[Health care networks in Germany: status quo and key success factors]. / Den Kinderschuhen entwachsen - Arztnetze in Deutschland leisten wertvollen Beitrag zur Optimierung der lokalen Versorgungssituation.

One third of all practicing physicians are currently working in one of the 400 German health care networks. These physicians' networks bring together GPs and specialists and cooperate with different partners, for example, nursing homes, hospitals, and self-help groups. To increase the quality and the efficiency of care and patient satisfaction by improving the collaboration and communication between physicians and other health care providers.The example of the accountable care organization "Gesundheitsnetz Qualität und Effizienz" (QuE; Health Quality and Efficiency Network) in Nuremberg is used to show that it is possible to achieve an increase in efficiency while providing above-average quality of care and achieving high patient satisfaction. Additionally, the article deals with the status quo, the core objectives, and the key activities of previous generations of health care networks. Quality indicators, satisfaction surveys, and economic parameters are the basis for measuring and representing the above-average performance of physicians' networks. Regional health care networks offer an entire range of patient care, from outpatients and inpatients to the complementary sector, and thereby have excellent prospects for playing an even more important role in the German health care system. The key success factors are: the consideration of specific regional characteristics, their proximity to the patient, and consistent patient orientation.

A race riot's effect on psychological symptoms.

Certain individually stressful events have been observed to increase the psychological distress of persons affected; reduced psychological distress following other events has been attributed to collective processes, including increased group cohesion. These possibilities are investigated by contrasting reported symptom levels of 938 adults interviewed before, during, and after a racial riot. White suburbanites interviewed after the riot and urban black women interviewed during the riot report significantly fewer psychological symptoms. Hypotheses of seasonal symptom changes, sampling biases, and the absence of symptom changes among relatively unimpaired respondents are rejected, suggesting that reductions in symptom level are associated with the riot. Serious methodological problems are raised by our finding that such events may significantly affect not only rates but also patterns of reported psychological symptoms obtained through epidemiological studies.

Exposing medical students to expanding populations.

Physicians are required to advocate for and counsel patients based on the best science and the interests of the individual while avoiding discrimination, ensuring equal access to health and mental services. Nonetheless, the communication gap between physician and patients has long been observed. To this end, the Institute for the Public Understanding of Health and Medicine of the Rutgers University New Jersey Medical School has expanded its efforts. This report describes two new programs: a legacy lecture series for medical students and an international "experience", in Huancayo, Peru, for medical students and faculty. The MiniMed outreach program, now in its ninth year and first described in this journal in 2012, was designed to empower the powerless to communicate more effectively with clinicians, thus improving both the effectiveness of the physician-patient relationship and health care outcomes. The approach of the two new programs and their effects on patients, particularly the underserved, and medical students and faculty, are outlined in the following article.

Ergotism: a possible etiology for puerperal psychosis.

Some reports in the medical literature have mentioned the occurrence of psychotic reactions in response to the use of certain ergot alkaloids in therapeutic doses. Prompted by these observations, we undertook a search for cases of "pure" puerperal psychosis (ie, typical manifestations 3-14 days postpartum) in order to evaluate the clinical background of this phenomenon. Special attention was paid to the medications that the patients had received peripartum. In the last 10 years, out of eight perinatal centers, we found only three cases that fulfilled the criteria of the quoted entity. In all instances, the manifestations of puerperal psychosis had been preceded by the administration of ergot derivatives. Based on the presented data, we hypothesize that typical postpartum psychosis may represent an idiosyncratic reaction to potent vasoactive drugs including ergot derivatives. The similarities between the clinical manifestations of ergotism and puerperal psychosis, and some of the epidemiologic features of the latter condition, appear to implicate ergot alkaloids as potential causative agents. Although the validity of the suggested interpretation requires further evaluation, we believe that the currently available data warrant caution with regard to the administration of ergot derivatives postpartum. These drugs should not be used in the absence of clear indication or in unnecessarily high doses. We suggest that ergotism be included in the differential diagnosis in cases of pure puerperal psychosis.

Toxicity of paracetamol in cultured chick hepatocytes treated with methotrexate.

Cultured chick hepatocytes were used to investigate the hepatotoxicity of methotrexate alone and in combination with paracetamol. Treatment with methotrexate alone at concentrations as high as 1 mg/ml resulted in no toxicity in cultured chick hepatocytes, as indicated by no detachment of cells and no effect on protein synthesis or on release of the intracellular enzyme lactate dehydrogenase. However, treatment with methotrexate alone resulted in a 30% decrease in reduced glutathione levels. Combined treatment with methotrexate and paracetamol was toxic, but only in cells preinduced for cytochrome P450 1A by treatment with beta-naphthoflavone. Under these conditions, methotrexate lowered the threshold concentration of paracetamol at which toxicity was observed. This methotrexate-mediated increase in paracetamol toxicity was associated with decreased formation of the glucuronide, sulfate and thiol metabolites of paracetamol and with increased covalent binding of radiolabeled paracetamol to macromolecules. In cells pretreated with beta-naphthoflavone, additional treatment with either methotrexate or buthionine sulfoximine, an inhibitor of glutathione synthesis, together with paracetamol, was associated with decreased restoration of glutathione levels. These results suggest that methotrexate increased paracetamol toxicity by decreasing the amount of glutathione available for conjugation with reactive metabolites of paracetamol.

The management of confidentiality in general medical practice: a comparative study in the U.S.A. and The Netherlands.

This paper describes the results of two studies in New Jersey and the eastern part of the Netherlands into the management of confidentiality among physicians in general medical practice. The physicians were presented with vignettes about confidentiality and were asked what course of action they would pursue. The results suggest that the physicians in New Jersey are less willing to disclose information without the patient's consent to insurance physicians or occupational health physicians than their Dutch colleagues. However, in more conflicting situations the American physicians tend to favor more disclosure of information than their Dutch counterparts. Explanations of these differences include aspects of the legal system in New Jersey and the Netherlands.

Consumers, clinicians and confidentiality.

KIE: Questionnaires on confidentiality in the physician-patient relationship were completed by 131 internists, 76 patients, and 76 nonpatients. The findings and implications of the study are discussed. It is suggested that concerns about confidentiality may undermine the sense of trust important to effective medical care and even deter some nonpatients from seeking treatment.^ieng

Quality and cost of healthcare: a cross-national comparison of American and Dutch attitudes.

OBJECTIVE: To compare attitudes of consumers in America and Holland toward the quality and cost of healthcare. STUDY DESIGN: Data were derived from one American (n = 466) and two Dutch (n = 260, n = 1629) surveys. PATIENTS AND METHODS: Questionnaires were completed by respondents. Pairwise comparisons requiring respondents to compare statements with one another were used to assess preferences for quality of care. Respondents were asked to "indicate the extent to which each of the factors listed plays a role in placing demands on the American (Dutch) healthcare system." Factors included the public's tendency to consume, high technology, defensive medicine, decrease in informal care, increase in standard diagnostic procedures, and medicalization. RESULTS: Americans reported comparatively greater concern with empathy, whereas the Dutch were more interested in the continuity of care. Effectiveness, knowledge, information, and patient-physician relationships were ranked higher in both nations than waiting time, autonomy, and efficiency. Respondents in both countries attributed the increase in healthcare cost primarily to the high cost of technology. Compared with their Dutch peers, Americans were less likely to attribute increases in the cost of healthcare to the public tendency to consume and to the decrease in informal care and were more likely to implicate defensive medicine and an increase in diagnostic procedures. CONCLUSIONS: As both nations experience pressures to reduce costs while maintaining and augmenting the quality of healthcare, planners and government officials should tailor their approaches to each nation's problems within the context of their public perspectives. Replication of such studies should help assess the impact of changing societal values on healthcare delivery.

Trauma recidivism.

Surgeons have long recognized that a proportion of hospitalized trauma patients present with a history of a previous admission for trauma, termed by the authors as "trauma recidivism." The incidence of trauma recidivism was addressed by a review of 150 consecutive admissions to a level I Trauma Center. This study identifies this subset of trauma patients, establishes their magnitude, and analyzes mechanisms of injury and hospital courses. The implications for those who care for trauma patients is discussed.

Confidentiality in medical practice.

To assess physicians' attitudes toward confidentiality, a questionnaire was mailed to general practitioners and family physicians in New Jersey. The questionnaire was designed to measure their attitudes regarding confidentiality as well as what course of action they believed should be pursued in specific situations involving confidentiality. Data regarding personal and practice characteristics were also collected. One hundred twenty (50%) of the physicians responded. A particularly strong reluctance was found among physicians to divulge information to other physicians. More physicians appeared willing to disclose information to relatives of the patient without their consent. The argument for disclosure among physicians to family members may flow from their belief that they should care for the health of the whole family, and not only that of the patient.

A proposal to study sociocultural influences leading to alcoholism.

The theoretical perspectives underlying informal social controls in the development of alcoholism are highlighted with a view to acquiring an understanding of the role played by these informal social controls.

Confidentiality in clinical psychiatry.

A brief history of the central role of confidentiality in the doctor-patient relationship is presented. Emphasis is placed on the positions of the American Medical Association and World Medical Association. The dilemma posed by the requirement of balancing the rights of the patient against those of society is portrayed. Particular attention is paid to the role of technology and mass society in exacerbating this tension, and the differences between the rights of confidentiality and those of privilege are offered. Recent court cases are cited to illustrate five legal theories to which a patient can resort in alleging damages for the inappropriate disclosure of confidences, as are others in an effort to show the directions in which American courts are heading. Several suggestions are offered to the clinician in dealing with confidentiality.

Methodological issues in the study of confidentiality: a reinterpretation of findings.

Investigations of confidentiality management have been constrained by an inability to obtain direct measures of clinicians' behaviors when deciding whether to breach or safeguard a confidence. Some researchers have used responses to hypothetical case vignettes to derive approximations of how clinicians manage confidences entrusted to them by their patients. However, these studies have focused primarily on total confidentiality scores, without exploring the possibility that subsets of clinical cases might elicit different confidentiality decisions. In this investigation, reanalysis of responses to case vignettes obtained from 436 psychologists, psychiatrists, and internists revealed that on the issue of confidentiality management, these health care providers discriminate among cases involving: Premeditated harm to others, socially irresponsible acts with possible dire consequences to self or others, and minor theft. Of these three categories of cases, those involving social irresponsibility elicited the greatest disagreement among the clinician groups studied.

Puerperal psychosis following ablaction with bromocriptine.

Addiction in the context of drug abuse usually is perceived as habitual dependence on the part of the consumer of a potentially habit forming drug. Attention is drawn to an alternative pattern of drug abuse, namely, unwarranted prescription of drugs on the part of physicians. An example of what the writers perceive is the habitual distribution of a potentially harmful drug in the absence of a clear-cut indication. Attention is being drawn to the worldwide use of bromocriptine, an agent suspected of causing occasional vasospasm, hypertensive cerebral accident and myocardial infarction, for the purpose of ablactation. An additional observation is described where, following administration of bromocriptine in the puerperium manifestations consistent with ergotism developed. The clinical picture was also consistent with pure puerperal psychosis. Attention is also drawn to the likelihood of a cause-effect relationship between the abovementioned drug (an ergot derivative) and the ensuing psychotic reaction.

The management of confidentiality in Egypt.

Patient confidentiality is an important issue for treating clinician regardless of the cultural background. Though cultural and religious issues may have an impact on the confidentiality standards. This article discusses the confidentiality standards in Egypt citing the laws and ethical codes governing them. This is followed by a research study in which a questionnaire containing ten vignettes representing different common themes confronted by the practicing clinician was completed by forty-one Egyptian psychiatrists. They checked off categories representing alternatives they might choose dealing with the themes. Each respondent received a score. The scores were compared with those of American and Israeli psychiatrists who participated in a similar study. There were no statistically significant differences though Egyptian and Israeli psychiatrists appear to be somewhat more inclined to break confidentiality. However, significant differences were found to exist for some of the vignettes between the three groups.

Patterns of cocaine abuse in an inner city emergency psychiatric service setting.

The reported study identifies the socio-demographic profile of the patient who presents himself to the emergency room of an inner city hospital with a history of recent cocaine use; and investigates the patterns of cocaine abuse.

Selected Jewish views of life and medical practice.

PIP: This article discusses some basic tenets of Judaism as they apply to 3 health care delivery issues: death, abortion, and triage. The most pervasive value in Judaism is the utter sanctity of life and an obligation to prevent disease. Orthodox Jewish thought requires the following criteria and standards of death: unresponsive coma, absence of spontaneous respiration and movement, absence of reflexes, absence of pupillary response to light, absence of oculocephalic response, substance screening, and radioisotope angiography to differentiate true brain death from other causes. General endorsement of euthanasia is rejected, but, in cases where these criteria have been met, further medical support systems can be discontinued. Jewish law generally prohibits abortion, except in cases where pregnancy poses a threat to the woman's life. However, those from the conservative denomination accept abortion in cases where there is a probability of severe physical deformities or profound retardation. Those from the reform movement recognize psychological factors as being as important as physical factors in the determination of the appropriateness of abortion; moreover, they stress that the decision regarding abortion should rest with the pregnant woman and her family. Triage, the allocation of health care on the basis of priority, is generally rejected in favor of serving people on a first-need basis.^ieng