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.

[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.