Entwicklung und Evaluation eines Fortbildungsprogramms zur Partizipativen Entscheidungsfindung f�r die haus�rztliche Versorgung depressiver Patienten

Patient surveys show that many patients want broad information about their disease and treatment. Often they are interested to participate in the process of medical decision making, which could be realised with the concept of shared decision making where patient's values and needs are considered to the same extent as the treatment recommendations of evidence-based medicine. In depression care, it has been demonstrated so far that the active involvement of patients contributes to higher motivation for treatment. For enhancing patient's acceptance and motivation to avail themselves of medical treatment, a training program for general practitioners was developed and evaluated. It was the aim of the training to involve depressive patients in medical decision making. The training consists of depression-specific components (e. g. diagnosis, patient information, therapy) and general components (communication and shared decision making). The training was carried out in five sessions within a 6-month period (May to October 2003) embracing 20 h of training. Participants were 20 general practitioners in Southwest Germany. Physician's satisfaction with the training program is high. Especially in the fields of diagnosis and shared decision making the physicians clearly benefited. Transfer of shared decision making into daily routine was assessed as possible by the large majority of the trainees. Application of the training concept to other diseases and evaluation on the basis of daily routine is recommended. The training effects on medical care are presently being assessed in a randomised controlled trial.

Fr�h- und Basisintervention bei Patienten mit schizophrenen St�rungen

THEORETICAL BACKGROUND

Of all outpatients with a diagnosis of schizophrenia, 30-40% refuse a psychiatrist's care. For this group of patients the general practitioner holds a key position for such different tasks as detection of prodromal schizophrenia or early warning signs of relapse and identification of risk variables for deteriorating outcome, gatekeeping (referral to specialists or other services), integration, and counseling of key relatives. Fifty percent of GPs are interested in disease-specific medical education programs.

STUDY DESIGN AND METHODS

A control trial examined the changes that participating GPs intended to make in three main topics of the curriculum: (1) changing attitudes (pessimistic outcome expectation, low self-esteem), (2) enhancement of detection skills (prodromal schizophrenia, early warning signs of relapse, and risk factors for poor social and vocational integration), and (3) enhancement of management skills (dosing schemes, motivational interviewing).

RESULTS

In the assessment 2 weeks after the training session, we found significant changes in favor of the trained group in detection and management skills and also improved self-confidence of GPs.

CONCLUSIONS

Problem-oriented and case-based learning strategies should be preferred to lectures in training programs for psychiatric skills in primary care.

Pharmacokinetic model of iodine-131-G250 antibody in renal cell carcinoma patients

A model that describes the pharmacokinetic distribution of 131I-labeled G250 antibody is developed.

METHODS

Previously collected pharmacokinetic data from a Phase I-II study of 131I-G250 murine antibody against renal cell carcinoma were used to develop a mathematical model describing antibody clearance from serum and the whole body. Survey meter measurements, obtained while the patient was under radiation precautions, and imaging data, obtained at later times, were combined to evaluate whole-body clearance kinetics over an extended period.

RESULTS

A linear two-compartment model was found to provide good fits to the data. The antibody was injected into Compartment 1, the initial distribution volume (Vd) of the antibody, which included serum. The antibody exchanged with the rest of the body, Compartment 2, and was eventually excreted. Data from 13 of the 16 patients fit the model with unique parameters; the maximum, median and minimum values for model-derived Vd were 6.3, 3.7 and 2.11, respectively. The maximum, median and minimum values for the excretion rate were 8 x 10(-2), 2.4 x 10(-2) and 1.3 x 10(-2) hr(-1), respectively. Parameter sensitivity analysis showed that a change in the transfer rate constant from serum to the rest of the body had the greatest effect on serum cumulative activity and that the rate constant for excretion had the greatest effect on whole-body cumulative activity.

CONCLUSION

A linear two-compartment model was adequate in describing the serum and whole-body kinetics of G250 antibody distribution. The median initial distribution volume predicted by the model was consistent with the nominal value of 3.81. A wide variability in fitted parameters was observed among patients, reflecting the differences in individual patient clearance and exchange kinetics of G250 antibody. By selecting median parameter values, such a model may be used to evaluate and design prolonged multiple administration radioimmunotherapy protocols.

Hypercoagulable states in patients with leg ischaemia

Hypercoagulable states are found in up to 10 per cent of patients with a history of unexplained venous thrombosis. To investigate the prevalence in arterial thrombosis, thrombophilia screening was performed on 124 patients who had previously undergone lower-limb revascularization, 45 claudicants and 27 controls. Of the patients who had undergone revascularization 40 per cent had a hypercoagulation abnormality (low levels of protein C, protein S and antithrombin III or presence of the lupus anticoagulant) in comparison with 27 per cent of claudicants and 11 per cent of controls (P < 0.01). Furthermore, patients who had suffered reocclusion after revascularization were significantly more likely to have a hypercoagulation abnormality than those who had not (P < 0.05), even if the occlusion had occurred more than 6 months previously. Lupus anticoagulant was the abnormality most frequently detected and, like low protein C levels, was found only in patients with peripheral vascular disease. It appears that hypercoagulable states are common in patients with arterial disease and may predispose to failure of revascularization.

Solitary benign papilloma (papillary adenoma) of the cystic duct: a rare cause of biliary colic

Benign tumours of the extrahepatic bile ducts are rare, mostly occurring in the common bile duct and hepatic ducts. Solitary papillomas occur mainly in the gallbladder or at the ampulla of Vater. Tumours of the cystic duct are extremely rare, and we are unaware of any reports of solitary papilloma of the cystic duct. Such a case in a 72-year-old woman is presented.

Detection of circulating cerebral emboli using Doppler ultrasound in a sheep model

We describe a validation study of a new technique for detecting circulating pathological cerebral emboli. Theoretically one would expect solid emboli to be detectable as high intensity signals on the Doppler waveform, and such signals have been reported in humans with potential embolic sources. Pathological cerebral emboli (thrombi, platelet aggregates and atheroma) were introduced into the proximal carotid artery of an in vivo sheep model, and their passage detected in the cerebral circulation using Doppler ultrasound. All of 74 emboli, with a maximum dimension as small as 0.24 mm, were detected as short duration high intensity signals. Smaller pathological emboli could not be made but glass microspheres as small as 5-20 micron resulted in high intensity signals. A significant positive correlation was found between embolus size and relative intensity increase of the embolic signal. A significant positive correlation was also found between embolus size and duration of embolic signal. This study demonstrates that detection of circulating cerebral emboli is possible in vivo. This technique may allow selection of patients at particularly high risk of cerebral embolisation so that they can be given specific prophylactic treatment. Analysis of the Doppler signal may give information on the size of the embolus, although using current signal analysis it is impossible to distinguish between the signals produced by say a larger platelet embolus or a smaller thrombus embolus.

Accuracy of intraoperative staging in colorectal cancer

In 216 patients with colorectal adenocarcinoma 'operative' and 'final' staging using Duke's classification were compared. The overall 'accuracy' of operative staging was 66% with 17% of tumours understaged and 17% overstaged. The major error was found in nodal staging. If selective peroperative adjuvant therapy is to be considered, efforts should be directed to improve operative nodal staging. Any recommendation for adjuvant perioperative chemotherapy based on operative staging alone will result in a significant number of patients having unnecessary treatment.

Simplified technique for peritoneal dissection during laparoscopic hernia repair

The use of a small rod (5-mm diameter, 20-cm length, code no. BN320, Aesculap Ltd., Sheffield, England) inserted extraperitoneally has been a useful tool in aiding peritoneal dissection during laparoscopic hernia repair. Experience gained in 100 such repairs using this instrument has helped to reduce the operating time in most instances.

Computerized detection of cerebral emboli and discrimination from artifact using Doppler ultrasound

BACKGROUND AND PURPOSE

Transcranial Doppler ultrasound can detect circulating cerebral emboli. Monitoring of patients with potential embolic sources may allow identification of high-risk patients who can then be selected for prophylactic treatment. However, practical patient monitoring will require automated programs that can detect emboli and differentiate them from artifact.

METHODS

A new off-line algorithm for the detection of emboli, which detects the characteristic relative power increase occurring with an embolus, was evaluated in both an animal model and in patients. (1) In a sheep model, solid embolic materials (thrombus, platelet aggregates, and atheroma) were introduced into the proximal carotid artery while the distal carotid artery or a major branch was insonated. The signals resulting from 77 emboli (mean size, 1.77 mm) were studied and compared with the Doppler signals resulting from artifact. (2) In patients, 100 embolic signals occurring in three patients were analyzed and compared with signals associated with artifact in the same patients.

RESULTS

(1) In the sheep model, emboli resulted in a short-duration, high-intensity signal, but intensity increase alone did not distinguish between emboli and artifact. In contrast, the algorithm discriminated embolus from artifact with a sensitivity of 98.7% and a specificity of 98.0%. (2) In patient studies, embolic signals were differentiated from artifact with a sensitivity of 97.2% and a specificity of 97.0% by the algorithm.

CONCLUSIONS

Using such an algorithm, detection of cerebral emboli and discrimination from artifact are possible with a high sensitivity and specificity. Incorporation of such an algorithm into an on-line system should make prolonged patient monitoring practical.

Microscopic air embolism during cerebral angiography and strategies for its avoidance

Cerebral angiography is associated with a risk of neurological complications and air embolism may contribute towards this risk. To test this hypothesis, transcranial doppler ultrasonography was used to monitor the presence of air emboli in the middle cerebral arteries of 7 patients undergoing cerebral angiography. Doppler signals consistent with numerous air emboli were noted during each injection of radiographic contrast. This phenomenon was studied further in sheep. Radiographic contrast medium was injected into the carotid artery while a major carotid branch was insonated transorbitally. Embolic signals similar to those seen in patients were noted. Air was introduced at two points. First, at the time of drawing up the contrast into the syringe, especially with more viscous media. Standing the media before injection resulted in a highly significant reduction of air embolism, reducing the total mean duration of emboli from 1.32 (SD 0.60) s after immediate injection to 0.04 (0.05) s after ten minutes standing for iohexol 340 mg/mL (p < 0.001). Second, air was introduced at the time of injection, possibly by the formation of cavitation bubbles under pressure. This occurred most prominently with the less viscous contrast media and with saline, and was significantly reduced by slow injection (mean duration of emboli for saline 2.85 [2.43] s with fast injection compared with 0.32 [0.37] s with slow injection, p = 0.004). Air embolism may contribute towards neurological dysfunction after angiography. Measures should be taken to reduce this by allowing contrast media to stand prior to injection, and by flushing catheters with saline injected slowly.

PTFE bypass grafting to isolated popliteal segments in critical limb ischaemia

Although the quality of the distal run-off has been considered as an important factor affecting the success of bypass grafting, reasonable results have nevertheless been reported for bypass grafts to a popliteal artery with no direct communication with the tibial or peroneal vessels (isolated popliteal segment, IPS). The use of autogenous vein has produced the best results in this situation with most authors finding polytetrafluoroethylene (PTFE) less satisfactory. Improved results have nevertheless been shown for femoropopliteal and femorotibial PTFE grafts by the incorporation of vein patches into the anastomoses. In this paper, the influence of this technique on the patency of PTFE grafts to IPS is evaluated. Thirty-three PTFE grafts to an IPS and 67 to the below knee (BK) popliteal artery with one or more run-off vessels were studied. All IPS grafts were carried out for limb salvage and in the BK popliteal group, 46 (69%) were for limb salvage and 21 (31%) were for severe claudication. Groups were matched in terms of age, smoking history and prevalence of diabetes mellitus. Cumulative patency rates of 84% at 1 year and 76% at 3 years were achieved in the IPS group compared to 90 and 81% for the BK popliteal group with one or more run-off vessels. Using the Taylor patch technique, comparable 3 year patency rates can be expected for PTFE grafts to IPSs and to BK popliteal arteries with patient tibial or peroneal run-off.

Infrapopliteal angioplasty for limb salvage

Fourteen infrapopliteal angioplasties were performed in 13 patients with critical limb ischaemia. Clinical indications were rest pain, ulceration, gangrene or a critically ischaemic limb from a graft occlusion secondary to an infrapopliteal lesion. The average ankle-brachial ratio was 0.22 in non-diabetics. Technical success was achieved in all lesions with an average increase of Doppler ratios of 0.5. Of the 13 patients, 11 (85%) showed early clinical improvement (with average length of follow-up of 8 months, range 1-18 months). With the introduction of smaller lower profile catheters, hydrophilic and steerable wires and the advent of digital subtraction angiography, infrapopliteal angioplasty can now be performed successfully and with few complications. The presence of spasm should be aggressively treated with intra-arterial nitroglycerin or verapamil.

Comparative tissue distribution of 125I- and U-14C-labeled recombinant human interleukin-2 in the rat

The distribution of recombinant human interleukin-2 (rhIL-2) after intravenous administration of 125I- or U-14C-labeled rhIL-2 is reported in the major organs of the rat. Five minutes after the administration of U-14C-labeled rhIL-2, the radioactivity had been rapidly cleared from the plasma, while 38% of the dose was found in the kidneys, confirming that the major site of clearance for rhIL-2 is the kidney. After 1 h, a large fraction of the radioactivity had disappeared from the kidney and was found in the carcass. When the same experiments were carried out with 125I-labeled rhIL-2, comparable distribution results were obtained: Preferential accumulation of 125I radioactivity (37.4%) was found in the kidney at 5 min after iv administration of 125I-labeled rhIL-2. One hour after dosing 125I label was predominantly present in the carcass (46%) and skin (15%). Similar percentages of the dose of 125I or 14C radioactivity were present in other organs or tissues. The present study indicates a similar distribution of the radiolabel in selected tissue and organs regardless of whether 14C or 125I was employed.

Improved technique for polytetrafluoroethylene bypass grafting: long-term results using anastomotic vein patches

Results of peripheral arterial bypass using polytetrafluoroethylene grafts have remained poor in comparison with those using saphenous vein grafts, particularly for anastomoses to tibial and peroneal vessels. A simple modification to the conventional operative technique, involving the incorporation of a vein patch into the distal anastomosis, has enabled considerable improvement. Five-year patency rates of 71 per cent for popliteal and 54 per cent for infrapopliteal grafts have been achieved in a series of 256 patients operated on between 1982 and 1989.

Anatomical repair of large incisional hernias

We present a method of repair for large incisional hernias using lateral relieving incisions of the anterior rectus sheath. This is a modification of the methods previously described by Young (1), Hunter (2) and Maguire and Young (3). There were no recurrences in the 13 patients reviewed. Other methods of repair for large incisional hernias are discussed.

Use of a breast template: an aid for orientation of breast biopsy specimens

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Evisceration and other complications of abdominal drains

Drainage following major abdominal surgery remains controversial. A case of small bowel evisceration through a Wallis drain site after an abdomino-perineal excision of rectum is reported as a complication of abdominal drainage.

Liquid chromatographic determination of narasin in feed premixes

A liquid chromatographic (LC) method has been developed to determine narasin in feed premixes. Narasin is extracted from the premix with a methanol-water solvent, and the extracted solution is assayed by using LC. Recovery of narasin from a 12.5 g/lb premix is quantitative (100%), with a relative standard deviation of 1.44%. The results correlated well (coefficient 0.92) with a turbimetric bioassay method.

Liquid chromatographic determination of nicarbazin in feeds and premixes

A liquid chromatographic (LC) method has been developed for the determination of nicarbazin in premixes and poultry feed. Liquid chromatography of the 4,4'-dinitrocarbanilide (DNC) portion of nicarbazin is performed isocratically with a reverse phase octadecylsilica column and a UV detector set at 340 nm. The 2-hydroxy-4,6-dimethylpyrimidine (HDP) portion of nicarbazin is chromatographed isocratically with a reverse phase octylsilica column and a UV detector set at 305 nm. Nicarbazin concentration can be calculated by assaying both DNC and HDP, or by assaying DNC or HDP and assuming that nicarbazin is a 1:1 molar ratio of the two. Average recoveries of DNC and HDP added to poultry feed were 101% and 87%, respectively. This procedure provides an alternative to existing colorimetric procedures for determining nicarbazin in premixes and poultry feeds.

High pressure liquid chromatographic determination of Monensin in feed premixes

A high pressure liquid chromatographic (HPLC) method has been developed to determine monensin in feed premixes. The method is simple and rapid. Monensin is extracted with methanol-water and determined in the extracting solution by HPLC. Average recovery for monensin from a 13.2% premix sample was 103% (coefficient of variation (CV), 2.6%) by HPLC and compares with the value of 100% (CV, 3.4%) obtained by the turbidimetric bioassay method.