Modeling the impact of alcohol dependence on mortality burden and the effect of available treatment interventions in the European Union.

Alcohol consumption is a major risk factor for the burden of disease, and Alcohol Dependence (AD) is the most important disorder attributable to this behavior. The objective of this study was to quantify mortality associated with AD and the potential impact of treatment. For the EU countries, for the age group 15-64 years, mortality attributable to alcohol consumption in general, to heavy drinking, and to AD were estimated based on the latest data on exposure and mortality. Potential effects of AD treatment were modeled based on Cochrane and other systematic reviews of the effectiveness of the best known and most effective interventions. In the EU 88.9% of men and 82.1% of women aged 15-64 years were current drinkers; and 15.3% of men and 3.4% of women in this age group were heavy drinkers. AD affected 5.4% of men and 1.5% of women. The net burden caused by alcohol consumption was 1 in 7 deaths in men and 1 in 13 deaths in women. The majority of this burden was due to heavy drinking (77%), and 71% of this burden was due to AD. Increasing treatment coverage for the most effective treatments to 40% of all people with AD was estimated to reduce alcohol-attributable mortality by 13% for men and 9% for women (annually 10,000 male and 1700 female deaths avoided). Increasing treatment rates for AD was identified as an important issue for future public health strategies to reduce alcohol-attributable harm and to complement the current focus of alcohol policy.

Cognitive and neurobiological alterations in electromagnetic hypersensitive patients: results of a case-control study.

BACKGROUND: Hypersensitivity to electromagnetic fields (EMF) is frequently claimed to be linked to a variety of non-specific somatic and neuropsychological complaints. Whereas provocation studies often failed to demonstrate a causal relationship between EMF exposure and symptom formation, recent studies point to a complex interplay of neurophysiological and cognitive alterations contributing to symptom manifestation in electromagnetic hypersensitive patients (EHS). However, these studies have examined only small sample sizes or have focused on selected aspects. Therefore this study examined in the largest sample of EHS EMF-specific cognitive correlates, discrimination ability and neurobiological parameters in order to get further insight into the pathophysiology of electromagnetic hypersensitivity. METHOD: In a case-control design 89 EHS and 107 age- and gender-matched controls were included in the study. Health status and EMF-specific cognitions were evaluated using standardized questionnaires. Perception thresholds following single transcranial magnetic stimulation (TMS) pulses to the dorsolateral prefrontal cortex were determined using a standardized blinded measurement protocol. Cortical excitability parameters were measured by TMS. RESULTS: Discrimination ability was significantly reduced in EHS (only 40% of the EHS but 60% of the controls felt no sensation under sham stimulation during the complete series), whereas the perception thresholds for real magnetic pulses were comparable in both groups (median 21% versus 24% of maximum pulse intensity). Intra-cortical facilitation was decreased in younger and increased in older EHS. In addition, typical EMF-related cognitions (aspects of rumination, symptom intolerance, vulnerability and stabilizing self-esteem) specifically differentiated EHS from their controls. CONCLUSIONS: These results demonstrate significant cognitive and neurobiological alterations pointing to a higher genuine individual vulnerability of electromagnetic hypersensitive patients.

[Pilot study on prescription of benzodiazepines in Switzerland: does cognitive availability of legal rules affect medical prescribing behavior]. / Pilotstudie zur Rezeptierung von Benzodiazepinen in der Schweiz: Beeinflusst die kognitive Verfügbarkeit von Gesetzesvorschriften das ärztliche Verschreibungsverhalten?

All 481 prescriptions of benzodiazepines from five Zurich pharmacies during a 6 week period were evaluated with respect to their compliance with the Swiss Law on Narcotics, which was formulated to prevent benzodiazepine dependence. Three weeks into the study, all 17 physicians with prescriptions of benzodiazepines practising in the catchment areas of two of the five pharmacies randomly selected were faxed an information sheet explaining formal juridical requirements for benzodiazepine prescription stipulated by the law. 28 % of all prescriptions were not compliant with the law. The older a patient, the greater his/her risk of receiving a non-compliant prescription. Neither sex of patients nor professional specialization of the prescribing doctor did impact prescription compliance. The preventive intervention, i. e. information on legal requirements, also had no significant impact on the compliance of prescriptions with the law. As other studies with soft interventions and educational measures directed to the prescribing physician also failed to reduce inappropriate prescription of benzodiazepines, it is concluded that sanctions against incompliant prescription behaviour should be considered as a preventive alternative.

[Fair hospital comparisons -- does the method contracted in Germany enable unbiased results?]. / "Fair ist, Gleiches mit Gleichem zu vergleichen" -- Eine Simulationsstudie zu den Krankenhausvergleichen nach section 5 Bundespflegesatzverordnung?

AIM: To evaluate the method for comparison of average length of stay in hospitals as defined in a contract between German health insurance companies and the "Deutsche Krankenhausgesellschaft" (German Hospital Association). METHOD: Simulation study executing the algorithm agreed upon in different scenarios, which varied the number of hospitals to be compared, the dispersion of diagnostic specialization over hospitals, and the distribution of hospitals' sizes. Scenarios were constructed to realistically reflect the situation in German inpatient treatment of mentally ill patients. RESULTS: By fixing casemix adjustments only on diagnoses of patients and by doing so aggregated on the level of hospitals, the method for comparison yielded artificial differences between hospitals even in a situation where each patient is treated with exactly the same amount of resource allocation (given the individual needs defined for all scenarios). Results of artificial differences were heavily biased against or in favour of the reference hospitals according to the specific condition of the scenario parameters. CONCLUSION: The contracted method is not capable of achieving fair hospital comparisons, at least not for psychiatric hospitals.

Sleep deprivation in depression stabilizing antidepressant effects by repetitive transcranial magnetic stimulation.

Partial sleep deprivation (PSD) has a profound and rapid effect on depressed mood. However, the transient antidepressant effect of PSD - most patients relapse after one night of recovery sleep - is limiting the clinical use of this method. Using a controlled, balanced parallel design we studied, whether repetitive transcranial magnetic stimulation (rTMS) applied in the morning after PSD is able to prevent this relapse. 20 PSD responders were randomly assigned to receive either active or sham stimulation during the following 4 days after PSD. Active stimulation prolonged significantly (p < 0.001) the antidepressant effect of PSD up to 4 days. This finding indicates that rTMS is an efficacious method to prevent relapse after PSD.

[Hospital financing in in-patient psychiatry via DRG-based prospective payment--The Salzburg experience]. / Fallpauschalen in der stationär-psychiatrischen Versorgung - Empirische Evaluation im Land Salzburg -

Hospital financing via case-related prospective payment sometimes is suspected to be responsible for accelerating the "revolving-door"-phenomenon in psychiatry. According to this reasoning, establishing diagnoses-related groups (DRGs) ruling a prospective payment system could not only reduce lengths of stay but could also simultaneously raise hospitalization and readmission rates. This study analyses the Austrian experience after the implementation of such a payment system, the "performance-oriented financing of hospitals" (leistungsorientierte Krankenanstalten-Finanzierung, LKF) in 1997. Time series analyses based on the complete hospital discharge statistics of the Salzburg province were used as methods. Results showed that neither length of stay, nor hospitalization or readmission rates in psychiatry have substansially changed or deviated from their long-term trends after implementation of the LKF system. Other medical disciplines have experienced statistically significant changes. The possibility to transfer these results to the German psychiatric health care system is discussed.

[Comparative hospital tours: visiting the oasis of psychiatry]. / Herr Tur-Tur und die Krankenhausvergleiche: Ein Besuch in der Psychiatrie-Oase.

AIM: Currently, financial sponsors and Government officials of the relevant ministries responsible for the German health care system request comparative length-of-stay figures in hospitals as indicators of efficacy of inpatient treatment. In psychiatry such comparisons are considered doubtful because of the heterogeneity of patients in different hospitals. This study compares the length of stay in eight German psychiatric hospitals accounting for individual as well as organisational characteristics. SAMPLE: 27,792 patient records according to the DGPPN-BADO (the standardized psychiatric assessment and discharge battery in Germany) from eight hospitals with a total of 135 wards. STATISTICAL ANALYSIS: Variance components modelling with random effects using three levels (patients, wards, hospitals). RESULTS: After adjustment for patient and organisational characteristics, there were no significant differences in the average length of stay between the eight hospitals. CONCLUSIONS: Hospital comparisons of quality of care require a multilevel approach. Based on our results further comparisons and implementation of quality improvements in inpatient psychiatry should focus on the ward level.

Methodological approaches to conducting pooled cross-sectional time series analysis: the example of the association between all-cause mortality and per capita alcohol consumption for men in 15 European states.

AIM: To compare different statistical models in order to estimate the association of alcohol consumption and total mortality when time series data stem from different regions. DATA AND METHODS: Data on per capita consumption in 15 European countries were combined with standardized mortality rates covering different periods between 1950 and 1995. An indicator of region-specific drinking patterns was measured without reference to a concrete time point, thus generating a hierarchical data structure. Two groups of models were compared: pooled cross-sectional time series models with different error structures and hierarchical linear models (random coefficient models). RESULTS: If historical time is not controlled for in cross-sectional models, this might result in estimating a negative association between alcohol consumption and total mortality. Hierarchical linear models or cross-sectional models controlling for historical time, however, resulted in the expected positive association. Only hierarchical linear models were able to adequately estimate the moderating effect of drinking patterns on the association between alcohol consumption and total mortality. CONCLUSION: For pooled cross-sectional time series data, control for the potential impact of historical time is of utmost importance. Hierarchical linear models constitute a superior alternative to analyze such complex data sets, especially as time-independent characteristics of regions can be implemented in the model.

Steps towards constructing a global comparative risk analysis for alcohol consumption: determining indicators and empirical weights for patterns of drinking, deciding about theoretical minimum, and dealing with different consequences.

In order to conduct a comparative risk analysis for alcohol within the Global Burden of Disease Study (GBD 2000), several questions had to be answered. (1) What are the appropriate dimensions for alcohol consumption and how can they be categorized? The average volume of alcohol and patterns of drinking were selected as dimensions. Both dimensions could be looked upon as continuous but were categorized for practical purposes. The average volume of drinking was categorized into the following categories: abstention; drinking 1 (> 0-19.99 g pure alcohol daily for females, > 0-39.99 g for males); drinking 2 (20-39.99 g for females, 40-59.99 g for males), and drinking 3 (> or =40 g for females, > or =60 g for males). Patterns of drinking were categorized into four levels of detrimental impact based on an optimal scaling analysis of key informant ratings. (2) What is the theoretical minimum for both dimensions? A pattern of regular light drinking (at most 1 drink every day) was selected as theoretical minimum for established market economies for all people above age 45. For all other regions and age groups, the theoretical minimum was set to zero. Potential problems and uncertainties with this selection are discussed. (3) What are the health outcomes for alcohol and how do they relate to the dimensions? Overall, more than 60 disease conditions were identified as being related to alcohol consumption. Most chronic conditions seem to be related to volume only (exceptions are coronary heart disease and ischemic stroke), and most acute conditions seem to be related to volume and patterns. In addition, using methodology based on aggregate data, patterns were relevant for attributing harms for men but not women.

Average volume of alcohol consumption, drinking patterns and related burden of mortality in young people in established market economies of Europe.

OBJECTIVE: To determine the burden of mortality in young people (age 15-29) in established market economies in Europe in 1999, which is attributable to alcohol consumption. Two dimensions of alcohol consumption were considered: average volume of consumption, and patterns of drinking. METHODS: Mortality data were obtained from the WHO EIP data bank, average volume data from the WHO global databank on alcohol, pattern of drinking data from a questionnaire sent out to experts, from the published literature and from the WHO global databank. Methods are explained and discussed in detail in two other contributions to this volume. RESULTS: More than 8,000 deaths of people aged 15-29 in Europe in 1999 were attributable to alcohol. Young males show a higher proportion of alcohol-attributable deaths (12.8%) than females (8.3%). Both average volume and patterns of drinking contribute to alcohol-related death. CONCLUSIONS: Alcohol-related deaths constitute a considerable burden in young people in Europe.

[Single sex or mixed sex treatment in the psychiatric clinic from the viewpoint of patients]. / Getrennt- oder gemischtgeschlechtliche Behandlung in der psychiatrischen Klinik aus Sicht der Patienten.

Patients in a psychiatric hospital were surveyed by questionnaire to evaluate their preferences on separate or mixed-sex treatment. The adjusted response rate was 74.5%. About 75% of the responders preferred a mixed ward and about 25% preferred a single-sex ward. Females more frequently chose the type of ward to which they had been allocated. By contrast, males were in favour of mixed wards, independently of their present type of ward. Younger patients, voluntarily admitted patients, and those with substance addiction preferred mixed-sex wards. After mixing the sexes in formerly single-sex wards, a significant increase in preference of mixed-sex wards was found, due to increased affirmation by female patients. However, about 9% of women and men preferred single-sex treatment. Two open general psychiatric wards, each with 20 beds and separating females and males, could be established in psychiatric hospitals to satisfy this preference.

Perception of traffic accident risk and decision to drive under light alcohol consumption--a double-blind experimental study.

PURPOSE: Public traffic safety campaigns in Germany have focussed on the changing risk perception of young drivers. While there is some consensus that perceptions of risk affect driving, less is understood about the relationship and interaction of alcohol consumption and risk perception on the decision to drive. We examined the influence of light alcohol consumption on risk perception and decision to drive, and the interaction of alcohol consumption and cognitive feedback on the handicapping effect of alcohol on risk perception and decision to drive. METHOD: In a double-blind block-randomized experimental study of 104 young drivers between 19 and 24 years of age, with two experimentally manipulated independent factors of alcohol consumption (three levels: 0% BAC, 0.015% BAC, 0.03% BAC) and feedback (positive or negative), we assessed three dependent variables: perception of traffic accident risk, subjective judgement about driving-relevant cognitive performance, decision to drive a car. Analyses of variance and covariance were used to analyze differences between levels of experimental factors. RESULTS: We found that persons with 0.015 BAC performed better than persons in both other alcohol conditions on the standardized risk perception task. Perceived handicap of driving was significantly more pronounced for negative feedback compared to positive feedback with no influence of the level of alcohol consumption. No significant influence on decision to drive was found of either level of alcohol consumption, feedback or sex. IMPLICATIONS: Decision to drive in young drivers could not be influenced by feedback or light consumption. Public health approaches have to find better determining factors.

Association of dopamine D3-receptor gene variants with neuroleptic induced akathisia in schizophrenic patients: a generalization of Steen's study on DRD3 and tardive dyskinesia.

Neuroleptic induced akathisia is a common and distressful extrapyramidal side effect of antipsychotic treatment. A significant proportion of the variability of its development has been left unexplained and has to be attributed to individual susceptibility. Since hereditary factors have been discussed in the etiology of acute akathisia (AA), part of the individual susceptibility might be of genetic origin. Moreover, AA is regarded as a forerunner of tardive dyskinesia, a drug-induced chronic movement disorder, which may be associated with homozygosity for the Ser9Gly variant of the DRD3 gene. Considering expression studies, which demonstrated functional variants of DRD3 polymorphisms, we investigated whether homozygosity for the Ser9Gly variant of the DRD3 gene is associated with AA. Homozygosity for the Ser9Gly variant of the DRD3 gene was connected to an 88% incidence of AA as compared with a considerably lower 46.9% incidence of AA in schizophrenic patients nonhomozygous for the 2-2 allele (exact P = 0.0223). Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:187-191, 2000.

Evaluation of a sensitive immunoluminometric assay for the determination of C-reactive protein (CRP) in serum and plasma and the establishment of reference ranges for different groups of subjects.

A sensitive immunoluminometric assay originally designed to measure C-reactive protein (CRP) in neonates and minimal serum volumes was adapted to measure this protein in a routine method without prior sample dilution. The concentration range covered without prior dilution was 10 micrograms/l to 20 mg/l using a sample volume of 5 microliters serum and a total assay time of less than 2 h. Serum samples were assayed from participants in a community medicine programme (SHIP--Study of Health in Pomerania) of the University of Greifswald, Germany (n = 414), as well as from mother-child pairs at birth (n = 30) and women attending the infertility clinic (n = 36). The validation of the assay was compared with a commercial latex-enhanced turbidimetric immunoassay (Roche Diagnostics--Integra 700) using routine serum samples (n = 60) from hospital patients. Comparison was made with the routine assay used in the SHIP study (Roche Diagnostics--Hitachi 717/Tina Quant). From 414 SHIP samples measured in the immunoluminometric assay, 289 were below the detection level in the turbidimetric (Tina Quant) assay. A significant positive correlation (p < 0.01) between log C-reactive protein concentration with age was found, both in the non-screened (all CRP values) (n = 414, r = 0.222) and selected (CRP < 5.00 mg/l = 90th percentile) (n = 370, r = 0.242) SHIP participants. Women were found to have significantly higher CRP levels than men (women: median age 47 a, median CRP 1.29 mg/l; men: median age 55 a, median CRP 1.00 mg/l--p = 0.016) in the non-selected SHIP participants. The situation was different in the selected group, (median age: men 54 a, women 48 a) where no significant difference in median CRP values between the sexes was seen (men: 0.874 mg/l, women 0.951 mg/l, p = 0.206). The distribution of CRP values in a "Normal Healthy Population" is skewed (mean/median--SHIP: all--2.08; selected--1.49). From the 414 SHIP samples measured in the immunoluminometric assay, 289 were below the detection level (2.5 mg/l) in the turbidimetric (Tina Quant) assay. From the 125 remaining samples the correlation between both methods was acceptable (r = 0.813), the regression line y = a + bx being: CRP (ILMA) = 1.83 + 0.842*CRP (Tina Quant). The Tina Quant assay gave values significantly higher than the ILMA in the range 2.5-25 mg/l CRP (p < 0.001). The total information loss in 289/414 subjects with a CRP < 2.5 mg/l with the Tina Quant assay makes it no longer suitable for epidemiological studies in which CRP is to be studied as a risk factor for cardiovascular events. The comparison between the immunoluminometric assay and the latex-enhanced immunoturbidimetric assay (Roche Integra) was much better. The latter measured down to less than 0.3 mg/l, thus being more suitable for epidemiological studies than the Tina Quant assay from the same producer. The correlation and regression data between the ILMA (x) and the Roche Integra assay (y) were: r = 0.971; CRP (Roche Integra) = 0.635 + 0.984*CRP (ILMA); n = 50.10 sera with CRP levels between 25 and 460 mg/l showed no high-dose hook effect in either assay. The remaining 50 sera were measurable in both assays. The turbidimetric assay gave rise to marginally but significantly higher values than the immunoluminometric assay (p = 0.004). The mothers at birth had a median CRP of 3.64 mg/l (range 1.49-12.6 mg/l), the neonates a median CRP of 34 micrograms/l (range 4-288 micrograms/l). All births were without complications, with gestational periods between 38 and 42 weeks. There was no correlation between maternal and neonatal CRP at birth. Mothers at birth had significantly higher CRP levels than healthy non-pregnant women (p < 0.001). Women attending the infertility clinic had CRP-values similar to age-matched healthy non-pregnant women (median 0.698 mg/l, range 0.05-9.97 mg/l). Interassay coefficients of variation at CRP concentrations of 0.85 and 7.9 mg/l were 8.99 and 7.93%, respectively, for the immunoluminometric

[Direct autotransfusion systems deliver blood of inadequate quality]. / Direkte Autotransfusionssysteme liefern Blut unzureichender Qualität.

OBJECTIVE: Systems for direct retransfusion of blood salvaged from the surgical field and in drainage systems (direct autotransfusion) have been in use for many years. The quality of the blood obtained with such systems, however, has not been systemically assessed in a comparative manner. The aim of our study was the analysis of the quality of the blood, obtained with three commercially available direct autotransfusion systems (drainage systems with filters). METHODS: With ethics committee approval and informed consent, 30 patients receiving knee arthroplasty were randomly allocated to three groups. Each group of 10 patients received treatment with one drainage system (Consta Vac, Solcotrans, Haem-o-Trans). In the salvaged blood, we measured cellular elements, variables of coagulation and fibrinolysis, complement activation and cellular elements, both before and after passage of the autotransfusion system. RESULTS: Analysis revealed a low haematokrit (< 30%) and platelet count (< 80 Gpt/l). The salvaged blood proved uncoagulable and defibrinised with no measurable clotting and fibrinogen; clotting activity, fibrinolysis and complement reaction were grossly induced (TAT, PAP and FDP high, C3 low). The blood was contaminated with cellular debris reflected by concentration of enzymes usually confined to the intracellular space (LDH, elastase, beta-thromboglobulin). CONCLUSION: The systems/filters assessed in this study do not improve quality of blood drained from the surgical field. Retransfusion of such blood can not be recommended.

[Behavioral pattern and behavioral characteristics of children in two pediatric clinics]. / Verhaltensmuster und Verhaltensauffälligkeiten von Kindern in zwei Kinderkliniken.

OBJECTIVES: To describe systematically patterns of behavior of children and parents in pediatric hospitals. METHODS: A questionnaire to systematically rate behavior of children and parents was administered by nurses to two independent samples in two different pediatric hospitals. At the von Haunersches Kinderspital, Klinikum Innenstadt of the Ludwig-Maximilian-University of Munich, 659 children were rated, at the Pediatric Hospital of the University of Freiburg, 484 children. Latent class analysis grouped children/parents according to similar patterns of behavior. RESULTS: In Munich a five-class model is most appropriate to classify children/parent behavior, in Freiburg a six-class model best first the data. Four classes in Munich and in Freiburg display nearly identical profiles. Three of them describe inconspicuous behavior of children in different age groups, whereas the fourth group describes disturbed children. These four groups classify 87% of the children in Munich and 73% of those in Freiburg. In Munich 25% of the children are rated as disturbed, as opposed to 39% in Freiburg. CONCLUSIONS: The questionnaire is suitable for everyday clinical practice. Results of both samples mostly correspond. Remaining differences are caused by type of hospital (pediatrics vs. pediatric surgery) and by the differing depth of nurses' rater training.