[Prospective Study of the Health Care Utilization of a Clinic by Outpatients in a Rural Region]. / Prospektive Untersuchung zur ambulanten Inanspruchnahme einer Klinik im ländlichen Bereich.

Background: Medical care of emergency cases is based primarily on the so called KV-emergency service in Germany. However, it seems that hospitals are more and more frequented in such cases, which was the focus of our study. Material and Methods: The prospective study started in April 2013 and ended in March 2014. All outpatients were analyzed according several items such as personal data, the reason, time and urgency for presentation. An emergency case was defined by the patient's need of acute ENT-care. Results: All in all 11 002 patients were enrolled in this study. There were 6 463 elective cases in the regular office hours, 2 438 emergencies were treated at our department. Evaluation of the acuteness of the emergencies according to the Manchester-Triage-System demonstrated that most of the patients did not require immediate treatment. This fact is also reflected by the small number of only 10% of admissions and 18% of surgical interventions. During office hours 38% patients presented themselves as emergency and 62% cases came after official service to our department. Discussion: Especially the emergency treatment was frequently used, however the medical reasons did not justify the presentation in the majority of cases.

Disturbed sleep patterns and limitation of noise.

Due to the undisputable restorative function of sleep, noise-induced sleep disturbances are regarded as the most deleterious effects of noise. They comprise alterations during bedtimes such as awakenings, sleep stage changes, body movements and after-effects such as subjectively felt decrease of sleep quality, impairment of mood and performance. The extents of these reactions depend on the information content of noise, on its acoustical parameters and are modified by individual influences and by situational conditions. Intermittent noise, that is produced by air traffic, rail traffic and by road traffic during the night is particularly disturbing and needs to be reduced. Suitable limits are suggested.

Noise induced nocturnal cortisol secretion and tolerable overhead flights.

Mainly dependent on level and dynamic increase sound produces over-shooting excitations which activate subcortical processing centers (e.g. the amygdala, functioning as fear conditioning center) besides cortical areas (e. g. arousing annoyance, awakenings) as well. In addition there exist very close central nervous connections between subcortical parts of the auditory system (e.g. amygdala) showing typical plasticity effects (sensitization) and the hypothalmic-pituitary-adrenal (HPA)-axis. Using that causal chain noise induce cortisol excretion even below the awakening threshold. Thus repeated noise events (e.g. overflights during night time) may lead to accumulation of the cortisol level in blood. This can happen because its time-constant of exponential decrease is about 50 to 10 times larger than that one for adrenaline and noradrenaline. This fact and the unusual large permeability of cortisol through the cell membranes opens a wide field of connections between stress-dependent cortisol production and the disturbance of a large number of other endocrine processes, especially as a result of long-term stress activation by environmental influences such as environmental noise. Based upon a physiological model calculating the cortisol accumulation starting at a nightly threshold of physiological over-proportional reactions around Lmax = 53 dB(A) the number of tolerable noise events (over-flights in a nightly time range) can be estimated for given indoor peak sound pressure levels, keeping the cortisol increase within the normal range. Examples of results for 8 hours in the night are for instance number and level combinations (NAL-values) of 13 events with 53 dB(A) indoor peak level or 6 events with 70 dB(A) indoor peak level respectively.

Protection goals for residents in the vicinity of civil airports.

Based on extensive and detailed reviews the present paper suggests evaluation criteria for aircraft noise for the prediction of noise effects and for the protection of residents living in the vicinity of (newly constructed or extended) civil airports. The protection concept provides graded evaluation criteria: Critical loads indicate noise loads that shall be tolerated only exceptionally during a limited time. Protection Guides are central evaluation criteria for taking actions to reduce noise immission. Threshold values inform about measurable physiological and psychological reactions due to noise exposures where long term adverse health effects are not expected. Evaluation criteria are provided for various protection goals, for hearing, communication and sleep, for the avoidance of annoyance and of suspected cardiovascular diseases. As protection of the residents is understood as a dynamic process, these criteria must be repeatedly tested and adapted to new scientific findings.

A behavioral study of alpha-1b adrenergic receptor knockout mice: increased reaction to novelty and selectively reduced learning capacities.

Knockout mice lacking the alpha-1b adrenergic receptor were tested in behavioral experiments. Reaction to novelty was first assessed in a simple test in which the time taken by the knockout mice and their littermate controls to enter a second compartment was compared. Then the mice were tested in an open field to which unknown objects were subsequently added. Special novelty was introduced by moving one of the familiar objects to another location in the open field. Spatial behavior and memory were further studied in a homing board test, and in the water maze. The alpha-1b knockout mice showed an enhanced reactivity to new situations. They were faster to enter the new environment, covered longer paths in the open field, and spent more time exploring the new objects. They reacted like controls to modification inducing spatial novelty. In the homing board test, both the knockout mice and the control mice seemed to use a combination of distant visual and proximal olfactory cues, showing place preference only if the two types of cues were redundant. In the water maze the alpha-1b knockout mice were unable to learn the task, which was confirmed in a probe trial without platform. They were perfectly able, however, to escape in a visible platform procedure. These results confirm previous findings showing that the noradrenergic pathway is important for the modulation of behaviors such as reaction to novelty and exploration, and suggest that this is mediated, at least partly, through the alpha-1b adrenergic receptors. The lack of alpha-1b adrenergic receptors in spatial orientation does not seem important in cue-rich tasks but may interfere with orientation in situations providing distant cues only.

Ear damage caused by leisure noise.

Noise is a health risk. Recent findings suggest that leisure noise is a substantial danger especially to children, teenagers and young adults. Epidemiological studies of teenagers with no occupational noise exposure show an increasing number with a substantial and measurable irreversible inner ear damage. This is basically due to the wide spread exposition to very loud toys (pistols and squibs), crackers and exposure to electronically amplified music, e.g. from personal cassette players (PCP), at discos or concerts etc. Protection against irreversible ear damage by leisure noise has an important impact in preventive medical care. Therefore the general public must be informed that loud leisure activities may cause damage to the ear. In order to protect children, young people and adults, the legislature ought to set limits for sound levels in discos, concert halls and for music equipment and toys by establishing the necessary standards and regulations.

The epilepsy tutorial.

Within the European Neurological Network (ENN) project an interactive multimedia tutorial covering the medical field of epilepsy has been created. The first priorities of that project to educate health care professionals, e.g. General Practitioners (GP), throughout the European community as how to best diagnose and treat patients (e.g. reduction of frequent consultations, avoiding of excessive and unnecessary medication and useless laboratory tests) and to inform patients and carers are reached by producing a distributable CD-ROM. Later frequent updates of the content of the installed tutorial will take place by a telematic network contacting the multimedia database of the ENN-project. Using the toolbook author-system with integrated sound, images, animation and videos the data collected from about 10 experts are arranged as an electronic book, with multiple-linked pages and an object oriented program design, based for instance on customisable navigation buttons, special text arrangement, graphics, and staging areas for content and interaction display. The multimedia tutorial about epilepsy contains case reports, specific multiple choice questions with scoring, video clips etc. and several possibilities for access such as help-pages available all times, index, search machine for phrases, bookmark settings and roadmaps for graphical orientation. Detailed text is prepared including physiology and pathophysiology, differential diagnosis, investigations, therapeutics, epilepsy in children, advice for patients and carers, and is supported by a glossary, special definitions and proposals for classification of the different kinds of epilepsy. The tutorial runs with Windows 3.1, 95 and NT and contains 1300 pages text with 382 Fig.s, 14 videos, 70 sound files, 196 definitions and 8 roadmaps. The epilepsy tutorial has been distributed in March/May 1998 to more than 100 general physicians in Germany, Portugal and France.

Central nervous system activation by noise.

Connections between thalamic structures of the auditory system and subcortical areas (amygdala, hippocampus, hypothalamus) had been hypothesized to act as a fast reacting "memory chain" establishing and enhancing adverse excitations during noise exposure. Recent studies prove that the lateral amygdala is an important part of a second separate pathway to the telencephalic projections of the auditory system. This fast, monosynaptic thalamo-amygdala tract is responsible for full-blown "fear responses" evoked by auditory stimuli as shown by several conditioning experiments in animals: A fear memory system. The appertaining basic processes of plasticity in the amygdala are reductions of latencies of neuronal excitations and recruiting of more elements with shorter latency, long-term potentiation causing enhancement of auditory-evoked responses by repeated stimulation, as well as sharpening of primary broad tuning curves of elements. Very recently a study using Functional-Magnetic-Resonance-Imaging (fMRI) demonstrated that an amygdalar contribution to conditioned fear learning can be revealed in normal human subjects too. These findings were supported by Positron-Emission-Tomography (PET) studies in depressive persons showing that amygdala metabolic abnormality predicted the cortisol concentration in blood. Using connections via central amygdala, lateral and medial hypothalamus to parts named nuclei paraventriculares and regio arcuata, the sound evoked excitations reach two essential components of endocrine functioning: a) the well-known hypothalamic-pituitary-adrenal (HPA) system with a subsequent rise (via Corticotropin-Releasing Hormone: CRH) in Corticotropin (Adreno-CorticoTropin Hormone: ACTH) and the corticosterone levels; b) the synthesis of ACTH and beta-endorphine-like substances in the arcuate region being axonally transported to extrahypothalamic brain regions. Longer-lasting activation of the HPA-axis, especially abnormally increased or periodically elevated levels of cortisol and the widespread extrahypothalamically distributed CRF/ACTH may lead to disturbed hormonal balance and even to severe diseases.

Possible health effects of noise induced cortisol increase.

The auditory system is permanently open - even during sleep. Its quick and overshooting excitations caused by noise signals are subcortically connected via the amygdala to the hypothalamic-pituitary-adrenal-axis (HPA-axis). Thus noise causes the release of different stress hormones (e.g. corticotropin releasing hormone: CRH; adrenocorticotropic hormone: ACTH) especially in sleeping persons during the vagotropic night/early morning phase. These effects occur below the waking threshold of noise and are mainly without mental control. Animal experiments show noise-induced changes in sensitivity of cellular cortisol receptors by increase of heat-shock proteins, and ultrastructural changes in the tissue of the heart and the adrenal gland. Increased cortisol levels have been found in humans when exposed to aircraft noise or road traffic noise during sleep. The effects of longer-lasting activation of the HPA-axis, especially long term increase of cortisol, are manifold: immuno suppression (e.g. eosinopenia), insulin resistance (e.g. diabetes), cardiovascular diseases (e.g. hypertension and arteriosclerosis), catabolism (e.g. ostoeporosis), intestinal problems (e.g. stress ulcer) etc. Even worse may be the widespread extrahypothalamical effects of CRH/and/or ACTH which have the potential to influence nearly all regulatory systems, causing for example stress-dysmenorrhea etc. as signs of disturbed hormonal balance.

[Hearing loss caused by leisure noise]. / Gehörschäden durch Freizeitlärm.

Although noise in general can induce hearing loss, environmental noise represents an important risk for children, teenagers and young adults. Epidemiological investigations now support the occurrence of an increasing number of irreversible hearing losses in these groups. Major causes of hearing loss are toys (guns), explosives and electroacoustically amplified music delivered by head sets or heard in discotheques and open air concerts. Clinical indications are discussed.

Unsupervised classification of EEG from subdural seizure recordings.

Whereas the visual EEG-inspection of epileptic seizures draws the attention to the waxing and waning of specific graphoelements in multi-channel recordings, the domain of computerized EEG-analysis for epilepsy diagnosis is detection of transients (i.e., spikes) and the quantification of background activity (i.e., mapping procedures). We present an approach to identify relatively fast changes of background activity by use of an automatic classifier. This algorithm is independent of the occurrence of any specific single type of graphoelement. The EEG is segmentated into short epochs of 0.64 sec duration each. For every segment a set of parameters (Hjorth, spectral power in classical frequency bands) is extracted, which taken together build elements of a vector-space. The elements are clustered in an automatic and unsupervised manner by use of a cosine-classifier, such that every EEG-epoch belongs to one class. Changes of brain activity as seen with the EEG are marked by transitions from one class to another. The class occurrence density is defined as the number of different classes that occur within a pre-defined number of EEG-epochs. It gives a new measure of variability of the EEG-signal. Comparing the epochs when class transitions take place in different channels, the class transitions coincidence between two channels is a measure of functional coupling of brain areas.

Extensible biosignal (EBS) file format: simple method for EEG data exchange.

Increasing use of computer technology in EEG research requires the creation of standardized data formats to transmit, exchange, analyze or modify mainly EEG/MEG as well as mere general polygraphic data. The extensible biosignal file format (EBS) has been designed for easy use. The concept of the EBS format is a simple structure of variable size, consisting of one fixed and two variable headers and a data section. In the variable header, any information can be stored in attributes. The data are archived in one of 3 organizational forms: channel order, temporal order, or compressed. The format supports various data types, multiple biosignals (ECG, EEG, MEG, polygraph), annotations, processing history, location diagrams (CGM), 16 hit ISO 10646 character set, random access to large amounts of data, global or private extensions, self-identification, and multiple tools for conversion, modification and visualization which are freely available in source code.

Antibacterial activity of marbofloxacin. A new fluoroquinolone for veterinary use against canine and feline isolates.

Marbofloxacin is a new fluoroquinolone developed exclusively for veterinary use. Minimum inhibitory concentrations of marbofloxacin were assessed for 816 recent isolates associated with canine or feline diseases. Marbofloxacin showed a broad spectrum of activity against gram-negative and gram-positive bacteria. In vitro rates of killing of marbofloxacin and enrofloxacin were compared against strains of Staphylococcus intermedius and Pasteurella multocida, and the results showed no marked difference between the two antibiotics. The duration of bactericidal activity was evaluated ex vivo in the urine of dogs and cats treated with marbofloxacin and lasted from 2 to 5 days after a single administration according to the dosages. Post-antibiotic effect durations were determined with Escherichia coli, Pasteurella multocida, Staphylococcus aureus and Staphylococcus intermedius and were found almost equal to those of enrofloxacin or ciprofloxacin. These results predict a great potential for marbofloxacin in the treatment of a wide range of diseases in dogs and cats.

Specific features of military low-altitude flight noise: criteria for risk of damage and physiological effects.

The impact of sound from military low-altitude flying (75 m) is characterized by high maximum levels of up to 125 dB, a rapid rise in sound pressure level (steepest 10-dB slope up to 111 dB/s, mean value 36 dB/s), and occasional (30%) follow-up oscillations of up to around 100 dB. The energy within this broadband sound is very often concentrated primarily in the 0.8 to 4 kHz range. A criterion for the risk of damage can be applied using constant-frequency spectral dose analysis in order to establish, for example, how many overflight events might be regarded as tolerable. We can also draw on findings from animal experiments revealing damage to the extremely sensitive stereocilia of the hair cells in the inner ear to derive a risk assessment which shows that slight impairment to hearing is possible in low-altitude flight zones given either the recorded mean frequency of 17 direct overflights a day (with maximum levels over 100 dB) or else a few extreme isolated events. In laboratory experiments involving exposure to this type of highly dynamic low-altitude flight noise, short-term increases in heart rate (up to 21 beats/min) were found to be much greater than those provoked by other forms of environmental noise with comparable maximum levels (pile driving, gunfire).

[Unconscious insecurity before and after breast examination in senology patients without pathologic findings]. / Unbewusste Unsicherheit vor und nach der Brustuntersuchung bei Senologie-Patientinnen ohne pathologischen Befund.

The study reported here surveyed unconscious insecurity among healthy women, who consulted a senological outpatient service because of suspected breast cancer. It was investigated whether and in what way the reduction in unconscious insecurity, after being informed that the diagnosis was favorable (no carcinoma), is dependent on certain psychological conditions. The patients were divided into various subgroups according to history and psychological criteria, and these subgroups were then compared with regard to the reduction in their feeling of insecurity after being advised that there were no pathological findings. The individual tendency to tenseness (Brauchli 1983, 1987 a, b) was used as an indicator of unconscious insecurity. Coming to terms consciously with the cancer risk and possible consequences of cancer, proved to be a prerequisite for an adequate reduction in unconscious insecurity after being informed that findings were negative.