Mit dem Drachen nach Berlin...

Das ist fast wie Bootfahren auf dem Bodensee - mit einem 7,5 Tonner nach Berlin fahren...der Laster fuhr tatsächlich nicht mehr als 90 kmh...auf jeden Fall eine besondere Erfahrung der Entdeckung der Langsamkeit...nach 6 Stunden sind wir angekommen...Nebeneffekt - ich habe ab sofort mehr Verständnis für Brummifahrer...

Der Fisch aus Key West durfte auch mit...

Durch's winterliche Franken ging es über die A 9 nach Berlin...am Nuthetal-Kreuz haben wir uns dann auch prompt verfahren...über kleine Straßen dann doch noch das Ziel erreicht!

Ausladen - Hochtragen, besser: Hochschleppen! (dritter Stock!!)...

Das Berliner Pils schmeckt tatsächlich, fast wie in Franken!

Pizza-Stilleben...

1985 begann seine Reise in Boston...jetzt ist er in Berlin angekommen...

Dann - Alles Gute zum Neustart in Berlin liebe Anja!

Silvester...

Ich wünsche Allen einen "Guten Rutsch"...

Der Silvestergruß Guten Rutsch ist etymologisch möglicherweise eine Ableitung aus dem Jiddischen, bzw. Bibel-Hebräischen und leitet sich vom hebräischen ראש השנה טוב Rosch ha-Schana tov (= einen guten Anfang – wörtlich Kopf – des Jahres; also etwa: „Gutes Neujahr“) ab.
Ob dieser Ausdruck tatsächlich aus dem Jiddischen stammt, ist allerdings umstritten, da es weder im Hebräischen noch im Jiddischen eine Grußformel gibt, die dieses „Rosch“ beinhaltet (etwa „Guten Rosch ha-Schana“ o.ä.); die gängige Formel lautet: „Schana tova“ (=Hebr.) oder „a gut yor“ (=Jidd.).
Andere Auffassungen (Lutz Röhrich im Lexikon der sprichwörtlichen Redensarten; Heinz Küpper im Wörterbuch der Alltagssprache) leiten den Silvestergruß vom Gebrauch des Wortes „Rutsch“ für „Reise“ ab.

Der Vorname Silvester – von lateinisch silva, deutsch Wald – bedeutet übersetzt Waldmensch.
Die Feuer-Feste am Jahresende haben alte germanische Wurzeln. Das Jahresendfest hatten bereits die Römer gefeiert, erstmals im Januar zu Beginn des Jahres 153 v. Chr., als der Jahresbeginn vom 1. März auf den 1. Januar verschoben wurde.
Die Assoziation des Jahresendes mit dem Namen Silvester geht auf das Jahr 1582 zurück. Jetzt verlegte die Gregorianische Kalenderreform den letzten Tag des Jahres vom 24. Dezember auf den 31. Dezember, den Todestag des Papstes Silvester I. († 31. Dezember 335). Der Liturgische Kalender führt den Tag seit 813 auch als dessen Namenstag. Bis zur Kalenderreform feierte man an ihm die jüdische Beschneidung Jesu. In einigen Gegenden heisst der Tag, quasi als Gegenstück zum folgenden Neujahrstag, auch Altjahr, Altjahrsabend oder das Alte Jahr (vgl. das spanische nochevieja = „alte Nacht“).

Quelle: wikipedia.de

Büchertisch

1. Ein Sommer, der bleibt von Peter Kurzeck. Supposé Verlag, Berlin (Hörbuch)
2. Die Geschichte der Israelis und Palästinenser von Noah Flug/Martin Schäuble, C. Hanser
3. Hänsel und Gretel von Jacob und Wilhelm Grimm/Susanne Janssen (Ill.), Hinstorff Verlag
4. Gier. Wie wir ticken, wenn es ums Geld geht von Jason Zweig, Campus
5. Der Zweiklassenstaat. Wie die Priveligierten Deutschland ruinieren von Karl Lauterbach, Rowohlt
6. Die Lehrjahre des Duddy Kravitz von Mordecai Richler, Liebeskind Verlag
7. Stuffed and Starved: Markets, Power and the Hidden Battle for the World's Food System von Raj Patel, Portobello Books (2007) Pp 352. £16·99. ISBN 1-84627-010-9
8. Homers Heimat - Der Kampf um Troia und seine realen Hintergründe von Raoul Schrott, Hanser
9. Cherubinischer Wandersmann von Angelus Silesius, Louise Gnädinger, Reclam
10. Geschichte eines Deutschen von Sebastian Haffner, dtv
11. Die Geschichte der Juden in Deutschland von Arno Herzig, Cay Rademacher, Ellert & Richter
12. Der Webstuhl der Zeit - Warum es die Welt gibt von Peter Eisenhardt, Rowohlt
13. Franziskus von Assisi und seine Bewegung von Helmut Feld, Wissenschaftliche Buchgesellschaft
14. Linden-Bibel von Michel Brunner, Haupt Verlag
15. Die Knoppschachtel. Neue und alte Gedichte in Frankfurter Mundart, von Ferdinand Happ, Kramer Verlag
16. Paul Cezanne - Ein Leben für die Malerei von Angela Wenzel, Prestel

Sie denken zu viel...

Was halten unsere Nachbarn vom deutschen Humor? Ein Gespräch mit der französischen Publizistin Pascale Hugues und Roger Boyes, dem Deutschland-Korrespondenten der Londoner "Times"

DIE ZEIT: Erzählen Sie doch mal Ihren deutschen Lieblingswitz.
Roger Boyes: Oh Gott! Ich sammle keine Witze, allenfalls Berliner Schnauze. Neulich stieg ein Tourist in den Bus und wusste nicht, was er mit dem Fahrschein tun musste. Der Fahrer sagte: Na, wat wohl? Soll ick reinbeißen oder wat? Ein typisch defensiver Humor.
Pascale Hugues: Mir fällt einer ein, den allerdings eine Schweizer Freundin erzählt hat. Ein Paar im Ehebett wacht auf, sie sagt: Ich hatte einen Albtraum, ich war bei Aldi und wollte alles in den Einkaufswagen packen, es ging nicht. Und was hast du geträumt? Sagt der Mann: Ich war mit zwei Frauen im Bett, beide wunderschön, sexy. Sie: War ich auch dabei? Er: Nein, du warst doch bei Aldi.
....
DIE ZEIT Nr 1 27. Dezember 2007, Seite 57

Ein Hamburger als afghanischer Fußballheld

Hamburg - In Afghanistan ist Obaidullah Karimi ein Held, in Deutschland nur Kennern des Hamburger Amateur-Fußballs ein Begriff.


Der 27-Jährige vom Verbandsligisten Eintracht Norderstedt schoss sich Ende Oktober mit seinem Treffer gegen Syrien in die Geschichtsbücher des afghanischen Fußballs - und in die Herzen seiner Landsleute. Denn sein Tor bei der 1:2-Niederlage war der erste Treffer Afghanistans in der WM-Qualifikation. «Es macht mich glücklich und stolz, dass ich diese Freude schenken konnte», sagt Karimi.
Unmittelbar nach seinem Linksschuss war dem Außenstürmer noch nicht klar, dass von nun an jedes fußballbegeisterte Kind in seinem Heimatland seinen Namen kennt. Erst der Referee sorgte für Aufklärung. «Auch ich werde jetzt in die Geschichtsbücher eingehen, weil ich das Spiel gepfiffen habe, in dem Afghanistan das erste WM-Quali-Tor erzielt hat, sagte der Schiedsrichter zu mir», erzählt Karimi. Ob sich das Leben seitdem verändert hat? «Keinesfalls, ich muss weiterhin arbeiten», sagt der Lastwagenhändler lachend. Seine Freundin Claudia, mit der er seit einem Jahr zusammen ist, unterbricht: «Seither hat er ganz viele weibliche Fans».
Danach sah es allerdings lange Zeit nicht aus. «Als ich 1990 mit meiner Mutter nach Hamburg kam, lachten mich die Mitschüler aus, weil ich nicht kicken konnte», erinnert sich Karimi. Doch bereits bei seiner ersten Station SC Hamm 02 wurde er in der D-Jugend Torschützenkönig. Anschließend nahm seine Karriere Fahrt auf: Über die Jugendmannschaft des Hamburger SV bekam er als 18-Jähriger einen Vertrag beim Oberligisten Vorwärts Wacker. Als dann ein Angebot des 1. FC Köln II vorlag, zerstörten vier Mittelfußbrüche seine Träume.
Umso mehr kostet Karimi heute seine Glückssträhne aus, ohne dabei die Bodenhaftung zu verlieren. Jede Einladung zur Nationalmannschaft ist für ihn Ehrensache. «Selbstverständlich gebe ich alles für mein Land, insbesondere wenn ich das Leid in Afghanistan sehe», sagt er. Fünf Länderspiele hat er bislang bestritten - für ihn jedes Mal ein tolles Erlebnis: «Dort spielst du vor 30 000 bis 50 000 Zuschauern, in der Verbandsliga vor 400 bis 500.» Eines hat sich seit dem 26. Oktober aber auch in Hamburg verändert: Seit seinem Tor schwenken die Eintracht-Fans bei jedem Heimspiel die afghanische Flagge.
In Deutschland hat Karimi jedoch auch mit Vorurteilen zu kämpfen. «Das ist ein so gebildetes Land. Und trotzdem werden mir unreflektierte Fragen gestellt: Bist Du auch ein Taliban?», sagt Karimi. Dass das Reisen zwischen den Ländern nicht immer einfach ist, gibt der Konstruktionsmechaniker zu. «In Afghanistan kennen dich alle, wollen Fotos und Autogramme mit und von dir. In Berlin und Frankfurt am Flughafen wirst du von oben bis unten durchsucht, wenn sie sich meine Herkunft anschauen und Kabul lesen», sagt Karimi, der sich mehr als Europäer denn als Afghane fühlt.
Die schwierige Situation in seiner Heimat macht ihm zu schaffen. «Kultur, Bildung, Infrastruktur - es gibt zahlreiche Baustellen.» Zumindest sportlich sind Fortschritte zu verzeichnen, Fußball ist führender Nationalsport. Zwischen 1984 und 2002 war die Sportart unter den Taliban verboten, sogar Menschen wurden zu jener Zeit auf den Spielfeldern hingerichtet. Karimi: «Unverständlich, dass darauf heute gespielt wird. Dort müssten Gedenkstätten errichtet werden.»

Quelle: fussball.com

Responding to HIV in Afghanistan

Impoverished and war-torn Afghanistan is now facing an epidemic of HIV infection owing to its increasing numbers of injecting drug users, many of whom have returned from refugee settings in Pakistan and Iran. Other vulnerable groups are also at high risk of HIV infection. As a low-prevalence but high-risk country, Afghanistan's national authorities recognise HIV control as a major priority. The country is adopting a public-health approach that includes harm reduction to reduce the spread of HIV among injecting drug users. Although the financial costs of HIV prevention will be substantial, the costs of failing to control HIV and AIDS will be far greater. Early and decisive action is crucial for containing HIV infection.

Afghanistan is one of the poorest countries in the world, with a yearly income per head estimated at $US300 in 2005.1 After nearly three decades of war and 5 years of drought, the population's health, social, and economic conditions have declined greatly. Life expectancy at birth is only 43 years, and maternal and child mortality remains among the highest in the world. The literacy rate in the general population is very low (28%), especially for women (13%).[2] and [3] The government, installed after the military intervention that began in 2001, now controls most of the country, with continuing major US and NATO military support. However, anti-government forces have made some advances in recent years, especially in the southern provinces bordering Pakistan, where 70% of the country's opium is cultivated.

Only recently has Afghanistan had to face the problem of HIV and AIDS. The Ministry of Public Heath reported a total of 69 cases of HIV infection in Afghanistan in late January, 2007, based on data from the Kabul blood bank and an HIV seroprevalence survey of injecting drug users in Kabul. Only a few months later (August, 2007), the government reported 245 cases of HIV infection in Afghanistan, although the actual number is likely to be much higher. Injecting drug use has ignited HIV epidemics in many central, east, and south Asian countries. As seen in these neighbouring countries,4 the epidemic in Afghanistan has the potential to grow quickly from a small base of injecting drug users and their partners. In countries with a concentrated HIV epidemic dominated by injecting drug users, a previous modelling study5 indicated a substantial risk of extensive spread to heterosexual men and women unless effective, vigorous, and sustained action is started early.

Almost all the known cases of HIV infection in Afghanistan today are due to injecting drug use. The sharing of contaminated injecting equipment is thought to confer the greatest risk of contracting HIV compared with other risk factors. Although the dominant routes of drug use in Afghanistan have previously been oral and inhalation, injecting practices are becoming increasingly prevalent. About 8 million Afghans fled to neighbouring countries, especially Pakistan and Iran, during the recent decades of conflict. Some began using, and injecting, heroin during their difficult years as refugees. HIV has spread rapidly among injecting drug users in Pakistan and Iran. In Quetta, a town in Pakistan bordering Afghanistan, for example, a 24% prevalence of HIV infection has been reported in a cluster of injecting drug users.[6] and [7] These data have increased the fears of an epidemic in Afghanistan, since an estimated 5·7 million Afghans have returned home in the past few years.

A recent study of 464 injecting drug users in Kabul showed an HIV prevalence rate of 3% and highlighted the extremely high risk of the spread of the disease among injecting drug users and their partners, and to the general population.8 An earlier study of the same population showed that high-risk behaviours were very common: 35% had ever shared syringes; 76% had ever paid for sex with a woman; 27% of men had ever had sex with men; 23% had received so-called therapeutic injections in the previous 6 months; 4% had ever been paid for donating blood; and 35% had injected drugs in prison.9 The four viral samples assessed in the study had the same genome sequences previously identified in injecting drug users in Iran, where HIV prevalence is known to be much higher than Afghanistan. Moreover, the prevalence of hepatitis C—also predominantly spread by the sharing of injecting equipment—was already 37%, which indicates the very high risk of spread of blood-borne viruses in this population.

Production of opium in Afghanistan has reached record levels in 2007, with the estimated amount produced reaching 8200 metric tonnes, an increase from the previous year of 34%, and amounting to 93% of the world's supply.[10], [11] and [12] The 2006 opium crop was estimated to have provided $3·1 billion to Afghanistan, representing 46% of the licit economy (excluding opium cultivation and drug trafficking) or 32% of the entire national economy.11 Whereas almost all of the opium and heroin produced in the country was previously exported, 2% of the output is now believed to be consumed locally. Since production is now believed to exceed worldwide demand by a vast margin, large quantities are probably being stockpiled.10
A 2005 survey estimated that Afghanistan has almost 1 million drug users including 200 000 opium users and 19 000 injecting users, of whom 12 000 inject prescription drugs and 7000 inject heroin.13 A 2006 survey in Kabul estimated that several categories of drug use had increased by more than 200% in 12 months. Most drug users were men but the proportion of women using prescription drugs was high, probably indicating the very difficult living conditions for many Afghan women. As the overall drug problem in Afghanistan continues to receive international attention, aggressive counter-narcotic efforts focus largely on supply reduction. A proposal to eradicate opium poppy cultivation by use of aerial herbicides and other chemicals is being debated. However, there is a real danger that more vigorous counter-narcotics policies are not without risk of exacerbating a transition from smoking or eating opium to injecting heroin, with subsequent risk of increased HIV infection associated with injecting drug use. The complexity of the problem is also highlighted by the risk that more vigorous counter-narcotics policies could undermine counter-insurgency efforts, which might also weaken efforts to control HIV infection. Opium eradication might predominantly affect poorer farmers. Opium cultivation generates an estimated 36 million days of farm labour and is deeply entrenched in the rural economy.

As in many other traditional and deeply religious countries, estimation of the scale of HIV spread associated with sex workers or men who have sex with men is difficult in Afghanistan. Local opinion varies as to the importance of these factors. Ex-inmates report that a substantial amount of drug injection occurs in Afghan prisons, a situation also reported in many other countries. Vulnerable groups potentially at risk of HIV infection include long-distance truck drivers and their helpers, the many women who have lost husbands or provide care for severely disabled husbands or sons, and the many abandoned children. Only a small proportion of transfused blood or blood products is currently tested for HIV, which will be of increasing concern as HIV prevalence rises. There is much re-use of injecting equipment and other medical equipment in the formal and informal health-care sectors, although there is little documentation about the extent and distribution of this practice.

Averting large numbers of HIV infections through harm reduction programmes will not only save lives but also makes sound development policy, even for a resource-constrained country such as Afghanistan. Because much HIV-related mortality occurs in adults in their productive age, the short-term and medium-term economic consequences for infected individuals, partners, and households are severe.[14] and [15] Although application of estimates from other regions and countries to the Afghan context is difficult, prevailing urban wages and health-care expenditure patterns in Afghanistan,[16] and [17] combined with standard mortality estimates by duration since infection,18 suggest that even if Afghanistan and international donors spend up to $2000 per HIV infection averted, the total economic returns (both private and public) on such an investment would be large—possibly as high as 300% per infection averted. This estimated return takes into account only the costs of wages foregone and of health and home care. The economic benefits would presumably be even higher if the subsequent detrimental outcomes to children and others in a household that suffers an HIV-related death are also included.

Control of HIV infection is a development priority in Afghanistan, in view of the links between poverty, drugs, and HIV. One of the pillars of the Interim Afghanistan National Development Strategy is to improve the wellbeing of the poor through social protection, counter-narcotics initiatives, and keeping HIV prevalence in the general population below 0·5%. The Millennium Development Goals for Afghanistan include halting and reversing the spread of HIV infection by 2020 and increasing substantially the proportion of injecting drug users in treatment by 2015.19 A national plan of operation to achieve these objectives has been prepared through a broad consultative process. To ensure the protection and rights of vulnerable populations at greatest risk of HIV infection, the Ministry of Public Health has drafted a code of ethics to be widely endorsed.20 Additionally, a national policy of harm reduction jointly prepared by the Ministries of Counter Narcotics and Public Health has been adopted, providing a sound framework for effective interventions to break HIV transmission for injecting drug users and their partners. Most importantly, best practices in HIV prevention in injecting drug users, including harm reduction, are being implemented by local non-governmental organisations and community-based organisations, providing successful local models for scaling up.[21] and [22]
A comprehensive approach to HIV prevention for injecting drug users is required. It includes communication, such as peer education and counselling, provision of the means for behaviour change (sterile needles, syringes, and condoms), substitution treatment (such as methadone or buprenorphine), and provision of effective outreach through drop-in centres. Special subpopulations (such as prison inmates) have to be adequately reached by these interventions.
A national policy decision will have to be made soon on substitution treatment. Some believe that methadone and buprenorphine are inappropriate for resource-constrained settings such as Afghanistan. Certainly, these interventions are too expensive to offer the large proportion of the 200 000 opium smokers and eaters who seek help. Many decades ago, opium registration systems in countries in west and south Asia were an inexpensive response to a widely prevalent problem before falling into disfavour. Although probably difficult to reintroduce in the present international environment, some form of carefully regulated opium dispensing could still be an option in this context. Afghanistan will pilot options to assess the most feasible, cost effective, and locally appropriate way to provide substitution treatment to its large drug-dependent population, who are mostly young people.

Afghanistan has much in common with the culture, language, and religion of neighbouring Iran, where injecting drug use is also the major driver of the HIV epidemic. Pragmatic responses to the control of HIV transmission among injecting drug users have received strong support in Iran, and there are encouraging indications that the Afghan government and religious authorities might also support these interventions. For example, triangular clinics, which provide harm reduction services to injecting drug users, treatment of sexually transmitted diseases, and care and support for people living with HIV and AIDS, are being implemented in Iran.22

Although interventions targeting injecting drug users and their partners are the first priority in responding to the threat of HIV in Afghanistan, comprehensive packages of preventive interventions are also needed for other vulnerable groups at high risk. Selling and buying sex, unprotected sex between men, and migration are all risk factors, especially where they intersect with injecting drug use. Raising awareness and advocacy efforts to build stronger political commitment, communication activities aimed at reducing stigma and improving knowledge among the general population, and capacity-building to ensure sustained and effective implementation are other government priorities.

Afghanistan is now deciding on its national response to the HIV epidemic. HIV prevention and AIDS treatment are not affordable for the Afghans and will require substantial external financial support (currently over half of the Afghan national budget is financed by external donors). France has already committed support to secure a safer blood supply, and the United Nations Population Fund will support HIV prevention for sex workers. A national implementation plan has been agreed on for World Bank support for surveillance, targeted interventions for vulnerable groups at high risk, communications and advocacy, and building programme management capacity.23 An application to the seventh round of the Global Fund to fight AIDS, Tuberculosis and Malaria has been approved. However, money alone will not be enough. Afghanistan will also need substantial technical assistance to support its HIV prevention priorities because of serious capacity constraints. Despite the very difficult local conditions, Afghanistan has several dedicated national and international non-governmental organisations and community-based organisations in almost all the provinces and most districts, and substantial progress has been made in reaching remote areas with basic health services.24 The developed world has, in the past, failed to fulfil many generous promises to Afghanistan. This time, promises made will have to be kept.


References
1 International Monetary Fund, World economic outlook database (September 2006) (accessed April 4, 2007)..
2 Central Intelligence Agency, The world fact book Afghanistan
3 UNICEF, Afghanistan statistics (accessed Oct 1, 2007)
4 S Moses, J Blanchard and H Kang et al., AIDS in South Asia: understanding and responding to a heterogeneous epidemic, World Bank, Washington DC (2006).
5 TJ Saidel, D Des Jarlais, W Peerapatanapokin, J Dorabjee, S Singh and T Brown, Potential impact of HIV among IDUs on heterosexual transmission in Asian settings: scenarios from the Asian epidemic model, Int J Drug Policy 14 (2003), pp. 63–74.
6 TJ Saidel, D Des Jarlais, W Peerapatanapokin, J Dorabjee, S Singh and T Brown, High HCV seroprevalence and HIV drug use risk behaviors among injection drug users in Pakistan, Harm Reduction J 3 (2006), p. 26.
7 M Kassi, HIV in injecting drug users of Quetta, Pakistan: reporting another outbreak (accessed Oct 1, 2007)..
8 CS Todd, AMS Abed and SA Strathdee et al., HIV, hepatitis C, and hepatitis B infections and associated risk behavior in injection drug users, Kabul, Afghanistan, Emerging Infect Dis (2007)
9 Todd CS, Abed A, Strathdee S, Botros A, Safi N, Earhart KC. Prevalence of HIV, viral hepatitis, syphilis, and risk behaviors among injecting drug users in Kabul, Afghanistan [abstract TUAC0304]. Toronto: 16th International AIDS Conference, 2006.
10 United Nations Office of Drugs and Crimes and the Government of Afghanistan, Ministry of Counter Narcotics, Kabul, Afghanistan Opium Survey 2007
11 United Nations Office of Drugs and Crime and the Government of Afghanistan, Ministry of Counter Narcotics, Afghanistan Opium Survey
12 United Nations Office on Drugs and Crime, and The World Bank, Afghanistan's drug industry. Structure, functioning, dynamics, and implications for counter-narcotics policy
13 United Nations Office on Drugs and Crime, Government of Afghanistan Ministry of Counter Narcotics. Afghanistan drug use survey 2005
14 S Bertozzi, N Padian and J Wegbreit et al., HIV/AIDS prevention and treatment. Disease control priorities in developing countries (2nd edn), Oxford University Press, New York (2006), pp. 331–370.
15 A Mills and S Shilcutt, Challenge paper on communicable diseases. Copenhagen Consensus Challenge Paper (accessed July 2, 2007)..
16 J Beall and S Schütte, Urban livelihoods in Afghanistan. Synthesis Paper Series, Afghanistan Research and Evaluation Unit
17 2004 Afghan National Health Services Performance Assessment. Health seeking behavior, health expenditures, and cost sharing practices in Afghanistan. Kabul: Johns Hopkins University Third-Party Evaluation Team and Afghanistan Ministry of Public Health, Policy and Planning Division, 2006.
18 B Zaba, A Whiteside and T Boerma, Demographic and socioeconomic impact of AIDS: taking stock of the empirical evidence, AIDS 18 (suppl 2) (2004), pp. S1–S7.
19 Afghanistan Country Management Unit, South Asia Region, World Bank, Interim strategy note for the Islamic Republic of Afghanistan
20 HIV and AIDS Coordinating Committee, National AIDS Control Program, DG Preventive Medicine and Primary Health Care, Afghanistan national HIV code of ethics (draft), Ministry of Public Health, Kabul (2007).
21 M Atanasijevic, MDM harm reduction (needle exchange) program in Kabul, Afghanistan, Inter-Country Consultation on Prevention of HIV among IDUs, Kolkata, India (April 9–13, 2007).
22 E Razzaghi, B Nassirimanesh, P Afshar, K Ohiri, M Claeson and R Power, HIV/AIDS harm reduction in Iran, Lancet 368 (2006), pp. 434–435.
23 World Bank, Afghanistan HIV/AIDS prevention project
24 Waldman R, Strong L, Wali A. Afghanistan's health system since 2001: condition improved, prognosis cautiously optimistic. Afghanistan Research and Evaluation Unit, Briefing Paper Series, December, 2006.

Saif-ur-Rehman, Mohammad Zafar Rasoul, Alex Wodak, Mariam Claeson , Jed Friedman and Ghulam Dastagir Sayed
The Lancet, Volume 370, Issue 9605, Pages 2167-2169

Correspondence to: Mariam Claeson, AIDS South Asia Region, World Bank, Washington, DC, USA

Lieber den Tod...

... als diesen Gemahl....
Am Hindukusch werden nicht selten Mädchen im Kindesalter an alte Männer verkauft

Qayyum ist nicht wiederzuerkennen. Der Tadschike, etwa Mitte vierzig, war der lebenslustigste aller "Driver" des Hotels Interconti. Bei einer Reise ins südostafghanische Chost erzählte er von seinen Liebschaften mit dem weiblichen Personal des Hotels. Jetzt sitzt Qayyum niedergeschlagen hinter dem Lenkrad seines Toyotas. "Ach, mein Herz ist gebrochen. Meine Tochter ist vor einem Monat in unserer Küche verbrannt. Sie war 14 Jahre alt." Wie das? "Sie hat Petroleum ins Feuer gegossen, und die Flammen erfassten ihr Haar und dann das Kleid." Eine Woche sei das Mädchen im Krankenhaus in Kabul gewesen. Aber die Ärzte hätten sie abgeschrieben. "Ich packte sie in das Auto und fuhr nach Peshawar. Dort soll es bessere Ärzte geben, haben die Leute gesagt. Doch nach einigen Tagen starb sie." Tränen laufen Qayyum über die lederne Haut.
"Das war kein Unfall, das weiß jeder hier", flüstert Akram, der älteste Fahrer des Interconti. Das Mädchen habe sich selbst verbrannt. "Allah möge ihr verzeihen." Die Geschichte bestätigt auch der Sicherheitschef des Hotels, Abidullah. Mit Mitgefühl, aber auch einer Spur Häme erzählt Akram, dass Qayyum verschuldet gewesen sei. Er habe sein Auto mit geliehenem Geld gekauft. Und in letzter Zeit war das Hotel fast leer. "Vor einigen Monaten kam ein reicher, weißbärtiger Mann um die 70 Jahre aus Bakram, ein ferner Verwandter von Qayyum, und bat um die Hand seiner Tochter", erzählt Akram. Qayyum, von den Gläubigern bedrängt, habe zugesagt. Einmal, fährt Akram fort, sei Qayyum mit seiner Tochter und seiner Frau nach Bakram gefahren. Dort habe das Mädchen das erste Mal den Mann gesehen, mit dem sie ihr Leben verbringen sollte. "Der Alte hatte keine Zähne. Das Mädchen wollte lieber sterben als diesen Mann heiraten." Wenn du dich weigerst, soll der Vater gesagt haben, werden wir alle hungern. Was hätte Qayyum bekommen, wenn die Geschichte nicht schiefgegangen wäre? Akram rechnet eine Weile und sagt schließlich: zehn- bis zwölftausend Dollar. Er lacht: "Das Mädchen soll hübsch gewesen sein."
Qayyums Tochter ist kein Einzelfall. Der Verkauf von Mädchen im Kindesalter an ältere Männer ist am Hindukusch gang und gäbe. Er kann armen Bauersfamilien helfen, ein mageres Jahr zu überstehen. In den Dörfern fügen sich die Mädchen zumeist in ihr Schicksal. Mit zehn oder elf Jahren wissen sie nicht, was sie erwartet. In ihrem neuen Zuhause müssen sie schuften, werden von ihrem Ehemann missbraucht und bringen Kinder auf die Welt.
Nach dem Sturz der Taliban hofften die Frauen auf eine bessere Zukunft. Sie durften wieder arbeiten. Die Tore der Mädchenschulen öffneten sich. Zum ersten Mal in der afghanischen Geschichte saßen Frauen in der Loya Jirga, der Ratsversammlung. Ihre bisweilen leidenschaftlichen Reden sorgen immer wieder für Tumulte. Es gibt Staatssekretärinnen und sogar eine Gouverneurin, bei der die Isaf-Generäle vorsprechen. Doch für das Gros der afghanischen Frauen hat sich nichts geändert. Die Bräuche der Stammesgesellschaft am Hindukusch sind zählebig.


Text: Frankfurter Allgemeine Sonntagszeitung, 23.12.2007, Nr. 51 / Seite 2

Der Tanz um's goldene Kalb...

Der Frankfurter Fußballpfarrer Eugen Eckert...

Erinnert Sie das millionenschwere Spektakel um den Fußball an den biblischen Tanz um das Goldene Kalb?
Manchmal schon...

FAS, 23. Dezember 2007, Nr51, Seite 16

Schlaf ist die beste Medizin

BMJ 2007;335:1216 (8 December), doi:10.1136/bmj.39419.464063.59
Sleep is the best medicine
Colin Martin, independent consultant in healthcare communication, London
Cmpubrel@aol.com
Colin Martin visits an exhibition that explores the biomedical and neurological processes that occur during the third of our lives when we are asleep

"Good sleep is as important as diet or exercise in keeping us happy and healthy," says Professor Kevin Morgan, director of the insomnia research programme at Loughborough University’s sleep research centre and participant in a forthcoming symposium in association with Sleeping and Dreaming, an exhibition at the Wellcome Collection in London. First shown at the Deutsches Hygiene-Museum in Dresden, the exhibition encourages visitors to explore the biomedical and neurological processes that occur during the third of our lives when we are asleep, and the social and cultural aspects of sleep and dreams.

Five major themes are developed using 250 objects, drawn from science, art, and social history collections, displayed in a dark, dramatically lit rectangular space. Smaller rooms, opening off the central space, cover subsidiary themes in greater depth. Because of the choices provided, no two visitors are likely to have identical experiences, in much the same way that their dreams differ, even though their lives might be similar. Designed as a labyrinthine sequence, the exhibition’s form mimics many unknown aspects of its content.
The "Dead Tired" section explores sleep deprivation, including attempts on the world record for staying awake. It is held by American student Randy Gardner, who clocked up 264 sleepless hours over the new year of 1963-4, breaking the previous record of 201 hours, set by American disc jockey Peter Tripp in 1959. Both men experienced hallucinations and became grumpy; however, unlike Tripp, Gardner did not take any stimulants, claiming his feat was "just mind over matter." My poor performance, on a "Test your tiredness" computer programme designed to evaluate attentiveness, was attributable to jet lag, as I had flown from Melbourne to London less than 24 hours before. This section covers other states of consciousness between wakefulness and sleep, such as hypnosis, fainting, and anaesthesia.
"A World Without Sleep?" examines how artificial lighting changed our sleeping habits and work patterns. It documents experiments, including US scientists Nathaniel Kleitman and Bruce Richardson’s investigation of whether the 24 hour cycle of sleep and wakefulness could be influenced by changes in light or temperature, undertaken in a Kentucky cave over 33 days in 1938. Richardson adjusted his body to a rhythm of 28 hours (nine hours asleep, 19 hours awake); Kleitman, however, did not.
Dedicating rooms solely to sleeping is a relatively new phenomenon, which is explored in "Elusive Sleep." Theo Frey’s black and white photographs, of a young girl receiving a bed for herself in 1955, following the Swiss Red Cross’s campaign to improve children’s sleeping conditions, exemplify social and cultural changes associated with sleeping. There’s also an instance of life imitating art. What at first glance appears to be a photograph of German performance artist Joseph Beuys wearing his trademark felt hat, carrying a mattress on his back through an alpine landscape, is actually Frey’s photograph of a farmer taking his bed with him to ensure that he would get a good night’s sleep while his livestock grazed their summer pastures.
"Dream Worlds" looks at how artists derive creative ideas from nocturnal inspiration. For several years Jane Gifford’s work has been exclusively concerned with dreams and ways of recording and perceiving them. Dream Paintings 2004 records 144 dreams she had that year, in a series of small paintings hung together as a grid, with text describing the dream depicted. Rodney Graham’s film Halcion Sleep 1994 shows the artist, clad in striped pyjamas and fast asleep on the back seat of a car, being driven through Vancouver after having taken a Halcion (triazolam) sleeping pill. Images of the urban landscape appear dreamlike in the car’s rear window, even though what the artist dreamt is unknown.
The exhibition is complemented by a book of essays on sleeping and dreaming, edited by Nadine Käthe Monem, with a wide ranging selection of literary excerpts and quotes chosen by Hugh Aldersey-Williams, including "Sleep is the best medicine," an English proverb that says much about our belief in its restorative power in five simple words.

Sleeping and Dreaming
An exhibition at the Wellcome Collection, London NW1, until 9 March 2008
http://www.wellcomecollection.org/

Rigour, respect and responsibility...Nicht nur für Wissenschaftler...

A universal ethical code for scientists

This is a public statement of the values and responsibilities of scientists. They are intended to include anyone whose work uses scientific methods, including social, natural, medical and veterinary sciences, engineering and mathematics. It aims to foster ethical research, to encourage active reflection among scientists on the wider implications and impacts of their work, and to support constructive communication between scientists and the public on complex and challenging issues.Individuals and institutions are encouraged to adopt and promote these guidelines. It is meant to capture a small number of broad principles that are shared across disciplinary and institutional boundaries. They are not intended to replace codes of conduct or ethics relating to specific professions or areas of research.

Rigour, respect and responsibility: A universal ethical code for scientistsRigour, honesty and integrity
Act with skill and care in all scientific work. Maintain up to date skills and assist their development in others.
Take steps to prevent corrupt practices and professional misconduct. Declare conflicts of interest.
Be alert to the ways in which research derives from and affects the work of other people, and respect the rights and reputations of others.

Respect for life, the law and the public good
Ensure that your work is lawful and justified.
Minimise and justify any adverse effect your work may have on people, animals and the natural environment.

Responsible communication: listening and informing
Seek to discuss the issues that science raises for society. Listen to the aspirations and concerns of others.
Do not knowingly mislead, or allow others to be misled, about scientific matters. Present and review scientific evidence, theory or interpretation honestly and accurately.

Commentary
There are already powerful incentives for individuals and for institutions to adhere to the principles set out in these guidelines. These include: the high professional and ethical standards upheld by the scientific community; structures put in place by employers, professional bodies and funders to enforce these standards; and national and international conventions, treaties and laws.Scientists and institutions are encouraged to reflect on and debate how these guidelines may relate to their own work. For example, acting with rigour, honesty and integrity may include: not committing plagiarism or condoning acts of plagiarism by others; ensuring that work is peer reviewed before it is disseminated; reviewing the work of others fairly; ensuring that primary data that may be needed to allow others to audit, repeat or build on work, are secured and stored. Similarly, in communicating responsibly, scientists need to make clear the assumptions, qualifications or caveats underpinning their arguments.

“Rigour, respect and responsibility” are the key concepts in a universal ethical code for scientists put forward by Sir David King, Chief Scientific Adviser to the UK Government, at a talk at Imperial College, London, UK, on March 13. The new code aims to raise awareness of ethical issues in research among scientists and the public, and support the development of more detailed discipline-specific principles. According to the code, scientists should accurately and honestly present scientific evidence, declare conflicts of interest, and prevent professional misconduct. Most importantly, perhaps, the code stresses the importance of minimising adverse events in research, and the need for justification in exposing people to such risks.

Großes Stadtgeläut

Das Große Frankfurter Stadtgeläute ist die harmonische Abstimmung aller 50 Glocken von zehn Kirchen in der Innenstadt von Frankfurt am Main, traditionelle Termine für das Stadtgeläute, entsprechend den Hochfesten des Kirchenjahres, sind
am Samstag vor dem Ersten Advent um 16:30 Uhr
am Heiligen Abend um 17:00 Uhr
am Samstag vor Osterns (Karsamstag) um 16:30 Uhr
am Samstag vor Pfingsten um 16:30 Uhr.
Auch in der Neujahrsnacht läuten um Mitternacht alle Glocken für eine Viertelstunde.Das erste überlieferte Gesamtgeläute fand am 28. und 29. Oktober 1347 zu Ehren des verstorbenen Kaisers Ludwig des Bayern statt. Bei den Kaiserwahlen gehörte das Stadtgeläute zum traditionellen Eröffnungszeremoniell, wenn die Kurfürsten gemeinsam vom Römer zur Wahlkapelle in der Bartholomäuskirche (=Dom) schritten.

Spaziergang am Heiligen Abend über den Eisernen Steg zum Römer - Bilder

Die bedeutendsten Werke der Weltliteratur...

1. Die Bibel
2. Die Ilias und die Odyssee
3. Sophokles' "König Ödipus" und "Antigone"
4. Dantes "Göttliche Komödie"
5. Shakespeares Tragödien
6. Goethes "Faust"
7. Tolstois "Krieg und Frieden"
8. Dostojewskijs "Die Brüder Karamasow"

MRR ind der FAS , 23. Dezember 2007, Nr 51, Seite 27

Robert Gernhardt: Geständnis

Ihr fragt nach meinem Lieblingssport?
Nun gut, es ist der Mord.
Ja, ich sag's laut, ich morde gern,
besonders, wenn es heiß ist,
und wenn das Wasser in dem See
so klar und kalt wie Eis ist.
Dann zieh ich die Kleider aus
Und springe in die Wellen,
um dort mit Karpfen, Barsch und Aal
durchs kühle Naß zu schnellen.
Ja, Bürger, lache nur getrost
Und bleib in deinem Bette -
Ich morde derweil frisch und froh
Mit Fischen um die Wette.
Wie? Was?
Ich hör' ein Widerwort?
Der Sport heißt Schwimmen?
Und nicht Mord?
Wie war das noch mal?
Schwimmen?
Moment - ihr seht mich sehr verwirrt...
Mein Gott - vielleicht hab' ich geirrt...
Doch - Schwimmen könnte stimmen.

FAS, 23 Dezember 2007, Nr 11, Seite 18

4. Advent

Die Liebe in den Zeiten der Cholera...

Garcia Marquez "Liebe in den Zeiten der Cholera" ist verfilmt worden...eine kritische Besprechung aus dem Lancet - Love conquers Ageing by Anne Hudson Jones, The lancet, Volume 370, Isuue 9605, Pages 2091-2092

Love in the Time of Cholera
Directed by Mike Newell, produced by Scott Steindorff, screenplay by Ronald Harwood, based on the novel by Gabriel García Márquez. New Line Cinema, 2007.
Now on general release in the USA and showing in the UK from March 21, 2008.

The film version of Love in the Time of Cholera simplifies and smooths out the complexity and unruliness of Gabriel García Márquez´ great novel. In so doing, screenwriter Ronald Harwood (The Pianist) and British director Mike Newell (Four Weddings and a Funeral and Harry Potter and the Goblet of Fire) have created a visually beautiful work that has lost much of the power of the original. García Márquez´ novel has much of interest and value to say about the difficulties of ageing, the challenges of bringing European medicine into late 19th-century Colombia, and the failure of western rationalism and scientism in face of the fecund life and imagination of the New World. Unfortunately, these dimensions of the novel do not survive translation to the screen. Although the basic contours of García Márquez´ plot are intact in the film, the episodes and details that have been cut away are the very ones that make the novel important for medical readers. And virtually no vestiges of magic realism survive. Even the brightly coloured exotic flowers on black backgrounds that appear on screen at the beginning of the movie are, like the film, beautiful but flat.

What remains in Harwood and Newell's version is a tight focus on the love story of Florentino Ariza (Unax Ugalde, then Javier Bardem) and Fermina Daza (Giovanna Mezzogiorno), which has been interrupted by her long marriage to Dr Juvenal Urbino (Benjamin Bratt). After he learns of Urbino's death (which occurs early in the film), Florentino goes immediately to visit Fermina, telling her that he has waited faithfully for 51 years, 9 months, and 4 days to begin his courtship of her again. She unceremoniously sends him packing, just as she had done all those years before. But Florentino has not waited so long to give up easily, or at all. As he did in the first days of their youthful love, he writes her letters, which she eventually begins to read. Winning through his letters what he could not win in person, Florentino finally receives a response and is allowed to visit Fermina. The film closes, as does the novel, with their voyage from Cartageña, up and down the Magdalena River on the New Fidelity, a riverboat flying the flag of cholera as a defence against other passengers or any interruption of their newly consummated love. The film maintains, even relishes, the irony of Florentino's proclaimed virginity as he professes his fidelity to Fermina, despite his having kept a careful count of the 622 women he has bedded during the half century that he has been separated from his true love. New fidelity, indeed.
Presumably to maintain the tight focus of the film, Harwood and Newell sacrifice the novel's opening episode, an unforgettable scene in which 81-year-old Dr Urbino is called to attend the death of his chess partner, the Antillean refugee Jeremiah de Saint-Amour. At the scene, Urbino recognises the smell of bitter almonds—cyanide—which reminds him of the many suicides he has seen from unrequited love. But it is not unrequited love that has motivated Saint-Amour's suicide. To the contrary. Years before, he had decided to take his life at the age of 60 years to make sure that he would never grow old. His is a rational, prophylactic suicide, carried out despite his health and the continuing love of his mistress. Against the backdrop of his suicide, the opening pages of the novel detail Urbino's struggles to deal with the physical and mental losses of his own ageing. He is living through exactly what Saint-Amour feared and wanted at all costs to avoid, but Urbino dares not think of suicide himself, presumably because of his Catholicism. Saint-Amour's act also provides a contrast with Florentino's passionate resolve not to commit suicide as a result of his unrequited love for Fermina but to outlive Urbino and woo Fermina again. In triumph over rational gerontophobia, the love of Florentino and Fermina survives “forever” because Florentino can not only endure but also prevail over ageing. The film captures the novel's ending but greatly diminishes the odds against which it was achieved.

García Márquez´ novel has recently enjoyed a renascence on The New York Times paperback trade fiction bestseller list since being chosen as a featured selection of Oprah's (Winfrey) Book Club. Just after the US release of the film last month, the novel moved into first place on that bestseller list. Thus, despite its shortcomings, I urge those who have not read the book to see the film, in the hope that they, too, will be motivated to read the novel and appreciate the true depth of García Márquez´ work.

Weihnachten

Kalt-flirrendes Schneegestöber
Wangen so rot
Und lachendes Kindergeschrei...

Mit Kufen schnell
übers Eis geflitzt
Geschickt getanzt,
dass es ja nicht bricht
So kann sie kommen
die Weihnachtszeit.

Kinderaugen erwartungsvoll froh
sie schauen dich an -
Mutter! Das Christkind ist da!
Walter Frank

Singstunde

Tiefe Stille herrscht im Wasser,
ohne Regung ruht das Meer,
und bekümmert sieht der Schiffer
glatte Fläche ringsumher.
Keine Luft von keiner Seite!
Todesstille fürchterlich!
In der ungeheuern Weite
reget keine Welle sich.

Text: Goethe
Vertonung: Franz Schubert (1797-1828) Op. 3 No.2

Drachen über Kabul...

Am Freitag (der Sonntag der Muslime) fuhren wir am Morgen los...wie groß war mein Erstaunen, an vielen Straßenecken Väter mit ihren Söhnen stehen zu sehen, die Drachen steigen ließen...über der ganzen Stadt schwebten Drachen...Später las ich dann den Bestseller - Drachenläufer...

In der westlichen Mythologie ist der Drache ein Symbol für das Böse - in der östlichen Mythologie ist der Drache aber gerade das Gegenteil - er ist das Symbol für alles Glück auf dieser Erde...

Impressionen aus Afghanistan hier ...

Eyd Qurban - das Opferfest hat heute begonnen...

Das Opferfest (arabisch: 'Īd ul-Adha bzw. arabisch عيد الاضحى‎ , türkisch: Kurban Bayrami persisch: eyd Qurban) ist das höchste islamische Fest. Es wird zum Höhepunkt des Hadsch gefeiert, der Wallfahrt nach Mekka welches jährlich am Zehnten des islamischen Monats Dhu al-hiddscha beginnt und vier Tage andauert.
Beim Opferfest wird des Propheten Ibrahim (Abraham) gedacht, der die göttliche Probe bestanden hatte und bereit war, seinen Sohn Ismael (vgl. Isaak) Allah zu opfern. Als Allah seine Bereitschaft und sein Gottvertrauen sah, gebot er ihm Einhalt und Ibrahim und Ismail opferten daraufhin voller Dankbarkeit im Kreis von Freunden und Bedürftigen einen Widder. Dies fand am Felsendom in Jerusalem statt. Getreu der 22. Sure des Korans, Vers 37.

Quelle: wikipedia

Das selbstsüchtige Gehirn...

Die Ursache für Übergewicht liegt im Gehirn begraben - die These wird von einer Forschungsgruppe aus Lübeck vertreten...
Hier geht es zu ihrer Webseite...

Der BVB feiert heute Geburtstag...

Am 19. Dezember 1909 wurde der Ballspielverein Borussia unweit des Borsigplatzes gegründet...
Heute Abend ab 19 Uhr steigt die Geburtstagsparty, die unter der Federführung von Annette Kritzler und Anette Plümpe organisiert wurde, im ehemaligen Wildschütz und heutigen „Pommes Rot-Weiss“ an der Oesterholzstraße 60...
Siehe auch Infos zu Führungen zur BVB-Geschichte...

Geschichte...

...wiederholt sich nicht, aber sie reimt sich...

Mark Twain

Die Chirurgie der Gallenwege...

Die chirurgische Therapie von Erkrankungen der Gallenwege - eine kleine Zusammenfassung nachfolgend...

Chirurgie Gallenwege Kassel2007 - Upload a Document to Scribd

Unicef-Foto des Jahres - Kinderbräute

Er ist vierzig, sie ist elf. Und sie sind ein Paar - der Afghane Mohammed F.* und das Kind Ghulam H.*. „Wir brauchten das Geld“, sagen die Eltern von Ghulam. Faiz behauptet, er wolle sie zur Schule schicken. Doch die Frauen im Dorf Damarda in der Provinz Ghor wissen es besser: „Unsere Männer wollen keine gebildeten Frauen.“ Sie prophezeien, dass Ghulam nach der Verlobung (im Jahre 2006) in wenigen Wochen verheiratet sein wird, um Nachwuchs für Faiz zu bekommen.
Während ihres Aufenthaltes in Afghanistan fiel der amerikanischen Fotografin Stephanie Sinclair immer wieder auf, wie viele junge Mädchen mit wesentlich älteren Männern verheiratet waren. Sie beschloss, mit Bildern auf das Thema aufmerksam zu machen, zumal das offizielle Mindestalter für Bräute in Afghanistan sechzehn ist und Kinderhochzeiten daher illegal sind.
Nach Schätzungen von UNICEF heiratet rund die Hälfte der afghanischen Frauen, bevor sie 18 Jahre alt sind. Kinderheiraten gib es aber nicht nur in Afghanistan.
Nach Untersuchungen von UNICEF wurden weltweit mehr als 60 Millionen Frauen, die heute zwischen 20 und 24 Jahren alt sind, verheiratet bevor sie volljährig wurden. Besonders häufig sind Kinderheiraten in afrikanischen Staaten südlich der Sahara und in Südasien. Im Niger wurden 77 Prozent der Frauen bereits als Minderjährige verheiratet. In Südasien leben rund 21,3 Millionen Frauen, die als Kind oder als Jugendliche verheiratet wurden.
Im indischen Bundesstaat Rajasthan sind 15 Prozent aller Ehefrauen bei ihrer Hochzeit sogar nicht einmal 10 Jahre alt. Kinderheiraten sind eine Reaktion auf extreme Armut, sie finden vor allem in Regionen Asiens und Afrikas statt, in denen notleidende Familien in Töchtern eine Last und Menschen zweiter Klasse sehen. Schon in jungen Jahren werden Mädchen in die „Obhut“ eines Ehemanns gegeben, eine Tradition, die in den meisten Fällen zur Ausbeutung führt. Viele Mädchen werden Opfer häuslicher Gewalt. So gaben bei einer Studie in Ägypten rund ein Drittel der befragten Kinderbräute an, von ihren Ehemännern geschlagen zu werden. Die kindlichen Bräute stehen unter Druck, möglichst bald ihre Fruchtbarkeit unter Beweis zu stellen. Dabei ist die Risiko für ein Mädchen zwischen zehn und 14 Jahren, eine Schwangerschaft nicht zu überleben, fünf mal größer als für eine erwachsene Frau. Jährlich sterben rund 150 000 schwangere Teenagerinnen an Komplikationen - vor allem, weil es keine medizinische Versorgung gibt, geschweige denn Aufklärung.
Sinclair fuhr für ihr Projekt auch nach Nepal und Äthiopien. Sie möchte das Thema Kinderheirat in weiteren Regionen recherchieren und ein Buch dazu herausbringen.
Foto: Stephanie Sinclair, USA, Freie Fotografin

Luxusleben im Armenhaus...

Nach der Diskussion über die Manager-Gehälter hat sich der Nachrichtensender n-tv Gedanken über die Fußballprofis gemacht. Die beim Meinungsforschungsinstitut Forsa in Auftrag gegebene repräsentative Umfrage unter 1001 Bürgern ergab ein Ergebnis, das nicht überraschte. 78 Prozent der Befragten halten die Gehälter für zu hoch, 18 Prozent schätzen sie als angemessen ein, und ein Prozent hält sie für zu niedrig - wobei sich in der letzten Gruppe offenbar ein paar Bundesligaprofis, ihnen nahestende Verwandte oder scheidungswillige Ehefrauen eingeschlichen hatten. Immerhin sind die Gehälter in den vergangenen Jahren auch in Deutschland explodiert, obwohl die etablierten Klubs allen ständig weismachen wollen, die Bundesliga sei aufgrund lächerlich geringer Fernsehverträge das Armenhaus in Europa und das mäßige internationale Abschneiden die logische Folge. Ähnlich wie bei den Managern ist für etablierte Profis das Risiko im Fall des Misserfolgs gering - entgangene Prämien sind angesichts siebenstelliger Jahres-Garantiesummen zu verschmerzen. Eher zur Verantwortung gezogen werden Trainer, von denen einige aber allein von ihren Abfindungen ein Leben lang in Luxus leben könnten. Der im März eingestellte und gerade beurlaubte Ernst Middendorp soll in Bielefeld zwischen einer und drei Millionen Euro für seinen vorzeitigen Abschied verlangen. Je nachdem, wie man seinen lukrativen Vertrag lesen will, wird er die Summe auch bekommen. Sorgen müssen sich auch die Spieler nicht, in der Regel findet sich immer noch ein Klub, der aufgrund von Meriten in der Vergangenheit der Verlockung nicht widerstehen kann, wie beispielsweise im Fall Ailton und MSV Duisburg. Die Zeiten, als ein halbwegs seriöser Profi am Ende der Karriere nach mehr als zehn Jahren Bundesliga zum wirtschaftlichen Überleben einen Tabakladen übernehmen musste, sind vorbei. Angesichts des zunehmenden Rauchverbots eine glückliche Fügung. Für die Profis. pep.Text: F.A.Z., 17.12.2007, Nr. 293 / Seite 26

Die führende Diagnose - Eine 23jährige Frau stellt sich mit seit einer Stunde andauernden, kolikartigen Bauchschmerzen in der Ambulanz vor...

A 23-year-old black woman presented to the emergency department with diffuse, colicky abdominal pain of 1 hour's duration. The pain was followed by nausea and episodes of bilious vomiting and did not radiate or change with the patient's position. She did not report fever, chills, diarrhea, hematochezia, or melena.
The differential diagnosis of acute abdominal pain in young adults is broad and includes appendicitis, peptic ulcer disease, nephrolithiasis, infectious enteritis, inflammatory bowel disease, hepatobiliary diseases such as cholecystitis, pancreatitis, and referred pain from pneumonia. In young women, gynecologic conditions (such as ectopic pregnancy, endometriosis, and pelvic inflammatory disease) are additional important considerations.
Nausea and bilious vomiting are consistent with hepatobiliary disease, pancreatitis, and small-bowel disorders such as obstruction, infection, and Crohn's disease. The diffuse nature of the pain in this patient makes hepatobiliary disease unlikely. The absence of reported diarrhea or gastrointestinal bleeding would argue against endoluminal infection or inflammatory bowel disease.
Diffuse abdominal pain may also suggest bowel obstruction or ischemia, or metabolic disease such as diabetic ketoacidosis or acute intermittent porphyria, although the latter condition is rare. I would first want to rule out evidence of peritonitis, which in a young woman may result from conditions such as ectopic pregnancy, a ruptured tubo-ovarian abscess or appendix, or a perforated ulcer.
The patient reported that a similar episode had occurred 6 months previously. It lasted 30 minutes and resolved on its own. At that time, she passed red blood from the rectum once but did not seek medical attention. Her other medical history included an elective abortion at 20 years of age and anemia and metromenorrhagia, neither of which had been further evaluated. She had no history of abdominal surgeries. She said that she did not use tobacco, alcohol, or illicit drugs, and she worked as a legal assistant. She was unaware of any gastrointestinal or sickle cell disease in her family.
A history of bright red blood from the rectum, if confirmed, would indicate endoluminal disease of the gastrointestinal tract — presumably the lower tract; if the source was the upper gastrointestinal tract, red blood would indicate very rapid transit, yet the previous episode was self-limited, without hemodynamic compromise. Bilious vomiting suggests a site proximal to the ileocecal valve. Inflammatory bowel disease is a leading possibility. The combination of vomiting and the absence of changes in stool volume, color, and frequency could be explained by a stricture complicating Crohn's disease, and it could also explain the patient's anemia, although her history of metromenorrhagia provides an alternative explanation for that condition. An underlying hematologic disorder (such as sickle cell disease, thalassemia, or glycerophosphoryl diester phosphodiesterase deficiency, all of which are more common in blacks) might also underlie her previously diagnosed anemia. Other less common causes of small-intestinal bleeding and pain include tumors, mesenteric ischemia, Meckel's diverticulum (although the pain is typically less severe), and endometrial deposits along the intestinal tract with pain that may correlate with the periodicity of the menses.
On examination, the patient was afebrile, with a heart rate of 100 beats per minute, a respiratory rate of 16 breaths per minute, an oxygen saturation of 100% while she was breathing ambient air, and a blood pressure of 115/65 mm Hg. Her height was 65 in. (165.1 cm), and she weighed 115 lb (52.3 kg). She was restless on the gurney, clutching her abdomen. Her sclerae were anicteric, and her conjunctivae were pale. The oropharynx was normal, and the neck was supple, without lymphadenopathy. The heart sounds were regular, and the lungs clear. There was no chest-wall or flank tenderness. Abdominal examination revealed hyperactive bowel sounds and diffuse tenderness on palpation without rebound tenderness, organomegaly, or masses. The rectal examination showed no masses. A stool sample was brown and was negative for occult blood. The pelvic examination revealed no masses, cervical motion, or adnexal tenderness. There was no edema in the legs. The neurologic examination was normal.

The observations that the patient is restless (as compared with the still appearance that would be expected in diffuse peritonitis), that she is clutching her abdomen but not avoiding touch, and that she has hyperactive bowel sounds and no rebound tenderness argue against generalized peritonitis, although these findings do not rule out early peritoneal inflammation. On this occasion, there is no occult blood in her stool, but conjunctival pallor suggests profound anemia. Given her history, I continue to be concerned about gastrointestinal blood loss, and I wonder in particular about inflammatory bowel disease as the cause of her condition.
Admission to the hospital is warranted to determine the cause of her severe pain. A negative serum human chorionic gonadotropin (hCG) test would rule out ectopic pregnancy. If routine laboratory tests do not point to the source of pain, urgent abdominal imaging with computed tomography (CT) is indicated. CT is more sensitive than plain radiography for detecting the presence and source of intraabdominal free air, and it may reveal small-bowel obstruction or bowel-wall thickening. This latter result, although nonspecific, would be compatible with bowel-wall edema due to ischemia, infection, inflammation, or neoplastic infiltration. Given my low suspicion for infection, this finding might lead to endoscopic evaluation of the bowel.

The serum sodium, potassium, and calcium levels were normal. The blood urea nitrogen level was 9 mg per deciliter (3.2 mmol per liter), creatinine 0.6 mg per deciliter (53 µmol per liter), lipase 22 U per liter (normal range, 1 to 60), aspartate aminotransferase 25 U per liter (normal range, 8 to 31), alanine aminotransferase 10 U per liter (normal range, 7 to 31), alkaline phosphatase 55 U per liter (normal range, 39 to 117), and total bilirubin 0.3 mg per deciliter (5.1 µmol per liter) (normal range, 0.1 to 1.2 mg per deciliter [2 to 21 µmol per liter]). The white-cell count was 6400 per cubic millimeter, with 87% neutrophils, 9% lymphocytes, and 4% monocytes. The hematocrit was 23%, with a mean corpuscular volume of 65 µm3. A peripheral-blood smear showed 2+ microcytosis, 2+ hypochromia, and no other abnormal cells. A serum test for hCG was negative. Dipstick testing of a specimen of voided urine revealed a specific gravity of 1.022 and a pH of 5.0; tests for protein, leukocyte esterase, nitrites, and blood were negative. Urine microscopical examination showed no white or red cells.

These results rule out ectopic pregnancy. Pyelonephritis would be unlikely without pyuria, and, although no amylase level was reported, the normal lipase level argues against pancreatitis. Advanced cholecystitis and cholangitis are unlikely given the normal results of the liver-function tests. A normal white-cell count soon after the onset of symptoms does not rule out bowel obstruction or inflammatory processes such as appendicitis. The most salient findings are the low hematocrit and mean corpuscular volume. Iron deficiency and thalassemia are the most common causes of these values. In this patient with metromenorrhagia and bleeding from the rectum, iron deficiency is a more likely cause. Although her menorrhagia could account for her iron deficiency, I am very suspicious about a bleeding lesion in the bowel. Her severe pain makes me particularly worried about obstruction or perforation. I would order a CT scan of the abdomen before considering endoscopic evaluation.
A CT scan of the abdomen showed intussusception of a segment of small intestine (Figure 1).
Figure 1. CT Scan of the Abdomen.
Small-bowel intussusception is shown by the "bowel-within-bowel" appearance (arrow) created when the leading edge telescopes into the lumen.

Small-bowel intussusception in a 23-year-old is unusual. This finding suggests that there is a "leading edge" (protruding tissue) that has caused the small intestine to telescope on itself. During normal intestinal propulsion, such tissue becomes an intraluminal bolus and moves distally, causing ischemia as the blood supply is compromised. Causes of small-intestinal intussusception include tumors, endometrial implants, foreign bodies, and unusual endoluminal infections such as ascariasis. In the United States, benign and malignant neoplasms are the most likely causes of small-bowel intussusception. I would obtain surgical consultation.

The patient received a transfusion of 2 units of packed red cells before laparoscopically assisted surgical exploration. Intraoperatively, a jejunojejunal intussusception was identified, and a firm irregular mass was palpated at the leading edge of the intussusception. There was no evidence of ischemia. The intussusception was manually reduced and the mass and adjacent jejunum were then resected. A pedunculated polyp measuring 4 by 2 by 2 cm was sent to the pathology laboratory.

The differential diagnosis of small-bowel polyps includes adenomas, adenocarcinomas, lymphomas, carcinoid tumors, metastases, hamartomas, and hyperplastic polyps. Primary or metastatic intestinal cancer would be unusual at this age. Of the benign tumors, hamartomas can protrude into the intestinal lumen and cause intussusception. Hamartomatous polyps are characteristic of the Peutz–Jeghers syndrome, a disorder that also includes pigmented mucocutaneous lentigines. While awaiting the interpretation of the pathological examination, I would examine the patient for these occasionally overlooked findings.
On closer inspection, several small hyperpigmented lentigines were detected on the patient's fingers (Figure 2A), tongue, and everted lips (Figure 2B). She stated that these lentigines had been present since childhood.
Figure 2. Hyperpigmented Lesions.
Hyperpigmented lesions are shown on the fingers (Panel A) and on the lips (Panel B).

The Peutz–Jeghers syndrome is my leading diagnosis. It would explain the mucocutaneous lentigines and intestinal polyp with bleeding. I would also expect at least one of the patient's relatives to have the disease. The specimen must be evaluated for evidence of a malignant condition that may occur in patients with the Peutz–Jeghers syndrome.
Histologic analysis (Figure 3) showed that the polyp was a hamartoma, consistent with the Peutz–Jeghers syndrome. There was no evidence of a malignant condition. When the patient's mother arrived after the operation, she said that her sister had been diagnosed with the syndrome. The patient was discharged on the fourth hospital day.

Commentary
In 1921, Peutz reported the combination of mucocutaneous melanin spots and gastrointestinal polyposis in a Dutch family.1 Jeghers described 10 additional cases in 1949, reinforcing Peutz's findings of a unique familial syndrome.2 The Peutz–Jeghers syndrome is an autosomal dominant disorder caused by a germ-line mutation of the STK11 gene, and it affects men and women equally and with high penetrance. Pigmented mucocutaneous lesions that are present in nearly all patients by 2 years of age occur most commonly on the lips and perioral region (in 94% of patients) followed by the hands (in 74%), buccal mucosa (in 66%), and feet (in 62%).3 Although they are similar in size to freckles (1 to 5 mm), lesions associated with the Peutz–Jeghers syndrome are distinguished by their perioral predilection, appearance at an early age, and growth in size and number until puberty, after which the skin lesions begin to regress, although they do not do so completely.3
A hallmark of the Peutz–Jeghers syndrome is the presence of hamartomatous polyps of the gastrointestinal tract, which is seen in 88% of patients. Hamartomatous polyps typically range in size from 0.1 to 5.0 cm and occur most commonly in the small intestine (in 64% of patients), colon (in 64%), stomach (in 49%), and rectum (in 32%).3,4 Rare reports describe polyps in the renal pelvis, urinary bladder, lungs, and nares.4 Hamartomatous polyps in the Peutz–Jeghers syndrome typically occur in patients between 10 and 30 years of age with symptoms of obstruction (in 43% of patients), abdominal pain (in 23%), bloody stool (in 14%), or anal extrusion of a polyp (in 7%).4 The most frequent complication of polyps is intussusception, which is reported in 47% of patients. The location of intussusception is the small bowel in 95% of patients with this syndrome.3 Other sequelae include obstruction due to lumen occlusion by the polyp, intestinal infarction, and autoamputation of the polyp.3
Patients with the Peutz–Jeghers syndrome are also at high risk for intestinal and extraintestinal cancer.5 The increase in the incidence of cancer begins around 30 years of age, and the cumulative lifetime risk is at least 85%.4,6 The most common cancers are gastrointestinal (in 57% of patients) and breast (in 45%).6 The incidences of tumors of the ovary, cervix, pancreas, lung, uterus, and testes are also increased.4 Germ-line mutations in STK11, a suspected tumor-suppressor gene located on chromosome 19p13.3, have been identified in 70% of families with the Peutz–Jeghers syndrome.7,8
To our knowledge, no prospective studies of cancer screening have been conducted in patients with the Peutz–Jeghers syndrome. On the basis of the markedly elevated lifetime cancer risk, experts have adopted the National Comprehensive Cancer Network recommendations for colorectal and breast-cancer screening for patients at high risk for these malignant conditions. Experts also recommend heightened surveillance for cancers of the small bowel, pancreas, ovaries, uterus, and cervix.4
In retrospect, the patient's mucocutaneous lesions were quite typical of the Peutz–Jeghers syndrome. Had they been identified earlier, the diagnosis might have been suspected sooner. As a diagnostic tool, physical examination is notoriously imperfect.9,10 Signs of disease may wax or wane over time, the examiner's technique may be flawed, the examiner may be inattentive or inexperienced in interpreting the finding, or the examiner may be biased, expecting to find normal or abnormal results based on other facts of the case.11 The last two limitations may have played roles in this case. Anticipating a normal skin examination, examiners may have overlooked the lentigines or may have underappreciated the labial involvement as a key feature distinguishing the Peutz–Jeghers lentigines from ordinary freckles.
Only 5% of intussusceptions occur in adults. An underlying cause of intussusceptions is identified in 90% of adults with this condition, and benign and malignant neoplasms account for the majority of cases.12,13 Knowing that a neoplasm will be identified as the leading edge in most instances, the discussant recommended surgical evaluation for diagnosis and treatment. Surgery is routinely recommended for small-intestinal intussusceptions because of the high prevalence of malignant conditions and the recognized risk of recurrence.12,13,14 The combination of pigmented mucocutaneous lentigines and a hamartoma at the leading edge of an intussusception prompted a leading diagnosis of the Peutz–Jeghers syndrome.

References

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2. Jeghers H, McKusick VA, Katz KH. Generalized intestinal polyposis and melanin spots of the oral mucosa, lips, and digits: a syndrome of diagnostic significance. N Engl J Med 1949;241:993-1005, 1031.
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NEJM Volume 357:2389-2393 December 6,2007 Number 23

Thomas E. Baudendistel, Amy K. Haase, and Faith Fitzgerald