[Movement and its significance: natural healing physiotherapy and modern pharmacological therapy of osteoporosis in the semantic differential. A quantitative study of a self-help group and two comparison groups]. / Bewegung und Bedeutung: Naturheilkundliche Physiotherapie und moderne Pharmakotherapie der Osteoporose im semantischen Differential. Quantitative Untersuchung einer Selbsthilfegruppe und zweier Vergleichsgruppen.

BACKGROUND: Physiotherapy is a frequently applied concomitant therapy for patients with osteoporosis. Compared to modern pharmacological therapy physiotherapy appears to receive sustained high regard, which should be further examined in view of the attribution pattern of the patients. OBJECTIVE: Elements of physiotherapy and Kneipp therapy were quantitatively examined in terms of their semantic content in a three-dimensional space of meaning. This was done in comparison with elements of modern pharmacological therapy. The questions regarding possible patterns of the attributions and a possible hierarchy of the therapy forms were analyzed by a survey of a self-help group for osteoporosis patients and two control groups. MATERIAL AND METHODS: According to the methods of semantic differentials, a self-help group for osteoporosis patients and two control groups (high-school female pupils, breast carcinoma patients) were queried about the individual elements of physiotherapy and modern pharmacological therapy in a polar profile of a questionnaire. The results were arranged onto a numerical matrix and by means of factor analysis, a location in a three-dimensional space of meaning was calculated for each element questioned. For purpose of illustration, the results were transferred to a succession of diagrams so that the assessments for the three axes of meaning became more distinct. The results are discussed on the background of a current neurolinguistic theory of meaning: Sensomotoric experience generates meaning in form of 'primary metaphors'; if reactivated e.g. by physiotherapy, these metaphors can give fundaments for an emergent and salutogenic system of meaning, which helps to reconstruct the patient's 'subjective anatomy' and helps to create new values of living one's life. HYPOTHESES: If sensomotoric experience has a central function in generating meaning, the axis of 'motion' and therapies stressing on sensomotoric experience (e.g. exercise group) will show a corresponding profile of evaluation throughout the three groups. RESULTS: For the axis 'motion' the interventions examined in all three groups show a harmonious profile. The most stable position for all three axes is reflected by 'exercise group', followed by 'whole-body pack'. This stability concerning the axis 'motion' as well as 'exercise group' is discussed in terms of a neurolinguistic theory of meaning, giving sensomotoric experiences the central function for generating meaning. CONCLUSIONS: The results allow conclusions concerning the concrete 'meaning-oriented' combination of physiotherapy with modern pharmacotherapy. Moreover, sensomotoric experiences in physiotherapy are possible reasons for an emergent system of meaning reconstructing the patient's 'subjective anatomy' from basic 'primary metaphors' of bodily experiences up to a whole salutogenetic system of meaning.

[Literature review of the latest research results concerning the positive effect of exercise therapy in chronic heart insufficiency]. / Literaturübersicht zu aktuellen Forschungsergebnissen zum positiven Effekt von Bewegungstherapie bei chronischer Herzinsuffizienz.

Scientific investigations indicate similarities in the pathophysiology of heart insufficiency and that of physical inactivity: similar changes in peripheral hemodynamics (increased peripheral vascular resistance, worsening of oxygen utilization during exercise), in autonomic control (activation of neurohumoral compensatory mechanisms, e.g. the renin-angiotensin system, overactivation of the sympathicus, reduction of vagal tonus, reduced pressosensitivity), in functional activity (reduced exercise tolerance and reduced maximum oxygen uptake), in skeletal muscle (decrease in mass, changes in structure), and in the psychological state (reduction in activity and feeling of well-being). In several, although small-scale studies it could be shown that patients with advanced left ventricular failure were able to take part in training programs without experiencing any ill effects, and that there was a positive shift in the usual typical effects of physical training, such as increase of heart rate, change in respiratory frequency, and maximum oxygen uptake. It could be shown that exercise therapy can result in a shift in the balance between the sympathetic and the parasympathetic tonus in the low- and high-frequency maxima of the R-R interval variability. The pre-training general predominance of the sympathetic tonus over the vagal tonus was changed dramatically by the training, leading to a predominance of the vagal tonus. Recent controlled studies with a randomized and controlled cross-over design and the application of a training program which was carried out regularly and independently have confirmed the positive effect of aerobic fitness training in cases of heart disease. At the end of the exercise phase, the patients experienced a significant improvement of the symptoms of left ventricular failure and of their capacity for exercise; furthermore, the training altered parts of the neurohumoral activation, which count as the main factors in the progression and death rate of patients with chronic cardiac disease.

[General medicine malpractice cases]. / Allgemeinmedizinische Behandlungsdefizite.

During the last five years legal proceedings about alleged treatment mistakes in Germany more than doubled. Using a standardized questionnaire about legal proceedings in general medicine, involving liability, an anonymous survey with the members of the workgroup law medicine of the Deutsche Anwaltsverein (DAV) was carried out. The questions included among other things the number and reasons of legal proceedings involving liability. Of 322 questioned lawyers who focused on medicine law 122 (38%) answered. 69.9% of the lawyers think poor information is the main reason for legal proceedings involving liability in general medicine. Three disease groups were mentioned more frequently: diseases of the digestive system (22 mentions), diseases of the circulatory system (21) and diseases of the muscles, skeleton and connective tissue (15). 40 mentions of injections as treatment mistakes build the most frequent therapeutic reason for legal proceedings involving liability. Most of the lawyers think that guidelines do not reduce legal proceedings involving liability. The most common reasons for legal proceedings involving liability such as poor information and insufficient medical examination may point out that the budgetary standards for consultation cannot guarantee enough time for firstly giving a sufficient individual information to the patient and secondly for developing a decision satisfactory for both sides.

[Cerebral hemodynamics in carbon dioxide applications]. / Zerebrale Hämodynamik bei Kohlendioxidapplikationen.

INTRODUCTION: We compare the effect of carbon dioxide (CO(2)) dry and wet applications on cerebral hemodynamics. METHODS: On 22 volunteers measurements were taken during CO(2) application. 10 probands were examined in CO(2) wet application (1,100-1,300 mg/l) and 12 probands in CO(2) dry application (500 g in a 800 l bathtub). The cerebral blood flow velocity (CBFV) in the middle cerebri artery (MCA) was measured as a parameter of cerebral hemodynamics by means of transcranial doppler sonography. Furthermore were recorded CO(2) expiratory concentration (CO(2)et), blood pressure, and sublingual temperature. RESULTS: At CO(2) wet application the CBFV increased during therapy phase by 15% (p = 0.001), parallel to the rise of the CO(2)et by 18% (p = 0.01). During CO(2) dry application CBFV decreased by 11% (p = 0.007), body temperature increased significantly by 0.2 degrees C. CONCLUSION: CO(2) applications have influence on cerebral hemodynamics. Assuming constant diameters of the great brain vessels, CO(2) wet application shows a raising and CO(2) dry application a reducing influence on cerebral blood flow. This influence will attain therapeutic relevance.

[Health situation of homeless in a health care home in Hannover]. / Gesundheitliche Situation von Wohnungslosen in einer Krankenwohnung für Wohnungslose.

BACKGROUND AND AIM: Extension of the medical health care system for social fringe groups by means of a special 'Health Care Apartment' for homeless people with an ambulatory nursing service. Between 55-70 % of the homeless people in Germany are in-patients for medical treatment nearly once a year. Only 10-20 % have a family doctor. METHOD: : The pilot experiment of a special Health Care Apartment for homeless people was scientifically evaluated for approximately one and a half year under socio-medical and socio-economic viewpoints. Every patient passes a standardized interview at admission and discharged with one validated systematic setup and one specifically developed questionnaire. RESULTS: : The mean age of the 36 investigated persons was 48.7. 36.1 % (13) of the patients lived in divorce. About 86.1 % (31) of the patients had secondary school qualifications, 69.4 % (25) had learnt a profession. All were unemployed. Two-thirds of them stated they had been found guilty of a criminal offence within the last few years. 44.5 % (16) had been homeless for 3 or more years. Approximately x of the homeless were addicted to alcohol, according to the employees entrusted with looking after the inmates. The main reasons for the average 8-week stay in the medical department were diseases of the skin and skeletal system, which had caused several hospital admissions in the past. The satisfaction of their own health status improved by 66 % from the day of their admission to the day of their discharge. 72.2 % (26) said they could get easier medical support in the Health Care Apartment. Supported by intensive socio-pedagogical care, 55.5 % (20) of the homeless people could be discharged from the special Health Care Apartment to other arrangements for homeless people, respectively to own apartments. CONCLUSION: : The pilot study of the special Health Care Apartment for homeless people in Hannover closes a gap in the provision of medical care which exists in many major cities. Moreover, hospital admissions for homeless people can be prevented and their social reintegration promoted.

[Effects of active and passive movement stimuli on cerebral hemodynamics and the cerebral metabolism]. / Wirkungen kinetischer Stimuli auf die zerebrale Hämodynamik und den zerebralen Stoffwechsel am Beispiel von aktiven und passiv ausgeführten Bewegungen.

INTRODUCTION: In contrast to the well-examined cardiovascular changes during movement stimuli, up to now changes of cerebral hemodynamics and cerebral metabolism have rarely been studied. We investigated the question if active and passive movement stimuli cause changes in the cerebral hemodynamics and the cerebral metabolism. METHOD: Active and passive repetitive movement stimuli on 14 volunteers (8 females, 6 males, age 35 +/- 8 years) were examined. As a parameter of cerebral hemodynamics the mean and the peak blood flow velocity (mCBFV(MCA), pCBFV(MCA)) in the middle cerebral artery (MCA) were recorded by transcranial Doppler sonography. At the same time the noninvasive blood pressure (Penaz method) and the CO(2) expiration concentration were investigated on 8 volunteers of the collective. As cerebral metabolic parameters we examined in 4 volunteers additionally the cerebral respiratory chain enzyme cytochrome aa3 (ccytaa3) and the cerebral oxygen saturation (cHbO(2)) by the transcranial near infrared spectroscopy. With each volunteer 4 measurement series were carried out with a special active and passive exercise program for the right upper as well as the right lower extremity. Each measurement series was formed according to the evoked flow test (R. Aaslid): Exercises were carried out for 20 s, followed by a break of 20 s; this was repeated 10 times for each series. RESULTS: During active exercises of the right lower extremity we found an increase of 13.6% (p < 0.001) of pCBFV(MCA) and an increase of 3.8% (p = 0.003) of mCBFV(MCA). During passive exercises of the lower extremity the increases ran up to 12.3% (p < 0.001) for pCBFV(MCA) and 3.4% (p = 0.004) for mCBFV(MCA). The increases of pCBFV(MCA) came up to 12.5% (p < 0.001) at active exercises of the right upper extremity, those of mCBFV(MCA) to 3.5% (p = 0.15). During passive exercises of the upper extremity the pCBFV(MCA) increased by 12.2% (p < 0.001) and the mCBFV(MCA) by 4.6% (p = 0.007). Significant increases of ccytaa3 were measured during active exercises of the upper extremity (1.6%; p = 0.04) and of the lower extremity (2.7%, p = 0.007). We also found an increase of ccytaa3 during passive exercises of the upper extremity (1.5%, p = 0.04). Significant changes of cHbO(2) were measured with 2.5% (p < 0.05) at active exercises of the lower extremity. CONCLUSION: These studies show that active as well as passive clinical exercises cause an increase of cerebral blood flow velocity. We attribute the increase of cerebral hemodynamics and cerebral metabolism to cerebral activation and autoregulative mechanisms.

[Guideline development for general medicine: the problem of dichotomized algorithm development]. / Allgemeinmedizinische Leitlinien-Entwicklung: Problematik der dichotomisierenden Algorithmenbildung.

Development of clinical guidelines in Germany is based on two divergent principles. One is the clinical position of individuality and clinical experience. The other is the strong adherence to the principles of evidence-based medicine and the scientific method, as demonstrated by the clear, algorithmic methodology of critical pathway development. We discuss the pros and cons of both concepts and try to find some sort of practical middle ground between the two extremes.

[Importance and possibilities of general guidelines in family practice strategies--do we need 'basic guidelines' in general practice?]. / Bedeutung und Möglichkeiten von allgemeinen Leitlinien für hausärztliche Versorgungsstrategien--Brauchen wir 'Basisleitlinien' in der Allgemeinmedizin?

General practice is distinguished particularly by complex patient problems and generic competencies to act and counsel as a family practitioner. Guidelines which are only centered on clinical topics like diagnoses, treatments etc. are not sufficient to support action and decision in general practice. The article proposes the concept of generic guidelines (basic guidelines) for family medicine. A need for basic guidelines in general practice is established in three areas: 1) cross sectional patient problems (e.g. care for immigrants, common strain and distress, counselling of screening procedures), 2) basic skills and strategies in family practice (e.g. problem-oriented consultation, home visits, patient information and informed consent), and 3) practice management and documentation. The development of generic guidelines seems to be difficult as the efforts to evidence-based professional practice are only recently started, but this is matched by the high importance of guidance for general practice, and certain concepts of family medicine support it. It is concluded that the development of basic guidelines in general practice will have a considerable impact on structuring the framework and fostering the quality improvement of general practice.

[Changes of cognitive brain functions in the elderly by Kneipp therapy]. / Veränderung kognitiver Hirnleistungen im Alter Durch Kneipp-Anwendungen.

INTRODUCTION: Pharmacological and nonpharmacological treatment of brain syndrome is multifarious. Until now, plain external applications of physical stimuli, as used daily in geriatric care, were not explored regarding their influence on cognitive brain function. The aim of this randomized cross-over study was to examine the influence of dermatoreceptive stimuli on cognitive brain function of healty geriatric volunteers. METHODS: 24 healthy volunteers (23 women, 1 man) were randomized into 2 groups (cross-over design). Group A (mean age +/- SD: 68.8 +/- 6.2 years) was treated according to the following regime: at first a 10-12 degrees C cold stimulus for 10 s (a so-called Kneipp face shower) and afterwards a cold wet pack of 10-12 degrees C at the neck for 1 min. Group B (age 69.8 +/- 5.3 years) was subjected to an identical procedure but with warm thermoindifferent temperatures of 34-36 degrees C. After 1 week the two groups were interchanged. The parameters of interest were the critical flicker frequency (CFF) and the latencies of the event-related P300 potentials of the visually evoked potentials (VEP), which can be considered the electroencephalographic substrate of the cognitive functional ability. The CFFs and the P300 latencies and amplitudes were measured directly before and 10 min after the application of the above-mentioned stimuli. Furthermore, the CFFs were recorded a second and third time 30 and 60 min later. RESULTS: Following application of cold-water stimuli, the CFF increased from (mean +/- SE) 32.55 +/- 0.44 s(-1) to 33.06 +/- 0.44 s(-1) (p = 0.003) 10 min after the stimulus. 30 min later the CFF was still elevated at 32.95 +/- 0.47 s(-1) (p = 0.043). The P300 latencies decreased by 4.8% (p < 0.001) after cold-water application from 266.5 +/- 5.28 to 253.7 +/- 4.22 ms. After warm stimuli they increased from 258.69 +/- 3.71 to 266.17 +/- 5.03 ms (p = 0.01). The P300 amplitudes were elevated by 5% only with the cold stimuli (p = 0.004). CONCLUSION: Cold water applied locally to face and neck region is able to provoke significant improvements of cognitive abilities.

[Metaphorical aspects of mistletoe therapy in patients' experiences--a qualitative study]. / Metaphorische Aspekte der Misteltherapie im Patientenerleben--eine qualitative Studie.

OBJECTIVE: Mistletoe therapy is an item of research because of its immunological features. Nevertheless, mistletoe should be also an item of research because of its semiotics. Long before R. Steiner proposed mistletoe as an anticancer drug, this plant seemed to have its meaning not by pharmacodynamics but by pharmacosemiotics and magic. Thus, metaphorical aspects of mistletoe therapy should be described by processing the transcript and paintings from a therapeutic group session of cancer patients. Especially the relation between individually and historically coded metaphors should be looked at. MATERIAL AND METHODS: Sample of this qualitative study is the transcript of a therapeutic session of 12 female malignoma patients getting mistletoe infusions (Isorel(r)) since 1.5 years in a general practitioners' practice. Sequential coding of the transcript, inventory of themes, and structural hypothesis are the first steps. The structural hypothesis is triangulated by a textual corpus containing anthroposophic and ethnographic material; then a grounded theory is made. RESULTS: The material is divided. On the one hand, there is a huge amount of historically coded, stereotypic metaphors (sun, cancer, ritual). On the other hand, 'ritual' seems not only a stereotypic metaphor but also a container of individually coded metaphors concerning body experiences (proprioceptive etc.). Metaphors from anthroposophy are rare - the metaphors seem to stem from a deeper level of ethnographic sources. The whole session has a polyphone narrative structure. Categories of semiotics such as icon, index and symbol are only by the context of interaction a suitable description for mistletoe's metaphoric function. CONCLUSIONS: Problems of bias (denominator problem, valid but not reliable) are discussed, and a proposal is made for further forms of generalization of the results (semantic differentials). Moreover, it has to be asked if different preparations of mistletoe (e.g. lectine standard, draft from planta tota) make different halos of metaphors.

[Early diagnosis and early treatment of cognitive disorders: a study of geriatric screening of an unselected patient population in general practice]. / Früherkennung und Frühbehandlung von kognitiven Funktionseinbussen: eine Studie über eine geriatrische Vorsorgeuntersuchung im unausgelesenen Patientengut der Allgemeinpraxis.

To investigate the feasibility of early assessment of preventable disabilities in primary care, we developed a geriatric preventive screening examination with various indicators of physical, emotional, and social functions as well as laboratory exams. Cognitive impairment was measured by the modified MMSE. Severe cases of dementia, who would deserve home visits were excluded. Results of the assessment procedure in 446 patients aged 70 and over (71.5% females) were compared to ratings of general practitioners (n = 67). In these patients we found 4250 medical, 374 psychiatric, and 528 social problems. 45.4% of medical, 61.8% of psychiatric, and 56.8% of social problems where hitherto unknown to the GPs. The prevalence of cognitive impairment was 4.6% according to GPs diagnosis and 21% according to the MMSE. The sensitivity of GPs diagnosis was 14%, the specificity 98%, and the overall agreement measured by kappa was 0.17. There were significant (p < 0.05) associations of cognitive impairment with poor health, vascular disease, syncope, weight loss, previous hospitalization, depression, and ADL and IADL-items. Hypertension, or pathological thyroid function, occurred more frequently in the cognitively impaired (p > 0.05). Only 19.5% of dementia cases had severe functional loss, which substantiates our hypothesis that mild dementia was studied. Of all cases with newly identified cognitive impairment (n = 83 of 446 patients), three (3.6%) had reversible disorder such as depression (n = 1), drug toxicity (n = 2) 3 (3.6%) received counseling, and 5 (6%) further diagnostic assessment or treatment. One (1.2%) patient did not accept any treatment. In the remainder of 71 patients (85.5%), the GPs adopted a wait and see strategy with no intervention. In conclusion, memory deficits seem to be underdiagnosed in general practice despite much treatable comorbidity or social problems, and some reversible conditions such as depression and drug adverse effects.

[The DEGAM-concept--development, dissemination, implementation and evaluation of guidelines for general practice]. / Das DEGAM-Konzept--Entwicklung, Verbreitung, Implementierung und Evaluation von Leitlinien für die hausärztliche Praxis.

The German Society for General Practice/Family Medicine (DEGAM) has launched a project to develop and implement national guidelines for general practice accordingly to international models. Guidelines are seen as statements to assist practitioners and patients in deciding about appropriate, effective and efficient health care. They should be evidence-based, feasible for primary care practices, and purposefully addressing to physicians as well as practice staff and patients. The development follows a comprehensive and well-structured programme (10 stages) which requires the appraisal of medical evidence, the involvement of experienced general practitioners on various stages (primary review, feasibility testing), and comments of concerned specialists, before a guideline is promulgated. Implementation of each guideline is promoted by at least five tools (full text, quick reference guide, telephone card for practice staff; patient leaflet, and information-prescription--"infozept"). Methodological quality is checked for the first time in Germany according to the standards of the German Agency for Quality Assurance. Different targets and criteria for evaluation of guidelines in primary care are mandatory part of the DEGAM-concept.

Changes of laboratory markers of cognitive brain function by thermostimuli in the elderly.

OBJECTIVE: Plain external applications of physical stimuli, which are used quite commonly in geriatric care in Germany, have not been studied for their influence on cognitive brain function. The aim of this randomized crossover study was to examine the influence of dermatoreceptive stimuli on cognitive brain function in healthy geriatric volunteers. METHODS: Twenty-four healthy volunteers (23 women, 1 man) were randomized into two groups (crossover design). Group A (mean age, 68.8+/-6.2 [SD] years) was treated with a 10 degrees C to 12 degrees C cold stimulus for 10 seconds (a so-called "Kneipp face shower"), followed by a cold 10 degrees C to 12 degrees C wetpack at the neck for 1 minute. Group B (mean age, 69.8+/-5.3 [SD] years) was subjected to an identical procedure but with warm to neutral temperatures of 34 degrees C to 36 degrees C. After I week the two groups were interchanged. The parameters of interest were the critical flicker frequency (CFF) and the latencies of the event-related P-300 potentials of the visual evoked potentials (VEP), which can be considered an electroencephalographic marker of the cognitive functional ability. The CFFs and the P-300 latencies and amplitudes were measured directly both before and 10 minutes after the application of the respective stimuli. In addition, the CFFs were recorded 30 and 60 minutes later. RESULTS: After cold water stimuli were applied, the CFF increased from 32.55+/-2.26/sec (mean+/-SD) to 33.06+/-2.25/sec (p = .003) 10 minutes after the stimulus. Thirty minutes later the CFF was still elevated at 32.95+/-2.3/sec (p = .043). The P-300 latencies, after cold water application, decreased by 4.8% (p < .001), from 266.5+/-21.1msec (mean+/-SD) to 253.7+/-16.9msec. After warm stimuli they increased from 258.69+/-14.8msec to 266.17+/-20.1msec (p = .01). The P-300 amplitudes were significantly elevated, by 5% (p = .004), only after cold stimuli. CONCLUSION: Cold water applied locally to the face and neck region can provoke significant changes in electroencephalographic markers as measured by an electroencephalographic marker (VEP and P-300 latency) and, by inference, may help to improve cognitive function in the elderly.

External stimuli in the form of vibratory massage after heart or lung transplantation.

Manual vibratory massage is part of the preventive physiotherapeutic activities performed in intensive care units. The vibratory massage can be performed manually or as electrovibratory massage. The manual massage is a fast rhythmical vibration performed by the arm and shoulder muscles of the masseur and transferred to the patient's thorax by the hand. The hand of the masseur has to achieve a tremor with a frequency of 8 to 11 tremors/s. The aim of the pilot study was to examine the influence of manual vibratory massage on the pulmonary function of postoperative patients who were receiving mechanical ventilation, with special interest being focused on pulmonary ventilation and perfusion and cerebral blood flow velocity. Manual vibratory massage was performed postoperatively in the intensive care unit on eight patients: three patients had undergone heart transplantation, three had undergone lung transplantation, and two had undergone coronary artery bypass grafting (mean age, 53.6+/-8 yr). With the aid of continuous monitoring, we examined the changes of the respiration parameters and the cerebral blood flow velocity (measured by transcranial Doppler sonography). The vibratory massage was performed with a frequency of 8 to 10 vibrations/s for 15 min, 7.5 min on each side of the thorax, starting from the lower costal arch and progressing to the upper thoracic aperture. For 10 min before, during, and 10 min after the massage, the parameters of peripheral oxygen saturation, central venous pressure, mean arterial pressure, heart rate, lung resistance and compliance, tidal volume, respiration rate, and cerebral blood flow velocity were recorded at 2-min intervals. Moreover, before and after vibratory massage, arterial blood gases were determined. In four of the eight patients, it was possible to determine pulmonary arterial pressure, pulmonary capillary wedge pressure, as well as pulmonary vascular resistance. During the vibratory massage, we could prove a significant increase of the mean tidal volume by 30% (P = 0.008). The percutaneous oxygen saturation significantly increased also, from 92 to 93.6% (P = 0.002). Central venous pressure significantly decreased by 11% (P = 0.04), and pulmonary vessel resistance was reduced by 18.3% (P = 0.001). The pulmonary resistance decreased from 10.5 to 9.2 H2O/l/s (P < 0.05) by the end of the observation period. Cerebral blood flow velocity showed no significant change. Vibratory massage seems to improve pulmonary mechanism and perfusion, thus, reducing ventilation perfusion mismatch and increasing oxygen saturation.

Cerebral autoregulation during whole-body hypothermia and hyperthermia stimulus.

The purpose of the study contained herein was to investigate the effects of old traditional physiotherapeutic treatments on cerebral autoregulation. Treatment consisted of complete body immersion in cold or warm water baths. Fifteen volunteers were investigated by means of transcranial Doppler sonography and a servo-controlled noninvasive device for blood pressure measuring. One group of 8 volunteers (mean age, 27.2+/-3.5 yr; gender, 3 females/5 males) was subjected to cold baths of 22 degrees C for 20 min Another group of 7 volunteers (mean age, 52.1+/-8.5 yr; gender, 4 females/3 males) took hyperthermic baths at rising water temperatures from 36 degrees to 42 degrees C, increased by 1 degree C every 5 min. Each volunteer in both groups underwent autoregulation tests two to four times before, during, and after the thermic bath. Dynamic autoregulation was measured by the response of cerebral blood flow velocity to a transient decrease of the mean arterial blood pressure, induced by rapid deflation of thigh cuffs. The autoregulation index, i.e., a measure of the speed of change of cerebral autoregulation, was used to quantify the response. Further parameters were core temperature, blood pressure (mm Hg) and CO2et. During hypothermic baths, core temperature decreased by 0.3 degrees C (P = 0.001), measured between preliminary phase and the end of the bath; the autoregulation index decreased significantly (P < 0.05) from 5.3 before the bath to 4.25 during the bath. During hyperthermic baths, the autoregulation index increased from 6.0 to 7.5 and 8.9 (P < 0.001), with an increase of core temperature of 0.4 degrees C. The main cerebral autoregulation system is dependent on changes of core temperature, provoked by hypothermic or hyperthermic whole-body thermostimulus. Application of hyperthermic baths increased the autoregulation index, and hypothermic baths decreased the autoregulation index. Further studies are needed to prove the positive effects of thermo-stimulating water applications on cerebral hemodynamics in patients with cerebral diseases.

[Diabetes mellitus and physical medicine]. / Diabetes mellitus und Physikalische Medizin.

In the treatment of diabetes, the importance of kinesitherapy increases steadily. In fact, a prospective study (1996) which was done on 897 Finnish middle-aged males over a period of 4 years, showed that the risk of diabetes can be reduced to 50% by moderate physical exercise of 40 minutes per week compared with less active persons of the same age. The amount of kinesitherapeutic measures depends on the physiological resilience of the diabetes patient and on the extent of existing diabetes-induced lesions. An endurance kinesitherapy activates the carbohydrate metabolism and affects the glucosensitive receptors situated in peripheral and central organs. A muscle activity of ten minutes can already multiply by fifteen the increase of glucose absorption from the blood. Another positive result by physical effort is to be seen in the preventine and therapeutic effect of an increased insuline action. The individually adapted kinesitherapeutic endurance stimulation should last from five to ten minutes each day and reach at least 50% of maximum capacity but not more than 70%. This maximum capacity can among other things be gauged from the heart rate as well as from the breathing rate.

[Possibilities and limits of geriatric assessment in general practice]. / Möglichkeiten und Grenzen des geriatrischen Assessments in der Hausarztpraxis.

Geriatric assessment is a means to collect health and functional data of an individual older person in a standard way. It has been developed on the secondary care level in the specialties of geriatric and rehabilitative medicine. Transferring geriatric assessment into primary care may improve health outcomes of older people, especially as it facilitates preventive diagnostic and therapeutic intervention. Yet, it is not possible to use geriatric assessment, as it is carried out in secondary care, under primary care conditions. Several adaptations will be necessary. An assessment instrument will have to be developed which takes epidemiological features of the older population into account. It will have to be tailored to the specific conditions of health delivery in primary care. Moreover, to achieve effectiveness and acceptance by health care providers and users, we see the necessity of creating an algorithmic assessment instrument which allows the use in different health situations with different levels of diagnostic detail. A primary care assessment for older people then would need to be evaluated according to its effectiveness of improving health outcomes. Potential negative effects on health beliefs may be worth considering. The final task lies in the implementation of a primary care assessment instrument into our existing health delivery format.

Passive and active exercises increase cerebral blood flow velocity in young, healthy individuals.

Unlike the well-examined cardiovascular changes during movement stimuli, changes of cerebral hemodynamics and cerebral metabolism in physical exercises have, as yet, rarely been studied. Our objective was to investigate whether there are changes in cerebral hemodynamics and cerebral metabolism caused by active and passive movement stimuli. Response to repetitive active and passive movement stimuli was studied in 14 volunteers (8 females, 6 males; mean age, 35.2+/-8 yr). Each volunteer was subjected to four measurement series while performing a defined active and passive exercise program of the right upper or right lower limb. Measurement series were designed according to Aaslid's "evoked flow test"; exercises were performed for 20 s, followed by a rest of 20 s. This sequence was repeated 10 times in each series. As a measure of cerebral hemodynamics mean and peak blood flow velocity of the middle cerebral artery were recorded by transcranial Doppler sonography (Multidop-X-DWL). In addition, cerebral metabolism was quantified in a subsample by means of oxygenic cytochrome aa3 (respiratory chain enzyme), cerebral oxygen saturation using near infrared spectroscopy (Critikon). As well, noninvasive blood pressure (Penaz method) and expiratory pCO2 were measured. Compared with resting measures, an increase in mean cerebral blood flow velocity of the middle cerebral artery of 3.8% (P = 0.003, paired t test) was observed after active exercises of the right lower limb and 3.5% after active exercises of the right upper limb. Respective changes were 3.4% (P = 0.004) for passive exercises of the lower limb and 4.6% (P = 0.007) for passive exercises of the right upper limb. Peak cerebral blood flow velocity of the middle cerebral artery showed an even more pronounced increase during passive and active exercises in all cases, with values of between 12.2% (P < 0.001) and 13.6% (P < 0.001). Significant increases (1.5-3%) of cytochrome aa3 and cerebral oxygen saturation were observed during active and passive exercises. These studies show that active as well as passive exercises are followed by an increase of cerebral blood flow velocity. We attribute the increase of cerebral hemodynamic and cerebral metabolism to cerebral activation and autoregulative mechanisms.

Standardising health outcome measurements in general practice.

BACKGROUND: Outcome measures are gaining importance especially in areas such as divisions of general practice. The plethora of outcome measurements and the rhetoric surrounding this may make it difficult for doctors to decide the place of such measures in daily practice. An understanding of outcomes and their indicators is emerging as an essential requirement for good practice. OBJECTIVE: The aim of this paper is to propose a practical framework for describing health outcome measurements that may be applied to general practice. METHODS: This paper outlines the key features of outcomes measurements and proposes a model for understanding health outcome indicators using a set of indicators relevant to clinical practice. RESULTS: Pertinent to developing outcome terminology for use with patients in general practice are the four key features: a clear description of the indicator utility in practice comparability between practices endurance over time. CONCLUSION: To have reliability and validity and be able to deliver outcomes with practical and clinical significance, we need to be sure that the instruments we use are precisely defined. It is also important that the meaning is universally understood by all who might want to use the instruments. The product should also have cultural applicability beyond English. In clinical practice, the definition of the instrument aims not only to give the general practitioner a clear understanding of what is being measured but how it is used and the implications for its future use.