verlauf und klinische Diagnostik.

The peripartum period represents a critical phase for the onset and course of mental disorders. During this phase, mental disorders occur as first onset or, more often, as recurrent or ongoing chronic conditions with onset and further course of illness in- or outside the peripartal period. No clear risk increase exists for the more prevalent mental disorders such as depressive and anxiety disorders during this period, whereas there is an increased risk for bipolar disorder. Peripartal mental disorders may impact fetal and child development through different mechanisms. The International Statistical Classification of Diseases and Related Health Problems (ICD-10) does not sufficiently take into account particularities of peripartal disorders with possible prognostic relevance. The present article gives an overview on prevalence, course, and clinical diagnostics and presents a proposal for consistent categorization of peripartal mental disorders.

[Prognosis and quality of life after decompressive hemicraniectomy: a nationwide survey in Germany on the attitudes held by doctors and nurses]. / Prognose und Lebensqualität nach Entlastungstrepanation : Eine deutschlandweite Erhebung zu den Einstellungen von Ärzten und Krankenpflegepersonal.

BACKGROUND: Decompressive hemicraniectomy reduces mortality in patients with space-occupying MCA infarction. Quality of life in surviving patients is discussed controversially. We assessed attitudes of neurologists and nurses providing care to this patient group towards decompressive hemicraniectomy. METHODS: A postal questionnaire on attitudes and opinions on prognosis and quality of life after decompressive hemicraniectomy was returned by 280 neurologists and 166 nurses from tertiary care centers throughout Germany. RESULTS: In both groups of professionals, estimates of the probability of survival after decompressive hemicraniectomy and the resulting degree of disability were consistent with results of clinical outcomes studies. Only 9% of the nurses and 33% of the physicians assumed that the majority of survivors achieve an acceptable quality of life; 58% of physicians and 32% of nurses would suggest decompressive hemicraniectomy to their nearest relative. Under the assumption of an uncertain outcome, 61% of physicians and 22% of nurses would agree to decompressive hemicraniectomy. In both professional groups, agreement for surgery increases when scenarios with a more favorable outcome were proposed [modified Rankin Scale (mRS) 2-5)]. If an outcome of 4 on the mRS is proposed, indicating moderately severe disability, only a minority favored decompressive hemicraniectomy (25% of doctors and 8% of nurses). CONCLUSIONS: Despite a realistic assessment of prognosis after decompressive hemicraniectomy, a majority of respondents estimated the quality of life of survivors as unsatisfactory. Nurses had a more pessimistic attitude towards decompressive hemicraniectomy. The majority of respondents consider an outcome of 4 on the mRS as unacceptable.

[Evidence-based therapy of depression: S3 guidelines on unipolar depression]. / Evidenzbasierte Therapie der Depression: Die S3-Leitlinie unipolare Depression.

Unipolar depressive disorders are among the most frequent reasons for utilizing the health care system. Although efficacious treatments are available and further advances have recently been made there is still a need for improving diagnostic and therapeutic procedures. Alignment of treatment on evidence-based treatment guidelines establishes an essential mainstay. The new S3 and National Health Care guidelines on unipolar depression, the compilation of which was coordinated by the German Society of Psychiatry, Psychotherapy and Neurology (DGPPN) and which were approved by 29 scientific and professional associations, is the ambitious effort to present state of the art evidence and clinical consensus for the treatment of depression. For pharmacotherapy of depression differentiated recommendations can be given, also separate from and in addition to psychotherapy.

[Perioperative fatal bleeding: link between acetabular anchoring of a cementless implant]. / Perioperative tödliche Blutungskomplikation: Lagebeziehung zwischen azetabulären Verankerungen einer zementfreien Hüftpfanne und den Iliakalgefässen.

This case report concerns a 75-year-old patient who suffered haemorrhagic shock and mors in tabula during implantation of a total hip arthroplasty. The cause was established as an injury of the external iliac vein, probably as a result of the predrilling of holes for the anchoring screws and pegs. The surgical method and topographic anatomy of the operating area are presented. Such vascular injuries are a rare but life-threatening complication of this procedure; the literature quotes a frequency of about 0.3%. So far, no fulminate venous bleeding process has been reported. Complications in such operations cannot always be avoided. However, detailed knowledge of the acetabular geometry can provide more safety for the surgeon when carrying out the secondary anchoring of a press-fit implant.

[Reconstruction of lower limbs in old age-an interdisciplinary approach : Geriatric assessment, perioperative management, diagnostics and treatment targets]. / Rekonstruktion der unteren Extremität im Alter ­ ein interdisziplinärer Ansatz : Geriatrisches Assessment, perioperatives Management, Diagnostik und Therapieziele.

Complex injuries of the lower extremities in geriatric patients with multiple pre-existing comorbidities represent an increasing challenge to an interdisciplinary team of surgeons. Functional reconstruction of the extremity through osteosynthesis, revascularization and defect coverage aims to preserve mobility and achieve an early return to activities of daily life at home, while avoiding major amputation and the associated risks regarding morbidity and mortality. An interdisciplinary assessment of geriatric patients regarding dystrophy of soft tissue and skín, cardiovascular and metabolic comorbidities as well as specific geriatric diagnostics are crucial steps in ensuring favorable outcomes. Perioperatively, all improvable risk factors should be actively optimized and a specialized interdisciplinary approach to treatment planning (extremity board) is absolutely necessary for success of treatment. It outlines the special features of the geriatric assessment, diagnostics, perioperative management and treatment targets.

[Reconstruction of lower limbs in old age-an interdisciplinary approach : Strategies for trauma surgery, vascular surgery and plastic surgery]. / Rekonstruktion der unteren Extremität im Alter ­ ein interdisziplinärer Ansatz : Unfallchirurgische, gefäßchirurgische und plastisch-chirurgische Strategien.

The treatment of complex injuries of the lower extremities in geriatric and/or multimorbid patients requires optimized preoperative and perioperative management as well as differentiated and interdisciplinary surgical approaches. Timely and definitive treatment should be strived for to avoid longer periods of immobilization. Temporary external stabilization of complex fractures, when necessary, should be followed by permanent loading stable internal osteosynthesis as soon as possible. Accompanying soft tissue defects are reconstructed after wound débridement using the full armamentarium of plastic and reconstructive surgical procedures, including microvascular free flap. In the context of perfusion compromised soft tissue situations, negative pressure wound therapy can provide sterile temporary defect coverage and aid in preconditioning poorly vascularized tissue before definitive reconstruction. A clarification of the vascular status in geriatric patients is paramount and relevant perfusion disorders should be treated either by intervention or open surgery before complex reconstructive interventions. Close interdisciplinary coordination of the various surgical procedures is imperative in order to guarantee an optimized stable reconstructive outcome with acceptable patient risk. Taking these principles into account, the reconstruction of complex trauma to the extremities can be carried out even in geriatric or multimorbid patients in specialized interdisciplinary surgical centers with excellent functional results.

Acetogenic bacteria: what are the in situ consequences of their diverse metabolic versatilities?

The four decades of the now classic studies by Harland G. Wood and Lars G. Ljungdahl lead to the resolution of the autotrophic acetyl-CoA 'Wood/Ljungdahl' pathway of acetogenesis. This pathway is the hallmark of acetogens, but is also used by other bacteria, including methanogens and sulfate-reducing bacteria, for both catabolic and anabolic purposes. Thus, the pathway is wide spread in nature and plays an important role in the global turnover of carbon. Because most historical studies with acetogens focused on the biochemistry of the acetyl-CoA pathway, the metabolic diversity and ecology of acetogens remained largely unexplored for many years. Although acetogens were initially conceived to be a somewhat obscure bacteriological group with limited metabolic capabilities, it is now clear that acctogens are arguably the most metabolically diverse group of obligate anaerobes characterized to date. Their anaerobic metabolic arsenal includes the capacity to oxidize diverse substrates, including aromatic, C1, C2, and halogenated compounds, and engage a large number of alternative energy-conserving, terminal electron-accepting processes, including classic fermentations and the dissimilation of inorganic nitrogen. In this regard, one might consider acetogens on a collective basis as the pseudomonads of obligate anaerobes. By virtue of their diverse metabolic talents, acetogens can be found in essentially all habitats. This review evaluates the metabolic versatilities of acetogens relative to both the engagement (regulation) of the acetyl-CoA pathway and the ecological roles likely played by this bacteriogical group.

[3-dimensional sonography in the diagnosis of meniscal lesions. An experimental and clinical study]. / Die dreidimensionale Sonographie in der Diagnostik von Meniscusläsionen. Eine experimentelle und klinische Studie.

There is no consensus regarding the clinical significance of conventional two-dimensional ultrasound in the diagnosis of meniscal tears of the knee. Three-dimensional ultrasound spatially reconstructs a transparent image of subsequent ultrasound scans. In an experimental study of 96 menisci, radial and oblique tears were detected more often by three-dimensional ultrasound. In a clinical study of 60 menisci the two- and three-dimensional ultrasound reached a sensitivity of 92% and 100%, a specificity of 83% and 88%, a positive predictive value of 58% and 67%, and a negative predictive value of 98% and 100%, respectively. Altogether, there was no statistically significant difference between both methods. The high negative predictive value, however, shows that the three-dimensional ultrasound may be a clinically relevant examination for special questions in the diagnostics of meniscal tears.

Flattened circadian cortisol rhythm in type 2 diabetes.

INTRODUCTION: While altered cortisol concentrations have been observed in subjects with type 2 diabetes their circadian cortisol profile is unknown. PATIENTS AND METHODS: Using a cross-sectional design, we studied 63 ambulatory individuals with type 2 diabetes and 916 non-diabetic control subjects of the Cooperative Research in the Region of Augsburg (KORA)-F3 study. Circadian cortisol profiles were derived from saliva cortisol concentrations, determined on a regular weekday upon wake-up (F0), as well as ½ h (F½), 8 (F8) and 14 h (F14) after wake-up. RESULTS: Diabetic subjects exhibited a flattened circadian cortisol profile (rm-ANOVA: F[3,654]=3.41, p=0.02), with lower morning and higher afternoon and evening cortisol concentrations. CONCLUSION: We observed a flattened circadian cortisol rhythm in subjects with type 2 diabetes, providing evidence for a specific HPA system dysfunction.

[Multiaxial classification of stalking. Guidelines for the assessment of criminal liability and prognosis]. / Multiaxiale Klassifikation von Stalkingfällen. Leitfaden zur Begutachtung von Schuldfähigkeit und Prognose.

Stalking is a widespread phenomenon describing a pattern of intrusive and threatening behaviour that leads to the victim's perception of being harassed and of him or her being rendered fearful. Physical assault and even homicide may occur in the context of stalking. Anglo-Saxon studies have revealed a lifetime prevalence of being a victim of stalking ranging from 4-7% in men and 12-17% in women. Recently, these rates have been confirmed by the first community based study carried out in Germany. As a stalker can have a number of victims during his or her lifetime, the prevalence of stalkers may be less than this, although at present data for this are lacking. Although the phenomenology of stalking appears to be rather homogenous, fairly distinct stalker typologies and perpetrator-victim relationships have to be considered. Requests for psychiatric and forensic assessment of stalkers are increasing. According to the German penal code, psychiatrists must provide expert opinion on criminal responsibility and the placement of stalkers. So far, all typologies of stalkers refer to the Anglo-Saxon cultural background and do not consider the special needs of German forensic psychiatry. In particular, the psychopathological dimension is widely neglected in common typologies. The present paper proposes a multiaxial typology of stalking that considers the psychopathological dimension, the relationship between stalker and victim and motivational aspects. Consequences for the forensic psychiatric assessment according to section 20, 21 StGB are outlined. It should be pointed out that stalking is not a new diagnostic category, but only involves, at a descriptive level, deviation from a normal behavioural pattern. The central components of the forensic psychiatric assessment remain the known diagnostic categories, the effects of which on behaviour can be analysed.

[Reliability and validity of the Revised Beck Depression Inventory (BDI-II). Results from German samples]. / Reliabilität und Validität des revidierten Beck-Depressionsinventars (BDI-II). Befunde aus deutschsprachigen Stichproben.

BACKGROUND: The Beck Depression Inventory (BDI) underwent revision in 1996 (BDI-II) with the goal of addressing DSM-IV depression criteria. The present study assessed psychometric properties of the German version of the BDI-II. PATIENTS AND METHODS: The BDI-II was translated into German and evaluated in a series of studies with clinical and nonclinical samples. RESULTS: The content validity of the BDI-II has improved by following DSM-IV symptom criteria. Internal consistency was satisfactorily high (alpha>or=0.84), and retest reliability exceeded r>or=0.75 in nonclinical samples. Associations with construct-related scales (depression, dysfunctional cognitive constructs) were high, while those with nonsymptomatic personality assessment (NEO-FFI) were lower. The BDI-II differentiated well between different grades of depression and was sensitive to change. CONCLUSION: The German BDI-II demonstrates good reliability and validity in clinical and nonclinical samples. It may now replace the older version of the BDI for assessing self-rated severity of depression and course of depressed symptoms under treatment.

[Psychiatric significance of stalking]. / Psychiatrische Relevanz von Stalking.

AIMS: To provide an overview on the psychiatric significance of stalking and the implications for the health care system. RESULTS: Stalking is a widespread phenomenon and can result in significant health care problems. CONCLUSION: In the future physicians will have to deal with this problem in a professional manner.

[Investigation of episode-characteristics of unipolar psychotic depression]. / Eine Untersuchung zur Episodencharakteristik unipolarer psychotischer Depression.

The present study examines episode characteristics in unipolar psychotic depression. From a sample of unipolar endogenous depressed inpatients, patients with a psychotic index episode (n = 19) were compared to nonpsychotic patients (n = 86) with regard to case history, characteristics of the inpatient episode, residual symptoms at discharge from hospital and course of illness up to seven months after discharge. Psychotic depressed patients displayed more severe observer-rated depressive symptoms at admission and were more likely to have attempted suicide prior to admission. In the post-discharge short-term course of depression, these patients showed a more pronounced symptom homogeneity in the extreme ranges, which occurred by stable remissions or by prolonged symptomatology in need of treatment. These findings, together with the observation of higher stabilities of symptom scores in the psychotically depressed, emphasize the prognostic significance of symptomatology at discharge to the post-discharge episode course in these patients.

[Vascularized fibula transplantation in orthopedic oncology. Personal experience and review of the literature]. / Die vaskularisierte Fibulatransplantation in der orthopädischen Onkologie. Eigene Erfahrung und Literaturübersicht.

Primary malignant bone tumors can be treated predominantly with limb salvage. After resection of large articular segments adjacent to the dia- or metaphysis of long bones modular endoprosthetic devices are most commonly used for reconstruction. In case non-vascularized corticocancellous bone is transplanted in order to bridge extensive bone defects, the risk of pseudarthrosis and fracture of the donor bone is significantly higher in comparison to a free vascularized transplant. From 1988 until 1999 we treated 20 patients with extensive bone defects after resection of tumors affecting the upper and lower extremity using a vascularized fibular graft. In this retrospective analysis we collected the data focusing on bone integration and functional outcome. The graft union was classified according to the standards of the "International Symposium of Limb Salvage". Evaluation of the functional outcome was quantified using the Enneking-score. The stabilisation of the transplant was obtained exclusively by plate fixation in the upper extremity. In 10 in a total of 12 patients the reconstruction using a vascularized fibula transfer was reinforced with an allograft in the lower extremity. The functional evaluation score reached 73% of normal function at the last follow-up. After 18 months the radiographic evaluation of graft union was "excellent" in 75%, "good" in 11%, "fair" in 6% and "poor" in 9% according to the criteria of the ISOLS. Main complications were graft fracture in of 15% and pseudarthrosis in 14.3%. Reconstruction of extensive bone defects using free vascularized fibula grafts are a demanding operative procedure. The procedure combines a biologic form of reconstruction with a legitimate expectation of good long term outcome and a relatively low rate of complications.

Relatives and depressive relapse: the critical period after discharge from in-patient treatment.

In a sample of 60 remitted depressed in-patients, the power of three basic parameters of the social support network--Kin Support Network Size; Non-kin Support Network Size; and Satisfaction with Support--to predict depressive symptom levels seven months after discharge was examined. The results suggest that even positive, supportive family relationships can have a distinctly detrimental effect, and that a depressed in-patient's return to his or her family represents a crucial period for the further course of the disorder. The findings are discussed with respect to the social support literature and the 'Expressed Emotion' concept. It is held that neither paradigm provides an adequate explanation, and alternative mediating mechanisms are suggested.

Component A2 of methylcoenzyme M reductase system from Methanobacterium thermoautotrophicum delta H: nucleotide sequence and functional expression by Escherichia coli.

The gene for component A2 of the methylcoenzyme M reductase system from Methanobacterium thermoautotrophicum delta H was cloned, and its nucleotide sequence was determined. The gene for A2, designated atwA, encodes an acidic protein of 59,335 Da. Amino acid sequence analysis revealed partial homology of A2 to a number of eucaryotic and bacterial proteins in the ATP-binding cassette (ABC) family of transport systems. Component A2 possesses two ATP-binding domains. A 2.2-kb XmaI-BamHI fragment containing atwA and the surrounding open reading frames was cloned into pGEM-7Zf(+). A cell extract from this strain replaced purified A2 from M. thermoautotrophicum delta H in an in vitro methylreductase assay.

Generation of a proton motive force by the anaerobic oxalate-degrading bacterium Oxalobacter formigenes.

The generation of transmembrane ion gradients by Oxalobacter formigenes cells metabolizing oxalate was studied. The magnitudes of both the transmembrane electrical potential (delta psi) and the pH gradient (internal alkaline) decreased with increasing external pH; quantitatively, the delta psi was the most important component of the proton motive force. As the extracellular pH of metabolizing cells was increased, intracellular pH increased and remained alkaline relative to the external pH, indicating that O. formigenes possesses a limited capacity to regulate internal pH. The generation of a delta psi by concentrated suspensions of O. formigenes cells was inhibited by the K+ ionophore valinomycin and the protonophore carbonyl cyanide-m-chlorophenylhydrazone, but not by the Na+ ionophore monensin. The H+ ATPase inhibitor N,N'-dicyclohexyl-carbodiimide inhibited oxalate catabolism but did not dissipate the delta psi. The results support the concept that energy from oxalate metabolism by O. formigenes is conserved not as a sodium ion gradient but rather, at least partially, as a transmembrane hydrogen ion gradient produced during the electrogenic exchange of substrate (oxalate) and product (formate) and from internal proton consumption during oxalate decarboxylation.

On the way to expert systems. Comparing DSM-III computer diagnoses with CATEGO (ICD) diagnoses in depressive and schizophrenic patients.

Operationalized diagnostics deal with the standardized assessment of psychiatric symptoms as well as diagnostic criteria. As a diagnostic system based on criteria, the DSM-III was chosen to identify operationalized diagnoses based on the Present State Examination (PSE-9) and some additional DSM-III specific items. By relating PSE symptoms to the diagnostic criteria of DSM-III, an easily applicable expert system leading to DSM-III diagnoses was developed. In two samples of 30 schizophrenic and 51 depressive patients the DSM-III computer diagnoses are contrasted with the ICD-8 diagnoses of the PSE/CATEGO system. In defining a "case", only minimal differences between the two computer programs were found. In the sample of schizophrenics, CATEGO led to 114 (81%) diagnoses and the DSM-III program to 112 (79%) diagnoses; for the depressive patients 43% cases were identified by CATEGO and 45% by the DSM-III algorithm. Comparing the diagnosis of "acute schizophrenic disorders", both programs arrived at similar percentages. (CATEGO: 51%; DSM-III: 57%). However, CATEGO is limited to two different subtypes (295.2 and 295.3), whereas the DSM-III program covers the total range of possible schizophrenic subtypes. Furthermore, the DSM-III program identified residual subtypes of schizophrenia in 23% of the diagnostic decisions. In the short-term course of the schizophrenic patients, CATEGO identified 27%-43% with affective diagnoses with high stability per cross-section. Using the DSM-III algorithm affective diagnoses were rather rare (maximum of 17%), marking unstable changes from acute to residual states of the psychosis.(ABSTRACT TRUNCATED AT 250 WORDS)