[Bernhard von Gudden's psychiatric assessment and the deposition of King Ludwig II of Bavaria in 1886 : Comments on the article by R. Steinberg in Der Nervenarzt 01/2019]. / Das psychiatrische Gutachten Bernhard von Guddens und die Entmachtung König Ludwigs II. von Bayern 1886 : Ein Kommentar zum Beitrag von R. Steinberg in Der Nervenarzt 01/2019.

King Ludwig II of Bavaria drowned himself in Lake Starnberg on 13 June 1886 after subduing and drowning Bernhard von Gudden, a Munich-based psychiatrist who had tried to hold him back. Commissioned by Prince Luitpold, Ludwig's successor to the throne, von Gudden had provided a psychiatric assessment on the king. Finding him to be suffering from a progressive mental illness and paranoia (madness), he declared Ludwig incapable of ruling. On the basis of this report Ludwig was unlawfully declared incapacitated, deposed, arrested and locked up in the Berg Castle under von Gudden's medical supervision. We conducted a 5-year psychiatric historical study of King Ludwig II, the most thorough of its kind ever undertaken. The main results were: the private, official and political letters the king wrote until his very last day were reasonable, well-argued and impeccable in style. Until his final days Ludwig had invariably fulfilled his administrative tasks in a prompt and proper way. His handling of political affairs was also wise and reasonable. Due to social phobia afflicting him since his youth he neglected his representative duties as a monarch. Von Gudden's report is marred by severe flaws. In his article published in Der Nervenarzt (01/2019) R. Steinberg adopts von Gudden's psychiatric diagnosis and misjudgement. Steinberg writes that the king's illness developed "in a clear crescendo". In fact, it was the behavioral anomalies associated with the king's homosexual relationships that grew increasingly prevalent at the court, whereas Ludwig's mental efficiency improved over time. Given the historical misjudgment and numerous other errors that Steinberg adopts from von Gudden, I considered it necessary to compare and contrast his conclusions with results from our own research.

Surgical treatment of hidradenitis suppurativa: an analysis of postoperative outcome, cosmetic results and quality of life in 255 patients.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease with increasing incidence. Severe disease stages are seen as a therapeutic challenge and pose the threat of significant restrictions on patients' life quality. OBJECTIVES: We evaluated postoperative outcome after wide local excision for HS as well as postoperative course, cosmetic results, disease recurrence and quality of life. METHODS: All patients receiving radical surgical treatment for HS (Hurley III) between 2006 and 2015 were identified and received a letter-based survey. They were asked about postoperative course, cosmetic results, recurrence and life quality. RESULTS: Two hundred and fifty-five patients (103 men, 152 women) answered the questionnaire. Ninety-five percentage of patients reported disease-specific restrictions on everyday life. Seventy-five percentage of patients did not experience any postoperative adverse events; however, postoperative pain with need for analgesics was reported in 38%. The majority of patients (80%) were very satisfied or satisfied after surgery, and 85% of patients would recommend surgery to other affected persons. LIMITATIONS: The retrospective design of the study was a limitation. CONCLUSIONS: The well-known negative psychological and social effects are a relevant part of HS and emphasize the importance of immediate therapy. As long-lasting local disease-control can be achieved, surgery should be considered as first-line therapy.

[A new optoelectronic measuring device for assessment of leg circumference in comparison with manual measurement]. / Ein neues optoelektronisches Messinstrument zur Erfassung von Beinumfängen im Vergleich zur manuellen Massbandmessung.

For compression treatment to be effective in patients with chronic venous insufficiency, it is vital that leg circumference be measured accurately. If compression stockings are custom fit and appropriate for the medical indications, patient compliance will be high. Exact measurements of circumference and length are prerequisites for a good fit. The aim of the present study was to compare an opto-electronic device for the contact-free measurement of calf circumference with the conventional manual method using a tape measure. We investigated the differences between the results obtained with the two methods, and also their reproducibility. Circumferences were measured at defined heights on an anatomically shaped non-yielding leg model and on the leg of a healthy volunteer by 10 different experimenters both with the tape measure and with the opto-electronic device. The calf circumferences measured manually with the tape measure varied significantly more than those measured opto-electronically, both in the leg model and in the leg of the volunteer. A systematic error in the opto-electronic method appears unlikely, since the manual measurements on the leg model were both larger and smaller than those obtained with the opto-electronic device. Reproducibility was exceptionally high with the opto-electronic device (standard deviation 0.11-0.42 cm). The opto-electronic method yields rapid accurate measurements of circumference with excellent intra- and inter-operator reproducibility.

Influence of an infectious disease service on antibiotic prescription behavior and selection of multiresistant pathogens.

BACKGROUND: A routine infectious disease service was established in January 1998 in order to optimize the antibiotic usage and prescription pattern of a neurologic intensive care unit (NICU). METHODS: Treatment guidelines for the most prevalent infections were implemented and individual antibiotic regimes were discussed at the bedside with infectious disease experts. RESULTS: This interdisciplinary cooperation reduced the total number of antibiotics prescribed by 38.1%, from 7,789 in 1997 to 4,822 in 1998, without compromising patient outcomes (mortality rate: 22/313 patients in 1997 vs. 32/328 patients in 1998). Total patient days (2,254 days vs. 2,296 days) and average length of stay in the NICU (7.2 days vs. 7.0 days) were comparable. Antimicrobial expenditure decreased by 44.8% (71,680 Euros in 1997 vs 39,567 Euros in 1998). Taking into account the costs for the infectious disease service (approximately 8,000 Euros in 1998), a total saving of 24,113 Euros was made. The dramatic reduction in antibiotic usage (mainly of carbapenems) resulted in a statistically significant decreased isolation of Stenotrophomonas maltophilia (p<0.05), Enterobacter cloacae (p<0.05), multiresistant Pseudomonas aeruginosa (p<0.05) and Candida spp. (p<0.05), without any change in the infection control guidelines. CONCLUSION: These data show that an infectious disease service can optimize and reduce antibiotic usage. This results in a decrease in the occurence of multiresistant gram-negative pathogens and Candida spp. in intensive care units and, at the same time, saves costs.

[A quarter of a century of rehabilitation of psychiatric patients in Germany]. / Ein Vierteljahrhundert Rehabilitation psychisch Kranker in Deutschland.

The past quarter of a century marks the first and decisive phase of mental health care reform in Germany and of psychiatric rehabilitation throughout the world. During this great awakening, psychiatry passed beyond the custodial system of care, where potent therapy instruments were lacking and the connection to society, its living standard and progress in medicine had been lost. In Germany, the crucial step to modernity was taken with the creation of the Expert Commission on Mental Health Care in 1970 to 1975. The birth hour of rehabilitation followed the insight produced by Wing and Brown in 1970 and Wing and Bennett in 1972 that secondary impairments caused by social deprivation during long-term hospital stay can be favourably influenced by means of rehabilitation programmes. Inspired by the Expert Commission's report, and encouraged further by the recommendations of the Central Institute of Mental Health for the State of Baden-Württemberg (1987) and of an expert commission for the Federal Republic of Germany (1988), the Federal, State and Local governments as well as public welfare organizations supplied considerable funds for the development of services and programmes aimed at the reintegration of the chronically mentally ill and disabled. Job centres, health insurance schemes and retirement pension schemes as paying authorities had greater difficulties in contributing to the development of a functioning system of rehabilitation services for the severely socially disabled mentally ill. Not only the costs were involved but also the complexity of the needs for rehabilitation and confusion about the definition of the measures and about the distinction from basic needs. The needs, objectives and instruments of psychiatric rehabilitation are discussed within the context of the present financial situation. In view of the current perspectives of decreasing financial and human resources in our society, humanitarian and social responsibility for the particularly vulnerable and distressed group of the mentally ill and disabled is called for.

[Motor potentials evoked by magnetic stimulation--a tool for objective assessment of motor conduction along the spinal cord and its roots].

Magnetic stimulation of the motor cortex and nerve roots in conjunction with F-wave recording was used for assessment of central and peripheral motor conduction times in 98 patients suffering from myelopathy and cervical or lumbo-sacral radiculopathy. Significant prolongation of the central motor conduction times was found in the myelopathy group. The Motor Evoked Potential was of low amplitude and distorted shape. The amplitude of the F-wave was markedly increased. The main feature of the radiculopathy group was prolonged motor root conduction time as evident by delayed F-wave. Motor evoked potentials proved to be a reliable objective tool in the functional evaluation of conduction along the spinal cord and its roots.

Methodological aspects of onset assessment in schizophrenia.

Psychiatric disorders in general and schizophrenia in particular often begin with a prodromal phase progressing into more specific syndromes long before the first treatment contact. More longitudinal studies on course and outcome of schizophrenia begin with first hospital admission not taking into account the preceding early course. The reason for this is the unsurmountable difficulties in observing and assessing real onsets with unspecific symptomatology directly and collecting a sufficient number of 'precontact' cases of rare diseases in the general population. There are in principle two practical ways of assessing time and type of onset and the early course of schizophrenia: the application of a screening procedure for establishing a prospective approach, e.g. the study of individuals at high risk for schizophrenia, and the retrospective assessment of the preceding course carried out at first treatment contact. Methodologically both strategies share the same problems, especially recall bias. In a comprehensive discussion of methodological issues ways are described to reduce and even control recall deficits by using appropriate techniques (standardised assessment with the IRAOS, the 'Interview for the Retrospective Assessment of the Onset of Schizophrenia'; time grids; interval assessment, comparison of independent sources of information etc.). A representative sample of 232 patients with a first episode of schizophrenia were selected from the 276 first admissions of the ABC schizophrenia study taken from a German population of 1.5 million. Results are represented for the crucial questions: when, how and with what symptoms does schizophrenia begin and how does the disorder develop up to the first admission? For example, the gender-specific mean age at different points in time during the development of the disease is presented, and the sequence and cumulation of symptoms in the early course examined. Additionally, the consecutive fulfillment of DSM-III criteria sets for schizophrenic and schizophreniform disorders are presented along with the frequency of different types of onset in schizophrenia.

Symptom assessment in casenotes and the clinical diagnosis of schizophrenia.

It is well known from several international studies that the incidence rates for schizophrenia, based on first-admission samples, are low in Denmark, especially in females, compared with other countries. This might be due to special diagnostic traditions in Denmark. To analyze how Danish psychiatrists reach a diagnosis of schizophrenia, a stratified subsample of 122 cases out of all 1,259 patients, aged between 12 and 64 years, with a first hospital admission in 1976 under the diagnosis of schizophrenia, paranoid psychosis, acute reactive paranoid psychosis, or casus limitaris was selected. For this subsample, psychopathological symptoms, as documented in the clinical casenotes, were rated by PSE-9 symptom lists for subsequent CATEGO analysis. The core syndrome of schizophrenia, as defined by the CATEGO class S+, showed no association with the clinical schizophrenia diagnosis compared with the other diagnoses mentioned. Also, positive symptoms of schizophrenia did not determine the diagnosis, but for typical negative symptoms such associations were indicated. Some negative symptoms also seemed to be linked to a depressive state. Furthermore, the present work indicates that using first-admission data leads to a higher age at schizophrenia onset and a lower first-admission rate in Denmark compared with Germany.

IRAOS: an instrument for the assessment of onset and early course of schizophrenia.

Since Kraepelin's first description of dementia praecox in 1889 many data and theories have been published on the onset and course of schizophrenia. Until now studies on these topics had to rely on first admission data and on the subsequent course of the disease. However, first hospitalisation is preceded by a wide variety of patterns and duration of the early course. Items taken from the pre-admission phase of the disease are often incorrectly used as premorbid characteristics, understandably preceding the subsequent course and outcome of schizophrenia with high predictive power. In relation to our interest to study the beginning of schizophrenia, systematically, paying special attention to the age and gender distribution of true onset and the symptomatology and pattern of the early and later course, we developed an 'Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS)'. It allows an objective, reliable, and valid assessment of the symptoms, psychological impairments, demographic and social characteristics as well as the referring points in time of the early course of psychosis. The instrument is administered as a semi-structured interview with both the patient and a key informant. The obtained information is extended by a systematic examination of the clinician's case notes. Some results derived from an ongoing study on age and gender differences in onset and patterns of early course are added to demonstrate the use of the instrument.

[Trends in the number of patients with senile dementia and need for nursing care in the upcoming 50 years--a demographic projection based on epidemiologic data for former West Germany]. / Die Entwicklung der Anzahl von Altersdemenzkranken und Pflegebedürftigkeit in den kommenden 50 Jahren--eine demographische Projektion auf der Basis epidemiologischer Daten für die Bundesrepublik Deutschland (alte Bundesländer).

According to population projections there will shortly be an increase in the number of aged people. Since these population groups show a high risk to develop old age dementia and because this sickness goes along with the need of care, it is necessary for planning future needs of buildings and funds to know about the extent of expected dementia and the number of people needing care. Based on population projections up to the year 2040 for the (West) German Länder of the Federal Republic of Germany and based on four epidemiological studies, we developed a model to project empirically the number of dementia cases for the next 50 years. This model is based on an exponential growth of prevalence with increasing age. According to our estimates the number of patients with severe and moderate dementia will rise by about 50% from 1990 until 2040. The expected number of people needing care is estimated to facilitate prospective planning as well as timely provision of adequate financial and personnel resources.

Evaluating effectiveness and cost of community care for schizophrenic patients.

The two main types of mental health services research are (1) the evaluation of the mental health sector within comprehensive systems of health care and (2) the evaluation of individual mental health facilities or types of care. Depending on the information systems available, the difficulties of evaluating complex systems of care can be partially obviated by using descriptive approaches. Structural quality can be assessed by structural indices, the functioning of a system by monitoring utilization, and the overall effectiveness of a national mental health care system roughly by health indicators. Causal analyses of effectiveness are practical when they are based on individual facilities or types of care, which can be studied as isolated systems on the basis of intervention and outcome variables. Reliable and reproducible results can be achieved only if a standardized intervention is used or if the intervention and its objectives are described clearly, the output indicators are defined in terms of identifiable and repeatable operations. The assets and liabilities of quasi-experimental designs and three types of naturalistic approaches will be discussed. When the cost of a new type of care is compared with the cost of traditional mental health care, the section of the population actually served out of the total of patients with comparable needs for care should be considered. Results from the authors' studies will show how the neglect of this epidemiological aspect can lead to false statements.

[A computer algorithm for diagnostic assessment with DSM-III in the early course of schizophrenic diseases]. / Ein Computer-Algorithmus zur Diagnosevergabe nach DSM-III im frühen Verlauf schizophrener Erkrankungen.

The purpose of the computer algorithm described here is the evaluation of diagnostic criteria according to DSM-III for schizophrenia and schizophreniform disorders. It also dates the first time point of the assessment of these diagnoses. The necessary information comes from a semistructured interview, called IRAOS (Interview for the Retrospective Assessment of the Onset of Schizophrenia). With this interview early indicators of a beginning schizophrenia can be evaluated in their chronological order and their type of course. The algorithm was first used in a sample of patients admitted for the first time with a diagnosis of either schizophrenia or paranoid psychosis. One third of these patients fulfills the DSM-III-criterion of a duration of at least six months. The other patients fulfill criterion B of a schizophreniform disorder. To strengthen the validity of a diagnosis including the criteria A up to E successively, the sample is reduced to 70%. The average time point of the first assessment of the diagnosis by the computer algorithm is about 1.5 years before the index-admission. Together with the IRAOS the computer algorithm allows an operationalized assessment of the real onset of schizophrenia.

The evaluation of mental health care systems.

While the demand for deinstitutionalization, strongly supported by the economic aspect of the issue, has resulted in a steep decline in the number of psychiatric beds in many Western countries, the evaluation of extramural psychiatric care has several difficulties, including that of proving effectiveness without experimental control of confounding influences. For a cohort of schizophrenic patients we investigated the impact of out-patient psychiatric treatment on length of stay in hospital and length of stay in the community. Out-patient care had a significant influence on readmission, but no effect on the length of in-patient treatment. While the average cost of community care was less than half that of traditional hospital care, in 6% of the patients this threshold value of continued in-patient care was exceeded. There also seems to be a non-monetary threshold, above which community care is no longer appropriate.

Effectiveness and cost of community care for schizophrenic patients.

Schizophrenic patients in Mannheim, West Germany, were studied to determine whether psychiatric treatment in the community reduces duration and frequency of rehospitalization, whether it has an impact on symptomatology and behavior, and whether it can be provided less expensively than hospital care. The findings showed a relationship between increased psychiatric outpatient treatment and lower levels of inpatient care as well as between psychiatric aftercare and reduced symptomatology and disease-related behavior. The cost of community care was found to be substantially lower than that of hospital care for less disabled patients, but it exceeded the cost of hospital care for the more severely disabled.

[Does unemployment cause illness? A review of the status of knowledge of the correlation between unemployment, physical and psychological health risks]. / Macht Arbeitslosigkeit krank? Ein Uberblick über den Wissensstand zu den Zusammenhängen zwischen Erwerbslosigkeit, körperlichen und seelischen Gesundheitsrisken.

Unemployment appears to be a complex condition that burdens the individuals affected in multiple ways both at job loss and in long-term unemployment. To a lesser extent unemployment may also relieve the stressors and risks associated with the place of work. The scope and nature of the burden experienced depends on individual factors, such as mental stability and coping resources, on economic, social and cultural factors, such as availability of alternative roles, system of social security and social context. In the industralized countries, especially in the Federal Republic of Germany, financial security and society's attitudes towards unemployment are less unfavourable than during the economic recession between the two world wars. Nevertheless, household income should not be overlooked as an important factor leading to stress beyond a certain threshold. In this respect it is noteworthy that the income of the unemployed households in the Federal Republic of Germany decreased by 8% between 1981 and 1983 (Brinkmann, 1986). Quantitative relationships between unemployment and physical health have frequently been reported. In studies whose designs allow such associations to be explained selection factors, i.e. an overrepresentation of frequently or chronically ill and disabled individuals among those losing their jobs and the long-term unemployed, contribute to the increased morbidity among the unemployed to a considerable extent. Causal relationships between unemployment and physical health risks have not yet been proven directly, which does not mean that there are none. The mediation of health risks by changes in behaviour during unemployment which as such might lead to or reduce morbidity and mortality risks has not yet been studied sufficiently. Unemployment appears to have both an increasing and a reducing effect, but also no effect at all on the use of alcohol and tobacco in different populations. But we do not yet know enough about the mechanisms bringing about these effects. There are more consistent findings indicating that sustained unemployment influences personal well-being. This influence is reflected primarily in unspecific physical complaints and mild or moderately severe depressive changes of mood. The most important finding of increased health risks in the unemployed versus the employed are elevated rates of suicide and attempted suicide. This finding, too, seems to be attributable to selection factors, i.e. predominantly to an overrepresentation of mental disorders and substance abuse associated with an increased suicide risk among job-losers.(ABSTRACT TRUNCATED AT 400 WORDS)

[Need for social psychiatric services--a management model in scientific evaluation]. / Zur Notwendigkeit Sozialpsychiatrischer Dienste--Ein Versorgungsmodell in der wissenschaftlichen Erprobung.

Social-psychiatric services have for a long time been a focus in the controversial discussion about the further development of outpatient mental health care. Presented is the Baden-Württemberg Social Psychiatric Services model, which is oriented towards outpatient social welfare provision of persons with chronic mental illness, complementing the medical-psychiatric treatment provided by office-practice psychiatrists. Evaluation of the Social Psychiatric Service for its first year of full operation, 1984, has shown that this type of service delivery organization is capable, above all, of reaching persons with "recently" chronic mental illness, who are serviced in the framework of community mental health care systems mainly on an outpatient basis. Provision of care, i.e. of social welfare and counselling measures, may in this group constitute an efficient contribution towards their social rehabilitation. Effective functioning of this organizational model presupposes sufficiently well-established cooperation with other facilities and services involved in service provision, which, as the Baden-Württemberg trial has shown, can in actual fact be ensured.

Patterns of mental health care in two European areas: Mannheim, Federal Republic of Germany; and Groningen, The Netherlands.

All consecutive cases entering the mental health services cooperating with the cumulative psychiatric case register of Mannheim between 1-31 July 1976 were followed up until the end of June 1978 and compared with the consecutive cases entering the mental health services cooperating with the psychiatric case register of Groningen between 1 January and 1 May 1979. Patterns of in-, day- and outpatient care delivered to these 2 cohorts of patients, who were greater than or equal to 15 years of age, and who had not been in contact with one of the services for at least 6 months prior to entry, were compared by diagnostic category. The most common episode of care was the relatively brief outpatient one. Mixed types of care and chronic cases were more common among patients with a psychosis or an addiction than in other diagnostic categories. Between 6 and 24 months after first contact 76% of the patients in Mannheim and 43% of the patients in Groningen had no more contacts. Between 18 and 24 months after the first contact the percentages had increased to 90 and 72% (respectively). In Groningen a higher percentage of patients received outpatient care only. Although a larger percentage of patients in Mannheim received inpatient care, the accumulation of "new chronic" patients was larger in Groningen, as a result of a greater length of stay in Groningen.

Do we still need beds for psychiatric patients? An analysis of changing patterns of mental health care.

While the utilization of outpatient psychiatric care increased steeply in the last few decades, the number of beds in psychiatric hospitals declined continuously in most countries. The future need for psychiatric hospital beds is influenced by changes in psychiatric morbidity, the range of services offered by mental hospitals and the availability of alternative forms of care for the chronically ill. A prospective cohort study conducted in Mannheim showed that currently, at a favourable standard of complementary service provision, one quarter of the schizophrenic patients requiring institutional care for more than one year - schizophrenics are the largest group of mental patients in need of long-term residential care - still need to be treated in mental hospitals. Beyond this threshold value the costs of alternative care exceed those of a continuous inpatient treatment, and, concurrently with them, the burden upon the people involved grows. Estimates of the future need can be made on the basis of field surveys, utilization data of a population and an analysis of long-term trends by using case register data. Provided a well-functioning system of alternative and outpatient mental health services is available, psychiatric bed ratios covering the actual needs in developed countries seem to range from 0.5 to 0.8 per 1000 population over 15 for the short-stay group and from 0.3 to 0.6 per 1000 for long-stay patients. The uncertainty inherent in the estimates requires a sufficient degree of flexibility in service planning and a continuous monitoring to make adjustments to changed conditions possible.