Psychotherapeutic and psychosocial therapy in general practice. Results of demonstration project on quality management in psychosocial primary care

Since 1987, psychosocial primary care (PPC) provided by General Practitioners, are reimbursed by German health insurances. The aim of the psychosocial primary care is to improve recognition and treatment of mental disorders in the primary care sector. As a part of a eight-center national demonstration program on quality management in the outpatient services, General Practitioners (n = 191) from 5 regions participated in the study. 1341 treatment episodes of patients with predominately psychosocial strain were documented. Differences between psychosocial strain, treatment and outcome were determined by analyses of variance. Men and patients beyond the age of 65 were underrepresented. Psychosocial treatments were offered more often to those patients, who had the highest level of anxiety and depression. Patients with physical illness, with pain and without psychological attribution to the illness belief were offered less psychosocial interventions and reached a worse outcome. The study outcome helps to improve training programs as to recognition and treatment of psychosocial problems in primary care. Male and generally elderly patients with somatic symptoms and lack of psychological attribution need a special psychosocial intervention to improve the outcome.     

Recent developments in systematic evaluation of the therapeutic process. Scales for the assessment of adherence and competence

The assessment of therapists' behaviour an essential part of psychotherapy research, especially for controlling the validity of studies. In the last decade, particularly in English-speaking countries, research has been developed that studied two constructs important in this context: adherence and competence. Adherence refers to the extent to which therapists use the strategies recommended in a therapy manual; competence refers to the quality of the use of these strategies. This article is a review of research associated with adherence and competence scales and its relevance. First of all, definitions and examples of use are presented and discussed. Secondly, some of the most important scales that have been developed in this context are described. Thirdly, aspects of realisation are presented. Finally, the pros and cons of this type of research are discussed. It is argued that despite some problems adherence and competence scales are a significant contribution to the systematic assessment of therapist behaviour.     

Diaphysäre Femurpseudarthrosen – nur ein technisches Problem?

Between 1981 and 1994 at the Bergmannsheil Ruhr University Hospital in Bochum, Germany, we treated 145 patients with femoral diaphyseal nonunions following initial operative treatment. Of these patients, 138 received this initial operative treatment at an outside institution. The primary reconstructions for the fractures utilized plates in 112 cases, reamed nails in 24 cases and external fixators in 9 cases. The average age of the patients was 35 years and the mean time from the initial operative treatment was 2 years. Twenty-seven patients (19%) presented with a hypertrophic nonunion and 118 (81%) with an atrophic nonunion. There was a significant correlation between primary "classic" plating and development of an atrophic nonunion (chi 2-test: P < 0.01). We observed 34 wound infections (23%) with no significant correlation to the type of primary osteosynthesis. We determined that 73 of the pseudarthroses were due to improper osteosynthesis techniques. Of these cases, 41% involved the use of plates, 83% involved the use of reamed nails, and 78% involved the use of external fixators. Fracture location near the diaphyseal-metaphyseal junctions was common in this problematic group. Ninety-two percent of all plates led to atrophic nonunions. There were 21 open fractures and of these 90% (n = 19) developed an atrophic pseudarthrosis and 29% (n = 6) developed a wound infection. Fifty-seven (39%) of all patients had additional injuries, but we found that did not increase the risk of disturbed bone healing. Our revision operations focused on the elimination of wound infections, refreshment of bone healing, and improvement in fragment stability. Only 28% of all "classic" plates and 11% of all external fixators were changed to an intramedullary implant at the time of the first revision surgery. Hypertrophic nonunions required a mean of 1.3 revision operations to achieve bone healing whereas a mean of 2 revision operations were necessary to fuse atrophic bone ends (P < 0.05). In cases of diaphyseal pseudarthrosis healing time was not affected by the type of osteosynthesis used for primary reconstructions. Since lack of fracture healing can often already be observed directly from postoperative X-rays, we recommend that revision procedures be performed early. The prolonged length of time to care for femoral nonunions underlines the importance of appropriate primary fracture treatment. That takes into consideration both the biomechanical and the biological aspects of bone healing.     

A dynamic system for delivering controlled bromine and chlorine vapor exposures to weanling swine skin

Context: Assessing the hazards of accidental exposure to toxic industrial chemical (TIC) vapors and evaluating therapeutic compounds or treatment regimens require the development of appropriate animal models.

Objective: The objective of this project was to develop an exposure system for delivering controlled vapor concentrations of TICs to the skin of anesthetized weanling pigs. Injury levels targeted for study were superficial dermal (SD) and deep dermal (DD) skin lesions as defined histopathologically.

Materials and methods: The exposure system was capable of simultaneously delivering chlorine or bromine vapor to four, 3-cm diameter exposure cups placed over skin between the axillary and inguinal areas of the ventral abdomen. Vapor concentrations were generated by mixing saturated bromine or chlorine vapor with either dried dilution air or nitrogen.

Results: Bromine exposure concentrations ranged from 6.5?×?10^?4 to 1.03?g/L, and exposure durations ranged from 1 to 45?min. A 7-min skin exposure to bromine vapors at 0.59?g/L was sufficient to produce SD injuries, while a 17-min exposure produced a DD injury. Chlorine exposure concentrations ranged from 1.0 to 2.9?g/L (saturated vapor concentration) for exposures ranging from 3 to 90?min. Saturated chlorine vapor challenges for up to 30?min did not induce significant dermal injuries, whereas saturated chlorine vapor with wetted material on the skin surface for 30–60?min induced SD injuries. DD chlorine injuries could not be induced with this system.

Conclusion: The vapor exposure system described in this study provides a means for safely regulating, quantifying and delivering TIC vapors to the skin of weanling swine as a model to evaluate therapeutic treatments.     

Ungeplante Zweiteingriffe nach Frakturen des oberen Sprunggelenks

The purpose of the present study was to analyze the risk factors associated with unexpected second procedures and strategies of revision surgery. Within a 5 year period 647 patients with closed ankle fractures AO type 44 were identified of which 77 (11.9%) needed revision surgery. Complications were addressed to 4 main groups: deep infections (IG) were seen in 29 patients (4.5%), problems with primary wound closure (WG) in 22 patients (3.4%), insufficient reduction (KG) in 22 patients (3.4%) and other causes (RG) included 4 patients (0.6%). Significant predictive factors for soft tissue complications were higher age, comorbidities with peripheral arteriosclerosis, high American Society of Anesthesiologists (ASA) score and diabetes mellitus. AO 44 type B2 and B3 fractures were often associated with soft tissue problems. The more complex fracture types AO 44 C1-C3 and A2-A3 were significantly associated with problems of insufficient congruency post-surgery. The distribution of the mean revision rate was significantly different (p<0.01) for all groups: IG 4.59, WG 3.5, KG 1.55, RG 1.25. In summary, we strongly recommend immediate reduction of displaced fractures and to consider a more detailed fracture classification. To reduce the amount of unexpected ankle procedures individual risk factors should be weighed against the advantages of optimal open reduction and internal fixation.     

Bodycontouring beim Mann

Body contouring procedures in men are gaining popularity. The annual statistics from the International Society of Aesthetic Plastic Surgery (ISAPS) confirm this development. Worldwide, approximately 20% of people undergoing body contouring surgery are male. For good treatment results and with respect to safety, it is important to know the special details of male anatomy and to take these into consideration for correct planning of surgery and determination of the incision lines. In this article the gender-specific characteristics are emphasized, especially with respect to abdominoplasty.