Cluster-randomized controlled trial of dissemination strategies of an online quality improvement programme for alcohol-related disorders.

AIMS: This project investigated different dissemination strategies of an online quality improvement programme for alcohol-related disorders into routine care in South Baden and South Württemberg in Germany. METHODS: In a cluster-randomized controlled trial, 112 general practices were randomized into three groups. The first group (n = 43) received access to the online system and a training programme for the general practitioners (GPs). The second group (n = 42) additionally received education for the whole practice team. The third group (n = 27) acted as control and received only access to the online system. RESULTS: Two thousand six hundred and forty-seven practitioners were asked to take part in the study, and it was possible to randomize 112 (4%) practices. There were no significant differences concerning the use of the system between the groups: 41.9% of the GPs in the first group, 42.9% in the second group and 44.4% in the control group used the system. In terms of only the system users, 55.6% of the GPs in the first group, 33.3% in the second group and 8.3% in the control group used the system six times or more (P = 0.019). Diagnostic assessments made by the GPs in the groups differed substantially: 72.2% of diagnoses in the first group were correct, while this figure lay at 69.7% in the second group and 36.4% in the control group (P = 0.034). CONCLUSIONS: No effect of the additional training on the primary outcome (acceptance) was identified, but on two of the secondary outcomes. Further cost-effectiveness studies should investigate whether the effort involved in providing training additionally to the system is justifiable. The study is registered at ClinicalTrials.gov: NCT00314067. This article conforms to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement (Moher et al., 2001; Campbell et al., 2004).

[Evidence-based therapy of depression: S3 guidelines on unipolar depression]. / Evidenzbasierte Therapie der Depression: Die S3-Leitlinie unipolare Depression.

Unipolar depressive disorders are among the most frequent reasons for utilizing the health care system. Although efficacious treatments are available and further advances have recently been made there is still a need for improving diagnostic and therapeutic procedures. Alignment of treatment on evidence-based treatment guidelines establishes an essential mainstay. The new S3 and National Health Care guidelines on unipolar depression, the compilation of which was coordinated by the German Society of Psychiatry, Psychotherapy and Neurology (DGPPN) and which were approved by 29 scientific and professional associations, is the ambitious effort to present state of the art evidence and clinical consensus for the treatment of depression. For pharmacotherapy of depression differentiated recommendations can be given, also separate from and in addition to psychotherapy.

[Ensuring safe medication in the physician's office]. / Arzneimittel-unsicherheit: Jede zwanzigste Verschreibung macht krank. Wie Sie das Risiko für lhre Patienten reduzieren.

The risk of adverse drug reactions can be appreciably reduced by limiting prescribing practice to a manageable number of medications, exercising restraint with regard to new drugs, and using a computerized system for the documentation of drug prescriptions. In order to further improve patient safety in this area appropriate efforts need to be made by medical self-administration, politicians and the computer industry to develop and apply computer-based prescription systems, with the additional requirement that their integration into existing doctor's office software should be simple and user-friendly, as well as free from "industrial contamination".

What do primary care patients think about generic drugs?

OBJECTIVE: To examine the attitude of patients towards generic drugs and prescriptions containing generic drugs as an alternative to brand-name products, with a special focus on information on patients attitude to generic drugs provided by their general practitioners (GPs). METHODS: A total of 804 patients in 31 general practices were surveyed using a self-questionnaire. The influence of age, sex, education, disease, knowledge of generic drugs, experience with generic substitution and information provided by the GP on patient attitudes towards generic drugs and substitutions were examined. RESULTS: Nearly two thirds of the patients (509/804) stated that they knew of the difference between brand-name drugs and generics; of these, one third were not satisfied with the information given by their GPs and 37% of patients expressed general skepticism towards generic drugs because of their lower price. This attitude was more frequent among those who felt that generic prescribing was "invented" to solve the financial crisis in the German health insurance system at their expense (odds ratio (OR): 6.2; 95% confidence interval: 4.0 - 9.8) and those who had not been confronted personally with a generic substitution (OR: 1.8; 1.3 3.0). Patients who had been skeptical when first confronted with a generic substitution were more frequently among those who considered inexpensive drugs to be inferior (OR: 4.5; 2.0 10.4) and they were frequently not satisfied with the information on substitution provided by their GP (OR: 2.7; 1.2 - 5.9). CONCLUSION: GPs are in an ideal position to inform their patients adequately about the equivalence of brand-name and generic drugs. However, the patient view that inexpensive drugs must be inferior may be difficult to rectify in the short term.

[Health-related quality of life in asthma patients from general practice]. / Gesundheitsbezogene Lebensqualität bei Asthmapatienten in der Hausarztpraxis.

OBJECTIVE: This study investigates health-related quality of life in asthma patients from general practices in comparison with a general population sample. It further examines the association between health-related quality of life, socio-demographic characteristics and smoking behaviour. PATIENTS AND METHODS: 838 asthma patients with a mean age of 47.8 +/- 16.3 years AND 66 % female participants from 83 general practices in the region of Göttingen and Freiburg/Germany completed the St. George's Respiratory Questionnaire (SGRQ), an instrument to assess health-related quality of life, and they completed questions on socio-demographic variables and smoking behaviour. SGRQ values were compared with estimates for the general population generated in Spain. The association between SGRQ and socio-demographic characteristics and smoking behaviour was analysed by multivariate linear regression models. RESULTS: The SGRQ total values for asthma patients were three times higher than in the general population sample corresponding to a higher level of restrictions in quality of life. Both in the general population sample and in asthma patients non-smokers had a better health-related quality of life than smokers, especially with respect to respiratory symptoms. In the multivariate analysis, socio-demographic characteristics and smoking behaviour were differently related to health-related quality of life. In smokers, the level of impairment by asthma symptoms was the higher the more they had smoked. Impairment in daily activities increased with increasing age and decreasing professional status. Increasing psycho-social restrictions were associated with higher age and lower educational level. CONCLUSION: Assessing health-related quality of life in its different dimensions enables the general practitioner to conclude on the individual impairment caused by the disease. This facilitates targeted therapeutic interventions. Results from this study underline once more that quality of life should be integrated as an additional clinical parameter in population-based analyses of health care use.

Antigen entry into early endosomes is insufficient for MHC class II processing.

Helper T-cell recognition of Ag requires that the Ag be processed and presented by class II-expressing Ag-presenting cells. Processing involves the introduction of Ag into acidic compartments where proteolysis occurs producing peptides that bind to the class II molecules. Although Ag can enter the processing pathway through fluid phase pinocytosis, Ag processing can be made over 1000-fold more efficient by binding the Ag to a variety of Ag-presenting cell surface structures. The increased efficiency in processing is presumably the result of the ability of such structures to deliver the bound Ag to compartments involved in processing. Here we report that Ag bound to the transferrin receptor (TfR), which cycles predominantly through early endosomal compartments, does not enter the processing pathway. We found that cytochrome c(c)covalently coupled to monovalent iron-saturated transferrin (Tf), (c-Tf), is not processed or presented significantly better than unconjugated c, indicating that the majority of cycling TfR does not enter compartments where processing proceeds. The conjugation of Tf to c does not affect its binding to the TfR, as the binding is both saturable and compatible with unmodified Tf. Moreover, c-Tf and unmodified Tf cycle equivalently with a t1/2 of internalization of 3 to 5 min and are released outside the cell with little detectable degradation. Significantly, we found that c-Tf is efficiently processed and presented when the TfR is cross-linked, altering its normal cycling. Indeed, c covalently coupled to polymerized Tf is presented at 1/100th the concentration of c alone. Cross-linking of c-Tf bound to the TfR using c-specific antibodies also results in efficient processing and presentation. Thus, the endosomal compartments through which Tf normally cycles are not sites of processing, whereas compartments into which cross-linked Tf is diverted allow efficient processing and presentation of Ag.

Campylobacter coli septicaemia associated with septic abortion.

A 19-year-old patient was 27 weeks pregnant when admitted to hospital with fever, chills and premature labours. The following day she aborted. Campylobacter coli was isolated from blood cultures, maternal placenta and amniotic fluid and from the ear, nose and pharynx of the stillbirth. Campylobacter could not be isolated from stool specimens after antimicrobial treatment had been started.

Time dependence of B cell processing and presentation of peptide and native protein antigens.

Th cell recognition of globular proteins requires the uptake and intracellular processing of the native Ag by an APC to produce a peptide fragment containing the T cell antigenic determinant, which is recognized in conjunction with Ia. This report describes the time course of the processing and presentation of a soluble globular protein Ag, pigeon cytochrome c (Pc), and of the presentation of a C-terminal peptide fragment of Pc, residues 81 to 104 (Pc 81-104), which does not require processing. Splenic B cells, acting as APC, require 6 to 8 h incubation with native Pc to process and present it to an I-Ek-restricted Pc-specific T cell hybrid, resulting in the secretion of IL-2. Moreover, the time required for B cells to process Pc is the same whether the Ag is taken up by nonspecific fluid phase pinocytosis or by binding to surface Ig. Once processed, Ag is lost from the B cell surface by 8 to 12 h, although when provided with fresh Pc, the same B cells are still capable of processing and presenting. In contrast to native Pc, only 1 to 2 h are required for the peptide fragment Pc 81-104 to become associated with B cells in a stimulatory fashion, and this time is similar for live and paraformaldehyde-fixed B cells, which cannot internalize or process the peptide. Washed free of excess peptide after 2 h, B cells lose their ability to stimulate T cells by 8 to 12 h, with a time course indistinguishable from that for the loss of processed native Pc. Prolonged incubation of B cells with the peptide for 18 to 24 h results in a dramatic loss of the ability to present Pc 81-104. Even when provided with fresh Pc or Pc 81-104, these cells have diminished ability to present these Ag. This loss is selective, inasmuch as these B cells remain equivalent to untreated B cells in the presentation of an unrelated Ag, OVA, to an I-Ak-restricted specific T cell. However, the ability to present another I-Ek-restricted antigenic peptide of the D glycoprotein of HSV to its specific T cell is also diminished. Loss of activity is observed after incubation only with the peptide and not with the native protein and is not due to a depletion of the antigenic peptide from the incubation medium.(ABSTRACT TRUNCATED AT 400 WORDS)

[Outcome of interactive training in detection and management skills for schizophrenic outpatient treatment by general practitioners]. / Früh- und Basisintervention bei Patienten mit schizophrenen Störungen. Ein interaktives und leitlinienorientiertes Trainingsprogramm für die Hausarztpraxis.

THEORETICAL BACKGROUND: Of all outpatients with a diagnosis of schizophrenia, 30-40% refuse a psychiatrist's care. For this group of patients the general practitioner holds a key position for such different tasks as detection of prodromal schizophrenia or early warning signs of relapse and identification of risk variables for deteriorating outcome, gatekeeping (referral to specialists or other services), integration, and counseling of key relatives. Fifty percent of GPs are interested in disease-specific medical education programs. STUDY DESIGN AND METHODS: A control trial examined the changes that participating GPs intended to make in three main topics of the curriculum: (1) changing attitudes (pessimistic outcome expectation, low self-esteem), (2) enhancement of detection skills (prodromal schizophrenia, early warning signs of relapse, and risk factors for poor social and vocational integration), and (3) enhancement of management skills (dosing schemes, motivational interviewing). RESULTS: In the assessment 2 weeks after the training session, we found significant changes in favor of the trained group in detection and management skills and also improved self-confidence of GPs. CONCLUSIONS: Problem-oriented and case-based learning strategies should be preferred to lectures in training programs for psychiatric skills in primary care.

[Implementation and evaluation of quality circles in general practice]. / Implementierung und Evaluation von Qualitätszirkeln in der hausärztlichen Versorgung.

In the beginning of 1993, society of panel doctors Südbaden, Germany, has constituted a group of experts from the Department of General Medicine of the university hospital and practising general practitioners (GPs) to develop an organisational and conceptional framework for setting up quality circles. At present, 23 quality circles with 6-12 participants are holding regular meetings every 4 to 8 weeks in the region of Südbaden. The group members, who are all physicians working in primary health care, are selecting and discussion topics which are important in general practice. In order to facilitate the discussions, the research group has developed predefined guidelines covering a wide range of common and important conditions in general practice (Hypertension, sleeping disorders, diabetes mellitus, COPD, dementia, lower back pain, cardio-vascular disease, depression, headache, vertigo etc). In presenting these structurized guidelines, the moderator prompts and encourage the group members to identify common problems in their own practices. The use of these guidelines in, quality circles and research may provide a starting point for developing consensus guidelines. The quality circle projects is given as systematic evaluation for both participants and moderators at different levels. Main objectives of the assessment are the recruitment, motivation and the specific goals of general practitioners to participate in quality circles. Currently, we are evaluating the development of quality circle for a period of 18 months.

[Guidelines for back pain]. / Leitlinie "Kreuzschmerzen" -- Eine evidenzbasierte Leitlinie der Deutschen Gesellschaft für Allgemeinmedizin und Familienmedizin.

Chronic back pain is one of our society's most important health problems, causing long periods of sick leave and early retirements. Recently the German Society of General Practice and Family Medicine (DEGAM) published an evidence-based guideline for low back pain. It has been developed according to the 10-step concept of guideline development of the DEGAM, aiming for early detection of complicated clinical conditions, avoidance of unnecessary diagnostic tests and prevention of chronicity. Complicated, uncomplicated and radicular pain are defined by patient history and a short clinical examination. Imaging and further diagnostic tests are reserved for patients at risk. Basic therapy consists of structured advice. The aim of the guideline is to get patients back to their usual activity supported by effective pain relief. Psychosocial factors which are important for the prognosis should be evaluated already during the first consultation. Manual therapy might help in acute pain. Patients with persistent pain symptoms and long periods of sick leave should be transferred to multiprofessional management including pain treatment, behavioural therapy and physiotherapy. A randomised controlled trial has been set up to study the efficacy of guideline implementation.

[Conception, implementation and evaluation of the new general medicine continuing education curriculum in Südbaden]. / Konzeption, Durchführung und Evaluation der neuen Kursweiterbildung Allgemeinmedizin in Südbaden.

Since 1994, seminars for the new curriculum in general practice are conducted by the Academy of Continuing Medical Education (consists of the regional medical board and the association of public health insurance in Südbaden). Specialists of different medical disciplines supported by general practitioners in the role of moderators are preparing and teaching a wide range of topics. The general practitioners are supervising the different courses, thus, facilitating the learning process of the participants. Furthermore, the facilitators have to work out the specific needs and requirements of general practice and family medicine. The topics are presented in a form of lessons and clinical cases discussed in small groups (problem-oriented approach). The evaluation of two seminars was carried out in 1994 and 1995 including two thirds of the complete curriculum in general practice. From the positive results of the evaluation, modification and improvement of the didactic concept for future seminars in 1996 are derived.

[Medical care research based on family doctor routine data--are interface-communicated treatment data feasible?]. / Versorgungsforschung mit hausärztlichen Routinedaten--Sind Behandlungsdatenträger-(BDT-)Exporte geeignet?

AIMS OF THE STUDY: As part of an ongoing project on the utilisation of generic drugs in general practice we aimed at determining whether the transfer of prescriptions and patient characteristics from doctors' computerized medical records via the BDT (Behandlungsdatenträger) interface was feasible, and whether these data are suitable for research in pharmacoepidemiology. METHODS: All 1,395 general practitioners from 6 regions in Germany were invited to participate in the 'generics project'; 232 (17 %) agreed. The 17 software companies whose systems were used by the participating practices were asked to grant access to the BDT interface. For a prescription survey, doctors were supposed to export BDT files from two 3-month periods each in 2000 and 2001. Data were anonymised and relevant information extracted with a special programme. RESULTS: So far, BDT data are available from 79 practices. They are suitable for practice- and patient-related prescribing analyses. By filter modifications, additional information (such as diagnoses, referrals, clinical findings or accounting codes) can be obtained. The procedure was well accepted if doctors and practice staff were assisted by computer experts. Some difficulties, however, were encountered in obtaining access to the BDT-interface from the software companies. Lack of standardisation of the BDT interface required additional conditioning of the data. CONCLUSION: The BDT interface offers an opportunity to export computerised patient records without the requirement of additional documentation. If routine data are more readily available for health services research, a standardised data structure and open access must be assured e. g. by centralised certification via the Federal statutory health organisation.

[Management of mental health and primary care. Development and evaluation of a training program based on the PLISSIT approach]. / Psychosomatische Grundversorgung auf der Grundlage des PLISSIT-Modells. Entwicklung und Evaluation einer Weiterbildungskonzeption.

Deficits in current approaches of psychosomatic and psychiatric education for general practitioners are reviewed. A skill-based training was developed in line with the four step counseling approach of the "PLISSIT" approach: The GP helps in first step ("permission") the patient to accept his problem and assesses informations about causing and maintaining factors of his symptomatology. In the second step he should provide information about the disorder and reverse misunderstanding and passivity (Limited Information). The GP's should develop preliminary strategies for change in the third step ("coping strategies", "symptom management", "special suggestions") and preparate the intensive phase of therapy as the last step. First results of the evaluation of the training program are presented demonstrate the effectiveness and acceptance of the education program.