Thomas Kron, MD

New research by Thomas Münzel, MD, senior professor of cardiology at Johannes Gutenberg University Mainz in Mainz, Germany, and colleagues again emphasized the harmful effects of noise on the heart and blood vessels. An analysis of current epidemiologic data provided strong indications that transportation noise is closely related to cardiovascular and cerebrovascular diseases, according to a statement on the data analysis. The results were published in Circulation Research.

Morbidity and Mortality

Epidemiologic studies have shown that road, rail, or air traffic noise increases the risk for cardiovascular morbidity and mortality, with strong evidence for ischemic heart disease, heart failure, and stroke, according to the scientists. The World Health Organization reported that at least 1.6 million healthy life years are lost annually in Western Europe because of traffic-related noise. Nighttime traffic noise leads to sleep fragmentation and shortening, an increase in stress hormone levels, and increased oxidative stress in the vessels and brain. These factors could favor vascular (endothelial) dysfunction, inflammation, and hypertension, thereby increasing cardiovascular risk.

Consequences and Pathomechanisms

In the current publication, the authors provided an overview of epidemiologic research on the effects of transportation noise on cardiovascular risk factors and diseases, discussed mechanistic insights from the latest clinical and experimental studies, and proposed new risk markers to address noise-induced cardiovascular effects in the general population. An integrated analysis in the article demonstrated that for every 10 dB(A) increase, the risk for cardiovascular diseases such as heart attack, stroke, and heart failure significantly increases by 3.2%.

The authors also explained the possible effects of noise on changes in gene networks, epigenetic pathways, circadian rhythms, signal transmission along the neuronal-cardiovascular axis, oxidative stress, inflammation, and metabolism. Finally, current and future noise protection strategies are described, and the existing evidence on noise as a cardiovascular risk factor is discussed.

Confirmed Cardiovascular Risk Factor

“As an increasing proportion of the population is exposed to harmful traffic noise, efforts to reduce noise and laws for noise reduction are of great importance for future public health,” said Dr. Münzel. “It is also important for us that due to the strong evidence, traffic noise is finally recognized as a risk factor for cardiovascular diseases.”

Heart Attack Outcomes

Dr. Münzel and other researchers from Mainz have been studying the cardiovascular consequences of air pollution and traffic noise for several years. For example, they found that heart attacks in people and animals exposed to high noise levels earlier in life healed poorly. These results were published last year in Cardiovascular Research. According to the authors, the findings suggest that traffic noise may play a significant role in the development and course of coronary heart disease, such as after a heart attack.

The scientists initially found in animal experiments that exposure to aircraft noise for 4 days led to increased inflammation in the vessels. Compared with mice not exposed to aircraft noise, the noise-exposed animals showed an increase in free radicals; these animals exhibited a significant inflammatory response and had impaired vessel function.

The researchers explained that the experimental data showed aircraft noise alone triggers a proinflammatory transcription program that promotes the infiltration of immune cells into cardiovascular tissue in animals with acute myocardial infarction. They noted an increased infiltration of CD45+ cells into the vessels and heart, dominated by neutrophils in vessel tissue and Ly6Chigh monocytes in heart tissue. This infiltration creates a proinflammatory milieu that adversely affects the outcome after myocardial infarction by predisposing the heart tissue to greater ischemic damage and functional impairment. Exposure of animals to aircraft noise before induction of myocardial infarction by left anterior descending (LAD) coronary artery ligation impaired left ventricular function and increased infarct size after cardiac ischemia. In addition, noise exposure exacerbated infarct-induced endothelial dysfunction of peripheral vessels as early as 24 hours after LAD ligation.

Clinical Confirmation

These experimental results were confirmed by observations in the population-based Gutenberg Health Study. The researchers analyzed data from 100 patients with heart attack. The lead and senior authors of the study Michael Molitor, MD, and Philip Wenzel, MD, of the University of Mainz, explained, “From our studies, we have learned that exposure to aircraft noise before a heart attack significantly amplifies subsequent cardiovascular inflammation and exacerbates ischemic heart failure, which is favored by inflammation-promoting vascular conditioning. Our translational results show that people who have been exposed to noise in the past have a worse course if they experience a heart attack later in life.”

Study participants who had experienced a heart attack in their medical history had elevated levels of C-reactive protein if they had been exposed to aircraft noise in the past and subsequently developed noise annoyance reactions (0.305 vs 1.5; P = .0094). In addition, left ventricular ejection fraction in these patients after a heart attack was worse than that in patients with infarction without noise exposure in their medical history (62.5 vs 65.6; P = .0053).

The results suggest that measures to reduce environmental noise could help improve the clinical outcomes of heart attack patients, according to the authors.

Mental Health Effects

Traffic noise also may be associated with an increased risk for depression and anxiety disorders, as reported 2 years ago by the German Society for Psychosomatic Medicine and Medical Psychotherapy. Evolution has programmed the human organism to perceive noises as indicators of potential sources of danger — even during sleep. “Noise puts the body on alert,” explained Manfred E. Beutel, MD, director of the Clinic for Psychosomatic Medicine and Psychotherapy at the University of Mainz. As a result, the autonomic nervous system activates stress hormones such as adrenaline and cortisol, leading to an increase in heart rate and blood pressure. If noise becomes chronic, chronic diseases can develop. “Indeed, observational and experimental studies have shown that persistent noise annoyance promotes incident hypertension, cardiovascular diseases, and type 2 diabetes,” said Dr. Beutel.

Depression Risk Doubled

Among the negative effects of noise annoyance are also mental illnesses, as has become increasingly clear. “Noise annoyance disrupts daily activities and interferes with feelings and thoughts, sleep, and recovery,” said Dr. Beutel. The interruptions trigger negative emotional reactions such as anger, distress, exhaustion, flight impulses, and stress symptoms. “Such conditions promote the development of depression over time,” said Dr. Beutel. This observation was confirmed by the large-scale Gutenberg Health Study using the example of the Mainz population, which suffers to a large extent from noise annoyance because of the nearby Frankfurt Airport. “With increasing noise annoyance, the rates of depression and anxiety disorders steadily increased, until the risks eventually doubled with extreme annoyance,” said Dr. Beutel. Other studies point in the same direction. For example, a meta-analysis found a 12% increase in the risk for depression per 10-dB increase in noise. Another study found an association between nocturnal noise annoyance and the use of antidepressants.

Fine Particulate Matter

According to an evaluation of the Gutenberg Study, people perceive noise annoyance from aircraft noise as the most pronounced, followed by road, neighborhood, industrial, and railway noise. Noise occurs most frequently in urban areas that also produce air pollution such as fine particulate matter. “Fine particulate matter is also suspected of promoting anxiety and depression,” said Dr. Beutel, “because the small particles of fine particulate matter can enter the bloodstream and trigger inflammatory processes there, which in turn are closely related to depression.”

This story was translated from Univadis Germany, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

New research by Thomas Münzel, MD, senior professor of cardiology at Johannes Gutenberg University Mainz in Mainz, Germany, and colleagues again emphasized the harmful effects of noise on the heart and blood vessels. An analysis of current epidemiologic data provided strong indications that transportation noise is closely related to cardiovascular and cerebrovascular diseases, according to a statement on the data analysis. The results were published in Circulation Research.

Morbidity and Mortality

Epidemiologic studies have shown that road, rail, or air traffic noise increases the risk for cardiovascular morbidity and mortality, with strong evidence for ischemic heart disease, heart failure, and stroke, according to the scientists. The World Health Organization reported that at least 1.6 million healthy life years are lost annually in Western Europe because of traffic-related noise. Nighttime traffic noise leads to sleep fragmentation and shortening, an increase in stress hormone levels, and increased oxidative stress in the vessels and brain. These factors could favor vascular (endothelial) dysfunction, inflammation, and hypertension, thereby increasing cardiovascular risk.

Consequences and Pathomechanisms

In the current publication, the authors provided an overview of epidemiologic research on the effects of transportation noise on cardiovascular risk factors and diseases, discussed mechanistic insights from the latest clinical and experimental studies, and proposed new risk markers to address noise-induced cardiovascular effects in the general population. An integrated analysis in the article demonstrated that for every 10 dB(A) increase, the risk for cardiovascular diseases such as heart attack, stroke, and heart failure significantly increases by 3.2%.

The authors also explained the possible effects of noise on changes in gene networks, epigenetic pathways, circadian rhythms, signal transmission along the neuronal-cardiovascular axis, oxidative stress, inflammation, and metabolism. Finally, current and future noise protection strategies are described, and the existing evidence on noise as a cardiovascular risk factor is discussed.

Confirmed Cardiovascular Risk Factor

“As an increasing proportion of the population is exposed to harmful traffic noise, efforts to reduce noise and laws for noise reduction are of great importance for future public health,” said Dr. Münzel. “It is also important for us that due to the strong evidence, traffic noise is finally recognized as a risk factor for cardiovascular diseases.”

Heart Attack Outcomes

Dr. Münzel and other researchers from Mainz have been studying the cardiovascular consequences of air pollution and traffic noise for several years. For example, they found that heart attacks in people and animals exposed to high noise levels earlier in life healed poorly. These results were published last year in Cardiovascular Research. According to the authors, the findings suggest that traffic noise may play a significant role in the development and course of coronary heart disease, such as after a heart attack.

The scientists initially found in animal experiments that exposure to aircraft noise for 4 days led to increased inflammation in the vessels. Compared with mice not exposed to aircraft noise, the noise-exposed animals showed an increase in free radicals; these animals exhibited a significant inflammatory response and had impaired vessel function.

The researchers explained that the experimental data showed aircraft noise alone triggers a proinflammatory transcription program that promotes the infiltration of immune cells into cardiovascular tissue in animals with acute myocardial infarction. They noted an increased infiltration of CD45+ cells into the vessels and heart, dominated by neutrophils in vessel tissue and Ly6Chigh monocytes in heart tissue. This infiltration creates a proinflammatory milieu that adversely affects the outcome after myocardial infarction by predisposing the heart tissue to greater ischemic damage and functional impairment. Exposure of animals to aircraft noise before induction of myocardial infarction by left anterior descending (LAD) coronary artery ligation impaired left ventricular function and increased infarct size after cardiac ischemia. In addition, noise exposure exacerbated infarct-induced endothelial dysfunction of peripheral vessels as early as 24 hours after LAD ligation.

Clinical Confirmation

These experimental results were confirmed by observations in the population-based Gutenberg Health Study. The researchers analyzed data from 100 patients with heart attack. The lead and senior authors of the study Michael Molitor, MD, and Philip Wenzel, MD, of the University of Mainz, explained, “From our studies, we have learned that exposure to aircraft noise before a heart attack significantly amplifies subsequent cardiovascular inflammation and exacerbates ischemic heart failure, which is favored by inflammation-promoting vascular conditioning. Our translational results show that people who have been exposed to noise in the past have a worse course if they experience a heart attack later in life.”

Study participants who had experienced a heart attack in their medical history had elevated levels of C-reactive protein if they had been exposed to aircraft noise in the past and subsequently developed noise annoyance reactions (0.305 vs 1.5; P = .0094). In addition, left ventricular ejection fraction in these patients after a heart attack was worse than that in patients with infarction without noise exposure in their medical history (62.5 vs 65.6; P = .0053).

The results suggest that measures to reduce environmental noise could help improve the clinical outcomes of heart attack patients, according to the authors.

Mental Health Effects

Traffic noise also may be associated with an increased risk for depression and anxiety disorders, as reported 2 years ago by the German Society for Psychosomatic Medicine and Medical Psychotherapy. Evolution has programmed the human organism to perceive noises as indicators of potential sources of danger — even during sleep. “Noise puts the body on alert,” explained Manfred E. Beutel, MD, director of the Clinic for Psychosomatic Medicine and Psychotherapy at the University of Mainz. As a result, the autonomic nervous system activates stress hormones such as adrenaline and cortisol, leading to an increase in heart rate and blood pressure. If noise becomes chronic, chronic diseases can develop. “Indeed, observational and experimental studies have shown that persistent noise annoyance promotes incident hypertension, cardiovascular diseases, and type 2 diabetes,” said Dr. Beutel.

Depression Risk Doubled

Among the negative effects of noise annoyance are also mental illnesses, as has become increasingly clear. “Noise annoyance disrupts daily activities and interferes with feelings and thoughts, sleep, and recovery,” said Dr. Beutel. The interruptions trigger negative emotional reactions such as anger, distress, exhaustion, flight impulses, and stress symptoms. “Such conditions promote the development of depression over time,” said Dr. Beutel. This observation was confirmed by the large-scale Gutenberg Health Study using the example of the Mainz population, which suffers to a large extent from noise annoyance because of the nearby Frankfurt Airport. “With increasing noise annoyance, the rates of depression and anxiety disorders steadily increased, until the risks eventually doubled with extreme annoyance,” said Dr. Beutel. Other studies point in the same direction. For example, a meta-analysis found a 12% increase in the risk for depression per 10-dB increase in noise. Another study found an association between nocturnal noise annoyance and the use of antidepressants.

Fine Particulate Matter

According to an evaluation of the Gutenberg Study, people perceive noise annoyance from aircraft noise as the most pronounced, followed by road, neighborhood, industrial, and railway noise. Noise occurs most frequently in urban areas that also produce air pollution such as fine particulate matter. “Fine particulate matter is also suspected of promoting anxiety and depression,” said Dr. Beutel, “because the small particles of fine particulate matter can enter the bloodstream and trigger inflammatory processes there, which in turn are closely related to depression.”

This story was translated from Univadis Germany, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

New research by Thomas Münzel, MD, senior professor of cardiology at Johannes Gutenberg University Mainz in Mainz, Germany, and colleagues again emphasized the harmful effects of noise on the heart and blood vessels. An analysis of current epidemiologic data provided strong indications that transportation noise is closely related to cardiovascular and cerebrovascular diseases, according to a statement on the data analysis. The results were published in Circulation Research.

Morbidity and Mortality

Epidemiologic studies have shown that road, rail, or air traffic noise increases the risk for cardiovascular morbidity and mortality, with strong evidence for ischemic heart disease, heart failure, and stroke, according to the scientists. The World Health Organization reported that at least 1.6 million healthy life years are lost annually in Western Europe because of traffic-related noise. Nighttime traffic noise leads to sleep fragmentation and shortening, an increase in stress hormone levels, and increased oxidative stress in the vessels and brain. These factors could favor vascular (endothelial) dysfunction, inflammation, and hypertension, thereby increasing cardiovascular risk.

Consequences and Pathomechanisms

In the current publication, the authors provided an overview of epidemiologic research on the effects of transportation noise on cardiovascular risk factors and diseases, discussed mechanistic insights from the latest clinical and experimental studies, and proposed new risk markers to address noise-induced cardiovascular effects in the general population. An integrated analysis in the article demonstrated that for every 10 dB(A) increase, the risk for cardiovascular diseases such as heart attack, stroke, and heart failure significantly increases by 3.2%.

The authors also explained the possible effects of noise on changes in gene networks, epigenetic pathways, circadian rhythms, signal transmission along the neuronal-cardiovascular axis, oxidative stress, inflammation, and metabolism. Finally, current and future noise protection strategies are described, and the existing evidence on noise as a cardiovascular risk factor is discussed.

Confirmed Cardiovascular Risk Factor

“As an increasing proportion of the population is exposed to harmful traffic noise, efforts to reduce noise and laws for noise reduction are of great importance for future public health,” said Dr. Münzel. “It is also important for us that due to the strong evidence, traffic noise is finally recognized as a risk factor for cardiovascular diseases.”

Heart Attack Outcomes

Dr. Münzel and other researchers from Mainz have been studying the cardiovascular consequences of air pollution and traffic noise for several years. For example, they found that heart attacks in people and animals exposed to high noise levels earlier in life healed poorly. These results were published last year in Cardiovascular Research. According to the authors, the findings suggest that traffic noise may play a significant role in the development and course of coronary heart disease, such as after a heart attack.

The scientists initially found in animal experiments that exposure to aircraft noise for 4 days led to increased inflammation in the vessels. Compared with mice not exposed to aircraft noise, the noise-exposed animals showed an increase in free radicals; these animals exhibited a significant inflammatory response and had impaired vessel function.

The researchers explained that the experimental data showed aircraft noise alone triggers a proinflammatory transcription program that promotes the infiltration of immune cells into cardiovascular tissue in animals with acute myocardial infarction. They noted an increased infiltration of CD45+ cells into the vessels and heart, dominated by neutrophils in vessel tissue and Ly6Chigh monocytes in heart tissue. This infiltration creates a proinflammatory milieu that adversely affects the outcome after myocardial infarction by predisposing the heart tissue to greater ischemic damage and functional impairment. Exposure of animals to aircraft noise before induction of myocardial infarction by left anterior descending (LAD) coronary artery ligation impaired left ventricular function and increased infarct size after cardiac ischemia. In addition, noise exposure exacerbated infarct-induced endothelial dysfunction of peripheral vessels as early as 24 hours after LAD ligation.

Clinical Confirmation

These experimental results were confirmed by observations in the population-based Gutenberg Health Study. The researchers analyzed data from 100 patients with heart attack. The lead and senior authors of the study Michael Molitor, MD, and Philip Wenzel, MD, of the University of Mainz, explained, “From our studies, we have learned that exposure to aircraft noise before a heart attack significantly amplifies subsequent cardiovascular inflammation and exacerbates ischemic heart failure, which is favored by inflammation-promoting vascular conditioning. Our translational results show that people who have been exposed to noise in the past have a worse course if they experience a heart attack later in life.”

Study participants who had experienced a heart attack in their medical history had elevated levels of C-reactive protein if they had been exposed to aircraft noise in the past and subsequently developed noise annoyance reactions (0.305 vs 1.5; P = .0094). In addition, left ventricular ejection fraction in these patients after a heart attack was worse than that in patients with infarction without noise exposure in their medical history (62.5 vs 65.6; P = .0053).

The results suggest that measures to reduce environmental noise could help improve the clinical outcomes of heart attack patients, according to the authors.

Mental Health Effects

Traffic noise also may be associated with an increased risk for depression and anxiety disorders, as reported 2 years ago by the German Society for Psychosomatic Medicine and Medical Psychotherapy. Evolution has programmed the human organism to perceive noises as indicators of potential sources of danger — even during sleep. “Noise puts the body on alert,” explained Manfred E. Beutel, MD, director of the Clinic for Psychosomatic Medicine and Psychotherapy at the University of Mainz. As a result, the autonomic nervous system activates stress hormones such as adrenaline and cortisol, leading to an increase in heart rate and blood pressure. If noise becomes chronic, chronic diseases can develop. “Indeed, observational and experimental studies have shown that persistent noise annoyance promotes incident hypertension, cardiovascular diseases, and type 2 diabetes,” said Dr. Beutel.

Depression Risk Doubled

Among the negative effects of noise annoyance are also mental illnesses, as has become increasingly clear. “Noise annoyance disrupts daily activities and interferes with feelings and thoughts, sleep, and recovery,” said Dr. Beutel. The interruptions trigger negative emotional reactions such as anger, distress, exhaustion, flight impulses, and stress symptoms. “Such conditions promote the development of depression over time,” said Dr. Beutel. This observation was confirmed by the large-scale Gutenberg Health Study using the example of the Mainz population, which suffers to a large extent from noise annoyance because of the nearby Frankfurt Airport. “With increasing noise annoyance, the rates of depression and anxiety disorders steadily increased, until the risks eventually doubled with extreme annoyance,” said Dr. Beutel. Other studies point in the same direction. For example, a meta-analysis found a 12% increase in the risk for depression per 10-dB increase in noise. Another study found an association between nocturnal noise annoyance and the use of antidepressants.

Fine Particulate Matter

According to an evaluation of the Gutenberg Study, people perceive noise annoyance from aircraft noise as the most pronounced, followed by road, neighborhood, industrial, and railway noise. Noise occurs most frequently in urban areas that also produce air pollution such as fine particulate matter. “Fine particulate matter is also suspected of promoting anxiety and depression,” said Dr. Beutel, “because the small particles of fine particulate matter can enter the bloodstream and trigger inflammatory processes there, which in turn are closely related to depression.”

This story was translated from Univadis Germany, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Patients with cancer receiving chemotherapeutics may develop diarrhea, which can be highly distressing. In a recent journal article, oncologist Marcus Hentrich, MD, and gastroenterologist Volker Penndorf, MD, PhD, both of Rotkreuzklinikum in Munich, Germany, explained how affected patients should be treated.

As Dr. Hentrich and Dr. Penndorf explained, classical cytostatic drugs can induce diarrhea through direct damage to the intestinal mucosa. The pathomechanisms of monoclonal antibodies and oral targeted substances are not yet fully understood. According to the authors, the risk for toxic mucosal damage (toxic enteritis) increases with the severity and duration of neutropenia. Up to two thirds of patients with neutropenia develop diarrhea, and an infectious cause is rarely identified.

The cytostatic drug irinotecan, which can lead to an acute cholinergic syndrome within 24 hours, is a special case. This syndrome is characterized by watery diarrhea, abdominal cramps, vomiting, sweating, and bradycardia. Additionally, the development of late-onset diarrhea, occurring approximately 3 days after administration, is frequent.

According to the authors, risk factors for toxic enteritis with diarrhea include advanced age, poor performance and nutritional status, simultaneous radiotherapy of the abdomen and pelvis, and preexisting intestinal conditions.

Medication prophylaxis for chemotherapy-induced diarrhea has not been established. An exception is atropine for prophylaxis and treatment of irinotecan-induced cholinergic syndrome.

Indications for diagnostic procedures are outlined in the current German guideline for supportive therapy in patients with cancer.

For diarrhea accompanied by fever, blood cultures are mandatory. A complete blood count provides information on various aspects (leukocytosis as an inflammatory reaction, neutropenia as a marker for infection risk, hemoglobin as a marker for possible hemoconcentration or existing bleeding, and thrombocytopenia as a marker for bleeding tendency). Disproportionate thrombocytopenia may warrant assessment of fragmented cells and enterohemorrhagic Escherichia coli diagnostics.

To assess electrolyte and fluid loss, electrolytes, albumin, and total protein should be measured. The C-reactive protein value may help identify inflammatory conditions. It may also be elevated, however, because of tumor-related factors. Measuring urea and creatinine allows for estimating whether there is already a prerenal impairment of kidney function. Liver function parameters are mandatory for critically ill patients. In patients with hypotension or tachycardia, blood gas analysis and lactate determination are advisable. Among imaging techniques, ultrasound may be helpful. Indications for conventional abdominal x-ray are rare. In the presence of clinical signs of peritoneal irritation (such as guarding and rebound tenderness), a CT scan should be considered to detect further complications (perforation, ileus, enterocolitis, etc.) promptly.

Endoscopic examinations are recommended only in cases of persistent, worsening symptoms, according to the guideline. Colonoscopy is contraindicated in suspected neutropenic enterocolitis (NEC) because of the risk for perforation.

According to Dr. Hentrich and Dr. Penndorf, diarrhea therapy is carried out in stages and depends on the severity and response to each therapy. The Common Terminology Criteria for Adverse Events distinguishes the following severity grades:

• Grade 1: < four stools per day above baseline
• Grade 2: Four to six stools per day above baseline
• Grade 3: ≥ seven stools per day above baseline; fecal incontinence, hospitalization indicated; limited activities of daily living
• Grade 4: Life-threatening consequences, urgent intervention indicated

Therapy for Grades 1-2

The standard therapeutic after excluding infectious causes is loperamide (initially 4 mg orally, followed by 2 mg every 2-4 hours). A daily dose should not exceed 16 mg.

For irinotecan-associated diarrhea, adjunctive administration of budesonide (3 mg orally three times per day) with loperamide was shown to be effective in a small, randomized study (off-label). Another randomized study demonstrated the efficacy of combining loperamide with racecadotril (100 mg orally three times per day for 48 hours).
 

Therapy for Grade 3 Diarrhea

In severe diarrhea persisting despite loperamide therapy for 24-48 hours, octreotide (100-150 μg subcutaneously three times per day) may be administered (maximum three times 500 μg). Although octreotide is often used successfully for chemotherapy-induced diarrhea, it is not approved for this indication (off-label use).

According to the authors, other therapy options for loperamide-refractory diarrhea include codeine, tincture of opium, budesonide, and racecadotril. Psyllium husk or diphenoxylate plus atropine may also be attempted. In patients with prolonged neutropenia, overdosing of motility inhibitors should be avoided because of the risk for ileus.

The use of probiotics for chemotherapy-induced diarrhea cannot be generally recommended because of insufficient evidence, and cases of probiotic-associated bacteremia and fungemia have been described.

A particularly serious complication of intensive chemotherapy associated with diarrhea is NEC. It is characterized by fever, abdominal pain, and diarrhea during severe neutropenia (neutrophil count < 500/μL), the authors explained. NEC occurs predominantly, but not exclusively, after intensive chemotherapy for hematologic malignancies, especially acute leukemias.

More common than NEC and often preceding it is the so-called chemotherapy-associated bowel syndrome. It is characterized by fever ≥ 37.8 °C and abdominal pain or absence of stool for at least 72 hours.

Therapy consists of conservative symptomatic measures such as diet, adequate hydration with electrolyte balance, and analgesia. Due to the high risk for bacteremia, antibiotic therapy is indicated after blood cultures are obtained (piperacillin-tazobactam or a carbapenem). According to the authors, NEC improves in most patients with neutrophil regeneration. Granulocyte colony-stimulating factor therapy appears reasonable in this context, although conclusive studies are lacking. Surgical intervention with removal of necrotic bowel segments may be considered in exceptional cases.

This story was translated from Univadis Germany, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Patients with cancer receiving chemotherapeutics may develop diarrhea, which can be highly distressing. In a recent journal article, oncologist Marcus Hentrich, MD, and gastroenterologist Volker Penndorf, MD, PhD, both of Rotkreuzklinikum in Munich, Germany, explained how affected patients should be treated.

As Dr. Hentrich and Dr. Penndorf explained, classical cytostatic drugs can induce diarrhea through direct damage to the intestinal mucosa. The pathomechanisms of monoclonal antibodies and oral targeted substances are not yet fully understood. According to the authors, the risk for toxic mucosal damage (toxic enteritis) increases with the severity and duration of neutropenia. Up to two thirds of patients with neutropenia develop diarrhea, and an infectious cause is rarely identified.

The cytostatic drug irinotecan, which can lead to an acute cholinergic syndrome within 24 hours, is a special case. This syndrome is characterized by watery diarrhea, abdominal cramps, vomiting, sweating, and bradycardia. Additionally, the development of late-onset diarrhea, occurring approximately 3 days after administration, is frequent.

According to the authors, risk factors for toxic enteritis with diarrhea include advanced age, poor performance and nutritional status, simultaneous radiotherapy of the abdomen and pelvis, and preexisting intestinal conditions.

Medication prophylaxis for chemotherapy-induced diarrhea has not been established. An exception is atropine for prophylaxis and treatment of irinotecan-induced cholinergic syndrome.

Indications for diagnostic procedures are outlined in the current German guideline for supportive therapy in patients with cancer.

For diarrhea accompanied by fever, blood cultures are mandatory. A complete blood count provides information on various aspects (leukocytosis as an inflammatory reaction, neutropenia as a marker for infection risk, hemoglobin as a marker for possible hemoconcentration or existing bleeding, and thrombocytopenia as a marker for bleeding tendency). Disproportionate thrombocytopenia may warrant assessment of fragmented cells and enterohemorrhagic Escherichia coli diagnostics.

To assess electrolyte and fluid loss, electrolytes, albumin, and total protein should be measured. The C-reactive protein value may help identify inflammatory conditions. It may also be elevated, however, because of tumor-related factors. Measuring urea and creatinine allows for estimating whether there is already a prerenal impairment of kidney function. Liver function parameters are mandatory for critically ill patients. In patients with hypotension or tachycardia, blood gas analysis and lactate determination are advisable. Among imaging techniques, ultrasound may be helpful. Indications for conventional abdominal x-ray are rare. In the presence of clinical signs of peritoneal irritation (such as guarding and rebound tenderness), a CT scan should be considered to detect further complications (perforation, ileus, enterocolitis, etc.) promptly.

Endoscopic examinations are recommended only in cases of persistent, worsening symptoms, according to the guideline. Colonoscopy is contraindicated in suspected neutropenic enterocolitis (NEC) because of the risk for perforation.

According to Dr. Hentrich and Dr. Penndorf, diarrhea therapy is carried out in stages and depends on the severity and response to each therapy. The Common Terminology Criteria for Adverse Events distinguishes the following severity grades:

• Grade 1: < four stools per day above baseline
• Grade 2: Four to six stools per day above baseline
• Grade 3: ≥ seven stools per day above baseline; fecal incontinence, hospitalization indicated; limited activities of daily living
• Grade 4: Life-threatening consequences, urgent intervention indicated

Therapy for Grades 1-2

The standard therapeutic after excluding infectious causes is loperamide (initially 4 mg orally, followed by 2 mg every 2-4 hours). A daily dose should not exceed 16 mg.

For irinotecan-associated diarrhea, adjunctive administration of budesonide (3 mg orally three times per day) with loperamide was shown to be effective in a small, randomized study (off-label). Another randomized study demonstrated the efficacy of combining loperamide with racecadotril (100 mg orally three times per day for 48 hours).
 

Therapy for Grade 3 Diarrhea

In severe diarrhea persisting despite loperamide therapy for 24-48 hours, octreotide (100-150 μg subcutaneously three times per day) may be administered (maximum three times 500 μg). Although octreotide is often used successfully for chemotherapy-induced diarrhea, it is not approved for this indication (off-label use).

According to the authors, other therapy options for loperamide-refractory diarrhea include codeine, tincture of opium, budesonide, and racecadotril. Psyllium husk or diphenoxylate plus atropine may also be attempted. In patients with prolonged neutropenia, overdosing of motility inhibitors should be avoided because of the risk for ileus.

The use of probiotics for chemotherapy-induced diarrhea cannot be generally recommended because of insufficient evidence, and cases of probiotic-associated bacteremia and fungemia have been described.

A particularly serious complication of intensive chemotherapy associated with diarrhea is NEC. It is characterized by fever, abdominal pain, and diarrhea during severe neutropenia (neutrophil count < 500/μL), the authors explained. NEC occurs predominantly, but not exclusively, after intensive chemotherapy for hematologic malignancies, especially acute leukemias.

More common than NEC and often preceding it is the so-called chemotherapy-associated bowel syndrome. It is characterized by fever ≥ 37.8 °C and abdominal pain or absence of stool for at least 72 hours.

Therapy consists of conservative symptomatic measures such as diet, adequate hydration with electrolyte balance, and analgesia. Due to the high risk for bacteremia, antibiotic therapy is indicated after blood cultures are obtained (piperacillin-tazobactam or a carbapenem). According to the authors, NEC improves in most patients with neutrophil regeneration. Granulocyte colony-stimulating factor therapy appears reasonable in this context, although conclusive studies are lacking. Surgical intervention with removal of necrotic bowel segments may be considered in exceptional cases.

This story was translated from Univadis Germany, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Patients with cancer receiving chemotherapeutics may develop diarrhea, which can be highly distressing. In a recent journal article, oncologist Marcus Hentrich, MD, and gastroenterologist Volker Penndorf, MD, PhD, both of Rotkreuzklinikum in Munich, Germany, explained how affected patients should be treated.

As Dr. Hentrich and Dr. Penndorf explained, classical cytostatic drugs can induce diarrhea through direct damage to the intestinal mucosa. The pathomechanisms of monoclonal antibodies and oral targeted substances are not yet fully understood. According to the authors, the risk for toxic mucosal damage (toxic enteritis) increases with the severity and duration of neutropenia. Up to two thirds of patients with neutropenia develop diarrhea, and an infectious cause is rarely identified.

The cytostatic drug irinotecan, which can lead to an acute cholinergic syndrome within 24 hours, is a special case. This syndrome is characterized by watery diarrhea, abdominal cramps, vomiting, sweating, and bradycardia. Additionally, the development of late-onset diarrhea, occurring approximately 3 days after administration, is frequent.

According to the authors, risk factors for toxic enteritis with diarrhea include advanced age, poor performance and nutritional status, simultaneous radiotherapy of the abdomen and pelvis, and preexisting intestinal conditions.

Medication prophylaxis for chemotherapy-induced diarrhea has not been established. An exception is atropine for prophylaxis and treatment of irinotecan-induced cholinergic syndrome.

Indications for diagnostic procedures are outlined in the current German guideline for supportive therapy in patients with cancer.

For diarrhea accompanied by fever, blood cultures are mandatory. A complete blood count provides information on various aspects (leukocytosis as an inflammatory reaction, neutropenia as a marker for infection risk, hemoglobin as a marker for possible hemoconcentration or existing bleeding, and thrombocytopenia as a marker for bleeding tendency). Disproportionate thrombocytopenia may warrant assessment of fragmented cells and enterohemorrhagic Escherichia coli diagnostics.

To assess electrolyte and fluid loss, electrolytes, albumin, and total protein should be measured. The C-reactive protein value may help identify inflammatory conditions. It may also be elevated, however, because of tumor-related factors. Measuring urea and creatinine allows for estimating whether there is already a prerenal impairment of kidney function. Liver function parameters are mandatory for critically ill patients. In patients with hypotension or tachycardia, blood gas analysis and lactate determination are advisable. Among imaging techniques, ultrasound may be helpful. Indications for conventional abdominal x-ray are rare. In the presence of clinical signs of peritoneal irritation (such as guarding and rebound tenderness), a CT scan should be considered to detect further complications (perforation, ileus, enterocolitis, etc.) promptly.

Endoscopic examinations are recommended only in cases of persistent, worsening symptoms, according to the guideline. Colonoscopy is contraindicated in suspected neutropenic enterocolitis (NEC) because of the risk for perforation.

According to Dr. Hentrich and Dr. Penndorf, diarrhea therapy is carried out in stages and depends on the severity and response to each therapy. The Common Terminology Criteria for Adverse Events distinguishes the following severity grades:

• Grade 1: < four stools per day above baseline
• Grade 2: Four to six stools per day above baseline
• Grade 3: ≥ seven stools per day above baseline; fecal incontinence, hospitalization indicated; limited activities of daily living
• Grade 4: Life-threatening consequences, urgent intervention indicated

Therapy for Grades 1-2

The standard therapeutic after excluding infectious causes is loperamide (initially 4 mg orally, followed by 2 mg every 2-4 hours). A daily dose should not exceed 16 mg.

For irinotecan-associated diarrhea, adjunctive administration of budesonide (3 mg orally three times per day) with loperamide was shown to be effective in a small, randomized study (off-label). Another randomized study demonstrated the efficacy of combining loperamide with racecadotril (100 mg orally three times per day for 48 hours).
 

Therapy for Grade 3 Diarrhea

In severe diarrhea persisting despite loperamide therapy for 24-48 hours, octreotide (100-150 μg subcutaneously three times per day) may be administered (maximum three times 500 μg). Although octreotide is often used successfully for chemotherapy-induced diarrhea, it is not approved for this indication (off-label use).

According to the authors, other therapy options for loperamide-refractory diarrhea include codeine, tincture of opium, budesonide, and racecadotril. Psyllium husk or diphenoxylate plus atropine may also be attempted. In patients with prolonged neutropenia, overdosing of motility inhibitors should be avoided because of the risk for ileus.

The use of probiotics for chemotherapy-induced diarrhea cannot be generally recommended because of insufficient evidence, and cases of probiotic-associated bacteremia and fungemia have been described.

A particularly serious complication of intensive chemotherapy associated with diarrhea is NEC. It is characterized by fever, abdominal pain, and diarrhea during severe neutropenia (neutrophil count < 500/μL), the authors explained. NEC occurs predominantly, but not exclusively, after intensive chemotherapy for hematologic malignancies, especially acute leukemias.

More common than NEC and often preceding it is the so-called chemotherapy-associated bowel syndrome. It is characterized by fever ≥ 37.8 °C and abdominal pain or absence of stool for at least 72 hours.

Therapy consists of conservative symptomatic measures such as diet, adequate hydration with electrolyte balance, and analgesia. Due to the high risk for bacteremia, antibiotic therapy is indicated after blood cultures are obtained (piperacillin-tazobactam or a carbapenem). According to the authors, NEC improves in most patients with neutrophil regeneration. Granulocyte colony-stimulating factor therapy appears reasonable in this context, although conclusive studies are lacking. Surgical intervention with removal of necrotic bowel segments may be considered in exceptional cases.

This story was translated from Univadis Germany, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

A power outage, like the 1977 blackout in New York City, can lead to an increase in violent crime. However, complete darkness can also have an upside, as it can encourage intimacy and subsequently boost birth rates. The Christmas season, sometimes called the festival of love, appears to stimulate human interactions. Yet this, also, has its downsides, as recently reported by Dr. Nikolaos Pyrgidis and other urologists at Ludwig Maximilian University of Munich in Germany. The less cheerful aspect of the holiday season is penile fractures.

The team found that the Christmas period, in particular, is that bit more risky for this injury after they evaluated data from about 3400 men (average age 42) treated for penile fractures between 2005 and 2021. The data was provided by Germany’s Federal Bureau of Statistics.

Out of the 3400 penile fractures that were reported during this period, 40 (1.2%) occurred over 51 Christmas days (from 24th to 26th December each year). The daily incidence rate of penile fractures during the Christmas period was 0.78, with an incidence rate ratio (IRR) of 1.43. The authors note that, if every day were like Christmas, there would have been a 43% increase in penile fractures in Germany since 2005. Interestingly, only 28 (0.82%) penile fractures were reported during the New Year (from 31 December to 2 January in the period between 2005 and 2021), with an IRR of 0.98.

More generally, most patients with penile fractures were admitted to the hospital over the weekend (n=1322; IRR 1.58). Notably, Sunday saw the most admissions due to this injury, followed by Saturday. This suggests that men engaging in sexual activities on Saturday night bear the highest risk of penile fractures, followed by those active on Friday nights.

Penile fractures also increased in the summer months (n=929; IRR 1.11). But the COVID-19 pandemic (n=385; IRR 1.06) and the lockdowns (n=93; IRR 1.95%) did not impact the frequency of this injury.

Rare, Painful, and an Emergency

Penile fractures are a rare urological emergency. The tunica albuginea of one or both corpora cavernosa must tear to be considered problematic, as another team of authors reported in a recent publication. Involvement of the urethra and corpus spongiosum is also possible.

Injuries often occur during an erection because it makes the tunica albuginea stiffer and thinner than when the penis is flaccid. Patients report hearing a snap when the penis is forced into an angle during sexual activity. This was reportedly the case with German singer-song writer Dieter Bohlen, whose ex-girlfriend Nadja Abd El Farrag is said to have written in her book “Ungelogen”, or “Honestly”, that there was a sudden snap during an intimate moment one December night (Christmas?), after which she called the fire brigade in her distress.

Multiple Causes Possible

Other factors contributing to penile fractures include rolling over in bed onto an erect penis, forced bending to achieve detumescence, and blunt external traumas like kicks.

Some penile fractures can be caused by patients “kneading and ripping” their erect penis to quickly reduce swelling. In an Iranian study, 269 out of 352 patients (76%) who underwent this process, known as “ taqaandan” in Iran, suffered a penile fracture.

Penile fractures can also occur in children, as evidenced by the case history of a 7-year-old boy described a few years ago in the journal Urology where the cause was a fall onto the penis.

Immediate Action Required

The treatment of choice for a fresh penile fracture is surgical repair of the tunica albuginea defect and, if necessary, the urethra. Timely surgical intervention yields significantly better long-term outcomes than conservative therapy regarding late complications such as erectile dysfunction and penile curvature. It also reduces the rate of early complications, such as severe corporal infections. Conservative therapy should be reserved for patients who explicitly refuse surgical intervention after thorough consultation.

This article was translated from Univadis Germany using ChatGPT followed by human editing.

A version of this article appeared on Medscape.com.

A power outage, like the 1977 blackout in New York City, can lead to an increase in violent crime. However, complete darkness can also have an upside, as it can encourage intimacy and subsequently boost birth rates. The Christmas season, sometimes called the festival of love, appears to stimulate human interactions. Yet this, also, has its downsides, as recently reported by Dr. Nikolaos Pyrgidis and other urologists at Ludwig Maximilian University of Munich in Germany. The less cheerful aspect of the holiday season is penile fractures.

The team found that the Christmas period, in particular, is that bit more risky for this injury after they evaluated data from about 3400 men (average age 42) treated for penile fractures between 2005 and 2021. The data was provided by Germany’s Federal Bureau of Statistics.

Out of the 3400 penile fractures that were reported during this period, 40 (1.2%) occurred over 51 Christmas days (from 24th to 26th December each year). The daily incidence rate of penile fractures during the Christmas period was 0.78, with an incidence rate ratio (IRR) of 1.43. The authors note that, if every day were like Christmas, there would have been a 43% increase in penile fractures in Germany since 2005. Interestingly, only 28 (0.82%) penile fractures were reported during the New Year (from 31 December to 2 January in the period between 2005 and 2021), with an IRR of 0.98.

More generally, most patients with penile fractures were admitted to the hospital over the weekend (n=1322; IRR 1.58). Notably, Sunday saw the most admissions due to this injury, followed by Saturday. This suggests that men engaging in sexual activities on Saturday night bear the highest risk of penile fractures, followed by those active on Friday nights.

Penile fractures also increased in the summer months (n=929; IRR 1.11). But the COVID-19 pandemic (n=385; IRR 1.06) and the lockdowns (n=93; IRR 1.95%) did not impact the frequency of this injury.

Rare, Painful, and an Emergency

Penile fractures are a rare urological emergency. The tunica albuginea of one or both corpora cavernosa must tear to be considered problematic, as another team of authors reported in a recent publication. Involvement of the urethra and corpus spongiosum is also possible.

Injuries often occur during an erection because it makes the tunica albuginea stiffer and thinner than when the penis is flaccid. Patients report hearing a snap when the penis is forced into an angle during sexual activity. This was reportedly the case with German singer-song writer Dieter Bohlen, whose ex-girlfriend Nadja Abd El Farrag is said to have written in her book “Ungelogen”, or “Honestly”, that there was a sudden snap during an intimate moment one December night (Christmas?), after which she called the fire brigade in her distress.

Multiple Causes Possible

Other factors contributing to penile fractures include rolling over in bed onto an erect penis, forced bending to achieve detumescence, and blunt external traumas like kicks.

Some penile fractures can be caused by patients “kneading and ripping” their erect penis to quickly reduce swelling. In an Iranian study, 269 out of 352 patients (76%) who underwent this process, known as “ taqaandan” in Iran, suffered a penile fracture.

Penile fractures can also occur in children, as evidenced by the case history of a 7-year-old boy described a few years ago in the journal Urology where the cause was a fall onto the penis.

Immediate Action Required

The treatment of choice for a fresh penile fracture is surgical repair of the tunica albuginea defect and, if necessary, the urethra. Timely surgical intervention yields significantly better long-term outcomes than conservative therapy regarding late complications such as erectile dysfunction and penile curvature. It also reduces the rate of early complications, such as severe corporal infections. Conservative therapy should be reserved for patients who explicitly refuse surgical intervention after thorough consultation.

This article was translated from Univadis Germany using ChatGPT followed by human editing.

A version of this article appeared on Medscape.com.

A power outage, like the 1977 blackout in New York City, can lead to an increase in violent crime. However, complete darkness can also have an upside, as it can encourage intimacy and subsequently boost birth rates. The Christmas season, sometimes called the festival of love, appears to stimulate human interactions. Yet this, also, has its downsides, as recently reported by Dr. Nikolaos Pyrgidis and other urologists at Ludwig Maximilian University of Munich in Germany. The less cheerful aspect of the holiday season is penile fractures.

The team found that the Christmas period, in particular, is that bit more risky for this injury after they evaluated data from about 3400 men (average age 42) treated for penile fractures between 2005 and 2021. The data was provided by Germany’s Federal Bureau of Statistics.

Out of the 3400 penile fractures that were reported during this period, 40 (1.2%) occurred over 51 Christmas days (from 24th to 26th December each year). The daily incidence rate of penile fractures during the Christmas period was 0.78, with an incidence rate ratio (IRR) of 1.43. The authors note that, if every day were like Christmas, there would have been a 43% increase in penile fractures in Germany since 2005. Interestingly, only 28 (0.82%) penile fractures were reported during the New Year (from 31 December to 2 January in the period between 2005 and 2021), with an IRR of 0.98.

More generally, most patients with penile fractures were admitted to the hospital over the weekend (n=1322; IRR 1.58). Notably, Sunday saw the most admissions due to this injury, followed by Saturday. This suggests that men engaging in sexual activities on Saturday night bear the highest risk of penile fractures, followed by those active on Friday nights.

Penile fractures also increased in the summer months (n=929; IRR 1.11). But the COVID-19 pandemic (n=385; IRR 1.06) and the lockdowns (n=93; IRR 1.95%) did not impact the frequency of this injury.

Rare, Painful, and an Emergency

Penile fractures are a rare urological emergency. The tunica albuginea of one or both corpora cavernosa must tear to be considered problematic, as another team of authors reported in a recent publication. Involvement of the urethra and corpus spongiosum is also possible.

Injuries often occur during an erection because it makes the tunica albuginea stiffer and thinner than when the penis is flaccid. Patients report hearing a snap when the penis is forced into an angle during sexual activity. This was reportedly the case with German singer-song writer Dieter Bohlen, whose ex-girlfriend Nadja Abd El Farrag is said to have written in her book “Ungelogen”, or “Honestly”, that there was a sudden snap during an intimate moment one December night (Christmas?), after which she called the fire brigade in her distress.

Multiple Causes Possible

Other factors contributing to penile fractures include rolling over in bed onto an erect penis, forced bending to achieve detumescence, and blunt external traumas like kicks.

Some penile fractures can be caused by patients “kneading and ripping” their erect penis to quickly reduce swelling. In an Iranian study, 269 out of 352 patients (76%) who underwent this process, known as “ taqaandan” in Iran, suffered a penile fracture.

Penile fractures can also occur in children, as evidenced by the case history of a 7-year-old boy described a few years ago in the journal Urology where the cause was a fall onto the penis.

Immediate Action Required

The treatment of choice for a fresh penile fracture is surgical repair of the tunica albuginea defect and, if necessary, the urethra. Timely surgical intervention yields significantly better long-term outcomes than conservative therapy regarding late complications such as erectile dysfunction and penile curvature. It also reduces the rate of early complications, such as severe corporal infections. Conservative therapy should be reserved for patients who explicitly refuse surgical intervention after thorough consultation.

This article was translated from Univadis Germany using ChatGPT followed by human editing.

A version of this article appeared on Medscape.com.

Standard therapies for depression are antidepressants and psychotherapy. In particularly severe cases, electroconvulsive therapy (ECT) or vagus nerve stimulation (VNS) may also be indicated. VNS is an approved, effective, well-tolerated, long-term therapy for chronic and therapy-resistant depression, wrote Christine Reif-Leonhardt, MD, and associates from the University Hospital Frankfurt am Main (Germany), in a recent journal article. In contrast to more common treatments, such as ECT, VNS is little known in the general population and among specialists. The cost of VNS is covered by health insurance funds in Germany.

Available since 1994

As the authors reported, invasive VNS was approved in the European Union in 1994 and in the United States in 1997 for the treatment of children with medicinal therapy–refractory epilepsy. Because positive and lasting effects on mood could be seen in adults after around 3 months of VNS, irrespective of the effectiveness of anticonvulsive medication, “a genuinely antidepressant effect of VNS [was] postulated,” and therefore it was further developed as an antidepressant therapy.

A VNS system first received a CE certification in 2001 in the European Union for the treatment of patients with chronic or relapsing depression who had therapy-resistant depression or who were intolerant of the current depression therapy. In 2005, VNS was approved in the United States for the treatment of patients aged 18 years or older with therapy-resistant major depression for which at least four antidepressant therapies had not helped sufficiently.
 

Few sham-controlled studies

According to Dr. Reif-Leonhardt and colleagues, there have been multiple studies and case series on VNS in patients with therapy-resistant depression in the past 20 years. Many of the studies highlighted the additional benefits of VNS as an adjuvant procedure, but they were observational studies. Sham-controlled studies are in short supply because of methodologic difficulties and ethical problems.

The largest long-term study is a registry study in which 494 patients with therapy-resistant depression received the combination of the usual antidepressant therapy and VNS. The study lasted 5 years; 301 patients served as a control group and received the usual therapy. The cumulative response to the therapy (68% vs. 41%) and the remission rate (43% vs. 26%) were significantly greater in the group that received VNS, according to the authors. Patients who underwent at least one ECT series of at least seven sessions responded particularly well to VNS. The combined therapy was also more effective in ECT nonresponders than the usual therapy alone.

To date, only one sham-controlled study of VNS treatment for therapy-resistant depression has been conducted. In it, VNS was not significantly superior to a sham stimulation over an observation period of 10 weeks. However, observational studies have provided evidence that the antidepressant effect of VNS only develops after at least 12 months of treatment. According to Dr. Reif-Leonhardt and colleagues, the data indicate that differences in response rate and therapy effect can only be observed in the longer term after 3-12 months and that as the therapy duration increases, so do the effects of VNS. From this, it can be assumed “that the VNS mechanism of action can be attributed to neuroplastic and adaptive phenomena.”

The typical, common side effects of surgery are pain and paresthesia. Through irritation of the nerve, approximately every third patient experiences postoperative hoarseness and a voice change. Serious side effects and complications, such as temporary swallowing disorders, are rare. By reducing the stimulation intensity or lowering the stimulation frequency or impulse width, the side effects associated with stimulation can be alleviated or even eliminated. A second small surgical intervention may become necessary to replace broken cables or the battery (life span, 3-8 years).
 

Criteria for VNS therapy

When should VNS be considered? The authors specified the following criteria:

• An insufficient response to at least two antidepressants from different substance classes (ideally including one tricyclic) at a sufficient dosage and duration, as well as to two augmentation agents (such as lithium and quetiapine) in combination with guideline psychotherapy
• Intolerable side effects from pharmacotherapy or contraindications to medicinal therapy
• For patients who respond to ECT, the occurrence of relapses or residual symptoms after cessation of (maintenance) ECT, intolerable ECT side effects, or the need for maintenance ECT
• Repeated or long hospital treatments because of depression

This article is a translation of an article from Univadis Germany and first appeared on Medscape.com.

Standard therapies for depression are antidepressants and psychotherapy. In particularly severe cases, electroconvulsive therapy (ECT) or vagus nerve stimulation (VNS) may also be indicated. VNS is an approved, effective, well-tolerated, long-term therapy for chronic and therapy-resistant depression, wrote Christine Reif-Leonhardt, MD, and associates from the University Hospital Frankfurt am Main (Germany), in a recent journal article. In contrast to more common treatments, such as ECT, VNS is little known in the general population and among specialists. The cost of VNS is covered by health insurance funds in Germany.

Available since 1994

As the authors reported, invasive VNS was approved in the European Union in 1994 and in the United States in 1997 for the treatment of children with medicinal therapy–refractory epilepsy. Because positive and lasting effects on mood could be seen in adults after around 3 months of VNS, irrespective of the effectiveness of anticonvulsive medication, “a genuinely antidepressant effect of VNS [was] postulated,” and therefore it was further developed as an antidepressant therapy.

A VNS system first received a CE certification in 2001 in the European Union for the treatment of patients with chronic or relapsing depression who had therapy-resistant depression or who were intolerant of the current depression therapy. In 2005, VNS was approved in the United States for the treatment of patients aged 18 years or older with therapy-resistant major depression for which at least four antidepressant therapies had not helped sufficiently.
 

Few sham-controlled studies

According to Dr. Reif-Leonhardt and colleagues, there have been multiple studies and case series on VNS in patients with therapy-resistant depression in the past 20 years. Many of the studies highlighted the additional benefits of VNS as an adjuvant procedure, but they were observational studies. Sham-controlled studies are in short supply because of methodologic difficulties and ethical problems.

The largest long-term study is a registry study in which 494 patients with therapy-resistant depression received the combination of the usual antidepressant therapy and VNS. The study lasted 5 years; 301 patients served as a control group and received the usual therapy. The cumulative response to the therapy (68% vs. 41%) and the remission rate (43% vs. 26%) were significantly greater in the group that received VNS, according to the authors. Patients who underwent at least one ECT series of at least seven sessions responded particularly well to VNS. The combined therapy was also more effective in ECT nonresponders than the usual therapy alone.

To date, only one sham-controlled study of VNS treatment for therapy-resistant depression has been conducted. In it, VNS was not significantly superior to a sham stimulation over an observation period of 10 weeks. However, observational studies have provided evidence that the antidepressant effect of VNS only develops after at least 12 months of treatment. According to Dr. Reif-Leonhardt and colleagues, the data indicate that differences in response rate and therapy effect can only be observed in the longer term after 3-12 months and that as the therapy duration increases, so do the effects of VNS. From this, it can be assumed “that the VNS mechanism of action can be attributed to neuroplastic and adaptive phenomena.”

The typical, common side effects of surgery are pain and paresthesia. Through irritation of the nerve, approximately every third patient experiences postoperative hoarseness and a voice change. Serious side effects and complications, such as temporary swallowing disorders, are rare. By reducing the stimulation intensity or lowering the stimulation frequency or impulse width, the side effects associated with stimulation can be alleviated or even eliminated. A second small surgical intervention may become necessary to replace broken cables or the battery (life span, 3-8 years).
 

Criteria for VNS therapy

When should VNS be considered? The authors specified the following criteria:

• An insufficient response to at least two antidepressants from different substance classes (ideally including one tricyclic) at a sufficient dosage and duration, as well as to two augmentation agents (such as lithium and quetiapine) in combination with guideline psychotherapy
• Intolerable side effects from pharmacotherapy or contraindications to medicinal therapy
• For patients who respond to ECT, the occurrence of relapses or residual symptoms after cessation of (maintenance) ECT, intolerable ECT side effects, or the need for maintenance ECT
• Repeated or long hospital treatments because of depression

This article is a translation of an article from Univadis Germany and first appeared on Medscape.com.

Standard therapies for depression are antidepressants and psychotherapy. In particularly severe cases, electroconvulsive therapy (ECT) or vagus nerve stimulation (VNS) may also be indicated. VNS is an approved, effective, well-tolerated, long-term therapy for chronic and therapy-resistant depression, wrote Christine Reif-Leonhardt, MD, and associates from the University Hospital Frankfurt am Main (Germany), in a recent journal article. In contrast to more common treatments, such as ECT, VNS is little known in the general population and among specialists. The cost of VNS is covered by health insurance funds in Germany.

Available since 1994

As the authors reported, invasive VNS was approved in the European Union in 1994 and in the United States in 1997 for the treatment of children with medicinal therapy–refractory epilepsy. Because positive and lasting effects on mood could be seen in adults after around 3 months of VNS, irrespective of the effectiveness of anticonvulsive medication, “a genuinely antidepressant effect of VNS [was] postulated,” and therefore it was further developed as an antidepressant therapy.

A VNS system first received a CE certification in 2001 in the European Union for the treatment of patients with chronic or relapsing depression who had therapy-resistant depression or who were intolerant of the current depression therapy. In 2005, VNS was approved in the United States for the treatment of patients aged 18 years or older with therapy-resistant major depression for which at least four antidepressant therapies had not helped sufficiently.
 

Few sham-controlled studies

According to Dr. Reif-Leonhardt and colleagues, there have been multiple studies and case series on VNS in patients with therapy-resistant depression in the past 20 years. Many of the studies highlighted the additional benefits of VNS as an adjuvant procedure, but they were observational studies. Sham-controlled studies are in short supply because of methodologic difficulties and ethical problems.

The largest long-term study is a registry study in which 494 patients with therapy-resistant depression received the combination of the usual antidepressant therapy and VNS. The study lasted 5 years; 301 patients served as a control group and received the usual therapy. The cumulative response to the therapy (68% vs. 41%) and the remission rate (43% vs. 26%) were significantly greater in the group that received VNS, according to the authors. Patients who underwent at least one ECT series of at least seven sessions responded particularly well to VNS. The combined therapy was also more effective in ECT nonresponders than the usual therapy alone.

To date, only one sham-controlled study of VNS treatment for therapy-resistant depression has been conducted. In it, VNS was not significantly superior to a sham stimulation over an observation period of 10 weeks. However, observational studies have provided evidence that the antidepressant effect of VNS only develops after at least 12 months of treatment. According to Dr. Reif-Leonhardt and colleagues, the data indicate that differences in response rate and therapy effect can only be observed in the longer term after 3-12 months and that as the therapy duration increases, so do the effects of VNS. From this, it can be assumed “that the VNS mechanism of action can be attributed to neuroplastic and adaptive phenomena.”

The typical, common side effects of surgery are pain and paresthesia. Through irritation of the nerve, approximately every third patient experiences postoperative hoarseness and a voice change. Serious side effects and complications, such as temporary swallowing disorders, are rare. By reducing the stimulation intensity or lowering the stimulation frequency or impulse width, the side effects associated with stimulation can be alleviated or even eliminated. A second small surgical intervention may become necessary to replace broken cables or the battery (life span, 3-8 years).
 

Criteria for VNS therapy

When should VNS be considered? The authors specified the following criteria:

• An insufficient response to at least two antidepressants from different substance classes (ideally including one tricyclic) at a sufficient dosage and duration, as well as to two augmentation agents (such as lithium and quetiapine) in combination with guideline psychotherapy
• Intolerable side effects from pharmacotherapy or contraindications to medicinal therapy
• For patients who respond to ECT, the occurrence of relapses or residual symptoms after cessation of (maintenance) ECT, intolerable ECT side effects, or the need for maintenance ECT
• Repeated or long hospital treatments because of depression

This article is a translation of an article from Univadis Germany and first appeared on Medscape.com.

Dietary supplements that contain omega-3 fatty acids have been widely consumed for years. Researchers have been investigating the benefits of such preparations for cardiovascular, neurologic, and psychological conditions. A recently published study on omega-3 fatty acids and depression inspired neurologist Hans-Christoph Diener, MD, PhD, of the Institute for Epidemiology at the University Duisburg-Essen (Germany), to examine scientific publications concerning omega-3 fatty acids or fish-oil capsules in more detail.

Prevention of depression

Dr. Diener told the story of how he stumbled upon an interesting article in JAMA  in December 2021. It was about a placebo-controlled study that investigated whether omega-3 fatty acids can prevent incident depression.

As the study authors reported, treatment with omega-3 preparations in adults aged 50 years or older without clinically relevant symptoms of depression at study initiation was associated with a small but statistically significant increase in the risk for depression or clinically relevant symptoms of depression. There was no difference in mood scale value, however, over a median follow-up of 5.3 years. According to the study authors, these results did not support the administration of omega-3 preparations for the prevention of depression.

This study was, as Dr. Diener said, somewhat negative, but it did arouse his interest in questions such as what biological effects omega-3 fatty acids have and what is known “about this topic with regard to neurology,” he said. When reviewing the literature, he noticed that there “were association studies, i.e., studies that describe that the intake of omega-3 fatty acids may possibly be associated with a lower risk of certain diseases.”
 

Beginning with the Inuit

It all started “with observations of the Inuit [population] in Greenland and Alaska after World War II, because it was remarked upon that these people ate a lot of fish and seal meat and had a very low incidence of cardiovascular diseases.” Over the years, a large number of association studies have been published, which may have encouraged the assumption that omega-3 fatty acids have positive health effects on various conditions, such as cardiovascular diseases, hyperlipidemia, type 2 diabetes, various malignancies, cognitive impairments, Alzheimer’s disease, depression and anxiety disorders, heart failure, slipped disks, ADHD, symptoms of menopause, rheumatoid arthritis, asthma, periodontitis, epilepsy, chemotherapy tolerance, premenstrual syndrome, and nonalcoholic fatty liver disease.

Dr. Diener believes that the problem is that these are association studies. But association does not mean that there is a causal relationship.
 

Disappointing study results

On the contrary, the results from the randomized placebo-controlled studies are truly frustrating, according to the neurologist. A meta-analysis of the use of omega-3 fatty acids in cardiovascular diseases included 86 studies with over 162,000 patients. According to Dr. Diener, it did not reveal any benefit for overall and cardiovascular mortality, nor any benefit for the reduction of myocardial infarction and stroke.

The results did indicate a trend, however, for reduced mortality in coronary heart disease. Even so, the number needed to treat for this was 334, which means that 334 people would have to take omega-3 fatty acids for years to prevent one fatal cardiac event.

Aside from this study, Dr. Diener found six studies on Alzheimer’s disease and three studies on dementia with patient populations between 600 and 800. In these studies, too, a positive effect of omega-3 fatty acids could not be identified. Then he discovered another 31 placebo-controlled studies of omega-3 fatty acids for the treatment or prevention of depression and anxiety disorder. Despite including 50,000 patients, these studies also did not show any positive effect.

“I see a significant discrepancy between the promotion of omega-3 fatty acids, whether it’s on television, in the ‘yellow’ [journalism] press, or in advertisements, and the actual scientific evidence,” said Dr. Diener. “At least from a neurological perspective, there is no evidence that omega-3 fatty acids have any benefit. This is true for strokes, dementia, Alzheimer’s disease, depression, and anxiety disorders.”
 

Potential adverse effects

Omega-3 fatty acids also have potentially adverse effects. The VITAL Rhythm study recently provided evidence that, depending on the dose, preparations with omega-3 fatty acids may increase the risk for atrial fibrillation. As the authors wrote, the results do not support taking omega-3 fatty acids to prevent atrial fibrillation.

In 2019, the global market for omega-3 fatty acids reached a value of $4.1 billion. This value is expected to double by 2025, according to a comment by Gregory Curfman, MD, deputy editor of JAMA and lecturer in health care policy at Harvard Medical School, Boston.

As Dr. Curfman wrote, this impressive amount of expenditure shows how beloved these products are and how strongly many people believe that omega-3 fatty acids are beneficial for their health. It is therefore important to know the potential risks of such preparations. One such example for this would be the risk for atrial fibrillation.

According to Dr. Curfman, in the last 2 years, four randomized clinical studies have provided data on the risk for atrial fibrillation associated with omega-3 fatty acids. In the STRENGTH study, 13,078 high-risk patients with cardiovascular diseases were randomly assigned to one of two groups. The subjects received either a high dose (4 g/day) of a combination of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) or corn oil. After a median of 42 months, there was no significant difference between the two groups in the primary composite cardiovascular endpoint, but more frequent atrial fibrillation in the omega-3 fatty acid group, compared with the corn oil group (2.2% vs. 1.3%; hazard ratio, 1.69; 95% confidence interval, 1.29-2.21; P < .001).

In the REDUCE-IT study, 8179 subjects were randomly assigned to a high dose (4 g/day, as in STRENGTH) of an omega-3 fatty acid preparation consisting of a purified EPA (icosapent ethyl) or mineral oil. After a median observation period of 4.9 years, icosapent ethyl was associated with a relative reduction of the primary composite cardiovascular endpoint by 25%, compared with mineral oil. As in the STRENGTH study, this study found that the risk for atrial fibrillation associated with omega-3 fatty acids, compared with mineral oil, was significantly higher (5.3% vs. 3.9%; P = .003).

In a third study (OMEMI), as Dr. Curfman reported, 1027 elderly patients who had recently had a myocardial infarction were randomly assigned to receive either a median dose of 1.8 g/day of omega-3 fatty acids (a combination of EPA and DHA) or corn oil. After 2 years, there was no significant difference between the two groups in primary composite cardiovascular endpoints, but 7.2% of the patients taking omega-3 fatty acids developed atrial fibrillation. In the corn oil group, this proportion was 4% (HR, 1.84; 95% CI, 0.98-3.45; P = .06).

The data from the four studies together indicate a potential dose-dependent risk for atrial fibrillation associated with omega-3 fatty acids, according to Dr. Curfman. At a dose of 4.0 g/day, there is a highly significant risk increase (almost double). With a median dose of 1.8 g/day, the risk increase (HR, 1.84) did not reach statistical significance. At a daily standard dose of 840 mg/day, an increase in risk could not be determined.

Dr. Curfman’s recommendation is that patients who take, or want to take, preparations with omega-3 fatty acids be informed of the potential development of arrhythmia at higher dosages. These patients also should undergo cardiological monitoring.

A version of this article first appeared on Medscape.com.

Dietary supplements that contain omega-3 fatty acids have been widely consumed for years. Researchers have been investigating the benefits of such preparations for cardiovascular, neurologic, and psychological conditions. A recently published study on omega-3 fatty acids and depression inspired neurologist Hans-Christoph Diener, MD, PhD, of the Institute for Epidemiology at the University Duisburg-Essen (Germany), to examine scientific publications concerning omega-3 fatty acids or fish-oil capsules in more detail.

Prevention of depression

Dr. Diener told the story of how he stumbled upon an interesting article in JAMA  in December 2021. It was about a placebo-controlled study that investigated whether omega-3 fatty acids can prevent incident depression.

As the study authors reported, treatment with omega-3 preparations in adults aged 50 years or older without clinically relevant symptoms of depression at study initiation was associated with a small but statistically significant increase in the risk for depression or clinically relevant symptoms of depression. There was no difference in mood scale value, however, over a median follow-up of 5.3 years. According to the study authors, these results did not support the administration of omega-3 preparations for the prevention of depression.

This study was, as Dr. Diener said, somewhat negative, but it did arouse his interest in questions such as what biological effects omega-3 fatty acids have and what is known “about this topic with regard to neurology,” he said. When reviewing the literature, he noticed that there “were association studies, i.e., studies that describe that the intake of omega-3 fatty acids may possibly be associated with a lower risk of certain diseases.”
 

Beginning with the Inuit

It all started “with observations of the Inuit [population] in Greenland and Alaska after World War II, because it was remarked upon that these people ate a lot of fish and seal meat and had a very low incidence of cardiovascular diseases.” Over the years, a large number of association studies have been published, which may have encouraged the assumption that omega-3 fatty acids have positive health effects on various conditions, such as cardiovascular diseases, hyperlipidemia, type 2 diabetes, various malignancies, cognitive impairments, Alzheimer’s disease, depression and anxiety disorders, heart failure, slipped disks, ADHD, symptoms of menopause, rheumatoid arthritis, asthma, periodontitis, epilepsy, chemotherapy tolerance, premenstrual syndrome, and nonalcoholic fatty liver disease.

Dr. Diener believes that the problem is that these are association studies. But association does not mean that there is a causal relationship.
 

Disappointing study results

On the contrary, the results from the randomized placebo-controlled studies are truly frustrating, according to the neurologist. A meta-analysis of the use of omega-3 fatty acids in cardiovascular diseases included 86 studies with over 162,000 patients. According to Dr. Diener, it did not reveal any benefit for overall and cardiovascular mortality, nor any benefit for the reduction of myocardial infarction and stroke.

The results did indicate a trend, however, for reduced mortality in coronary heart disease. Even so, the number needed to treat for this was 334, which means that 334 people would have to take omega-3 fatty acids for years to prevent one fatal cardiac event.

Aside from this study, Dr. Diener found six studies on Alzheimer’s disease and three studies on dementia with patient populations between 600 and 800. In these studies, too, a positive effect of omega-3 fatty acids could not be identified. Then he discovered another 31 placebo-controlled studies of omega-3 fatty acids for the treatment or prevention of depression and anxiety disorder. Despite including 50,000 patients, these studies also did not show any positive effect.

“I see a significant discrepancy between the promotion of omega-3 fatty acids, whether it’s on television, in the ‘yellow’ [journalism] press, or in advertisements, and the actual scientific evidence,” said Dr. Diener. “At least from a neurological perspective, there is no evidence that omega-3 fatty acids have any benefit. This is true for strokes, dementia, Alzheimer’s disease, depression, and anxiety disorders.”
 

Potential adverse effects

Omega-3 fatty acids also have potentially adverse effects. The VITAL Rhythm study recently provided evidence that, depending on the dose, preparations with omega-3 fatty acids may increase the risk for atrial fibrillation. As the authors wrote, the results do not support taking omega-3 fatty acids to prevent atrial fibrillation.

In 2019, the global market for omega-3 fatty acids reached a value of $4.1 billion. This value is expected to double by 2025, according to a comment by Gregory Curfman, MD, deputy editor of JAMA and lecturer in health care policy at Harvard Medical School, Boston.

As Dr. Curfman wrote, this impressive amount of expenditure shows how beloved these products are and how strongly many people believe that omega-3 fatty acids are beneficial for their health. It is therefore important to know the potential risks of such preparations. One such example for this would be the risk for atrial fibrillation.

According to Dr. Curfman, in the last 2 years, four randomized clinical studies have provided data on the risk for atrial fibrillation associated with omega-3 fatty acids. In the STRENGTH study, 13,078 high-risk patients with cardiovascular diseases were randomly assigned to one of two groups. The subjects received either a high dose (4 g/day) of a combination of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) or corn oil. After a median of 42 months, there was no significant difference between the two groups in the primary composite cardiovascular endpoint, but more frequent atrial fibrillation in the omega-3 fatty acid group, compared with the corn oil group (2.2% vs. 1.3%; hazard ratio, 1.69; 95% confidence interval, 1.29-2.21; P < .001).

In the REDUCE-IT study, 8179 subjects were randomly assigned to a high dose (4 g/day, as in STRENGTH) of an omega-3 fatty acid preparation consisting of a purified EPA (icosapent ethyl) or mineral oil. After a median observation period of 4.9 years, icosapent ethyl was associated with a relative reduction of the primary composite cardiovascular endpoint by 25%, compared with mineral oil. As in the STRENGTH study, this study found that the risk for atrial fibrillation associated with omega-3 fatty acids, compared with mineral oil, was significantly higher (5.3% vs. 3.9%; P = .003).

In a third study (OMEMI), as Dr. Curfman reported, 1027 elderly patients who had recently had a myocardial infarction were randomly assigned to receive either a median dose of 1.8 g/day of omega-3 fatty acids (a combination of EPA and DHA) or corn oil. After 2 years, there was no significant difference between the two groups in primary composite cardiovascular endpoints, but 7.2% of the patients taking omega-3 fatty acids developed atrial fibrillation. In the corn oil group, this proportion was 4% (HR, 1.84; 95% CI, 0.98-3.45; P = .06).

The data from the four studies together indicate a potential dose-dependent risk for atrial fibrillation associated with omega-3 fatty acids, according to Dr. Curfman. At a dose of 4.0 g/day, there is a highly significant risk increase (almost double). With a median dose of 1.8 g/day, the risk increase (HR, 1.84) did not reach statistical significance. At a daily standard dose of 840 mg/day, an increase in risk could not be determined.

Dr. Curfman’s recommendation is that patients who take, or want to take, preparations with omega-3 fatty acids be informed of the potential development of arrhythmia at higher dosages. These patients also should undergo cardiological monitoring.

A version of this article first appeared on Medscape.com.

Dietary supplements that contain omega-3 fatty acids have been widely consumed for years. Researchers have been investigating the benefits of such preparations for cardiovascular, neurologic, and psychological conditions. A recently published study on omega-3 fatty acids and depression inspired neurologist Hans-Christoph Diener, MD, PhD, of the Institute for Epidemiology at the University Duisburg-Essen (Germany), to examine scientific publications concerning omega-3 fatty acids or fish-oil capsules in more detail.

Prevention of depression

Dr. Diener told the story of how he stumbled upon an interesting article in JAMA  in December 2021. It was about a placebo-controlled study that investigated whether omega-3 fatty acids can prevent incident depression.

As the study authors reported, treatment with omega-3 preparations in adults aged 50 years or older without clinically relevant symptoms of depression at study initiation was associated with a small but statistically significant increase in the risk for depression or clinically relevant symptoms of depression. There was no difference in mood scale value, however, over a median follow-up of 5.3 years. According to the study authors, these results did not support the administration of omega-3 preparations for the prevention of depression.

This study was, as Dr. Diener said, somewhat negative, but it did arouse his interest in questions such as what biological effects omega-3 fatty acids have and what is known “about this topic with regard to neurology,” he said. When reviewing the literature, he noticed that there “were association studies, i.e., studies that describe that the intake of omega-3 fatty acids may possibly be associated with a lower risk of certain diseases.”
 

Beginning with the Inuit

It all started “with observations of the Inuit [population] in Greenland and Alaska after World War II, because it was remarked upon that these people ate a lot of fish and seal meat and had a very low incidence of cardiovascular diseases.” Over the years, a large number of association studies have been published, which may have encouraged the assumption that omega-3 fatty acids have positive health effects on various conditions, such as cardiovascular diseases, hyperlipidemia, type 2 diabetes, various malignancies, cognitive impairments, Alzheimer’s disease, depression and anxiety disorders, heart failure, slipped disks, ADHD, symptoms of menopause, rheumatoid arthritis, asthma, periodontitis, epilepsy, chemotherapy tolerance, premenstrual syndrome, and nonalcoholic fatty liver disease.

Dr. Diener believes that the problem is that these are association studies. But association does not mean that there is a causal relationship.
 

Disappointing study results

On the contrary, the results from the randomized placebo-controlled studies are truly frustrating, according to the neurologist. A meta-analysis of the use of omega-3 fatty acids in cardiovascular diseases included 86 studies with over 162,000 patients. According to Dr. Diener, it did not reveal any benefit for overall and cardiovascular mortality, nor any benefit for the reduction of myocardial infarction and stroke.

The results did indicate a trend, however, for reduced mortality in coronary heart disease. Even so, the number needed to treat for this was 334, which means that 334 people would have to take omega-3 fatty acids for years to prevent one fatal cardiac event.

Aside from this study, Dr. Diener found six studies on Alzheimer’s disease and three studies on dementia with patient populations between 600 and 800. In these studies, too, a positive effect of omega-3 fatty acids could not be identified. Then he discovered another 31 placebo-controlled studies of omega-3 fatty acids for the treatment or prevention of depression and anxiety disorder. Despite including 50,000 patients, these studies also did not show any positive effect.

“I see a significant discrepancy between the promotion of omega-3 fatty acids, whether it’s on television, in the ‘yellow’ [journalism] press, or in advertisements, and the actual scientific evidence,” said Dr. Diener. “At least from a neurological perspective, there is no evidence that omega-3 fatty acids have any benefit. This is true for strokes, dementia, Alzheimer’s disease, depression, and anxiety disorders.”
 

Potential adverse effects

Omega-3 fatty acids also have potentially adverse effects. The VITAL Rhythm study recently provided evidence that, depending on the dose, preparations with omega-3 fatty acids may increase the risk for atrial fibrillation. As the authors wrote, the results do not support taking omega-3 fatty acids to prevent atrial fibrillation.

In 2019, the global market for omega-3 fatty acids reached a value of $4.1 billion. This value is expected to double by 2025, according to a comment by Gregory Curfman, MD, deputy editor of JAMA and lecturer in health care policy at Harvard Medical School, Boston.

As Dr. Curfman wrote, this impressive amount of expenditure shows how beloved these products are and how strongly many people believe that omega-3 fatty acids are beneficial for their health. It is therefore important to know the potential risks of such preparations. One such example for this would be the risk for atrial fibrillation.

According to Dr. Curfman, in the last 2 years, four randomized clinical studies have provided data on the risk for atrial fibrillation associated with omega-3 fatty acids. In the STRENGTH study, 13,078 high-risk patients with cardiovascular diseases were randomly assigned to one of two groups. The subjects received either a high dose (4 g/day) of a combination of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) or corn oil. After a median of 42 months, there was no significant difference between the two groups in the primary composite cardiovascular endpoint, but more frequent atrial fibrillation in the omega-3 fatty acid group, compared with the corn oil group (2.2% vs. 1.3%; hazard ratio, 1.69; 95% confidence interval, 1.29-2.21; P < .001).

In the REDUCE-IT study, 8179 subjects were randomly assigned to a high dose (4 g/day, as in STRENGTH) of an omega-3 fatty acid preparation consisting of a purified EPA (icosapent ethyl) or mineral oil. After a median observation period of 4.9 years, icosapent ethyl was associated with a relative reduction of the primary composite cardiovascular endpoint by 25%, compared with mineral oil. As in the STRENGTH study, this study found that the risk for atrial fibrillation associated with omega-3 fatty acids, compared with mineral oil, was significantly higher (5.3% vs. 3.9%; P = .003).

In a third study (OMEMI), as Dr. Curfman reported, 1027 elderly patients who had recently had a myocardial infarction were randomly assigned to receive either a median dose of 1.8 g/day of omega-3 fatty acids (a combination of EPA and DHA) or corn oil. After 2 years, there was no significant difference between the two groups in primary composite cardiovascular endpoints, but 7.2% of the patients taking omega-3 fatty acids developed atrial fibrillation. In the corn oil group, this proportion was 4% (HR, 1.84; 95% CI, 0.98-3.45; P = .06).

The data from the four studies together indicate a potential dose-dependent risk for atrial fibrillation associated with omega-3 fatty acids, according to Dr. Curfman. At a dose of 4.0 g/day, there is a highly significant risk increase (almost double). With a median dose of 1.8 g/day, the risk increase (HR, 1.84) did not reach statistical significance. At a daily standard dose of 840 mg/day, an increase in risk could not be determined.

Dr. Curfman’s recommendation is that patients who take, or want to take, preparations with omega-3 fatty acids be informed of the potential development of arrhythmia at higher dosages. These patients also should undergo cardiological monitoring.

A version of this article first appeared on Medscape.com.

A vegetarian or vegan diet is said to be particularly popular among girls and young women. But despite what some people think, these diets, especially vegan diets, are not automatically healthy. A vegan diet can lead to nutritional deficits as a result of the limited choice of foods. These deficits can cause clinically relevant symptoms if they are not balanced out. One of the things to keep in mind is the need for a sufficient amount of vitamins B₁₂ and B₆, as well as vitamin D, explains nutritional scientist Bettina Dörr, PhD, from Munich, who specializes in how nutritional science is applied in everyday practice.

Vegetarian and vegan diets

According to Dr. Dörr, vegetarian diets can be categorized into the following main types:

• Ovo-lacto vegetarian (excludes meat and fish).
• Ovo vegetarian (excludes meat, fish, and dairy products).
• Lacto vegetarian (excludes meat, fish, and eggs).
• Vegan (excludes meat, fish, eggs, dairy products, and honey).
• Raw vegan (excludes meat, fish, eggs, dairy products, honey, and heated food).

The following are additional groups:

• Fruitarians want to eat only plant products that do not result in any damage to the plant itself (apples and nuts, for example, but not carrots or potatoes).
• Pescatarians exclude meat but still eat fish or seafood.
• Dirty vegetarians avoid meat and fish but, according to Dr. Dörr, they do not pay particular attention to their diet and eat lots of ready-made and confectionery products.
• Flexitarians value a balanced diet and eat meat or fish in moderation, but not particularly often.

Another diet is the orthorexic diet. Followers of this diet force themselves to have a healthy diet and are afraid of getting sick from unhealthy food. As the nutritional scientist explains, orthorexic persons set their own definitions of what is healthy. While some refrain from certain foods (e.g., household sugar), others eliminate whole food groups and eat nothing but raw food. Compulsive behavior can appear in specific methods of food preparation or adherence to fixed meal schedules.

The overwhelming majority of orthorexic persons are young women. As shown in a study from the University of Göttingen, orthorexic behavior is displayed above all in active women who play sports, particularly high-performance athletes. Children can also be affected by orthorexia if their parents are.

Critical nutrients

When following a vegan diet, it is possible to ingest sufficient critical nutrients, even with plant-based foods, according to Dr. Dörr. The prerequisite for this is good knowledge regarding food and nutrients. However, it is increasingly the case that foods are “simply left out,” without consideration of the consequences. This factor should be considered when providing medical advice.

Some of the important nutrients in this respect are proteins and vitamins B₆, B₁₂, and D.

Proteins

Girls need 0.9 g/kg per day of protein. For a person whose body weight is 60 kg, this corresponds to 54 g. The daily protein requirement for a person who weighs 60 kg can be fulfilled through a vegan diet. According to Dr. Dörr, 54 g of protein is contained in 300 g of tofu, 350 g of cooked soybeans, 350 g of hazelnuts, 750 g of whole grain bread (15 slices at 50 g each), 750 g of cooked lentils, and 1 kg of white beans.

Vitamin B₆

Vitamin B₆ (pyridoxine) has, Dr. Dörr explains, multiple metabolic functions, especially in the metabolization of amino acids, and is important from a neurologic perspective. For girls, the vitamin is important for hormone metabolism. Data show that approximately 14% of girls aged 14-18 years ingest less than the recommended amount of vitamin B₆. For vegans, the percentage of those with insufficient intake is even higher, since vitamin B₆ has low bioavailability in plant-based foods. For girls, there is the additional factor of oral contraceptives. There are indications that those who use oral contraceptives containing estrogen have lower levels of pyridoxal-5’-phosphate (PLP), a marker for vitamin B₆. Since the PLP-dependent enzymes are essential for the synthesis of hormones such as serotonin, symptoms such as depressive moods, increased irritability, nervousness, and loss of libido can indicate a vitamin B₆ deficiency.

The daily B₆ requirement for girls is 1.4 mg and can be fulfilled, for example, by consuming 200 g of hazelnuts, 200 g of walnuts, 400 g of bananas (two to three bananas, depending on weight), 700 g of cooked green beans, 1 kg of cooked potatoes, and 1.4 kg of oats.

Vitamin B₁₂

Since vitamin B₁₂ is not present in plant-based food, following a vegan diet in the long term can result in deficiency unless dietary supplements are taken. When researching the choices of various dietary supplements, it should be taken into consideration that the utilization of vitamin B₁₂ from plant-based sources such as algae, seaweed, and fungi is not necessarily a given. Careful selection and regular monitoring of B₁₂ status is recommended.

Vitamin D

According to Dr. Dörr, evidence has increased in recent years that vitamin D is crucial not only for the bones but also for numerous metabolic processes. The fact is that foods are barely capable of covering the vitamin D requirement in amounts that can be expected to be consumed. Vegan foods are not able to contribute to the supply of vitamin D, since considerable amounts are present only in food of an animal origin. The decision to take supplements and in what amounts should be made on the basis of one’s condition.

Minerals

Calcium, iodine, iron, selenium, and zinc are not easily available in sufficient quantities from a purely plant-based diet. Plant-based foods usually contain lower quantities of these minerals than do foods of animal origin, and the minerals from plant-based sources have lower bioavailability. According to Dr. Dörr, current evidence suggests that a vegan diet can have negative effects on bone health. In an ongoing cross-sectional study, ultrasound measurements of the heel bone are being made, and biomarkers in the blood and urine are being measured. On average, people who follow a vegan diet have lower ultrasound readings than those of omnivores.

The European Prospective Investigation into Cancer and Nutrition (EPIC) study from Great Britain, which involved almost 55,000 people, revealed that vegans had a 43% higher risk of fracture, compared to meat eaters.

An important nutrient, especially for cell development, is choline, which, Dr. Dörr explains, can be absorbed mainly through eating eggs, fish, meat, and dairy products. There is increasing evidence that a vegan diet is not able to supply sufficient quantities of choline, particularly if requirements increase, such as during pregnancy and breastfeeding. Evidence has grown that women who wish to conceive a child benefit not only from a sufficient intake of folate intake for the prevention of neural tube defects and for favorable fetal development but also from sufficient quantities of choline (the recommended daily amount for pregnant women is 480 mg).

A version of this article first appeared on Medscape.com.

A vegetarian or vegan diet is said to be particularly popular among girls and young women. But despite what some people think, these diets, especially vegan diets, are not automatically healthy. A vegan diet can lead to nutritional deficits as a result of the limited choice of foods. These deficits can cause clinically relevant symptoms if they are not balanced out. One of the things to keep in mind is the need for a sufficient amount of vitamins B₁₂ and B₆, as well as vitamin D, explains nutritional scientist Bettina Dörr, PhD, from Munich, who specializes in how nutritional science is applied in everyday practice.

Vegetarian and vegan diets

According to Dr. Dörr, vegetarian diets can be categorized into the following main types:

• Ovo-lacto vegetarian (excludes meat and fish).
• Ovo vegetarian (excludes meat, fish, and dairy products).
• Lacto vegetarian (excludes meat, fish, and eggs).
• Vegan (excludes meat, fish, eggs, dairy products, and honey).
• Raw vegan (excludes meat, fish, eggs, dairy products, honey, and heated food).

The following are additional groups:

• Fruitarians want to eat only plant products that do not result in any damage to the plant itself (apples and nuts, for example, but not carrots or potatoes).
• Pescatarians exclude meat but still eat fish or seafood.
• Dirty vegetarians avoid meat and fish but, according to Dr. Dörr, they do not pay particular attention to their diet and eat lots of ready-made and confectionery products.
• Flexitarians value a balanced diet and eat meat or fish in moderation, but not particularly often.

Another diet is the orthorexic diet. Followers of this diet force themselves to have a healthy diet and are afraid of getting sick from unhealthy food. As the nutritional scientist explains, orthorexic persons set their own definitions of what is healthy. While some refrain from certain foods (e.g., household sugar), others eliminate whole food groups and eat nothing but raw food. Compulsive behavior can appear in specific methods of food preparation or adherence to fixed meal schedules.

The overwhelming majority of orthorexic persons are young women. As shown in a study from the University of Göttingen, orthorexic behavior is displayed above all in active women who play sports, particularly high-performance athletes. Children can also be affected by orthorexia if their parents are.

Critical nutrients

When following a vegan diet, it is possible to ingest sufficient critical nutrients, even with plant-based foods, according to Dr. Dörr. The prerequisite for this is good knowledge regarding food and nutrients. However, it is increasingly the case that foods are “simply left out,” without consideration of the consequences. This factor should be considered when providing medical advice.

Some of the important nutrients in this respect are proteins and vitamins B₆, B₁₂, and D.

Proteins

Girls need 0.9 g/kg per day of protein. For a person whose body weight is 60 kg, this corresponds to 54 g. The daily protein requirement for a person who weighs 60 kg can be fulfilled through a vegan diet. According to Dr. Dörr, 54 g of protein is contained in 300 g of tofu, 350 g of cooked soybeans, 350 g of hazelnuts, 750 g of whole grain bread (15 slices at 50 g each), 750 g of cooked lentils, and 1 kg of white beans.

Vitamin B₆

Vitamin B₆ (pyridoxine) has, Dr. Dörr explains, multiple metabolic functions, especially in the metabolization of amino acids, and is important from a neurologic perspective. For girls, the vitamin is important for hormone metabolism. Data show that approximately 14% of girls aged 14-18 years ingest less than the recommended amount of vitamin B₆. For vegans, the percentage of those with insufficient intake is even higher, since vitamin B₆ has low bioavailability in plant-based foods. For girls, there is the additional factor of oral contraceptives. There are indications that those who use oral contraceptives containing estrogen have lower levels of pyridoxal-5’-phosphate (PLP), a marker for vitamin B₆. Since the PLP-dependent enzymes are essential for the synthesis of hormones such as serotonin, symptoms such as depressive moods, increased irritability, nervousness, and loss of libido can indicate a vitamin B₆ deficiency.

The daily B₆ requirement for girls is 1.4 mg and can be fulfilled, for example, by consuming 200 g of hazelnuts, 200 g of walnuts, 400 g of bananas (two to three bananas, depending on weight), 700 g of cooked green beans, 1 kg of cooked potatoes, and 1.4 kg of oats.

Vitamin B₁₂

Since vitamin B₁₂ is not present in plant-based food, following a vegan diet in the long term can result in deficiency unless dietary supplements are taken. When researching the choices of various dietary supplements, it should be taken into consideration that the utilization of vitamin B₁₂ from plant-based sources such as algae, seaweed, and fungi is not necessarily a given. Careful selection and regular monitoring of B₁₂ status is recommended.

Vitamin D

According to Dr. Dörr, evidence has increased in recent years that vitamin D is crucial not only for the bones but also for numerous metabolic processes. The fact is that foods are barely capable of covering the vitamin D requirement in amounts that can be expected to be consumed. Vegan foods are not able to contribute to the supply of vitamin D, since considerable amounts are present only in food of an animal origin. The decision to take supplements and in what amounts should be made on the basis of one’s condition.

Minerals

Calcium, iodine, iron, selenium, and zinc are not easily available in sufficient quantities from a purely plant-based diet. Plant-based foods usually contain lower quantities of these minerals than do foods of animal origin, and the minerals from plant-based sources have lower bioavailability. According to Dr. Dörr, current evidence suggests that a vegan diet can have negative effects on bone health. In an ongoing cross-sectional study, ultrasound measurements of the heel bone are being made, and biomarkers in the blood and urine are being measured. On average, people who follow a vegan diet have lower ultrasound readings than those of omnivores.

The European Prospective Investigation into Cancer and Nutrition (EPIC) study from Great Britain, which involved almost 55,000 people, revealed that vegans had a 43% higher risk of fracture, compared to meat eaters.

An important nutrient, especially for cell development, is choline, which, Dr. Dörr explains, can be absorbed mainly through eating eggs, fish, meat, and dairy products. There is increasing evidence that a vegan diet is not able to supply sufficient quantities of choline, particularly if requirements increase, such as during pregnancy and breastfeeding. Evidence has grown that women who wish to conceive a child benefit not only from a sufficient intake of folate intake for the prevention of neural tube defects and for favorable fetal development but also from sufficient quantities of choline (the recommended daily amount for pregnant women is 480 mg).

A version of this article first appeared on Medscape.com.

A vegetarian or vegan diet is said to be particularly popular among girls and young women. But despite what some people think, these diets, especially vegan diets, are not automatically healthy. A vegan diet can lead to nutritional deficits as a result of the limited choice of foods. These deficits can cause clinically relevant symptoms if they are not balanced out. One of the things to keep in mind is the need for a sufficient amount of vitamins B₁₂ and B₆, as well as vitamin D, explains nutritional scientist Bettina Dörr, PhD, from Munich, who specializes in how nutritional science is applied in everyday practice.

Vegetarian and vegan diets

According to Dr. Dörr, vegetarian diets can be categorized into the following main types:

• Ovo-lacto vegetarian (excludes meat and fish).
• Ovo vegetarian (excludes meat, fish, and dairy products).
• Lacto vegetarian (excludes meat, fish, and eggs).
• Vegan (excludes meat, fish, eggs, dairy products, and honey).
• Raw vegan (excludes meat, fish, eggs, dairy products, honey, and heated food).

The following are additional groups:

• Fruitarians want to eat only plant products that do not result in any damage to the plant itself (apples and nuts, for example, but not carrots or potatoes).
• Pescatarians exclude meat but still eat fish or seafood.
• Dirty vegetarians avoid meat and fish but, according to Dr. Dörr, they do not pay particular attention to their diet and eat lots of ready-made and confectionery products.
• Flexitarians value a balanced diet and eat meat or fish in moderation, but not particularly often.

Another diet is the orthorexic diet. Followers of this diet force themselves to have a healthy diet and are afraid of getting sick from unhealthy food. As the nutritional scientist explains, orthorexic persons set their own definitions of what is healthy. While some refrain from certain foods (e.g., household sugar), others eliminate whole food groups and eat nothing but raw food. Compulsive behavior can appear in specific methods of food preparation or adherence to fixed meal schedules.

The overwhelming majority of orthorexic persons are young women. As shown in a study from the University of Göttingen, orthorexic behavior is displayed above all in active women who play sports, particularly high-performance athletes. Children can also be affected by orthorexia if their parents are.

Critical nutrients

When following a vegan diet, it is possible to ingest sufficient critical nutrients, even with plant-based foods, according to Dr. Dörr. The prerequisite for this is good knowledge regarding food and nutrients. However, it is increasingly the case that foods are “simply left out,” without consideration of the consequences. This factor should be considered when providing medical advice.

Some of the important nutrients in this respect are proteins and vitamins B₆, B₁₂, and D.

Proteins

Girls need 0.9 g/kg per day of protein. For a person whose body weight is 60 kg, this corresponds to 54 g. The daily protein requirement for a person who weighs 60 kg can be fulfilled through a vegan diet. According to Dr. Dörr, 54 g of protein is contained in 300 g of tofu, 350 g of cooked soybeans, 350 g of hazelnuts, 750 g of whole grain bread (15 slices at 50 g each), 750 g of cooked lentils, and 1 kg of white beans.

Vitamin B₆

Vitamin B₆ (pyridoxine) has, Dr. Dörr explains, multiple metabolic functions, especially in the metabolization of amino acids, and is important from a neurologic perspective. For girls, the vitamin is important for hormone metabolism. Data show that approximately 14% of girls aged 14-18 years ingest less than the recommended amount of vitamin B₆. For vegans, the percentage of those with insufficient intake is even higher, since vitamin B₆ has low bioavailability in plant-based foods. For girls, there is the additional factor of oral contraceptives. There are indications that those who use oral contraceptives containing estrogen have lower levels of pyridoxal-5’-phosphate (PLP), a marker for vitamin B₆. Since the PLP-dependent enzymes are essential for the synthesis of hormones such as serotonin, symptoms such as depressive moods, increased irritability, nervousness, and loss of libido can indicate a vitamin B₆ deficiency.

The daily B₆ requirement for girls is 1.4 mg and can be fulfilled, for example, by consuming 200 g of hazelnuts, 200 g of walnuts, 400 g of bananas (two to three bananas, depending on weight), 700 g of cooked green beans, 1 kg of cooked potatoes, and 1.4 kg of oats.

Vitamin B₁₂

Since vitamin B₁₂ is not present in plant-based food, following a vegan diet in the long term can result in deficiency unless dietary supplements are taken. When researching the choices of various dietary supplements, it should be taken into consideration that the utilization of vitamin B₁₂ from plant-based sources such as algae, seaweed, and fungi is not necessarily a given. Careful selection and regular monitoring of B₁₂ status is recommended.

Vitamin D

According to Dr. Dörr, evidence has increased in recent years that vitamin D is crucial not only for the bones but also for numerous metabolic processes. The fact is that foods are barely capable of covering the vitamin D requirement in amounts that can be expected to be consumed. Vegan foods are not able to contribute to the supply of vitamin D, since considerable amounts are present only in food of an animal origin. The decision to take supplements and in what amounts should be made on the basis of one’s condition.

Minerals

Calcium, iodine, iron, selenium, and zinc are not easily available in sufficient quantities from a purely plant-based diet. Plant-based foods usually contain lower quantities of these minerals than do foods of animal origin, and the minerals from plant-based sources have lower bioavailability. According to Dr. Dörr, current evidence suggests that a vegan diet can have negative effects on bone health. In an ongoing cross-sectional study, ultrasound measurements of the heel bone are being made, and biomarkers in the blood and urine are being measured. On average, people who follow a vegan diet have lower ultrasound readings than those of omnivores.

The European Prospective Investigation into Cancer and Nutrition (EPIC) study from Great Britain, which involved almost 55,000 people, revealed that vegans had a 43% higher risk of fracture, compared to meat eaters.

An important nutrient, especially for cell development, is choline, which, Dr. Dörr explains, can be absorbed mainly through eating eggs, fish, meat, and dairy products. There is increasing evidence that a vegan diet is not able to supply sufficient quantities of choline, particularly if requirements increase, such as during pregnancy and breastfeeding. Evidence has grown that women who wish to conceive a child benefit not only from a sufficient intake of folate intake for the prevention of neural tube defects and for favorable fetal development but also from sufficient quantities of choline (the recommended daily amount for pregnant women is 480 mg).

A version of this article first appeared on Medscape.com.

The German Society for Internal Medicine (DGIM) has announced it has withdrawn the honorary membership of five of its former members who were followers of the Nazi regime and perpetrators of atrocities between 1933 and 1945. The decision was made after the DGIM reappraised its own history during the Nazi period.

On the DGIM - Commemoration and Remembrance website, created in 2020, members who suffered under the Nazi regime are commemorated and those who committed crimes and caused suffering are called out.

The reappraisal began in 2012, when the DGIM commissioned two historians — Hans-Georg Hofer, PhD, from the University of Münster, and Ralf Forsbach, PhD, from the Institute for Ethics, History and Theory of Medicine at the University of Münster — to research the history of the society and its members during the periods of the National Socialism dictatorship and the young Federal Republic.

“Reappraising our own history, even at this late stage, is important and the right thing to do, although of course it cannot in any way make up for the suffering caused by individual DGIM members during that time,” Georg Ertl, MD, secretary general of the DGIM, states in a press release.

It is important, however, that the Society takes appropriate action in response to the historians’ findings, he adds.

The DGIM has done just that by retrospectively withdrawing the honorary membership status of five of its former members: Alfred Schittenhelm, Alfred Schwenkenbecher, Hans Dietlen, Siegfried Koller, and Georg Schaltenbrand.

“Out of opportunism or on the basis of Nazi beliefs, they intentionally harmed colleagues, other members of our Society, or simply other people on the basis of their ethnicity. Therefore, the DGIM can no longer accept them as honorary members,” said Markus M. Lerch, MD, chair of the DGIM and medical director of the Ludwig Maximilian University of Munich.

The board has also distanced itself from two other honorary members: Gustav von Bergmann and Felix Lommel. “More research is needed and we cannot currently make a responsible decision on withdrawal of honorary membership,” Dr. Lerch explained.

Early results from the historical reappraisal were presented to the public in 2015 at an exhibition held during the 121st DGIM Congress in Mannheim. The Society concurrently underwent a process of public self-reflection, stating that it was ashamed of having allowed 70 years to pass before it objectively examined its actions under National Socialism and acknowledged its responsibility.

The exhibition used photos, documents, and explanatory texts to show the actions, or lack of action, taken by some Society members during the Nazi regime. For example, it showed how then DGIM chair Alfred Schittenhelm — whose honorary membership has since been withdrawn — put the Society on the track to National Socialism. It also shone light on the role played by internists who consulted with the Wehrmacht in the treatment of Soviet prisoners of war and others, and on criminal experiments conducted on humans.

The exhibition also highlighted Jewish doctors who were persecuted and expelled, such as Leopold Lichtwitz, MD, who lost his position as clinic director in Berlin in 1933 and was forced to resign his chairmanship of the Society. And it presented portraits of members who loudly objected to and even actively resisted the regime, such as Wolfgang Seitz, MD, who became director of the Medical Outpatient Clinic at the University of Munich and deputy of the state parliament of the Social Democratic Party of Germany (SPD) in Bavaria after the war.

The historians focused on the years after 1945, because “1945 was no zero hour,” said Dr. Forsbach. Some culpable doctors continued to practice or became honorary DGIM members, he explained. The DGIM’s attitude toward history was characterized by suppression, denial, silence, and attempts at justification, consistent with the postwar attitude in the Federal Republic of Germany and in the medical profession as a whole.
 

After 1945

Behavior before 1945 is not the only source of shame. Crimes committed by doctors were never really confronted until the late 1970s, Jörg-Dietrich Hoppe, MD, former president of the German Medical Association, explained to ZEIT, a German newspaper, in 2011.

The psychoanalyst Alexander Mitscherlich, MD, and Fred Mielke were official observers from the German Commission of Physicians at the Nuremberg Doctors’ Trial who were made painfully aware that National Socialism was by no means over when the regime came to an end. They were both reviled as traitors to their country and for fouling their own nest, and, according to Mitscherlich, the behavior of the “authorities” bordered on character assassination.

As late as 1973, a renowned internist threatened that German internists would leave the room locked at the upcoming DGIM Congress if — as had been planned by congress chair Herbert Begemann — Mitscherlich gave a talk on this subject, journalist and doctor Renate Jäckle reported in her book on doctors and politics.

Even toward the end of the 1980s, Karsten Vilmar, MD, then president of the German Medical Association, reacted in an insensitive and defensive manner — during an interview — to an article in the Lancet, written by the Mainz pediatrician Hartmut M. Hanauske-Abel, MD, on the role of the German medical profession in the Third Reich and the suppression that followed after 1945.

A group of 400 doctors, at most, were culpable, and coming to terms with the past should not defame doctors collectively, Dr. Vilmar said in a statement chillingly reminiscent of declarations made by the Wehrmacht, which described itself as mainly “clean.”

Of course, the end of the Nazi regime was not the end of all barbarity, not even in Europe. “Violence will be something we have to confront in our future lives, too. Belief in the healing powers of civilization is nothing but a fairytale,” Berlin historian Jörg Barberowski wrote in a 2012 essay.

Nevertheless, as Michael Hallek, MD, from the University Hospital of Cologne, said, it is important to keep memory alive.

A version of this article first appeared on Medscape.com.

The German Society for Internal Medicine (DGIM) has announced it has withdrawn the honorary membership of five of its former members who were followers of the Nazi regime and perpetrators of atrocities between 1933 and 1945. The decision was made after the DGIM reappraised its own history during the Nazi period.

On the DGIM - Commemoration and Remembrance website, created in 2020, members who suffered under the Nazi regime are commemorated and those who committed crimes and caused suffering are called out.

The reappraisal began in 2012, when the DGIM commissioned two historians — Hans-Georg Hofer, PhD, from the University of Münster, and Ralf Forsbach, PhD, from the Institute for Ethics, History and Theory of Medicine at the University of Münster — to research the history of the society and its members during the periods of the National Socialism dictatorship and the young Federal Republic.

“Reappraising our own history, even at this late stage, is important and the right thing to do, although of course it cannot in any way make up for the suffering caused by individual DGIM members during that time,” Georg Ertl, MD, secretary general of the DGIM, states in a press release.

It is important, however, that the Society takes appropriate action in response to the historians’ findings, he adds.

The DGIM has done just that by retrospectively withdrawing the honorary membership status of five of its former members: Alfred Schittenhelm, Alfred Schwenkenbecher, Hans Dietlen, Siegfried Koller, and Georg Schaltenbrand.

“Out of opportunism or on the basis of Nazi beliefs, they intentionally harmed colleagues, other members of our Society, or simply other people on the basis of their ethnicity. Therefore, the DGIM can no longer accept them as honorary members,” said Markus M. Lerch, MD, chair of the DGIM and medical director of the Ludwig Maximilian University of Munich.

The board has also distanced itself from two other honorary members: Gustav von Bergmann and Felix Lommel. “More research is needed and we cannot currently make a responsible decision on withdrawal of honorary membership,” Dr. Lerch explained.

Early results from the historical reappraisal were presented to the public in 2015 at an exhibition held during the 121st DGIM Congress in Mannheim. The Society concurrently underwent a process of public self-reflection, stating that it was ashamed of having allowed 70 years to pass before it objectively examined its actions under National Socialism and acknowledged its responsibility.

The exhibition used photos, documents, and explanatory texts to show the actions, or lack of action, taken by some Society members during the Nazi regime. For example, it showed how then DGIM chair Alfred Schittenhelm — whose honorary membership has since been withdrawn — put the Society on the track to National Socialism. It also shone light on the role played by internists who consulted with the Wehrmacht in the treatment of Soviet prisoners of war and others, and on criminal experiments conducted on humans.

The exhibition also highlighted Jewish doctors who were persecuted and expelled, such as Leopold Lichtwitz, MD, who lost his position as clinic director in Berlin in 1933 and was forced to resign his chairmanship of the Society. And it presented portraits of members who loudly objected to and even actively resisted the regime, such as Wolfgang Seitz, MD, who became director of the Medical Outpatient Clinic at the University of Munich and deputy of the state parliament of the Social Democratic Party of Germany (SPD) in Bavaria after the war.

The historians focused on the years after 1945, because “1945 was no zero hour,” said Dr. Forsbach. Some culpable doctors continued to practice or became honorary DGIM members, he explained. The DGIM’s attitude toward history was characterized by suppression, denial, silence, and attempts at justification, consistent with the postwar attitude in the Federal Republic of Germany and in the medical profession as a whole.
 

After 1945

Behavior before 1945 is not the only source of shame. Crimes committed by doctors were never really confronted until the late 1970s, Jörg-Dietrich Hoppe, MD, former president of the German Medical Association, explained to ZEIT, a German newspaper, in 2011.

The psychoanalyst Alexander Mitscherlich, MD, and Fred Mielke were official observers from the German Commission of Physicians at the Nuremberg Doctors’ Trial who were made painfully aware that National Socialism was by no means over when the regime came to an end. They were both reviled as traitors to their country and for fouling their own nest, and, according to Mitscherlich, the behavior of the “authorities” bordered on character assassination.

As late as 1973, a renowned internist threatened that German internists would leave the room locked at the upcoming DGIM Congress if — as had been planned by congress chair Herbert Begemann — Mitscherlich gave a talk on this subject, journalist and doctor Renate Jäckle reported in her book on doctors and politics.

Even toward the end of the 1980s, Karsten Vilmar, MD, then president of the German Medical Association, reacted in an insensitive and defensive manner — during an interview — to an article in the Lancet, written by the Mainz pediatrician Hartmut M. Hanauske-Abel, MD, on the role of the German medical profession in the Third Reich and the suppression that followed after 1945.

A group of 400 doctors, at most, were culpable, and coming to terms with the past should not defame doctors collectively, Dr. Vilmar said in a statement chillingly reminiscent of declarations made by the Wehrmacht, which described itself as mainly “clean.”

Of course, the end of the Nazi regime was not the end of all barbarity, not even in Europe. “Violence will be something we have to confront in our future lives, too. Belief in the healing powers of civilization is nothing but a fairytale,” Berlin historian Jörg Barberowski wrote in a 2012 essay.

Nevertheless, as Michael Hallek, MD, from the University Hospital of Cologne, said, it is important to keep memory alive.

A version of this article first appeared on Medscape.com.

The German Society for Internal Medicine (DGIM) has announced it has withdrawn the honorary membership of five of its former members who were followers of the Nazi regime and perpetrators of atrocities between 1933 and 1945. The decision was made after the DGIM reappraised its own history during the Nazi period.

On the DGIM - Commemoration and Remembrance website, created in 2020, members who suffered under the Nazi regime are commemorated and those who committed crimes and caused suffering are called out.

The reappraisal began in 2012, when the DGIM commissioned two historians — Hans-Georg Hofer, PhD, from the University of Münster, and Ralf Forsbach, PhD, from the Institute for Ethics, History and Theory of Medicine at the University of Münster — to research the history of the society and its members during the periods of the National Socialism dictatorship and the young Federal Republic.

“Reappraising our own history, even at this late stage, is important and the right thing to do, although of course it cannot in any way make up for the suffering caused by individual DGIM members during that time,” Georg Ertl, MD, secretary general of the DGIM, states in a press release.

It is important, however, that the Society takes appropriate action in response to the historians’ findings, he adds.

The DGIM has done just that by retrospectively withdrawing the honorary membership status of five of its former members: Alfred Schittenhelm, Alfred Schwenkenbecher, Hans Dietlen, Siegfried Koller, and Georg Schaltenbrand.

“Out of opportunism or on the basis of Nazi beliefs, they intentionally harmed colleagues, other members of our Society, or simply other people on the basis of their ethnicity. Therefore, the DGIM can no longer accept them as honorary members,” said Markus M. Lerch, MD, chair of the DGIM and medical director of the Ludwig Maximilian University of Munich.

The board has also distanced itself from two other honorary members: Gustav von Bergmann and Felix Lommel. “More research is needed and we cannot currently make a responsible decision on withdrawal of honorary membership,” Dr. Lerch explained.

Early results from the historical reappraisal were presented to the public in 2015 at an exhibition held during the 121st DGIM Congress in Mannheim. The Society concurrently underwent a process of public self-reflection, stating that it was ashamed of having allowed 70 years to pass before it objectively examined its actions under National Socialism and acknowledged its responsibility.

The exhibition used photos, documents, and explanatory texts to show the actions, or lack of action, taken by some Society members during the Nazi regime. For example, it showed how then DGIM chair Alfred Schittenhelm — whose honorary membership has since been withdrawn — put the Society on the track to National Socialism. It also shone light on the role played by internists who consulted with the Wehrmacht in the treatment of Soviet prisoners of war and others, and on criminal experiments conducted on humans.

The exhibition also highlighted Jewish doctors who were persecuted and expelled, such as Leopold Lichtwitz, MD, who lost his position as clinic director in Berlin in 1933 and was forced to resign his chairmanship of the Society. And it presented portraits of members who loudly objected to and even actively resisted the regime, such as Wolfgang Seitz, MD, who became director of the Medical Outpatient Clinic at the University of Munich and deputy of the state parliament of the Social Democratic Party of Germany (SPD) in Bavaria after the war.

The historians focused on the years after 1945, because “1945 was no zero hour,” said Dr. Forsbach. Some culpable doctors continued to practice or became honorary DGIM members, he explained. The DGIM’s attitude toward history was characterized by suppression, denial, silence, and attempts at justification, consistent with the postwar attitude in the Federal Republic of Germany and in the medical profession as a whole.
 

After 1945

Behavior before 1945 is not the only source of shame. Crimes committed by doctors were never really confronted until the late 1970s, Jörg-Dietrich Hoppe, MD, former president of the German Medical Association, explained to ZEIT, a German newspaper, in 2011.

The psychoanalyst Alexander Mitscherlich, MD, and Fred Mielke were official observers from the German Commission of Physicians at the Nuremberg Doctors’ Trial who were made painfully aware that National Socialism was by no means over when the regime came to an end. They were both reviled as traitors to their country and for fouling their own nest, and, according to Mitscherlich, the behavior of the “authorities” bordered on character assassination.

As late as 1973, a renowned internist threatened that German internists would leave the room locked at the upcoming DGIM Congress if — as had been planned by congress chair Herbert Begemann — Mitscherlich gave a talk on this subject, journalist and doctor Renate Jäckle reported in her book on doctors and politics.

Even toward the end of the 1980s, Karsten Vilmar, MD, then president of the German Medical Association, reacted in an insensitive and defensive manner — during an interview — to an article in the Lancet, written by the Mainz pediatrician Hartmut M. Hanauske-Abel, MD, on the role of the German medical profession in the Third Reich and the suppression that followed after 1945.

A group of 400 doctors, at most, were culpable, and coming to terms with the past should not defame doctors collectively, Dr. Vilmar said in a statement chillingly reminiscent of declarations made by the Wehrmacht, which described itself as mainly “clean.”

Of course, the end of the Nazi regime was not the end of all barbarity, not even in Europe. “Violence will be something we have to confront in our future lives, too. Belief in the healing powers of civilization is nothing but a fairytale,” Berlin historian Jörg Barberowski wrote in a 2012 essay.

Nevertheless, as Michael Hallek, MD, from the University Hospital of Cologne, said, it is important to keep memory alive.

A version of this article first appeared on Medscape.com.