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.     

Radiologically placed temporary hepatic artery catheter for treatment of liver cancer

Hepatic artery infusion (HAI) chemotherapy is associated with higher response rates compared to systemic chemotherapy in those patients with unresectable liver malignancies. Operative hepatic artery catheter (HAC) insertion has significant morbidity and mortality, especially in patients with high‐volume disease, some of whom may not respond to HAI chemotherapy. We report our experience in 45 patients with high‐volume liver disease who were initially treated with HAI chemotherapy via a radiologically placed temporary HAC to try to select the responders who then went on to have an operative HAC. In these 45 patients who had 62 radiologically placed HAC, we found very few major complications, and certainly no complications such as cholecystitis, vascular or malperfusion problems.     

Suppression of aminoacyladenylate synthesis by methyl mercury in vitro and in vivo

Methyl mercury (MeHg) at a concentration of 20 microM significantly inhibits the synthesis of aminoacyladenylates (AAA) in vitro from serine and histidine, and fails to inhibit AAA synthesis from phenylalanine, leucine, arginine and aspartate. In vivo administration of MeHg (single i.p. injection of 50 nmol/g body weight) leads to 75-80% suppression of AAA synthesis from serine, histidine, phenylalanine, leucine, arginine and aspartate in rat brain tissue.     

Long-term efficacy of argon laser trabeculoplasty

Long-term efficacy of 360 degrees argon laser trabeculoplasty was studied in 118 eyes of 93 patients with uncontrolled chronic open-angle glaucoma. The mean intraocular pressure (IOP) decrease was 8.9 +/- 5.4 mmHg (mean +/- standard deviation [SD] in 71 eyes at 1 year, 9.3 +/- 4.3 mmHg (mean +/- SD) in 51 eyes at 3 years, and 10.3 +/- 3.9 mmHg (mean +/- SD) in 28 eyes at 5 years. The probability of success at 4 years (decrease in IOP greater than or equal to 3 mmHg, IOP less than or equal to 19 mmHg, stable visual field, stable optic nerve, and no further laser or surgical intervention) was 52%. Pretreatment IOP, diagnosis, previous operations, age, and sex were not significant determinants for success or failure. Eyes receiving argon laser trabeculoplasty before cataract surgery maintained control of IOP after surgery. Failure was most common in the first year after treatment (23%), and thereafter failure occurred at a rate of 7 to 10% per year.