Budget Impact Analysis of the FreeStyle Libre Flash Continuous Glucose Monitoring System® in Patients with Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus with Multiple Daily Insulin Injections in Argentina

OBJECTIVE

To estimate the budget impact of the potential coverage of FreeStyle Libre Flash Continuous Glucose Monitoring System (FSL) for glycemia monitoring in all type 1 diabetes mellitus (T1DM) patients and in those with type 2 diabetes mellitus (T2DM) with multiple daily insulin injections, from the social security and the private third-party payer's perspective in Argentina.

METHODS

A budget impact model was developed to estimate the cost difference between the self-monitoring of blood glucose (standard of care) and FSL over 5 years. Input parameters were retrieved from local literature complemented by expert opinion. Health care costs were estimated by a micro-costing approach and reported in USD as of April 2022 (1 USD = 113.34 Argentine pesos). One-way sensitivity and scenario analyses were conducted.

RESULTS

From a social security third-party payer perspective, the incorporation of FSL was associated with net savings per member per month (PMPM) of $0.026 (Year 1) to $0.097 (Year 5) and net savings PMPM of $0.002 (Year 1) to $0.008 (Year 5) for T1DM and T2DM patients, respectively. Similar findings are reported from the private third-party payer perspective. The budget impact results were more sensitive to the acquisition costs of the FSL and test strips.

CONCLUSION

The potential coverage of FSL in patients with T1DM and T2DM with multiple daily insulin injections could be associated with small financial savings considering current technology acquisition costs (FSL and test strips) for social security and the private sector third-party payers in Argentina.

Publication activities relating to digital teaching and learning in the GMS Journal for Medical Education - a descriptive analysis (1984-2020)

AIMS AND OBJECTIVES

Digital teaching, learning and assessment have been part of medical education and continuing education for decades. The objective of this review paper is to highlight developments and perspectives in these areas in the GMS Journal for Medical Education (GMS JME).

METHODOLOGY

In the spring of 2020, we conducted a systematic literature search of the Journal for Medical Education (JME) and analysed the articles with regard to different categories such as article type, digital tools used or mode of data collection.

RESULTS

Of the 132 articles analysed, 78 were digital interventions (53 of which were exploratory-descriptive), 28 were project descriptions, 16 were surveys of needs or equipment and 10 were concept papers. About one-third of the studies and project reports each dealt with virtual patients or case-based learning, whereas no articles were published on trends such as serious games or virtual reality. Overall, our analysis shows that in many respects, the studies on digital teaching were more broadly based, especially between 2006 and 2010, after which this trend tended to decline again.

CONCLUSIONS

Our analysis shows that publications in the JME consider some key aspects of digital teaching in medical education and continuing education, such as educational videos or virtual patients. The variability of information and methods of presentation advocate the use of guidelines to optimise the quality of scientific papers. Furthermore, clues for future research topics and experimental study designs are identified.

Effects of Computer-Assisted Social Skills Training in Children With Disruptive Behavior Disorders: A Randomized Controlled Trial

OBJECTIVE

Computer-assisted child-focused interventions are expected to improve efficiency and personalization of therapist-led treatments for children and adolescents. However, therapist-led, outpatient interventions using computer assistance are lacking for children with oppositional defiant disorder (ODD) or conduct disorder (CD). The present randomized controlled trial examined the efficacy of individualized computer-assisted social skills training for children with aggressive behavior compared to a resource activation intervention.

METHOD

A total of 100 children aged 6-12 years with a diagnosis of ODD/CD and peer-related aggression were randomly (1:1) assigned to either individually delivered computer-assisted social skills training (ScouT) or an individually delivered supportive resource activation treatment (STARK). The primary outcome was parent-rated peer-related aggression, assessed with the respective scale of the Questionnaire for Aggressive Behavior of Children (FAVK) and measured at pre-assessment and after the 16-week intervention (post-assessment). Further parent-, self-, teacher- and/or clinician-rated outcomes included ODD and CD symptoms, a wide range of behavioral and emotional symptoms, callous-unemotional traits, functional impairment, and quality of life.

RESULTS

After correcting for multiple testing, analyses of covariance comparing the efficacy of ScouT to the efficacy of STARK yielded small to moderate treatment effects in favor of the ScouT condition regarding parent-rated peer-related aggression (primary outcome; d = -0.64, 95% CI = -1.05, -0.24), parent-rated callous and uncaring traits, and parent-rated quality of life. However, the analyses did not reveal any significant effects for self- or teacher-rated peer-related aggression assessed with the respective scale of the FAVK (self-report: d = -0.21, 95% CI = -0.69, 0.29; teacher rating: d = -0.17, 95% CI = -0.56, 0.22). Moreover, after controlling for multiple comparisons, no significant effects emerged for the following: parent-, self-, and teacher-rated adult-related aggression; parent-, self-, teacher-, and clinician-rated ODD and CD symptoms; parent-, self-, and teacher-rated emotional and behavioral symptoms; and parent-rated functional impairment.

CONCLUSION

According to parent ratings, school-age children with disruptive behavior disorders and peer-related aggression seem to benefit more from individualized, computer-assisted social skills training than from resource activation treatment. However, this conclusion is limited by the missing effects on the clinician-, self-, and teacher-rated measures.

CLINICAL TRIAL REGISTRATION INFORMATION

Treatment of Children With Peer Related Aggressive Behavior (ScouT); https://clinicaltrials.gov/; NCT02143427.

The Alcohol Dependence Scale and DSM-5 alcohol use disorder: Severity ratings correspond insufficiently in older patients

OBJECTIVES

To investigate the psychometric properties of the frequently used Alcohol Dependence Scale (ADS) in older adults and the associations between ADS scores and alcohol use and DSM-5 AUD symptom counts.

METHODS

Using baseline data from an international multicenter RCT on outpatient AUD treatment for adults aged 60+ with DSM-5 alcohol use disorder (AUD; n = 529), we computed Cronbach's alpha (α) and applied confirmatory (CFA) and exploratory factor analysis (EFA) to determine the underlying factor structure. A structural equation model (SEM) explored the interrelationship of latent ADS factors with alcohol use and number of DSM-5 criteria endorsed.

RESULTS

Internal consistency of the ADS (α = 0.81) was good. EFA revealed a three-factor structure. Factor 1 ("Severe withdrawal symptoms") consisted of severe psychoperceptual and psychophysical consequences of excessive drinking, Factor 2 ("Loss of control") consisted of acute physical reactions of intoxication, and Factor 3 ("Obsessive-compulsive drinking") described habitual drinking. The SEM suggested that only Factor 3 had large effects on DSM-5 symptom score and drinking behavior.

CONCLUSION

Lowering the ADS threshold or focusing on ADS items from Factor 3 may be more suitable measures of severity of alcohol dependence in treatment-seeking older adults as ADS scores are low and not closely related to DSM-5 AUD.

Intermittent low dose carbon monoxide inhalation does not influence glucose regulation in overweight adults: a randomized controlled crossover trial

NEW FINDINGS

What is the central question of this study? Low dose carbon monoxide (CO) inhalation plays a role in regulating proteins involved in glucose metabolism; does low dose CO improve glucose and insulin responses to an oral glucose tolerance test in overweight adults? What is the main finding and its importance? Five days of intermittent CO inhalation does not alter the glucose or insulin responses to ingestion of a glucose bolus in overweight adults. Low dose CO is utilized in various physiological assessment procedures; these findings allow researchers and clinicians to utilize these procedures without concern of altering glucose metabolism.

ABSTRACT

Low dose carbon monoxide (CO) inhalation upregulates several proteins important for glucose metabolism. Such changes could be clinically significant and may be relevant to those who use CO as a research tool. We hypothesized that low dose CO inhalation would improve glucose and insulin responses to an oral glucose bolus in overweight humans. Eleven young adults (5 men, 6 women; body mass index: 25-35 kg m^-2 ) were included in this randomized, placebo-controlled, single-blinded crossover study. Following screening, participants completed two 7-day protocols with a 4-week washout. Twenty-four hours prior to and following five consecutive days of either once daily CO (men: 1.2 ml (kg body mass)^-1 ; women: 1.0 ml (kg body mass)^-1 ) or placebo (room air) inhalation, participants underwent oral glucose tolerance tests (OGTT). For key outcome variables, there were no significant main effects or interactions across condition or time point (mean ± SD), including fasting glucose (mg dl^-1 : pre-placebo: 85.2 ± 10.1; post-placebo: 82.9 ± 10.6; pre-CO: 83.6 ± 7.7; post-CO: 84.0 ± 9.0), 2 h post glucose (mg dl^-1 : pre-placebo: 100.9 ± 20.0; post-placebo: 98.7 ± 13.1; pre-CO: 94.2 ± 23.2; post-CO: 94.4 ± 14.9), or the Matsuda index (pre-placebo: 16.1 ± 11.5; post-placebo: 20.3 ± 24.7; pre-CO: 15.6 ± 15.3; post-CO: 17.5 ± 16.8). In conclusion, 5 days of low dose CO administration did not influence glucose and insulin responses to an OGTT in overweight adults. Low dose CO inhalation is utilized in a variety of physiological assessment procedures; these findings allow researchers to utilize these procedures without concern of altering glucose metabolism.

Evaluation of adding the community reinforcement approach to motivational enhancement therapy for adults aged 60 years and older with DSM-5 alcohol use disorder: a randomized controlled trial

AIM

To examine whether adding the Community Reinforcement Approach for Seniors (CRA-S) to Motivational Enhancement Therapy (MET) increases the probability of treatment success in people aged ≥ 60 years with alcohol use disorder (AUD).

DESIGN

A single blind multi-centre multi-national randomized (1 : 1) controlled trial.

SETTING

Out-patient settings (municipal alcohol treatment clinics in Denmark, specialized addiction care facilities in Germany and a primary care clinic in the United States).

PARTICIPANTS

Between January 2014 and May 2016, 693 patients aged 60+ years and fulfilling DSM-5 criteria for AUD participated in comparing MET (n = 351) and MET + CRA-S (n = 342).

INTERVENTION AND COMPARATOR

MET (comparator) included four manualized sessions aimed at increasing motivation to change and establishing a change plan. CRA-S (intervention) consisted of up to eight further optional, manualized sessions aimed at helping patients to implement their change plan. CRA-S included a specially designed module on coping with age and age-related problems.

MEASUREMENTS

The primary outcome was either total alcohol abstinence or an expected blood alcohol concentration of ≤ 0.05% during the 30 days preceding the 26 weeks follow-up (defined as success) or blood alcohol concentration of > 0.05% during the follow-up period (defined as failure). This was assessed by self-report using the Form 90 instrument. The main analysis involved complete cases.

FINDINGS

The follow-up rate at 26 weeks was 76.2% (76.9% in the MET group and 76.0% in the MET + CRA-S group). The success rate in the MET group was 48.9% [95% confidence interval (CI) = 42.9-54.9%] versus 52.3% (95% CI = 46.2-58.3%) in the MET + CRA-S group. The odds of success in the two conditions did not differ (odds ratio = 1.22. 95% CI = 0.86-1.75, P = 0.26, Bayes factor = 0.10). Sensitivity analyses involving alternative approaches to missing values did not change the results.

CONCLUSIONS

In older adults with an alcohol use disorder diagnosis, adding the 'community reinforcement approach for seniors' intervention to brief out-patient motivational enhancement therapy treatment did not improve drinking outcome.

What do elderly problem drinkers aim for? Choice of goal for treatment among elderly treatment-seeking alcohol-dependent patients

OBJECTIVE

The patient's free choice of treatment goals for alcohol use disorder (AUD) is predictive for treatment outcome. Presently there is limited knowledge of whether the age at onset of AUD influences the choice of goal for treatment. The present study investigates whether there are differences in choice of treatment goal between patients with very late onset alcohol use disorder (VLO AUD ≥ 60 years) and those having early or mid-age onset of AUD (EMO AUD < 60 years).

METHOD

Participants were 341 persons, voluntarily enrolled in the Elderly Study, who were seeking treatment for AUD in outpatient centres for alcohol treatment in Denmark. Data regarding thoughts about abstinence, alcohol use in the last 90 days, motivation for treatment and psychiatric diagnosis were collected via questionnaires. A logistics regression was used to analyse the data.

RESULTS

32.1% of the participants with VLO AUD chose temporary abstinence goals, compared to 18.2% of the patients with earlier-onset AUD (p = 0.024). Further, 10.7% of participants with VLO AUD chose total abstinence goals compared to 31.3% of participants with early or mid-age onset AUD (p = 0.002).

CONCLUSION

There are significant differences in choice of goal between participants with very late onset AUD and early or mid-age onset AUD. Individuals with very late onset alcohol use disorder tend to choose temporary abstinence over any other treatment goal whereas, in general, individuals with early onset alcohol use disorder choose permanent abstinence over other treatment goals.

Estimation of the Number of People With Opioid Addiction in Germany

BACKGROUND

Opioid addiction is one of the most common substance-related disorders worldwide, and morbidity and mortality due to opioid addiction place a heavy burden on society. Knowing the size of the population that is addicted to opioids is a prerequisite for the development and implementation of appropriate health-policy measures.

METHODS

Our estimate for Germany for 2016 is based on an enumeration of opioid-addicted persons who were entered in a registry of persons receiving substitution therapy, an enumeration of persons receiving outpatient and inpatient care for addiction without substitution therapy, an extrapolation to all addiction care facilities, and an estimation of the number of opioid-addicted persons who were not accounted for either in the substitution registry or in addiction care.

RESULTS

The overall estimate of the number of opioid-addicted persons in Germany in 2016 was 166 294 persons (lower and upper bounds: 164 794 and 167 794), including 123 988 men (122 968 to 125 007) and 42 307 women (41 826 to 42 787). The estimates for each German federal state per 1000 inhabitants ranged from 0.1 in Brandenburg to 3.0 in North Rhine-Westphalia and 5.5 in Bremen. The average value across Germany was 3.1 per 1000 inhabitants.

CONCLUSION

Comparisons with earlier estimates suggest that the number of persons addicted to opioids in Germany has hardly changed over the past 20 years. Despite methodological limitations, this estimate can be considered highly valid. Nearly all persons who are addicted to opioids are in contact with the addiction care system.

Who uses self-exclusion to regulate problem gambling? A systematic literature review

BACKGROUND AND AIMS

Self-exclusion programs offer an intervention for individuals with problem gambling behavior. However, these programs are insufficiently used. This review describes sociodemographic features and gambling behavior of self-excluders as well as goals and motives for initiating self-exclusion from terrestrial and online gambling. In addition, use of further professional help and barriers to self-exclusion are examined.

METHODS

Based on systematic literature search and quality assessment, n = 16 original studies (13 quantitative, 2 qualitative, and 1 mixed method) published between 1997 and 2017 in English or German language were analyzed. Results are presented for online and terrestrial gambling separately.

RESULTS

Online self-excluders were on average 10 years younger than terrestrial self-excluders. Self-exclusion was mainly motivated by financial problems, followed by feelings of losing control and problems with significant others. Financial problems and significant others were less important for online than for terrestrial gamblers. Main barriers for self-exclusion were complicated enrollment processes, lack of complete exclusion from all venues, little support from venue staff, and lack of adequate information on self-exclusion programs. Both self-excluders from terrestrial and online gambling had negative attitudes toward the need of professional addiction care.

CONCLUSION

To exploit the full potential of self-exclusion as a measure of gambler protection, its acceptance and its utilization need to be increased by target-group-specific information addressing financial issues and the role of significant others, simplifying the administrative processes, facilitating self-exclusion at an early stage of the gambling career, offering self-determined exclusion durations, and promoting additional use of professional addiction care.

Help-seeking behaviour of problem gamblers: a narrative review

Abstract. Background: There is evidence for low rates of help-seeking among problem gamblers. Identifying reasons for and barriers to seeking help is essential for improving help supply and gamblers’ treatment utilisation. The present study examines treatment utilisation of problem or pathological gamblers and reviews the evidence related to motives for and barriers to seeking help. Methods: The databases Medline, PsycInfo, and PubMed were searched for English-, Swedish- and German-language studies published between 2000 and 2017. Furthermore relevant references of included studies were analysed. Results: After exclusion of non-relevant publications 34 journal articles and seven reports covering the prevalence of help-seeking among gamblers or self-reported reasons for/barriers to help-seeking were maintained. The proportion of problem gamblers seeking help was less than 10 % in most studies. Problem severity was found positively associated with treatment attendance. Financial issues, negative emotions and crises were identified as main motives for seeking treatment. Main barriers to seeking treatment were shame, problem denial and lack of treatment availability. The results were similar across the examined studies. Conclusion: Low rates of treatment utilisation by problem gamblers strongly indicate that treatment providers and the society should strive to eliminate structural barriers that hinder gamblers to seek help. To better match problem gamblers´ needs, low-threshold early intervention, increasing knowledge of treatment options and efforts to reduce stigmatisation are important strategies to enhance access to help offers.

Older adults in treatment for alcohol use disorders: service utilisation, patient characteristics and treatment outcomes

Background

In western countries demographic changes are leading to an ageing society. Consequently, the number of older adults with alcohol use disorders (AUDs) will rise and the demand of treatment is likely to increase. However, thus far not many older adults with an AUD are seeking treatment and little is known about the efficacy of treatment for older adults. The present study aimed at determining the proportion of older adults with an AUD in addiction treatment, particular characteristics and treatment outcomes of this clientele.

Methods

Using data of 10,860 patients with an AUD aged 60 and over that are documented within the national German addiction care system we conducted exploratory analyses with regard to prevalence, sociodemographic, disorder- and treatment-related variables.

Results

Overall, we found a low proportion of older patients in treatment due to AUDs, but highly positive treatment outcomes. With regard to sociodemographic and disorder-related characteristics, older females and late-onset patients in particular constitute a unique clientele.

Conclusions

The low service utilisation on the one hand but good treatment prognosis on the other emphasise the need to promote treatment seeking among older adults with AUDs. In this context, the special characteristics we found among older patients may contribute to better reach this population and to improve provisions of targeted treatment approaches.

DSM-5 alcohol use disorder features among treatment-seeking older adults

Abstract. Background: The number of older adults with alcohol use disorder (AUD) is expected to rise. Adapted treatments for this group are lacking and information on AUD features in treatment seeking older adults is scarce. The international multicenter randomized-controlled clinical trial “ELDERLY-Study” with few exclusion criteria was conducted to investigate two outpatient AUD-treatments for adults aged 60+ with DSM-5 AUD. Aims: To add to 1) basic methodological information on the ELDERLY-Study by providing information on AUD features in ELDERLY-participants taking into account country and gender, and 2) knowledge on AUD features in older adults seeking outpatient treatment. Methods: baseline data from the German and Danish ELDERLY-sites (n=544) were used. AUD diagnoses were obtained with the Mini International Neuropsychiatric Interview, alcohol use information with Form 90. Results: Lost control, desired control, mental/physical problem, and craving were the most prevalent (> 70 %) AUD-symptoms. 54.9 % reported severe DSM-5 AUD (moderate: 28.2 %, mild: 16.9 %). Mean daily alcohol use was 6.3 drinks at 12 grams ethanol each. 93.9 % reported binging. More intense alcohol use was associated with greater AUD-severity and male gender. Country effects showed for alcohol use and AUD-severity. Conclusion: European ELDERLY-participants presented typical dependence symptoms, a wide range of severity, and intense alcohol use. This may underline the clinical significance of AUD in treatment-seeking seniors.

Die ELDERLY-Studie: Design und Stichprobe einer Untersuchung zur ambulanten Psychotherapie von Alkoholkonsumstörungen bei älteren Erwachsenen

Ziel Über die ELDERLY-Studie zur Erprobung zweier ambulanter Kurzinterventionen (Einzelsetting) für Menschen im Alter 60+ mit DSM-5 Alkoholkonsumstörung (AKS) in Deutschland zu informieren.

Methoden Eine internationale, multizentrische, randomisiert-kontrollierte Studie ohne Medikamentengabe, mit einer Eingangs- und 4 Folgeuntersuchungen. Studienteilnehmer wurden zufallsbasiert einer Behandlungsvariante zugewiesen: 4 Sitzungen Motivierende Gesprächsführung (MET) oder 12 Sitzungen MET und Community Reinforcement Approach for Seniors (CRAS).

Ergebnisse N=203 Personen nahmen in Deutschland an der Studie teil (47,8% Frauen, Durchschnittsalter: 66,5 Jahre). Alle Schweregrade einer DSM-5 AKS waren vertreten (schwergradig: 32,5%). Die Intervention wurde von den Teilnehmern überwiegend positiv bewertet.

Schlussfolgerungen Ältere Menschen mit AKS sind einer ambulanten Kurzintervention gegenüber aufgeschlossen. Sie weisen nicht zwingend nur leichtgradige AKS auf.

Spielersperren in Deutschland: Stand der gesetzlichen Glücksspielregelungen und ihre Umsetzung

Spielersperren stellen eine Maßnahme des Spielerschutzes dar. Ziel der vorliegenden Arbeit ist die Darstellung der derzeitigen Gesetzesgrundlage von Spielersperren in Deutschland und den Bundesländern und beispielhaft ihrer Nutzung in Bayern. Während auf Basis des Glücksspielstaatsvertrags für das staatliche Glücksspiel eine bundesweite Sperrdatei existiert, werden Spielersperren für das gewerbliche Glücksspiel länderspezifisch organisiert. Aufgrund der uneinheitlichen Gesetzeslage besteht trotz einer ausgesprochenen Spielersperre die Möglichkeit, auf andere Spielformen oder Spielstätten auszuweichen. Diese Gegebenheiten sollten im Beratungs- oder Behandlungskontext aufgegriffen werden, um betroffenen Glücksspielenden eine Abstinenz zu erleichtern. Für eine breite Nutzung von Spielersperren sind strukturelle Veränderungen der derzeitigen Organisation von Spielersperren nötig. Zum einem bedarf es unter Einbeziehung des gewerblichen Glücksspiels einer einheitlichen Regelung mit einer übergreifenden Sperrdatei. Zum anderen könnte über den Abbau von Barrieren und die Einführung transparenter Kriterien für die Entsperrung die Akzeptanz von Spielersperren erhöht werden.

Co-occurring Mental Disorders in Substance Abuse Treatment: the Current Health Care Situation in Germany

Aim of this study was to investigate the current health care situation for patients with co-occurring mental disorders in addiction treatment. Therefore, data from the German Substance Abuse Treatment System (N = 194,406) was analysed with regard to the prevalence of comorbid mental disorders, treatment characteristics and outcomes of patients with comorbid psychiatric diagnosis. In outpatient setting, the prevalence of comorbid diagnoses was considerably lower (4.6%) than in inpatient setting (50.7%), but mood and anxiety disorders were the most prevalent additional diagnoses in both settings. In the treatment of patients with these comorbid disorders, we found higher rates of complementary internal and external (psychiatric) treatment, more co-operations and referrals after treatment, and positive treatment process outcomes. Findings indicate that the knowledge of an additional diagnosis influences the health care provision of affected patients and can therefore be seen as the essential precondition for providing adequate and comprehensive treatment. This highlights the importance of a sufficient consideration and diagnostic assessment of mental disorders in addiction treatment to further improve the health care situation of comorbid patients.

Prenatal and adult androgen activities in alcohol dependence

OBJECTIVE

Alcohol dependence is more prevalent in men than in women. The evidence for how prenatal and adult androgens influence alcohol dependence is limited. We investigated the effects of prenatal and adult androgen activity on alcohol dependence. Moreover, we studied how the behaviours of pregnant women affect their children's prenatal androgen load.

METHOD

We quantified prenatal androgen markers (e.g., second-to-fourth finger length ratio [2D : 4D]) and blood androgens in 200 early-abstinent alcohol-dependent in-patients and 240 controls (2013-2015, including a 12-month follow-up). We also surveyed 134 women during pregnancy (2005-2007) and measured the 2D : 4D of their children (2013-2016).

RESULTS

The prenatal androgen loads were higher in the male alcohol-dependent patients compared to the controls (lower 2D : 4D, P = 0.004) and correlated positively with the patients' liver transaminase activities (P < 0.001) and alcohol withdrawal severity (P = 0.019). Higher prenatal androgen loads and increasing androgen levels during withdrawal predicted earlier and more frequent 12-month hospital readmission in alcohol-dependent patients (P < 0.005). Moreover, stress levels (P = 0.002), alcohol (P = 0.010) and tobacco consumption (P = 0.017), and lifetime stressors (P = 0.019) of women during pregnancy related positively to their children's prenatal androgen loads (lower 2D : 4D).

CONCLUSION

Androgen activities in alcohol-dependent patients and behaviours of pregnant women represent novel preventive and therapeutic targets of alcohol dependence.

500 years of reformation: The history of Martin Luther's pathography and its ethical implications

Introduction

In the context of the 500th anniversary of the Reformation, it is time to take a survey of the history of Martin Luther's (1483–1546) pathography.

Method

Relevant writings were evaluated.

Results

While in a 1035 page work written in German between 1937 and 1941, the Dane Paul Reiter retrospectively diagnosed Luther as manic-depressive, Kretschmer (1888–1964) in 1955 saw in Luther “a great polemic and organizer”. In 1956, Grossmann was unable to prove persistent synchronicity of depressive mood and reduced motivation in Luther in the key years 1527 and 1528, which led him to conclude that Luther had a cyclothymic personality with a pyknic constitution. In Roper's view in 2016, Luther suffered from “a condition […], that we would call depression today”.

Discussion

In 1948, Werner concluded that Reiter's pathography was based on an incorrect assumption: Luther's solution of the cloister conflict as a dilemma situation between paternal and clerical authority was not a flight into “the mysticism of despair”. Hamm adopted this interpretation in 2015 in viewing the escalation of the emotional conflict potential as a logical consequence of an interiorized and individualized intensified piety. In 2015, Scott saw a cyclothymic temperament in Luther starting in about 1519, but emphasized the elasticity of Luther's emotional reserves: “For the rest of his life, Luther oscillated between euphoria and dejection but not to the point of dysfunction”.

Conclusion

Luther can be used as an example of the importance of religiousness as a curative resource for the psyche.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Proactive coping and gambling disorder among young men

Objectives Male sex, young age, and frequent gambling are considered as risk factors for gambling disorder (GD) and stress might be one of the triggers of gambling behavior among problem gamblers. Conversely, well-developed coping with stress might counteract gambling problems. The Proactive Coping Theory provides a promising approach for the further development of preventive and treatment measures. The objective of the study was to investigate different facets of proactive coping (PC) in young male gamblers. Methods Young men from Bavaria were recruited via the Munich citizens' registry (n = 2,588) and Facebook invitations (n = 105). In total, 173 out of 398 individuals were positively screened for frequent gambling and/or signs of related problems and completed the baseline questionnaire of the Munich Leisure-time Study. Factors investigated include gambling problems, PC, impulsiveness, social support, and psychological distress. Results Gambling problems were associated with lower levels of preventive coping as well as of adaptive reaction delay. The associations were also significant when controlled for impulsiveness and general psychological distress. Preventive coping moderated the association between social support and gambling problems. Discussion and conclusions Young men with gambling problems less frequently prevent the occurrence of stressors and more often react hasty when these occur. While the investigated group reported good social support, this factor was negatively associated with GD only among individuals with good preventive coping. Preventive coping poses a useful construct for selective prevention and treatment as it can be modified in professional interventions.

[Talus Fractures - an Update]

Background: Talus fractures are rare and often result from axial trauma. As most of the talus surface is covered by cartilage, the blood supply is limited. Thus talus fractures are seen as one of the most severe fractures and often lead to significant long-term complications. Several studies suggest that the initial fracture classification can lead to correct treatment and that this can influence the long-term outcome. The aim of the current study was to investigate the importance of the initial fracture classification in respect to the radiological outcome in a large patient cohort. Patients and Methods: Over a span of 12 years, 61 patients with talus fractures were treated at our institution. Overall 45 patients were available for a retrospective analysis. Correlation analysis was performed between the initial fracture severity and the radiological outcome. Results: The average follow-up was 17.3 months (range 6-68). Significant correlations were found between the Marti-Weber Classification and Bargon Score (r_s = 0.78; p < 0.0001), as well as between the Hawkins Classification and the Bargon Score (r_s = 0.80; p < 0.0001). Conclusions: Precise prediction of the expected radiological outcome of talar neck and body fractures is possible through the initial fracture classification alone. Computed tomography is the accepted standard to determine the exact diagnosis and extent of injury.

Elderly-study – treatment for alcohol problems among 60+

Introduction

The western societies have a rapidly aging population and an increasing number of elderly with alcohol use disorders.

Objective

The purpose of the elderly study is to develop and test an outpatient behavior therapy program for people with an alcohol use disorders.

Aim of this abstract

To investigate the association between ages, gender, drinking pattern and psychology distress.

Method

The study is a randomized study expected to enroll and treat 1000 participants aged 60+ years before April 2017; 200 in USA; 400 in Germany and 400 in Denmark. To be included in the study the participants have to fulfil the DSM-5 criteria for alcohol use disorder. All participants are examined at baseline, and at four follow up interviews. After the baseline interview all participants are randomized to Motivational Enhancement Therapy (MET); or MET followed by 8 weeks of counseling based on the Community Reinforcement Approach (CRA) with a module added to address problems relevants to elderly people.

Results

The presentation will include baseline characteristics of the Danish participants including demographics, expectations to treatment, history of drinking in the last 90 days before baseline and their psychological distress. We have now enrolled 259 participants in the Danish database. We expect to present results from 320 patients.

Conclusion

The data will present information about the profile of 60+ years’ individuals seeking treatment for alcohol use disorder, and thereby provide knowledge about which characteristics that may be important when planning treatment for this age group.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Is it all in the hinge? A kryptoracemate and three of its alternative racemic polymorphs of an aminonitrile

A kryptoracemate, a racemic crystal in a Sohncke space group, and three additional polymorphs, well-ordered racemic structures.

Dioxygenation of cysteamine to hypotaurine at a tris(pyrazolyl)borate iron(ii) unit - cysteamine dioxygenase mimicking?

A novel complex Tp(Me,Ph)Fe(SCH2CH2NH2) has been synthesized as a speculative model for ADO. Indeed its reaction with O2 led to the dioxygenation of the S atom and thus to hypotaurine. This finding may allow us to draw conclusions on the constitution of the ADO active site, whose structure is still unknown.

[Remember, Avert, Prevent: Franz Ludwig Berthold Kihn--A Typology of "Euthanasia"]

BACKGROUND

The current debate on assisted suicide provides the occasion for calling to mind the role of Berthold Kihn as a psychiatrist under National Socialism. With a historical presentation of a typology of euthanasia, the Academic Psychiatry of Erlangen together with the Medical Ethics would like to sensitize discussions on assisted suicide by drawing attention to the start and end of Kihn's scientific career.

METHOD

Relevant archive material, primary and secondary literature were analyzed and evaluated.

RESULTS

As Assistant and Senior Physician at the Psychiatric and Neurological Hospital of the University of Erlangen, Kihn lectured on "the elimination of the inferiors". As Director of the Psychiatric and Neurological Hospital of Jena University, Kihn selected psychiatric patients to be murdered under the "T4 action". Kihn participated in drafting a "Euthanasia Law". Despite his involvement in the murder of mentally ill, Kihn returned to Erlangen as a "Soviet Zone refugee", where a Denazification Court considered him a "hanger-on". Kihn was reintegrated in the academic faculty of the Friedrich-Alexander-University and headed a private clinic. On 21.01.1963, the State's Attorney Nuremberg-Fuerth dropped the criminal procedure against Kihn--officially due to a lack of proof of punishable guilt.

DISCUSSION

An appropriate medical historical contextualization can represent an important condition for an adequate medical ethical debate on physician-assisted suicide and the involvement of psychiatrists. FINAL COMMENT: The analysis of Kihn's patterns of thought and argumentation can help sensitize those involved in debates on physician-assisted suicide and highlights the critical role of psychiatry as a discipline in this context.

DSM-5 criteria for gambling disorder: Underlying structure and applicability to specific groups of gamblers

BACKGROUND AND AIMS

DSM-5 provides nine diagnostic criteria for gambling disorder. All criteria have a pre-assumed equal diagnostic impact and are applied to all individuals and groups in an equal manner. The aims of the study are to analyse the structure underlying the diagnosis and to assess whether DSM-5 is equally applicable to different groups of gamblers.

METHODS

Data from the 2009 German Epidemiological Survey of Substance Abuse and from a study on slot machine gamblers were used. Item Response Theory analysis was applied to estimate discrimination and severity parameters of the criteria. With the use of Differential Item Functioning analysis, potential criterion biases were analysed. We analysed data from 107 participants from the general population sample and 376 participants from the slot machine gamblers' sample who answered a 19-item diagnostic questionnaire based on the DSM criteria for gambling disorder.

RESULTS

A single underlying factor, the severity of gambling disorder, was identified in both samples. In the general population sample the criteria of preoccupation and chasing were least severe and showed low discriminatory power. Bailout, withdrawal and jeopardized matters criteria had highest severity and discriminatory power. The comparison of the two samples revealed two criterion biases in the preoccupation and tolerance criteria.

CONCLUSIONS

The structure underlying the criteria is unidimensional but the disorder is manifested differently depending on disorder severity. The assumed equal impact of each criterion lacks support in the findings. The DSM-5 criteria measure a partially different construct in slot machine gamblers than in gamblers in the general population.

Reaction of a polydentate cysteine-based ligand and its nickel(ii) complex with electrophilic and nucleophilic methyl-transfer reagents - from S-methylation to acetyl coenzyme A synthase reactivity

The L-cysteine derived N2S2 ligand precursor H2L and its nickel(ii) complex L2Ni2 were investigated with respect to their behaviour in contact with electrophilic and nucleophilic methylation reagents (H2L = (N,N'-dimethyl-(2R,5R)-bis-(sulfanylmethyl)-piperazine). Treatment of deprotonated L(2-) with MeI led to the selective methylation of the thiolate groups thus generating a novel potential ligand, Me2L, which is neutral and contains two thioether donors. The coordinating properties of Me2L were demonstrated by the synthesis of a first nickel(ii) complex: reaction with NiBr2 led to a mononuclear complex 2 where all donor atoms coordinate to the nickel ion, which completes its octahedral coordination sphere by the two bromide ligands. If, however, the complex [LNi]2 (1) is treated with MeI only one thiolate function per ligand moiety is methylated, while the other one remains a thiolate. This leads to [MeLNi](+) complex metal fragments, which trimerize including a μ3-bridging iodide ion to give the compound 3 that was tested with regards to ACS reactivity. While it behaved inert towards CO, attempts to replace the bridging iodide ligand by methyl units in reactions with nucleophilic methylation reagents led to a product, which could not be identified but reacted with CO. Work-up showed that this protocol had converted the thiolate function of MeL(-) into a thioester function, which corresponds to an ACS-like reactivity.

Outpatient treatment of alcohol use disorders among subjects 60+ years: design of a randomized clinical trial conducted in three countries (Elderly Study)

BACKGROUND

The proportion of 60+ years with excessive alcohol intake varies in western countries between 6-16 % among men and 2-7 % among women. Specific events related to aging (e.g. loss of job, physical and mental capacity, or spouse) may contribute to onset or continuation of alcohol use disorders (AUD). We present the rationale and design of a multisite, multinational AUD treatment study for subjects aged 60+ years.

METHODS/DESIGN

1,000 subjects seeking treatment for AUD according to DSM-5 in outpatient clinics in Denmark, Germany, and New Mexico (USA) are invited to participate in a RCT. Participants are randomly assigned to four sessions of Motivational Enhancement Treatment (MET) or to MET plus an add-on with eight sessions based on the Community Reinforcement Approach (CRA), which include a new module targeting specific problems of older adults. A series of assessment instruments is applied, including the Form-90, Alcohol Dependence Scale, Penn Alcohol Craving Scale, Brief Symptom Inventory and WHO Quality of Life. Enrolment will be completed by April 2016 and data collection by April 2017. The primary outcome is the proportion in each group who are abstinent or have a controlled use of alcohol six months after treatment initiation. Controlled use is defined as maximum blood alcohol content not exceeding 0.05 % during the last month. Total abstinence is a secondary outcome, together with quality of life andcompliance with treatment.

DISCUSSION

The study will provide new knowledge about brief treatment of AUD for older subjects. As the treatment is manualized and applied in routine treatment facilities, barriers for implementation in the health care system are relatively low. Finally, as the study is being conducted in three different countries it will also provide significant insight into the possible interaction of service system differences and related patient characteristics in predictionof treatment outcome.

TRIAL REGISTRATION

Clinical Trials.gov NCT02084173 , March 7, 2014.

Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery

IMPORTANCE

Previous studies suggested that a bundled intervention was associated with lower rates of Staphylococcus aureus surgical site infections (SSIs) among patients having cardiac or orthopedic operations.

OBJECTIVE

To evaluate whether the implementation of an evidence-based bundle is associated with a lower risk of S. aureus SSIs in patients undergoing cardiac operations or hip or knee arthroplasties.

DESIGN, SETTING, AND PARTICIPANTS

Twenty hospitals in 9 US states participated in this pragmatic study; rates of SSIs were collected for a median of 39 months (range, 39-43) during the preintervention period (March 1, 2009, to intervention) and a median of 21 months (range, 14-22) during the intervention period (from intervention start through March 31, 2014).

INTERVENTIONS

Patients whose preoperative nares screens were positive for methicillin-resistant S. aureus (MRSA) or methicillin-susceptible S. aureus (MSSA) were asked to apply mupirocin intranasally twice daily for up to 5 days and to bathe daily with chlorhexidine-gluconate (CHG) for up to 5 days before their operations. MRSA carriers received vancomycin and cefazolin or cefuroxime for perioperative prophylaxis; all others received cefazolin or cefuroxime. Patients who were MRSA-negative and MSSA-negative bathed with CHG the night before and morning of their operations. Patients were treated as MRSA-positive if screening results were unknown.

MAIN OUTCOMES AND MEASURES

The primary outcome was complex (deep incisional or organ space) S. aureus SSIs. Monthly SSI counts were analyzed using Poisson regression analysis.

RESULTS

After a 3-month phase-in period, bundle adherence was 83% (39% full adherence; 44% partial adherence). Overall, 101 complex S. aureus SSIs occurred after 28,218 operations during the preintervention period and 29 occurred after 14,316 operations during the intervention period (mean rate per 10,000 operations, 36 for preintervention period vs 21 for intervention period, difference, -15 [95% CI, -35 to -2]; rate ratio [RR], 0.58 [95% CI, 0.37 to 0.92]). The rates of complex S. aureus SSIs decreased for hip or knee arthroplasties (difference per 10,000 operations, -17 [95% CI, -39 to 0]; RR, 0.48 [95% CI, 0.29 to 0.80]) and for cardiac operations (difference per 10,000 operations, -6 [95% CI, -48 to 8]; RR, 0.86 [95% CI, 0.47 to 1.57]).

CONCLUSIONS AND RELEVANCE

In this multicenter study, a bundle comprising S. aureus screening, decolonization, and targeted prophylaxis was associated with a modest, statistically significant decrease in complex S. aureus SSIs.

Cleaning and disinfecting environmental surfaces in health care: Toward an integrated framework for infection and occupational illness prevention

BACKGROUND

The Cleaning and Disinfecting in Healthcare Working Group of the National Institute for Occupational Safety and Health, National Occupational Research Agenda, is a collaboration of infection prevention and occupational health researchers and practitioners with the objective of providing a more integrated approach to effective environmental surface cleaning and disinfection (C&D) while protecting the respiratory health of health care personnel.

METHODS

The Working Group, comprised of >40 members from 4 countries, reviewed current knowledge and identified knowledge gaps and future needs for research and practice.

RESULTS

An integrated framework was developed to guide more comprehensive efforts to minimize harmful C&D exposures without reducing the effectiveness of infection prevention. Gaps in basic knowledge and practice that are barriers to an integrated approach were grouped in 2 broad areas related to the need for improved understanding of the (1) effectiveness of environmental surface C&D to reduce the incidence of infectious diseases and colonization in health care workers and patients and (2) adverse health impacts of C&D on health care workers and patients. Specific needs identified within each area relate to basic knowledge, improved selection and use of products and practices, effective hazard communication and training, and safer alternatives.

CONCLUSION

A more integrated approach can support multidisciplinary teams with the capacity to maximize effective and safe C&D in health care.

A pregnancy lifestyle intervention to prevent gestational diabetes risk factors in overweight Hispanic women: a feasibility randomized controlled trial

AIMS

To pilot the feasibility of a prenatal lifestyle intervention to modify physical activity and diet among pregnant overweight and obese Hispanic women, with the aim of reducing risk factors for gestational diabetes mellitus.

METHODS

Women were randomized either to a lifestyle intervention (n = 33, 48.5%), consisting of a culturally and linguistically modified, motivationally targeted, individually tailored 6-month prenatal programme, or to standard care (n = 35, 51.5%). Bilingual and bicultural health educators encouraged women to achieve guidelines for physical activity, decrease saturated fat and increase dietary fibre. Outcomes included gestational weight gain, infant birth weight and biomarkers associated with insulin resistance.

RESULTS

Patient retention up to delivery was 97% in both study groups. The lifestyle intervention attenuated the pregnancy-associated decline in moderate-intensity physical activity, but differences between groups were not significant (mean ± se -23.4 ± 16.6 vs -27.0 ± 16.2 metabolic equivalent of task h/week; P = 0.88). Vigorous-intensity activity increased during the course of pregnancy in the lifestyle intervention group (mean ± se 1.6 ± 0.8 metabolic equivalent of task h/week) and declined in the standard care group (-0.8 ± 0.8 metabolic equivalent of task h/week; P = 0.04). The lifestyle intervention group also had slightly lower gestational weight gain and infant birth weights compared with the standard care group; however, these differences were not statistically significant. There were no statistically significant differences in biomarkers of insulin resistance between groups.

CONCLUSIONS

Findings suggest that a motivationally matched lifestyle intervention is feasible and may help attenuate pregnancy-related decreases in vigorous physical activity in a population of overweight and obese Hispanic women. The intervention protocol can readily be translated into clinical practice in underserved and minority populations.

[The "Erlangen System" of open care: a tribute to Gustav Kolb (1870-1938)]

BACKGROUND

This year marks the 80th anniversary of the forced retirement (1st March 1934) of Gustav Kolb (1870 - 1938). He is considered the founder of the "Erlangen System" of open care. The following article pays tribute to Gustav Kolb's "life's work", by delineating the formation, active period and the fall of his "Erlangen system" in its historical context.

METHOD

Relevant archive materials and secondary literature were assessed.

RESULTS

Beginning in 1914, Gustav Kolb, as Director of the Mental Asylum in Erlangen (1911 - 1934) introduced the care of the emotionally ill in their own families. In 1930, 4200 of the 770 000 residents in a catchment area covering about 3200 square kilometers were being treated in open care. The "Erlangen system" was the largest organisation of its kind in Germany. Although Gustav Kolb was inspired by eugenic ideas, he opposed the national-socialist health politics. Kolb withdrew professionally in 1933 and died five years later.

DISCUSSION

The situation in the tense area of open care between helping institutions for and controlling bodies over emotionally ill people was relatively balanced in the Weimar Republic. Later, Gustav Kolb's organisational thoroughness, with its creation of a central register of people under open care in the Erlangen system, provided considerable biogenetic information. Tragically, this was abused as an important source in carrying out the national-socialist law for prevention of genetically-impaired offspring (14.7.1933). Several aspects contributed to the misfortune that Kolb's liberal system could be distorted to a recording instrument by the National Socialists. Final Comment: Individual efforts to reestablish open care facilities after 1945 were not implemented. It was not until during the socio-psychiatric movement of the 1960 s that Kolb's concept could achieve a renaissance, although it was unnamed and unrecognised at the time.

Perceived psychosocial stress and glucose intolerance among pregnant Hispanic women

AIM

Prior literature suggests a positive association between psychosocial stress and the risk of diabetes in non-pregnant populations, but studies during pregnancy are sparse. We evaluated the relationship between stress and glucose intolerance among 1115 Hispanic (predominantly Puerto Rican) prenatal care patients in Proyecto Buena Salud, a prospective cohort study in Western Massachusetts (2006-2011).

METHODS

Cohen's Perceived Stress Scale (PSS-14) was administered in early (mean = 12.3 weeks gestation; range 4.1-18 weeks) and mid- (mean = 21.3 weeks gestation; range 18.1-26 weeks) pregnancy. Participants were classified as having a pregnancy complicated by gestational diabetes mellitus, impaired glucose tolerance, and abnormal glucose tolerance, based on the degree of abnormality on glucose tolerance testing between 24 and 28 weeks of gestation.

RESULTS

The prevalence of gestational diabetes mellitus, impaired glucose tolerance, and abnormal glucose tolerance was 4.1%, 7.2%, and 14.5%, respectively. Absolute levels of early or mid-pregnancy stress were not significantly associated with glucose intolerance. However, participants with an increase in stress from early to mid-pregnancy had a 2.6-fold increased odds of gestational diabetes mellitus (95% confidence intervals: 1.0-6.9) as compared to those with no change or a decrease in stress after adjusting for age and pre-pregnancy body mass index. In addition, every one-point increase in stress scores was associated with a 5.5mg/dL increase in screening glucose level (β=5.5; standard deviation=2.8; P=0.05), after adjusting for the same variables.

CONCLUSION

In this population of predominantly Puerto Rican women, stress patterns during pregnancy may influence the risk of glucose intolerance.

Physical activity before and during pregnancy and risk of abnormal glucose tolerance among Hispanic women

AIM

Women diagnosed with abnormal glucose tolerance and gestational diabetes mellitus are at increased risk for subsequent type 2 diabetes, with higher risks in Hispanic women. Studies suggest that physical activity may be associated with a reduced risk of these disorders; however, studies in Hispanic women are sparse.

METHODS

We prospectively evaluated this association among 1241 Hispanic participants in Proyecto Buena Salud. The Pregnancy Physical Activity Questionnaire was used to assess pre, early, and mid pregnancy physical activity. Medical records were abstracted for pregnancy outcomes.

RESULTS

A total of 175 women (14.1%) were diagnosed with abnormal glucose tolerance and 57 women (4.6%) were diagnosed with gestational diabetes. Increasing age and body mass index were strongly and positively associated with risk of gestational diabetes. We did not observe statistically significant associations between total physical activity or meeting exercise guidelines and risk. However, after adjusting for age, BMI, gestational weight gain, and other important risk factors, women in the top quartile of moderate-intensity activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio=0.48, 95% Confidence Interval 0.27-0.88, Ptrend=0.03) as compared to those in the lowest quartile. Similarly, women with the highest levels of occupational activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio=0.48, 95% Confidence Interval 0.28-0.85, Ptrend=0.02) as compared to women who were unemployed.

CONCLUSION

In this Hispanic population, total physical activity and meeting exercise guidelines were not associated with risk. However, high levels of moderate-intensity and occupational activity were associated with risk reduction.

Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial

IMPORTANCE

Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria.

OBJECTIVE

To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012.

INTERVENTIONS

In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room.

MAIN OUTCOMES AND MEASURES

The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care–associated infections, and adverse events.

RESULTS

From the 26,180 patients included, 92,241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference,  0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24).

CONCLUSIONS AND RELEVANCE

The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT0131821.

Gambling experiences, problems, research and policy: gambling in Germany

AIMS

The objective of this paper is to present an overview of gambling in Germany, including historical development, legislative and economic changes as well as treatment options and their effectiveness.

METHODS

The available scientific literature and research reports on gambling in Germany were reviewed to obtain relevant information on history, commercialization, legislation, treatment and research agenda.

RESULTS

Gambling in Germany is characterized by compromises between protective and economic efforts. At present, gambling is illegal in Germany, and provision is subject to the state monopoly. Mere gaming machines (specific slot machines) are not classified as gambling activity, permitting commercial providers. In recent years, implementing regulations for state gambling and gaming machines have been changed. Concerning the treatment of pathological gambling, various options exist; treatment costs have been covered by health and pension insurance since 2001. Information on the effectiveness of treatment in Germany is limited. Similarly, the number of peer-reviewed publications on gambling is small.

CONCLUSIONS

German gambling legislation was subject to major changes in the past years. Based on the available body of research (longitudinal), studies on risk and protective factors and the aetiology of pathological gambling are needed. The effectiveness of pathological gambling treatment in Germany and the impact of gambling regulations on gambling behaviour also need to be investigated.

Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis

OBJECTIVE

To evaluate studies assessing the effectiveness of a bundle of nasal decolonization and glycopeptide prophylaxis for preventing surgical site infections caused by Gram positive bacteria among patients undergoing cardiac operations or total joint replacement procedures.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed (1995 to 2011), the Cochrane database of systematic reviews, CINAHL, Embase, and clinicaltrials.gov were searched to identify relevant studies. Pertinent journals and conference abstracts were hand searched. Study authors were contacted if more data were needed.

ELIGIBILITY CRITERIA

Randomized controlled trials, quasi-experimental studies, and cohort studies that assessed nasal decolonization or glycopeptide prophylaxis, or both, for preventing Gram positive surgical site infections compared with standard care.

PARTICIPANTS

Patients undergoing cardiac operations or total joint replacement procedures. DATA EXTRACTION AND STUDY APPRAISAL: Two authors independently extracted data from each paper and a random effects model was used to obtain summary estimates. Risk of bias was assessed using the Downs and Black or the Cochrane scales. Heterogeneity was assessed using the Cochran Q and I(2) statistics.

RESULTS

39 studies were included. Pooled effects of 17 studies showed that nasal decolonization had a significantly protective effect against surgical site infections associated with Staphylococcus aureus (pooled relative risk 0.39, 95% confidence interval 0.31 to 0.50) when all patients underwent decolonization (0.40, 0.29 to 0.55) and when only S aureus carriers underwent decolonization (0.36, 0.22 to 0.57). Pooled effects of 15 prophylaxis studies showed that glycopeptide prophylaxis was significantly protective against surgical site infections related to methicillin (meticillin) resistant S aureus (MRSA) compared with prophylaxis using β lactam antibiotics (0.40, 0.20 to 0.80), and a non-significant risk factor for methicillin susceptible S aureus infections (1.47, 0.91 to 2.38). Seven studies assessed a bundle including decolonization and glycopeptide prophylaxis for only patients colonized with MRSA and found a significantly protective effect against surgical site infections with Gram positive bacteria (0.41, 0.30 to 0.56).

CONCLUSIONS

Surgical programs that implement a bundled intervention including both nasal decolonization and glycopeptide prophylaxis for MRSA carriers may decrease rates of surgical site infections caused by S aureus or other Gram positive bacteria.

[Germany's unique panoptical asylum--an appreciation of the first Bavarian mental home in Erlangen]

INTRODUCTION

There are only two edifices left that represent one of the most impressive cultural monuments of mental homes in Middle Europe. Government and institutions are removing these historical buildings to establish a modern "Translational Research Centre". Our objective is to illustrate the significance of the asylum in the history of psychiatric architecture.

METHODS

In the context of the history of psychiatry we analysed and interpreted relevant primary sources, secondary literature and selected illustrations.

RESULTS

Several panoptical asylums were built in Great Britain. In France, Italy and Germany, a unique example was realised. The entire ward could be checked from a central room. This ensured the optimal surveillance of the patients and enabled the minimisation of staff. In contrast to the vicinal emergent industrial cities Erlangen disposed of enough building ground. There, Johann Michael Leupoldt (1794-1874) gave lectures dealing only with psychiatry. Thanks to his advice, the first Bavarian mental home was completed within only 12 years. The cruciform floor plan was supplemented by cross buildings. This constituted a relevant modification of the panoptical system.

DISCUSSION

Although the "H-design" has been evaluated as more adequate, the obsolete architectural "concept of rays" was chosen for the asylum in Erlangen. Did financial distress play a decisive role? Neither the files nor Leupoldt's autobiography take a firm stand on this point.

CONCLUSION

As the TRC-project may serve as a document for future medical progress, it is important to remember the "Kreis-Irrenanstalt Erlangen" as a milestone in the evolution of psychiatric architecture.