[Cannabis--Position Paper of the German Respiratory Society (DGP)]. / Cannabis--Positionspapier der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e.V. (DGP).

In this position paper, the adverse health effects of cannabis are reviewed based on the existing scientific literature; in addition possible symptom-relieving effects on some diseases are depicted. In Germany, cannabis is the most widely used illicit drug. Approximately 600,000 adult persons show abusive or addictive cannabis consumption. In 12 to 17 year old adolescents, cannabis use increased from 2011 to 2014 from 2.8 to 6.4%, and the frequency of regular use from 0.2 to 1.5%. Currently, handling of cannabinoids is much debated in politics as well as in general public. Health aspects have to be incorporated into this debate. Besides analysing mental and neurological side effects, this position paper will mainly focus on the influences on the bronchopulmonary and cardiovascular system. There is strong evidence for the induction of chronic bronchitis. Allergic reactions including asthma are known, too. Associations with other diseases like pulmonary emphysema, lung cancer and pneumonia are not sufficiently proven, however cannot be excluded either. In connection with the use of cannabis cardiovascular events such as coronary syndromes, peripheral vascular diseases and cerebral complications have been noted. Often, the evidence is insufficient due to various reasons; most notably, the overlapping effects of tobacco and cannabis use can frequently not be separated adequately. Empirically, early beginning, high-dosed, long-lasting and regular cannabis consumption increase the risk of various psychological and physical impairments and negatively affect age-based development. Concerns therefore relate especially to children and adolescents. There is only little scientific evidence for medical benefits through cannabis as a remedy; systematic research of good quality, in particular prospective, randomised, placebo-controlled double-blinded studies are rare. The medical societies signing this position paper conclude that cannabis consumption is linked to adverse health effects which have to be taken into consideration in the debate about the social attitude towards cannabinoids. The societies agree that many aspects regarding health effects of cannabis are still uncertain and need clarification, preferably through research provided by controlled studies.

[Psychiatric comorbidities with tobacco-related disorders]. / Psychiatrische Komorbiditäten bei tabakbedingten Störungen.

The coincidence of tobacco smoking and psychiatric disorders is of great epidemiological and therapeutic importance. Tobacco smoking by people with mental disorders leads to disproportionately high somatic health risks, an adverse clinical course, poorer clinical outcomes and reduced quality of life (QoL). The etiological causes of the high comorbidity between smoking and mental disorders are still unclear: currently, tobacco smoking is discussed as being either the consequence or contributory cause of psychological disorders or both disorders share common antecedents and interactions. Psychiatric patients are motivated to quit and smoking cessation is not generally less effective with smokers with mental disorders than with mentally healthy individuals. Specific smoking cessation programs in the inpatient and outpatient settings are time-consuming and complex but effective. Within the framework of the current S3 guidelines the international evidence has been updated and transformed into treatment guidelines following an elaborate consensus process. Basically the same interventional measures should be used as with mentally healthy individuals; however, smokers with a psychological comorbidity often need more intensive adjuvant psychotherapeutic interventions and often need pharmaceutical support, (bupropion, varenicline and nicotine replacement therapy). Due to the overall unsatisfactory findings the treatment guidelines are partially based on clinical consensus decisions. In this field, a considerable need for research has been determined.

[Psychotherapy and pharmacotherapy for harmful tobacco use and tobacco dependency]. / Psycho- und Pharmakotherapie bei schädlichem Tabakgebrauch und -abhängigkeit.

Tobacco consumption is one of the major preventable health risk factors. In Germany approximately 110,000 people prematurely die from tobacco-related diseases and approximately 50% of regular smokers are considered to be tobacco dependent. Nevertheless, motivation to quit smoking is low and the long-term abstinence rates after attempts to stop smoking without professional support are far below 10%. As part of the S3 treatment guidelines 78 recommendations for motivation and early interventions for smokers unwilling to quit as well as psychotherapeutic and pharmacological support for smokers willing to quit were formulated after an systematic search of the current literature. More than 50 professional associations adopted the recommendations and background information in a complex certification process. In this article the scientific evidence base regarding the psychotherapeutic and pharmacological treatment options as well as recommendations and further information about indications and treatment implementation are presented. By following these guidelines for treatment of heavy smokers who are willing to quit combined with individual and group therapies on the basis of behavioral treatment strategies and pharmacological support, long-term success rates of almost 30% can be achieved.

EPA guidance on tobacco dependence and strategies for smoking cessation in people with mental illness.

Tobacco dependence is the most common substance use disorder in adults with mental illness. The prevalence rates for tobacco dependence are two to four times higher in these patients than in the general population. Smoking has a strong, negative influence on the life expectancy and quality of life of mental health patients, and remains the leading preventable cause of death in this group. Despite these statistics, in some countries smokers with mental illness are disadvantaged in receiving intervention and support for their tobacco dependence, which is often overlooked or even tolerated. This statement from the European Psychiatric Association (EPA) systematically reviews the current evidence on tobacco dependence and withdrawal in patients with mental illness and their treatment. It provides seven recommendations for the core components of diagnostics and treatment in this patient group. These recommendations concern: (1) the recording process, (2) the timing of the intervention, (3) counselling specificities, (4) proposed treatments, (5) frequency of contact after stopping, (6) follow-up visits and (7) relapse prevention. They aim to help clinicians improve the care, health and well-being of patients suffering from mental illness.

[Evaluation of a structured smoking cessation program for primary care medicine]. / Evaluierung eines strukturierten Tabakentwöhnungsprogramms für die ärztliche Praxis.

BACKGROUND: Despite the fact that 9 of 10 general practitioners in Germany believe that smoking cessation is an important topic structured programs are only rarely offered to patients. Beside a lack of time and missing reimbursement, physician's limited treatment skills are frequent reasons for this observation. Therefore we aimed to develop a structured, easy to learn and time-effective smoking cessation program for the general practice. Evidence based treatment elements were combined and standardized by a step by step treatment guideline. METHODS: In a non-interventional observation we tested the program's integration in the daily routines of physicians, the rate of continuous tobacco abstinence after 12 weeks and both patient's and physician's satisfaction with the program and the medication. RESULTS: 44 physicians participated in the study. 184 patients were observed over a mean period of 12.8 weeks and were treated with an individually adapted nicotine replacement therapy for 10 weeks. At the end of treatment (12.1 weeks after the target quit date) 48.4% of the patients reported continuous abstinence. The combination of structured counseling with nicotine substitution in this program was easily implemented in doctor's practice, induced a high user satisfaction and a long usage of medication. The encouraging abstinence rate could have been influenced by selecting highly motivated patients, by offering structured and regular consultations at fixed intervals over the first weeks and by the treatment with the individually adapted nicotine substitution. CONCLUSION: This study shows an easy way to implement an individual and structured smoking cessation therapy in primary care medicine in Germany. Nevertheless, the results should be confirmed in larger cohorts and on a higher methodological level.

[Analysis of spinal stress during surgery in otolaryngology]. / Analyse der Wirbelsäulenbelastung bei Operationstätigkeiten in der HNO-Heilkunde.

BACKGROUND: Back pain is a common cause of sick leave in industrialized countries. Performing surgery is often associated with considerable cervical spine disorders. However, only a few studies have examined to what extent working posture or individual surgical techniques can be seen as stress indicators. MATERIAL AND METHODS: Posture and movement of the spine and trunk were assessed by means of a newly developed analysis system (3-D-SMG). The individual-case study was carried out during six sinus operations using varying techniques (microscope, endoscope or headlamp only). RESULTS: Spine and trunk deviation from neutral position (upright standing) was strongest in the sagittal plane. Awkward distortions were primarily observed in the cervical and lumbar spine. The analysis of work characteristics revealed static postures in 65-90% of sinus operations. Isometric positions were mainly related to microscopic surgery. CONCLUSIONS: The data from this explorative individual-case study indicate that prevalence and magnitude of forced isometric and awkward postures are strongly associated with work-related spinal stress in sinus surgery. The new measurement device enables not only the recommendation of individual preventive strategies but also the objective evaluation of ergonomics.

Performance, training and lifestyle parameters of marathon runners aged 20-80 years: results of the PACE-study.

Successful finishing of marathon requires regular endurance training and appropriate lifestyle. Thus, marathon running times and training data from large samples of physically active and fit elderly are ideal for the assessment of age-related performance. In the present study we analyzed 439 278 running times from result lists of 108 marathon competitions and data from a survey via internet questionnaire about training and behavioural factors of marathon finishers. Marathon times and 6 992 data sets from the internet questionnaire were separated into groups based on age and sex and analyzed by two-way ANOVA. Our main findings are that 1) there are virtually no relevant running time differences (p<0.01) in marathon finishers from 20 to 55 years and 2) the majority of middle-aged and elderly athletes have training histories of less than seven years of running. With the exception of marathon running times we did not encounter any significant gender related differences (p>0.01). The present findings strengthen the concept that considers aging as a biological process that can be considerably speeded up or slowed down by multiple lifestyle related factors.

Validation of a short-term memory test for the recognition of people and faces.

Memorising and processing faces is a short-term memory dependent task of utmost importance in the security domain, in which constant and high performance is a must. Especially in access or passport control-related tasks, the timely identification of performance decrements is essential, margins of error are narrow and inadequate performance may have grave consequences. However, conventional short-term memory tests frequently use abstract settings with little relevance to working situations. They may thus be unable to capture task-specific decrements. The aim of the study was to devise and validate a new test, better reflecting job specifics and employing appropriate stimuli. After 1.5 s (short) or 4.5 s (long) presentation, a set of seven portraits of faces had to be memorised for comparison with two control stimuli. Stimulus appearance followed 2 s (first item) and 8 s (second item) after set presentation. Twenty eight subjects (12 male, 16 female) were tested at seven different times of day, 3 h apart. Recognition rates were above 60% even for the least favourable condition. Recognition was significantly better in the 'long' condition (+10%) and for the first item (+18%). Recognition time showed significant differences (10%) between items. Minor effects of learning were found for response latencies only. Based on occupationally relevant metrics, the test displayed internal and external validity, consistency and suitability for further use in test/retest scenarios. In public security, especially where access to restricted areas is monitored, margins of error are narrow and operator performance must remain high and level. Appropriate schedules for personnel, based on valid test results, are required. However, task-specific data and performance tests, permitting the description of task specific decrements, are not available. Commonly used tests may be unsuitable due to undue abstraction and insufficient reference to real-world conditions. Thus, tests are required that account for task-specific conditions and neurophysiological characteristics.

Two cases of symptomatic cluster-like headache suggest the importance of sympathetic/parasympathetic balance.

Despite several reports on symptomatic cluster-like headache, there is no clear explanation of how different lesions thought to be causative are related to cluster-like headache. On the basis of two additional cases of symptomatic cluster headache, we discuss the possibility that an acute imbalance of the autonomic nervous system, namely a net overactivity of the parasympathetic system, may be able to trigger these headache attacks in patients who probably have an additional individual predisposition to react with a cluster-like headache. Such an imbalance can be due to an increase in parasympathetic tone (e.g. stimulation of parasympathetic fibres) or to a reduction of the sympathetic tone (e.g. a lesion of the sympathetic fibres).

Age-related changes in marathon and half-marathon performances.

We examined age-related changes in endurance performance of marathon and half-marathon finishers. A total of 405 515 running times were separated into groups based on age, sex, and distance. After exclusion of repetitive running times, 300 757 runners were analyzed by ANOVA (factors: age, sex). For each age group (six decades, 20-79 years), mean running times for all finishers, as well as top-ten performers, were assessed. As expected, age and sex had significant influence on running times. Female running times were about 10 % (marathon) and 13 % (half-marathon) above the corresponding times of their age-matched peers. The main finding is that in our sample of trained subjects significant age-related losses in endurance performance did not occur before the age of 50 years. Mean marathon and half-marathon times were virtually identical for the age groups from 20-49 years. Moreover, age-related performance decreases (p < 0.01) of the 50 - 69-year-old subjects were only in the range of 2.6 - 4.4 % per decade. These results suggest that the majority of older athletes are able to maintain a high degree of physical plasticity. The hypothesis that lifestyle factors have considerably stronger influences on functional capacity than the factor age is also supported by these findings from physically active and fit elderly.

Hand-grip strength of young men, women and highly trained female athletes.

Hand-grip strength has been identified as one limiting factor for manual lifting and carrying loads. To obtain epidemiologically relevant hand-grip strength data for pre-employment screening, we determined maximal isometric hand-grip strength in 1,654 healthy men and 533 healthy women aged 20-25 years. Moreover, to assess the potential margins for improvement in hand-grip strength of women by training, we studied 60 highly trained elite female athletes from sports known to require high hand-grip forces (judo, handball). Maximal isometric hand-grip force was recorded over 15 s using a handheld hand-grip ergometer. Biometric parameters included lean body mass (LBM) and hand dimensions. Mean maximal hand-grip strength showed the expected clear difference between men (541 N) and women (329 N). Less expected was the gender related distribution of hand-grip strength: 90% of females produced less force than 95% of males. Though female athletes were significantly stronger (444 N) than their untrained female counterparts, this value corresponded to only the 25th percentile of the male subjects. Hand-grip strength was linearly correlated with LBM. Furthermore, both relative hand-grip strength parameters (F (max)/body weight and F (max)/LBM) did not show any correlation to hand dimensions. The present findings show that the differences in hand-grip strength of men and women are larger than previously reported. An appreciable difference still remains when using lean body mass as reference. The results of female national elite athletes even indicate that the strength level attainable by extremely high training will rarely surpass the 50th percentile of untrained or not specifically trained men.

Physical performance, body weight and BMI of young adults in Germany 2000 - 2004: results of the physical-fitness-test study.

In westernized countries the sedentary lifestyle in conjunction with a hypercaloric diet has caused an increase in the number of obese adults. Moreover, recent studies suggest that the prevalence of overweight in children increased during the last decade. However, the literature has to be interpreted with some caution since the majority of epidemiological studies examining health, fitness, and obesity rely on self-reported data rather than measurements. A further limitation is that most studies examine either physical activity or nutrition, only few deal with both aspects simultaneously. In the present study we analyzed both aspects in more than 58,000 persons aged between 17 and 26 years. All of them were applicants for the German Bundeswehr, which accepts only volunteers with school leaving certificates and a body mass index (BMI) below 30 kg . m (-2). The admitted subjects performed a Physical-Fitness-Test (PFT) consisting of 5 simple sport tests (shuttle run, sit-ups, push-ups, standing jump, Cooper test). For 23 000 subjects additional measurements of body height and body weight as well as information about their education level were available. These data were combined with the PFT results. We found large deficits in the physical fitness of young adults: More than 37 % of the participants failed to pass the PFT, with failure rates of the male volunteers increasing significantly since 2001. While the female volunteers showed virtually constant body weight and BMI, the corresponding values of men increased monotonously between the age of 17 and 26 years. Physical fitness was positively, BMI negatively correlated with education level. The present findings suggest that body weight increases and fitness decreases in non-obese young adults in Germany. Despite the correlations between BMI and physical fitness the terms "overweight" and "physically unfit" should not be regarded as synonyms.

Recovery of hand grip strength and hand steadiness after exhausting manual stretcher carriage.

Rescue activities frequently require not only substantial and sustained hand-grip forces but also a subtle coordination of hand and finger muscles, e.g. when manipulating injection syringes after manual stretcher carriage. We investigated the recovery kinetics of manual coordination and muscle strength after exhausting stretcher carriage (4.5 km/h, load at each handle bar: 25 kg). Hand steadiness (frequency and duration of wall contacts when holding a metal pin into a small bore) and parameters of hand-grip strength were determined in 15 male volunteers before and immediately after the stretcher carriage. Measurements were repeated after 0.5, 1, 4 and 24 h of recovery. Mean carrying time was 215+/-87 s (SD), mean transport distance amounted to 264+/-104 m. During the carriage test, forces at the stretcher handles oscillated in the order of +/-50 N within each gait cycle. Immediately after exhaustion, hand steadiness was significantly deteriorated (threefold increase in frequency and duration of wall contacts), maximum and mean hand-grip force over 15 s were reduced by almost 20%. While the recovery of hand steadiness was complete by minute 30 after stretcher carriage, a significant reduction in maximum and mean hand-grip force by 12% could still be observed after 24 h. The present findings demonstrate that hand steadiness recovers much faster than maximum hand-grip strength after exhaustive manual stretcher carriage (less than 30 min vs. more than 24 h). Probably, muscle damage induced in particular by the eccentric components during stretcher transport seems to affect only the generation of large forces. By contrast, the generation and coordination of the much lower forces required for hand-steadiness appears to be impaired only during the short transient of metabolic recovery.

[Treatment of vitally endangered anorexia nervosa patients based on guardianship laws]. / Behandlung vital gefährdeter Anorexia-nervosa-Patienten unter Berücksichtigung der Möglichkeiten des Betreuungsrechts.

Anorexia nervosa is a psychiatric disorder occurring primarily in young women. Especially when chronic or the body mass index is less than 12 kg/m(2), it has a mortality of up to 20%. Often these patients are admitted to emergency units and treated internistically. If they accept psychiatric treatment, they are normally transferred to specialized psychosomatic units for further therapy. If patients are not able to accept necessary further therapy to overcome the danger to health and life, the question arises in terms of guardianship law of whether they are able to handle their personal concerns alone. After several vitally endangered anorexia nervosa patients had been admitted to our closed psychiatric ward, we developed a therapeutic concept for this subgroup of patients, taking the possibilities of guardianship law into account. This concept aims at restoring the body weight continuously and finally enable the patients to be transferred to less restrictive psychosomatic units. The chosen treatment is shown with the therapy courses of 25 patients treated according to this concept.

Prolonged confusional state following electroconvulsive therapy--diagnostic clues from serial electroencephalography.

INTRODUCTION: Cognitive impairment occasionally occurs after electroconvulsive therapy (ECT) and usually resolves within a few days. Any prolonged cognitive alterations or confusional states may have additional causes and require extensive diagnostic effort. Since cognitive dysfunction can also be caused by ictal states, electroencephalography (EEG) is an essential tool for these conditions. METHODS: We report on a female patient with pharmacotherapy resistant major depression who had been treated by a series of ECT and subsequently developed severe confusion and fluctuating amnesia. RESULTS: Laboratory and neuroimaging examinations were normal, however, EEG revealed a severe intermittent slowing with rhythmic high amplitude delta-/theta-activity and sporadic bitemporal sharp waves. Oral application of 1 mg lorazepam led to a sudden improvement of EEG abnormalities. Consequently, non-convulsive status epilepticus (NCSE) was suspected and the patient was regularly treated with lorazepam, accordingly. Clinically the confusional and amnesic symptoms declined, whereas serial EEG recordings showed a further improvement and normalization of brain electric activity. CONCLUSION: Routine EEG is an indispensable tool in patients with sudden deterioration of cognitive functions and unclear neuropsychiatric symptomatology. A testing dose of lorazepam can help to classify EEG abnormalities in terms of ictal EEG patterns.

Hypermetabolic pattern in frontal cortex and other brain regions in unmedicated schizophrenia patients. Results from a FDG-PET study.

We report results of a FDG-PET study in 10 patients with schizophrenia (6 unmedicated, 4 never medicated) and 12 healthy age-matched controls. The patients met ICD-10 and DSM-IV criteria for schizophrenia and all reported psychotic, "positive" symptoms when tested. Schizophrenic patients had higher absolute CMRGlu values in almost all quantified regions compared to normal subjects. Using the occipital cortex as the reference region patients showed a hyperfrontal metabolic pattern. Other significant regional differences were found with respect to thalamus, striatum and temporal cortex. The finding of a hyperfrontality in un- and never medicated psychotic schizophrenic patients must be discussed in the light of the psychopathological symptoms of patients when tested, a possible disruption of cortico-striato-thalamic feedback loops and recent findings of a hyperfrontality in experimentally induced psychosis (ketamine- and psilocybin-model of schizophrenia).

Reduction of blood pressure response during strength training through intermittent muscle relaxations.

UNLABELLED: The increase in blood pressure during training is a disadvantage of strength training in the elderly. To reduce this effect it is generally recommended to apply lower levels of relative muscle strength with longer contraction durations or higher number of repetitions (continuous mode (CM), e. g. 50% of maximal strength, 10 to 15 repetitions without pauses). Alternatively, higher contraction forces could be combined with frequent periods of muscle relaxation and fewer repetitions (intermittent mode (IM), e. g. 80% of maximal strength, 8 repetitions consisting of 1.5 s concentric contraction, 1.5 s eccentric contraction and 3 s pause). We compared the blood pressure effects of both approaches during leg press exercise in two age groups (10 subjects aged 22 to 42 y, 9 subjects aged 60 to 72 y). Blood pressure was measured continuously by a non-invasive method (FINAPRES, Ohmeda 2300, Englewood USA). RESULTS: 1. The age of the subjects had no significant influence on the slopes of blood pressure increase during the different exercise modes. 2. The frequent insertion of short (3 s) periods of muscle relaxation (IM) decreased the blood pressure response more effectively than a reduction in contraction strength alone (CM). Short muscle relaxations have an immediate, mechanical effect on blood pressure and they allow a metabolic recovery which attenuates the trend of blood pressure increase.

PET and SPECT findings in alcohol hallucinosis: case report and super-brief review of the pathophysiology of this syndrome.

Alcohol hallucinosis is a rare complication of chronic alcoholism with schizophreniform symptomatology. The pathophysiology is basically unclear. We report the case of a 48-year-old, never-medicated, long-term alcoholic suffering from alcohol hallucinosis with pure acoustic hallucinations for at least six months. Current FDG PET data suggest a hypofrontality and possibly a thalamic hypofunction in alcohol hallucinosis, findings similar to those reported in unmedicated schizophrenics. Current IBZM SPECT data do not support a dopamine receptor dysfunction in alcohol hallucinosis but TRODAT SPECT showed reduced dopamine transporter binding. Possible implications of these findings are discussed.

[Trichophyton tonsurans var. sulfureum subvar. perforans in Tinea gladiatorum]. / Trichophyton tonsurans var.sulfureum subvar.perforans bei Tinea gladiatorum.

This is the first report on an isolation of Trichophyton tonsurans var.sulfureum subvar.perforans in Germany. In our patient, the strain had caused typical tinea corporis, which was most likely acquired during a wrestling competition. Based on the macroscopic and microscopic morphology and on the physiologic properties occurring under various growth conditions, the identification of Trichophyton tonsurans and the particular characteristics of its var.sulfureum subvar.perforans are described. Partial 18S and 23S nuclear ribosomal RNA sequences and the internal transcribed spacer region I sequences of our strain were completely identical with those of a Trichophyton tonsurans reference strain. The epidemiology of Trichophyton tonsurans var.sulfureum subvar.perforans and a possible association of this variety with tinea in wrestlers (tinea gladiatorum) have not yet been investigated.