[Field of tension between psychomatics and psychiatry]. / Spannungsfeld Psychosomatik und Psychiatrie.

As a medical topic psychosomatic medicine is able to look back on an almost 100-year-old tradition. Nevertheless, questions about its definition, area of application and by whom it should be practiced remains unsolved. This causes considerable tension with the field of psychiatry which has always seen psychosomatic medicine as a subspecialty of its own discipline. In the article, the development and current position of psychosomatic medicine in German speaking countries other than Germany (Austria, Switzerland and South Tyrol) is presented. While psychosomatic care is currently planned and also partially already executed in Austria, psychosomatic medicine in Switzerland is located with general practitioners on the one hand and consultation-liaison psychiatry on the other. After the radical psychiatric reform of the late 1970s in South Tyrol psychosomatic medicine proved to be a means to remove taboos regarding psychiatric institutions and the mentally ill.

The Pictorial Representation of Illness and Self Measure (PRISM) instrument reveals a high burden of suffering in patients with chronic urticaria.

BACKGROUND: Chronic urticaria severely affects quality of life. To date, no gold standard has been established to measure the burden of suffering, which often correlates poorly with the skin symptoms observed in patients with chronic urticaria. OBJECTIVE: To investigate the effect of psychological factors on the course of urticaria. METHODS: Health-related quality of life was assessed in 95 patients with chronic urticaria using the following instruments: Pictorial Representation of Illness and Self Measure (PRISM), Dermatology Life Quality Index (DLQI), and Skindex-29. Correlations were calculated. Cognitive flexibility and its correlation with the course of urticaria were assessed. Two case reports are presented to further elucidate features of PRISM. RESULTS: PRISM revealed a high burden of suffering that was consistent with considerably impaired quality of life as measured by DLQI and Skindex-29 in the same patients. However, no significant correlation was observed between PRISM and the 2 quality of life questionnaires. From the baseline visit to the follow-up visit, quality of life scores improved significantly (DLQI, P = .001; Skindex-29, P = .001), whereas the PRISM score remained unchanged (P = .085). Disease course was favorable more often in cognitively flexible patients (n=54) (91%) than cognitively inflexible patients (P = .007). CONCLUSIONS: PRISM revealed a high burden of suffering in chronic urticaria and provided helpful additional information for the management of these patients. In our cohort, cognitive flexibility was a positive predictive marker for the course of chronic urticaria.

Neonatal procedural pain exposure and pain management in ventilated preterm infants during the first 14 days of life.

OBJECTIVES: Ventilated preterm infants are at high risk for procedural pain exposure. In Switzerland there is a lack of knowledge about the pain management in this highly vulnerable patient population. The aims of this study were to describe the type and frequency of procedures and to determine the amount of analgesia given to this patient group in two Swiss neonatal intensive care units. METHOD: A retrospective cohort study was performed examining procedural exposure and pain management of a convenience sample of 120 ventilated preterm infants (mean age = 29.7 weeks of gestation) during the first 14 days of life after delivery and born between May 1st 2004 and March 31st 2006. RESULTS: The total number of procedures all the infants underwent was 38,626 indicating a mean of 22.9 general procedures performed per child and day. Overall, 75.6% of these procedures are considered to be painful. The most frequently performed procedure is manipulation on the CPAP prongs. Pain measurements were performed four to seven times per day. In all, 99.2% of the infants received either non-pharmacological and/or pharmacological agents and 70.8% received orally administered glucose as pre-emptive analgesia. Morphine was the most commonly used pharmacological agent. DISCUSSION: The number of procedures ventilated preterm infants are exposed to is disconcerting. Iatrogenic pain is a serious problem, particularly in preterm infants of low gestational age. The fact that nurses assessed pain on average four to seven times daily per infant indicates a commitment to exploring a painful state in a highly vulnerable patient population. In general, pharmacological pain management and the administration of oral glucose as a non-pharmacological pain relieving intervention appear to be adequate, but there may be deficiencies, particularly for extremely low birth weight infants born <28 weeks of gestation.

Parents' mental health after the birth of an extremely preterm child: a comparison between bereaved and non-bereaved parents.

OBJECTIVE: To assess the impact of extremely preterm birth (24-26 weeks of gestation) on the mental health of parents two to six years after delivery, and to examine potential differences in post-traumatic growth between parents whose newborn infant died and those whose child survived. METHOD: A total of 54 parents who had lost their newborn and 38 parents whose preterm child survived were assessed by questionnaires with regard to depression and anxiety (HADS) and post-traumatic growth (PTGI). RESULTS: Neither group of parents had clinically relevant levels of depression and anxiety. Mothers showed higher levels of anxiety than fathers. Bereaved parents with no other, living child reported higher levels of depression than bereaved parents with one or more children. Mothers reported higher post-traumatic growth compared to fathers. In particular, bereaved mothers experienced the value and quality of their close social relationships more positively compared to the non-bereaved parents. CONCLUSION: In the long term, bereaved and non-bereaved parents cope reasonably well with an extremely preterm birth of a child. Post-traumatic growth appears to be positively related to bereavement, particularly in mothers.

Quality of life and dyadic adjustment in oral cancer patients and their female partners.

The diagnosis of cancer affects not only the lives of patients, but also the lives of their family members. The purpose of this study was to examine the impact of oral cancer on quality of life (QoL), psychological distress and marital satisfaction in a sample of patients and their wives. Thirty-one men treated for oral cancer (mean time since diagnosis 3.7 years) and their female partners (n = 31) were assessed by questionnaires with regard to QoL (WHOQOL-BREF), anxiety and depression (Hospital Anxiety and Depression Scale, HADS), quality of relationship (Dyadic Adjustment Scale, DAS) and physical complaints (EORTC QOL-H&N35). Quality of life was remarkably high in patients and their partners. In patients, lower QoL was associated with more physical complaints and higher levels of psychological distress (HADS), whereas in wives, QoL was found to be related to marital quality (DAS) and levels of distress. In couples with highly discrepant ratings of marital satisfaction, wives reported more psychological distress. The findings indicate that overall QoL is considerably high in patients treated for oral cancer and their partners living in stable relationships. Quality of life correlates stronger with the quality of relationship in spouses than in patients. Generally, marital satisfaction appears to be an important moderating factor regarding QoL and psychological distress.

[Cell count and Schalm test results of milk from dairy sheep with healthy udders during the course of a complete lactation]. / Zellzahlen und Schalmtestbefunde von Milch eutergesunder Milchschafe im Verlaufe einer ganzen Laktation.

The somatic cell count (SCC) was determined in 28 milk sheep with normal udder health using the California Mastitis Test (CMT) and a fluoro-opto-electronic cell counter (Partec Counter). The examinations were made at two week intervals throughout the lactation period. 92% of the premilking samples had a negative CMT reaction and in 0.5% of the samples the reaction was distinctly positive. In 95% of the premilking samples the SCC showed less than 200,000/ml and in 95% of the individual total milkings it was less than 350,000/ml. Elevated SCC were common towards the end of lactation when milk yield was low.

[How do patients assess caring they have experienced from nurses. Patients evaluate caring]. / Wie schätzen Patientinnen und Patienten Caring ein, welches sie von Pflegenden erfahren haben? Patientinnen und Patienten beurteilen Caring.

In this study, former patients who received a questionnaire by mail, were asked to evaluate Caring from their point of view. As a base, the 59-items measuring instrument "Humane Caring Scale HSC" by Töyry et al., which was translated into German by the author of this article and a team of experts, was used to collect data. In general, the patients (n = 178) feel they are respected, secure, treated friendly and with patience, pain is relieved, they can ask questions and receive answers in a language which they understand. On the other hand, patients cannot enough influence the planning of the care, they cannot always confide in the nurses or personnel, they experience the hospital activity as hectic, they feel nursing staff do not have sufficient time and there is not enough personnel. These results clearly show that nursing is not yet patient focused enough and that the patients have little possibility to influence the course of action. Should this situation be improved, a change of attitude is asked of individual members of the nursing staff as well as of the nursing management, but structures would also have to be adapted. The purpose of questioning patients is the development of quality. It is, therefore, important to ask for the significance of the results, and it has to be determined through which appropriate measures the quality of nursing can be improved and further developed. This measuring instrument has proved to be sound. A clear strong/weak profile could be presented. A final judgement of the validity and reliability of the instrument can, however, not be made today and should be subject to further studies.

[Psychological distress and quality of life in COPD-patients and their spouses]. / Psychische Belastung und Lebensqualität bei COPD-Patienten und bei deren Partnern.

OBJECTIVE: To investigate psychological distress, quality of life, and satisfaction with medical support of patients with COPD and their spouses. METHOD: Questionnaires concerning psychological distress and quality of life were sent by mail to 97 patients and 54 spouses (43 couples). RESULTS: We found increased scores of anxiety and depression. In terms of quality of life the patients reported significantly lower scores than their spouses. Patients as well as their spouses reported a high satisfaction about the given medical support. CONCLUSION: Spouses of COPD patients are at increased risk for psychiatric morbidity und should therefore be included regularly in care programs.

[Shared decision-making and individualized goal setting - a pilot trial using PRISM (Pictorial Representation of Illness and Self Measure) in psychiatric inpatients]. / «Shared decision making¼ und individualisierte Therapiezielsetzung - eine Pilotuntersuchung mit PRISM (Pictorial Representation of Illness and Self Measure) bei stationären Psychiatriepatienten.

BACKGROUND: Although there is much talk about shared decision making and individualized goal setting, there is a lack of knowledge and knowhow in their realization in daily clinical practice. There is a lack in tools for easy applicable tools to ameliorate person-centred individualized goal setting processes. METHOD: In three selected psychiatric inpatients the semistructured, theory driven use of PRISM (Pictorial Representation of Illness and Self Measure) in patients with complex psychiatric problems is presented and discussed. RESULTS: PRISM sustains a person-centred individualized process of goal setting and treatment and reinforces the active participation of patients. The process of visualisation and synchronous documentation is validated positively by patients and clinicians. The visual goal setting requires 30 to 45 minutes. CONCLUSIONS: In patients with complex psychiatric illness PRISM was used successfully to ameliorate individual goal setting. Specific effects of PRISM-visualisation are actually evaluated in a randomized controlled trial.

[Are there associations of health status, disease activity and damage in SLE patients?---Results of a study of a cohort of a Swiss specialized outpatient clinic]. / Gibt es Zusammenhänge von Lebensqualität/Gesundheitszustand und Krankheitsaktivität resp. Krankheitsschädigung bei SLE-Patienten? Resultate einer Kohortenstudie eines Schweizer Rheumatologen.

AIM: To study the relationship between self assessed health status of patients with Systemic Lupus Erythematosus (SLE), lupus activity, damage, patients' age and disease duration in a cohort of a Swiss specialized outpatient clinic. PATIENTS AND METHODS: A cross sectional study of 38 patients fulfilling the classification criteria for SLE. The patients visited a rheumatology outpatient clinic in Switzerland between January 2002 and December 2004. The last assessment during this period was used for the study. The assessment included, besides demographic data, the measurement of disease activity using the BILAG index, the measurement of disease damage using the SLICC/ACR damage index (SDI), as well as the patient's self assessed health status using the patient's questionnaire Medical Outcome Survey Short Form 36 (SF-36). RESULTS: A total of 36 women and 2 men were included in the study (median age: 43 yrs, median disease duration: 11 yrs). Increased disease activity (total BILAG) was shown to be significantly correlated with reduced physical function. A greater damage (total SDI) correlated significantly with reduced role function due to emotional limitations. Neither age nor disease duration showed any significant correlation with health status in this study. CONCLUSION: The present study, which is based on internationally accepted assessment tools for SLE patients, shows a significant relationship between increased disease activity and reduced physical function. This result emphasizes the importance of optimizing treatment aiming at reducing disease activity.

[Prevalence of anxiety and depression in cancer outpatients and their spouses]. / Prävalenz von Angst und Depression bei ambulanten Krebspatienten und deren Angehörigen.

OBJECTIVE: To assess prevalence rates of anxiety disorder and depression in patients and their spouses treated in a cancer outpatient clinic of a university hospital. Also the distress-thermometer (DT) was tested as a screening instrument for anxiety disorders and depression. METHOD: 109 patients with different cancer types of different stages as well as their 109 spouses were assessed by questionnaires. RESULTS: In the patient sample anxiety levels were increased in 24.7% and in 20.2% for depression. In spouses anxiety levels were increased in 41.0% and in 21.6% for depression. Female spouses had higher anxiety levels than male spouses (p < 0.01); increased anxiety levels were found in 48% of the female spouses. In the patients sample the distress-thermometer has good values for sensitivity [0.93 (anxiety); 0.82 (depression)] and satisfying measures of specifity [0.68 (anxiety); 0.62 (depression)]. CONCLUSION: Female spouses of cancer patients are at increased risk for psychiatric morbidity, a fact that should be considered in future oncological care. The distress-thermometer is a simple, time saving and sensitive screening instrument to assess psychiatric morbidity in cancer patients, which can be recommended for clinical use.

[Therapy of anxiety disorders in family practice]. / Die Therapie von Angsterkrankungen in der hausärztlichen Praxis.

A treatment algorithm for anxiety disorders in primary care practice is introduced. Anxiety is understood as a complex pattern which consists of thoughts, emotions, behaviour and physiologic reactions. Patient education is outlined as a crucial factor for the management of anxiety. Some examples of patient education are given. The most important pharmacological agents for the treatment of anxiety are benzodiazepines, antidepressants and buspirone. The drug treatment of some common anxiety disorders is presented. Finally the limits of anxiety management in primary care are discussed and some techniques of cognitive behaviour therapy are outlined.

[Diagnosis of depression in general practice]. / Diagnostik der Depression in der allgemeinärztlichen Praxis.

About 10 percent of all patients in general practice suffer from a depression. In about one half of these cases depressive syndromes remain undetected by the physician. Common leading symptoms in these undiagnosed patients are: pain, rapid exhaustion, irritability and sexual problems. Depressive episodes in women are twice as frequent as in men. Furthermore, chronic diseases, chronic pain symptoms, addiction problems as well as recent, psychologically burdening events increase the risk for a depression. If anamnesis or clinical investigation are suggestive for a depression, the patient should be explored systematically with respect to his symptoms. Main symptoms of a depression are depressed mood, loss of enthusiasm and joyfulness as well as depressed motivation and increased fatigability. Further common symptoms are reduced self-confidence, unfounded self-accusations, suicidal thoughts, reduced ability to concentrate, hyperagitation or psychomotor restriction, sleeping disorders as well as loss of appetite. Since depression can be positively influenced by antidepressive drugs or suitable psychotherapeutic methods, early diagnosis by the physician is of decisive importance.

PRISM: Pictorial Representation of Illness and Self Measure. A brief nonverbal measure of illness impact and therapeutic aid in psychosomatic medicine.

The burden of illness is important for patients but complex and difficult to describe, let alone measure. A novel instrument is described that, according to preliminary data, measures what in German is termed Leidensdruck--the perceived burden of suffering due to illness. The measure--Pictorial Representation of Illness and Self Measure (PRISM)--takes less than 5 minutes to complete and is unusual in relying only minimally on language. The PRISM is being developed as a research tool and has been used effectively in routine clinical practice. To illustrate the latter application, three case vignettes are presented, demonstrating how the PRISM can enhance the patient's description and understanding of his/her illness and circumstances, facilitate patient-clinician communication, and help to monitor salient changes with treatment.

[The significance of somatic and psychosocial factors for coping with illness by patients with multiple sclerosis]. / Die Bedeutung somatischer und psychosozialer Faktoren für die Krankheitsverarbeitung von Multiple-Sklerose-Kranken.

The coping behavior of 298 multiple sclerosis patients was assessed by means of a questionnaire. Despite more pronounced somatic complaints, women view their psychological situation more positively than men; they are more optimistic, less anxious, less depressed, and less preoccupied with their illness and its consequences. In the event of reduced working capacity due to the disease, men are more frequently disabled than housewives. However, there is evidence that early disability compensation may have a negative effect on the psychological well-being and the coping behavior. Careful thought should therefore be given to the timing when the question of a pension is discussed.

Graphic representation of illness: a novel method of measuring patients' perceptions of the impact of illness.

BACKGROUND: Health outcome is multi-faceted, and for both research and clinical practice, greater knowledge of its facets is required. The Pictorial Representation of Illness and Self Measure (PRISM) was developed as a simple, rapid measure of the current impact of illness and symptoms on the individual. METHODS: The PRISM task was completed by 26 outpatients with rheumatoid arthritis participating in a larger study of psychosocial correlates of arthritis, which included assessment of disease variables, functional impairment, pain, depression and patients' appraisals of their illness. In the PRISM task, the patient was asked to imagine that a small board represents his/her life and a fixed disk on the board represents his/her 'self'. The task was to place another (Illness) disk on the board to represent the current importance of illness in the patients' life. The main outcome measure was the distance between the Self and Illness disks. FINDINGS: Only 2 patients had difficulty understanding the task. PRISM distance did not correlate with any disease variables. It correlated inversely with pain, functional impairment and depression, and positively with coping resources. PRISM distance correlated with perceived control over illness and negatively with awareness of illness. INTERPRETATION: PRISM is an innovative measure, simple and well accepted by patients. It appears to measure what in German is termed leidensdruck, the burden of suffering due to illness. It offers a promising measure of an intangible but important health outcome, hitherto neglected, applicable to research interventions and clinical practice.

Antonovsky's sense of coherence: trait or state?

BACKGROUND: The aim of this study was first to analyze the stability of Antonovsky's Sense of Coherence (SOC) as a measure of a person's world view over time; secondly, to investigate its relationship with depression and anxiety. METHODS: Data from two longitudinal studies were used: a study of severely injured accident victims (n = 96), and a study of patients suffering from rheumatoid arthritis (RA, n = 60). The 13 items short version of the SOC scale and measures of depression and anxiety (Symptom Checklist, Hospital Anxiety and Depression Scale) were administered repeatedly over 6-12 months in both studies. RESULTS: In the sample of accident victims, a significant decrease in the SOC mean score was observed during the first half year after the accident. During the same time period, symptoms of anxiety and depression decreased significantly. In the second half year after the accident, SOC as well as measures of psychopathology remained stable. RA patients showed high stability of SOC and measures of anxiety and depression over time. In both samples, between-time correlations of SOC scores were high (r > or = 0. 70, p<0.01), indicating a high test-retest stability of SOC. Furthermore, in both samples, significant negative correlations of a moderate to high degree (r = -0.28 to -0.73, p<0.01) were found between SOC and measures of anxiety and depression. CONCLUSIONS: SOC can be seen as a relatively stable (trait) measure. However, traumatic events such as life-threatening accidents may change a person's world view and thus their SOC, even if psychiatric symptoms abate. This suggests that SOC is not merely a proxy measure of psychopathology, but rather a partially independent, general measure of a person's world view.

[Effect of inpatient treatment on pulmonary findings and subjective well-being of patients with chronic bronchitis]. / Einfluss einer stationären Behandlung auf die pulmonale Befunde und die subjektive Befindlichkeit bei Patienten mit chronischer Bronchitis.

In a prospective study, inpatient therapy results (mean duration of hospitalization 27.3 days) has been assessed in 70 patients with COPD (mean age 62.4 years). Therapeutic success was observed in the objective pulmonary parameters (an increase of FEV1 from 50.5% to 57.6%, p < 0.001) and an increase in PaO2 from 7.7 kPa to 8.5 kPa (p < 0.001) as well as an improvement in life quality established by questionnaire. The best pulmonary results were achieved by patients with least pulmonary obstruction and by those with subjective well-being on entry. Women and younger patients experienced the biggest improvement in life quality. Furthermore, there was a correlation between coping with chronic bronchitis and subjective well-being. Importantly, no correlation between changes in the objective pulmonary parameters and changes in well-being was observed; a finding which puts in question the previous rating of inpatient therapy success in COPD.

[Postcoital uterine microbe colonization and endometritis in the mare]. / Die postkoitale uterine Keimbesiedlung und Endometritis bei der Stute.

In the mare, natural breeding is associated with bacterial contamination of the reproductive tract. The purpose of this study was to examine postcoital bacterial contamination and the resulting inflammatory response of the uterus. Uterine swabs for bacteriological and cytological examination were obtained from 80 mares. Each mare was sampled once between 4 and 69 hours postbreeding. In mares which did not conceive, sampling was repeated at the following estrus. The findings were compared with those obtained prior to breeding and correlated with the breeding outcome. Bacteria were cultured from 72.5% of the postcoital swabs. There was a wide spectrum of organisms which included species known as potential causes of endometritis. Neutrophilic granulocytes were found in varying concentrations in 48.8% of cases. In 16.3% of mares both bacteriological and cytological examinations were negative. Mares with positive bacteriological and/or cytological results at the postcoital examination had better foaling rates compared to the remaining mares (p less than 0.05). The postcoital findings did not correlate with those of the prebreeding examination, or with the interval between breeding and sampling, or with the different stallions.