Seltene virale Infektionen der Lunge

Die Lunge ist aufgrund ihres direkten Kontakts mit der Umwelt gegenüber einer Vielzahl von Viren exponiert. Im folgenden Beitrag werden Infektionen durch 4 virale Erreger dargestellt, die zu pulmonalen Manifestationen führen können, die in Deutschland aufgrund ihrer Seltenheit wenig bekannt sind. Bei der zoonotischen Influenza, dem „Middle East respiratory syndrome“ (MERS) und der Infektion durch Hantaviren handelt es sich um zoonotische Infektionen, während es sich bei den Masern um eine rein humane Erkrankung handelt. Allen 4 Infektionen gemein sind die potenziell schweren pulmonalen Komplikationen mit hoher Mortalität. Über den einzelnen Patienten hinaus können die Masern, MERS und auch die zoonotische Influenza zu weiteren Übertragungen mit weitreichenden Konsequenzen führen. Der Beitrag beleuchtet für die jeweiligen Erreger relevante Aspekte von Epidemiologie, klinischem Verlauf, Therapie und Prävention. Diese Kenntnisse erscheinen wichtig, da jederzeit mit dem Auftreten von Fällen in Deutschland gerechnet werden muss.

Infections caused by extended-spectrum β-lactamase-producing Enterobacterales after rectal colonization with ESBL-producing Escherichia coli or Klebsiella pneumoniae

OBJECTIVES

Infections as a result of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) are considered infections with a high public health burden. In this study, we aimed to identify incidences of and risk factors for healthcare-associated infections (HAIs) after rectal colonization with ESBL-producing Escherichia coli (ESBL-EC) or Klebsiella pneumoniae (ESBL-KP).

METHODS

This prospective cohort study was performed in 2014 and 2015. Patients colonized with ESBL-EC or ESBL-KP were monitored for subsequent HAI with ESBL-E and other pathogens. In the case of an ESBL-E infection, rectal and clinical isolates were compared using pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing (WGS) for ESBL-KP isolates. Proportional hazard models were applied to identify risk factors for HAIs, and to analyse competing risks.

RESULTS

Among all patients admitted to the hospital during the study period, 13.6% were rectally screened for third-generation cephalosporin-resistant Enterobacterales (3GCREB). A total of 2386 rectal carriers of ESBL-EC and 585 of ESBL-KP were included in the study. Incidence density (ID) for HAI with ESBL-E was 2.74 per 1000 patient days at risk (95% confidence interval (CI) 2.16-3.43) among carriers of ESBL-EC, while it was 4.44 per 1000 patient days at risk (95% CI 3.17-6.04) among carriers of ESBL-KP. In contrast, ID for HAI with other pathogens was 4.36 per 1000 patient days at risk (95% CI 3.62-5.21) among carriers of ESBL-EC, and 5.00 per 1000 patient days at risk (95% CI 3.64-6.69) among carriers of ESBL-KP. Cox proportional hazard regression analyses identified colonization with ESBL-KP (HR = 1.58, 95% CI 1.068-2.325) compared with ESBL-EC as independent risk factor for HAI with ESBL-E. The results were consistent over all competing risk analyses.

CONCLUSIONS

Clinicians should be aware of the increased risk of ESBL-E infections among patients colonized with ESBL-KP compared with ESBL-EC that might be caused by underlying diseases, higher pathogenicity of ESBL-KP and other factors.

Supporting the improvement of air quality management practices: The "FAIRMODE pilot" activity

This paper presents the first outcomes of the "FAIRMODE pilot" activity, aiming at improving the way in which air quality models are used in the frame of the European "Air Quality Directive". Member States may use modelling, combined with measurements, to "assess" current levels of air quality and estimate future air quality under different scenarios. In case of current and potential exceedances of the Directive limit values, it is also requested that they "plan" and implement emission reductions measures to avoid future exceedances. In both "assessment" and "planning", air quality models can and should be used; but to do so, the used modelling chain has to be fit-for-purpose and properly checked and verified. FAIRMODE has developed in the recent years a suite of methodologies and tools to check if emission inventories, model performance, source apportionment techniques and planning activities are fit-for-purpose. Within the "FAIRMODE pilot", these tools are used and tested by regional/local authorities, with the two-fold objective of improving management practices at regional/local scale, and providing valuable feedback to the FAIRMODE community. Results and lessons learnt from this activity are presented in this paper, as a showcase that can potentially benefit other authorities in charge of air quality assessment and planning.

Long-Term Follow-Up of Adults with Gender Identity Disorder

The aim of this study was to re-examine individuals with gender identity disorder after as long a period of time as possible. To meet the inclusion criterion, the legal recognition of participants' gender change via a legal name change had to date back at least 10 years. The sample comprised 71 participants (35 MtF and 36 FtM). The follow-up period was 10-24 years with a mean of 13.8 years (SD = 2.78). Instruments included a combination of qualitative and quantitative methods: Clinical interviews were conducted with the participants, and they completed a follow-up questionnaire as well as several standardized questionnaires they had already filled in when they first made contact with the clinic. Positive and desired changes were determined by all of the instruments: Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. Despite these positive results, the treatment of transsexualism is far from being perfect.

Assessing reliability, validity, and clinical utility of the BEST-Index in measuring living skills among forensic inpatients

The assessment of behavioral change as a result of inpatient treatment in forensic psychiatry is an important precondition for violence risk prediction in forensic psychiatry. In relation to a multitude of diagnostically based risk assessment instruments, there is a shortage of appropriate instruments with which to carry out valid and reliable therapeutic assessments that are behaviorally based and therefore appropriate for use within varied psychiatric contexts. There is also a need for instruments which will offer assessors the opportunity to examine possible relationships between criteria of social risk and criteria of more general aspects of social functioning. Tapping the issues pointed out above, the authors present an overview of a normatively based social profiling instrument (the BEST-Index), and discuss evidence for its validity, reliability, and aspects of clinical utility.

The DSM diagnostic criteria for gender identity disorder in adolescents and adults

Apart from some general issues related to the Gender Identity Disorder (GID) diagnosis, such as whether it should stay in the DSM-V or not, a number of problems specifically relate to the current criteria of the GID diagnosis for adolescents and adults. These problems concern the confusion caused by similarities and differences of the terms transsexualism and GID, the inability of the current criteria to capture the whole spectrum of gender variance phenomena, the potential risk of unnecessary physically invasive examinations to rule out intersex conditions (disorders of sex development), the necessity of the D criterion (distress and impairment), and the fact that the diagnosis still applies to those who already had hormonal and surgical treatment. If the diagnosis should not be deleted from the DSM, most of the criticism could be addressed in the DSM-V if the diagnosis would be renamed, the criteria would be adjusted in wording, and made more stringent. However, this would imply that the diagnosis would still be dichotomous and similar to earlier DSM versions. Another option is to follow a more dimensional approach, allowing for different degrees of gender dysphoria depending on the number of indicators. Considering the strong resistance against sexuality related specifiers, and the relative difficulty assessing sexual orientation in individuals pursuing hormonal and surgical interventions to change physical sex characteristics, it should be investigated whether other potentially relevant specifiers (e.g., onset age) are more appropriate.

Good enough to eat

In mythology, religion, and literature, there are many examples of cannibalism that have been passed down over the centuries and which do not strike us as shocking as long as they remain fixed in a symbolic context. Things only become problematic when cannibalistic impulses are taken literally and put into practice. Apart from situations of extreme emergency in which this rare phenomenon might enjoy a certain sympathy, it also occurs within the context of serious sexual offences. Recently, in Germany, there was the case of a man who used the internet to find a person who wanted to have himself eaten. The victim's consent unsettled not only the public at large, but also the judiciary, which at first did not know how the case was legally to be appropriately assessed. In a first trial in January 2004, the man was sentenced to a comparatively short prison term of only a few years, a sentence that was lifted by the Federal Supreme Court. In a fresh trial in May 2006, he was sentenced to life imprisonment for murder. In this essay, I discuss to what extent mythological, religious, and artistic models of cannibalism express something fundamentally anthropological and how concrete examples should be assessed against this background.

Die Beurteilung von lebenspraktischen Fertigkeiten forensisch-psychiatrischer Patienten mit dem BEST-Index

The role of daily living skills in forensic psychiatric patients in relation to psychotherapeutic progress and the potential reduction of dangerous behaviour has been neglected in the scientific discussion about clinical instruments for the evaluation of dangerousness and recidivism. This is mainly due to the lack of adequate observationally based instruments allowing for valid and reliable therapeutic assessments. Therefore, a new means of assessment focusing on daily living skills and social risk (the BEST-Index [Behavioural Status Index] was applied to n = 86 German forensic psychiatric patients. Two widely known actuarial instruments tapping violence risk were administered for cross validation (Psychopathy Checklist Revised [PCL-R], HCR-20). Within intervals of nine months, all instruments were applied three times. Sufficient inter rater reliability and good convergent validity of the sub-scales in relation to the actuarial instruments (HCR-20, PCL-R) could be demonstrated; supported by empirical data, clinicians working with the BEST-Index may use it to monitor behavioural change over long treatment periods. It is suggested that treatment planning and evaluation of mentally ill offenders might profit from its use.

Begutachtung und Behandlung von Sexualstraftätern

Sexual offences are a heterogeneous group of offences that entail very different diagnostic categories relevant for key issues of expert assessment. Sexual offender trials usually deal with issues related to (diminished) responsibility and the necessity of a referral to a forensic psychiatric hospital ( section sign 63 StGB, German penal code). Furthermore, risk assessment is seen as a necessary precondition for relapse prevention and consequently, it forms part of any expert assessment in sex offender trials. In terms of treatment, manualized treatment programs prevail. Usually they lend themselves to psycho-educative, cognitive-behavioral and psychodynamic concepts. Notwithstanding the focus of any individual program, core elements of all programs pertain to offence related (e.g., victim empathy, attitudes and individual values, minimizations, etc.) and more general psychotherapy modules (anger management, substance abuse, social skills training, etc.). Advantages and disadvantages of these programs are named and discussed.

[COMSKILLS: assessing community living skills in offender groups]

OBJECTIVE

An international network study involving parallel, complementary interventions in three EU countries and an associate country (Germany, United Kingdom, The Netherlands and Norway) is reported. The aim is to develop a unified approach to the assessment of social risk and related behaviours in offender groups.

METHOD

The Behavioural Status Index (BEST-Index) and a set of cross-validating instruments (PCL-R, HCR-20; SCL-90-R; BDHI-D) were applied to a sample of n = 231 mentally ill offenders.

RESULTS

Selected results using a sub-sample of n = 89 German offenders are reported and discussed.

CONCLUSIONS

The BEST-Index shows convergent validity with respect to a social risk criterion and it helps to determine an objective data base for the improvement of carer assessments, related care planning, and delivery.

What happens in therapy with sexual offenders? A model of process research

This paper presents two studies (one single case and one comparative study) examining change processes within individual therapy sessions as well as during the course of treatment. The Therapeutic Cycle Model (TCM), developed for general psychotherapy to objectify change events in the course of psychotherapies, is applied to transcribed tape recordings of therapy sessions with sexual offenders. The TCM focuses on emotional experience and cognitive mastery and uses computer assisted text analysis. In addition to the TCM approach clinical ratings are used as independent criteria. The predicted relationship between the phases of the TCM and scores on the respective scales of the clinical ratings were supported.

[Change events during the psychotherapy process of a patient detained by court order due to sexual offences in a high security forensic clinic]

BACKGROUND

Psychotherapy of sex offenders is effective and reduces relapse rates when compared with untreated controls. As compared to the effectiveness of psychotherapy at large, however, effect sizes are much lower.

OBJECTIVE

To provide evidence for change processes in a therapy with a sex offender.

METHOD

This is an exploratory single case study in which the Therapeutic Cycles Model (TCM)--developed for general psychotherapy and based on emotional experience and cognitive mastery--is being applied. In addition to the computer assisted approach of the TCM clinical ratings are used as independent criteria.

RESULTS

The predicted relationship between the phases of the TCM, the rating for Quality of Sessions and the Therapeutic Alliance was observed.

[Educational reform in medical education--effects of the 8th revision of the medical approbation regulation on the psychosomatic/psychotherapy specialty]

Since the end of 1993 a draft of the 8th revision of the Educational Rules in Medicine (Arztliche Approbationsordnung) was published by the Federal Ministry of Health, suggesting substantial changes of ways and contents of medical education the consequences of which for university departments of psychosomatics and psychotherapy are discussed in this paper.

[Expert assessment within the scope of legal social determination of the extent of economic responsibility of insurance for analytic psychotherapy]

Expert Opinions and Social Insurance Tribunal Rulings on the Scope of Medical Insurance Cover for Analytic Psychotherapy.--In Germany at present medical insurance cover is more or less automatic for a bone-marrow transplant costing anything up to 100,000 dollars--an operation where the death of the patients is by no means infrequent. In view of this state of affairs it is hard to comprehend the refusal on the part of insurance cover reviewers to approve ongoing cover for analytic psychotherapy beyond the 240-hour limit. In the case presented here, privately financed continuation by some 180 hours demonstrated that this prolongation and intensification of therapy was in fact essential to ensure the success of the treatment.

[Transsexual defense]

The prevalent approach to the treatment of patients displaying transsexual symptoms is one that favours somatic intervention of either a hormonal or surgical nature. Normally these patients refuse to avail themselves of the possibility of psychotherapy and are indeed regarded by many therapists as largely inaccessible to therapy of this kind. Pfäfflin looks into the factors involved in the disinclination displayed by both patients and therapists to embark upon such a process. He discusses the unconscious defence mechanisms operative in this disinclination with particular reference to the incipient stages of a course of treatment extending over a number of years and involving a patient initially determined to undergo a surgical "sex change". The patient's insistence on being acknowledged as a woman is regarded here as a creative defence against a major diffusion of identity from a genetically earlier phase, connected with incomplete separation and individuation. In the author's opinion the patient's ability to relinquish this defence will depend largely on the therapist's ability to acknowledge its creativity.

[Treatment of especially severe sex offenses]

"Therapy" is a currency with two different notations, as far as court practice is concerned. If the offences are of a minor nature, such as exhibitionism, the judge will usually expect the expert to mention the word, which prompts him to refer the delinquent to a therapist without delay, even if he is not at all hopeful that therapy may be successful. "Therapy" is an inflationary currency. In severe cases, its notation is correspondingly lower. This development has been promoted by the increasing division between forensic and therapeutic perspectives in psychiatry. The difficulties resulting therefore are discussed, taking the example of expertise and therapy of a patient accused of attempted murder as basis. Suggestions are advanced in what manner this division between forensic and therapeutic psychiatry could be avoided or even reduced in future.

H-Y antigen in transsexuality, and how to explain testis differentiation in H-Y antigen-negative males and ovary differentiation in H-Y antigen-positive females

H-Y antigen was determined in eight transsexual patients. Two of the four male-to-female transsexual patients typed as H-Y antigen-negative, while the other two typed as expected from their phenotypic and gonadal sex, namely H-Y antigen-positive. Of the four female-to-male transsexual patients, three typed as H-Y antigen-positive and one was H-Y antigen-negative, as expected. The presence of normal testes in H-Y antigen-negative males is assumed to result from a mutation of nucleotide sequences of the H-Y structural gene for antigenic determinants. Thus, an H-Y is produced with normal receptor-binding activity which can sustain the testis determination of the bipotent gonadal anlage. In the case of H-Y antigen-positive females with normal ovaries a deletion of the autosomally located H-Y structural gene is assumed. This deletion should affect sequences for repressor-binding (as was suggested for H-Y antigen-positive XX-males) and for receptor-binding activity of the H-Y antigen molecule. The resulting H-Y antigen is unable to bind to the gonadal receptor of the bipotent gonadal anlage. Thus an ovary is determined. The relevance of H-Y antigen for the aetiology of transsexualism is discussed.

Changes in personality scores among couples subsequent to sex therapy

Changes in personality scores and self-perception of 92 couples through sex therapy are reported. The sample included 52 couples with female symptoms (orgasmic dysfunction and vaginismus) and 40 couples with male symptoms (erectile dysfunction and premature ejaculation), who all completed therapy. One-year follow-up showed significant changes indicating a general increase of emotional stability and a reduction of neurotic tendencies in both partners.