Improving outpatient treatment in schizophrenia: effects of computerized guideline implementation--results of a multicenter-study within the German research network on schizophrenia.

Schizophrenia clinical practice guidelines are developed to provide expert- and evidence-based advice to practicing psychiatrists in order to improve the management of this disorder. However, the application of these guidelines in everyday health care can still be described as nonsatisfying. Within the project "Guideline-supported quality management in outpatient treatment", we investigated whether guideline adherence and quality of outcome can be improved by implementing a computer-based, guideline-oriented decision-support system. Therefore, a disease-specific decision-support system was developed interactively presenting guidelines to support the physicians decision-making process during the treatment of schizophrenia patients. We evaluated the system in a control group design: An experimental group consisting of 15 psychiatrists in private practice used the decision-support system, thus documenting the treatment of schizophrenic patients. Guideline-based algorithms were interactively and case specifically displayed on the PC-screen as soon as predefined triggers were met. A first control group in Munich provided treatment-as-usual, documenting the treatment via paper-pencil. Two further physician groups served as additional comparison groups: one also documented electronically using the decision-support system, however without receiving electronic guideline support, the second group carried out traditional quality circles while also using the paper-pencil approach. As a result of the intervention, we observed a strong initial but time-limited improvement with respect to the core aspects of outpatient treatment in schizophrenia in the experimental group. The findings suggest that decision-support systems, despite their limitations, can be used to enhance treatment outcome in schizophrenia outpatient care.

Dinuclear zinc catalysts with unprecedented activities for the copolymerization of cyclohexene oxide and CO2.

A variety of new dinuclear zinc catalysts was developed and tested for the copolymerization of cyclohexene oxide and carbon dioxide. Electron-withdrawing groups thereby led to unprecedented activities with turnover frequencies up to 155,000 h(-1). These are by far the highest polymerization rates ever reported for the copolymerization of cyclohexene oxide and CO2.

Quality management in psychiatry.

Over the past 50 years, treatment possibilities in psychiatry have drastically improved, but the results we actually achieve under everyday treatment conditions fall far short of what could be accomplished. Quality management represents a suitable method of reducing this gap. Although it has been successfully practiced in other medical disciplines for a long time, its implementation in psychiatry has previously been restricted to pilot projects. Quality management programs in psychiatry have been slow to be accepted because, up to now, only a few mental health professionals have received training in quality management techniques. In order to compensate for this information deficit and to familiarize psychiatrists and other mental health care workers with this increasingly important topic, we will provide in this paper a brief survey of the most important principles and techniques of quality management. This information should encourage psychiatrists to apply this new method to their own areas of responsibility. The results of one of our own studies on schizophrenic outpatients, which are presented at the end of the paper, are intended to show that the outcome can be improved and costs reduced by implementing quality management programs in psychiatry.

Formation constants for the complexes of levulinate and acetate with manganese(II), cobalt(II), nickel(II), copper(II), zinc(II) and hydrogen ions.

Formation constants are reported for the levulinate complexes of manganese(II), cobalt(II), nickel(II), copper(II) and zinc(II) at 25 degrees in 0.1M chloride medium. In addition, results are presented for the corresponding acetate complexes for comparison. Protonation constants for the two ligands are also reported.

[Prevention of relapse in schizophrenia is discontinued too soon. Many colleagues make this mistake!]. / Rezidivprophylaxe bei Schizophrenen viel zu früh abgesetzt. Diesen Fehler machen viele Kollegen!

OBJECTIVE: The recommendations given by general practitioners in the treatment of schizophrenia were investigated empirically and compared with those given by psychiatrists as well as with the accepted standards for the prophylactic treatment of schizophrenic psychoses. METHOD: In an interview based on case reports, 64 randomly selected general practitioners in private practice were asked 6 questions on the treatment of schizophrenic psychoses. RESULTS: 75% of the general practitioners recommend a duration of prophylactic measures that is significantly shorter than that recommended by international standards, and also significantly shorter than that recommended by psychiatrists. This undertreatment correlates with an overestimation of the risk of side effects and--at least in first-time patients--an underestimation of the relapse risk. CONCLUSION: Despite a number of significant differences between general practitioners and psychiatrists, both groups fall far short of international treatment standards in terms of recommended duration of prophylaxis, both underestimate the relapse risk and overestimate the risk of side effects. Possible approaches to improving the quality of relapse prevention in schizophrenia are, for example, joint educational activities for family doctors and psychiatrists, and the establishment and implementation of joint treatment guidelines.

[Development of the specialty "hypertonology"]. / Zur Herausbildung des Wissenschaftsgebietes Hypertonologie.

The general tendency of the development of the sciences to differentiation is to be seen also within the discipline of internal medicine. By the formation of special tasks with a limited aim of realization the scientific subject of hypertonology developed. According to the regularities of the genesis of the discipline the process took place gradually. In the 18th and 19th century (prehistory) above all the method of measuring the blood pressure (technical prerequisite) developed. With the intensification of the process of cognition since the beginning of the 20 the century the actual development began (preparatory or initial phase). The qualitative breach (phase of constituation) was evoked by 1950 by making available highly effective remedies decreasing the blood pressure, the recommendations of the WHO concerning the limiting values of the blood pressure and the recognition of risk factors. Nowadays the scientific subject of hypertonology is fully acknowledged in research and health policy (phase of establishment); the process leads over to the phase of consolidation.

[Contact eczema in housewives. Update from 1986 with reference to results of epicutaneous tests in 2,633 patients]. / Kontaktekzeme bei Hausfrauen. Update nach 1986 unter Berücksichtigung der Epikutantestergebnisse von 2633 Patienten.

The development of hand eczema is a relatively commonly seem dermatosis in housewives. In 1986 we presented a first survey of potential contact dermatitis sources for a housewife. Now, we present an update in which we analyse the different contact sources in the household and grade them in comparison to the data of 1986. The results are based on the analysis of a large population of 2633 patients with the occupation "housewife" and the diagnosis "eczema" who have been seen in departments of dermatology belonging to the Information Network of Departments of Dermatology (IVDK).

Contact allergy in patients with periorbital eczema: an analysis of allergens. Data recorded by the Information Network of the Departments of Dermatology.

BACKGROUND: Periorbital eczema may be an expression of a constitutional disease or an irritant or allergic dermatitis. An allergic contract dermatitis is believed to be the most common cause. OBJECTIVE: We tried to determine which allergens may cause an allergic contact dermatitis and if there exists a leading allergen. METHODS: 609 patients with periorbital eczema were assessed with patch testing in 22 hospitals to evaluate the relevance of an allergic contact dermatitis in the pathogenesis of periorbital eczema. Additionally, 116 patients were tested with their own products. RESULTS: 81% of the cases involving the eyelids were women. A relevant allergic contact dermatitis was found in 52% of the patients with periorbital eczema. Furthermore, a positive patch test was present in every third patient with the clinical diagnosis of an atopic dermatitis. Antibiotics, phenylephrine and thimerosal could be determined to be the leading allergens responsible for allergic periorbital eczema. Positive reactions for potassium dichromate and fragrance mix occurred less frequently in patients with periorbital eczema. 132 positive reactions were found in patients tested with their own products, including 33% with a positive reaction to eye ointments, 15% to face creams, 10% to eye shadows, 10% to makeup, 10% to shampoos and 4% to nail varnish. Only 6% reacted to perfume. CONCLUSION: The data underline the importance of performing patch tests in the case of periorbital eczema, especially in atopic patients.

[Psychological health at school entrance]. / Psychische Gesundheit im Schuleintrittsalter.

INTRODUCTION: The rate of psychiatric disorders in childhood and adolescence was investigated in numerous studies and was found to be between 10% and 18%, boys having more problems to tackle than girls. These studies often concern school-age children, but it is sure that psychiatric disorders already occur in early childhood. In the present study, mental health was assessed in children of Jena, who were starting with school. A comparison with methodologically similar studies in Heidelberg and Cologne was possible. METHODS: The study was conducted in cooperation with the health department of Jena. Parents had to fill in the CBCL (Child Behaviour Checklist), which assesses behavioural disturbances and social competence. Participation was voluntary and anonymous. RESULTS AND DISCUSSION: From the total population of 1039 children 749 (72.0%) checklists were filled in by the parents. 674 (64.9%) checklists were completely filled in and included in the study. 86 out of 674 (64.9%) of the children had a psychiatric disorder, boys (13.4%) more often than girls (12.2%), especially in the scales "Externalizing disorders", "delinquent behaviour", "aggressive behaviour" and "attention deficit disorders". Children coming from certain areas (Lobeda, Winzerla) had not have more disturbances than children from the central part of the city. Only 8.1% of the parents of children with psychiatric disorders recognise such problems, and only 16.3% of these children had a visit with a physician or psychologist within the last year. This leads to the conclusion, that the sensitivity for psychiatric disorders of children must be improved.

Prevalence of endocrine dysfunction in HIV-infected men.

OBJECTIVE: Endocrine dysfunction is a common problem in patients with human immunodeficiency virus infection (HIV). We therefore evaluated the endocrine function in 31 male homosexual HIV-1-infected men: mean age 37 +/- 7.2 years (range 24-52). METHODS AND MATERIALS: Blood was obtained for baseline T3, T4, TSH, LH, FSH, prolactin, testosterone, ACTH and cortisol values. Endocrine function tests were performed as TRH, CRH, ACTH, LH-RH and HCG tests. RESULTS: Thyroid function: There was a temporarily increased TSH in 3 of 17 patients but normal levels for T3, T4 and fT4 (without thyroid antibodies). One patient showed signs of latent hyperthyroidism (no response in TRH test). Adrenocortical function: Two patients had adrenal insufficiency. They showed a normal baseline cortisol level, an elevated ACTH level and no increase in cortisol levels after stimulation with CRH. All other patients revealed normal responses on the CRH/ACTH tests. Gonadal function: 9 patients had elevated FSH levels (tubular insufficiency), 4 patients additionally had increased LH levels (hypergonadotropic hypogonadism). 5 patients showed signs of tertiary hypogonadism (low LH and testosterone, increase of LH after stimulation with LH-RH). CONCLUSION: In disorders of thyroid and adrenocortical function of primary or tertiary origin, a substitution of hormones should be taken into consideration.

Humoral and cellular immune responses in asthmatic isocyanate workers: report of two cases.

Two workers (23 and 28 years old) developed rhinitis and bronchial asthma after occupational contact with the isocyanate MDI. Positive skin prick test results for MDI-HSA and IgE antibodies to all isocyanate-HSA conjugates were obtained in both cases, and the inhalation challenge test with MDI produced immediate and late asthmatic reactions. In the patch test and the stimulation assay of peripheral mononuclear blood cells, a specific sensitization to the diamine MDA (in both cases) and to further amines (in one case), as well as to hydrolysates of the respective diisocyanates, was seen, which appears to be independent of the IgE response to isocyanate-HSA conjugates. Our results offer evidence of IgE-mediated, as well as lymphocyte, responses induced by exposures to isocyanate products over several months or years.

The boundary effect in magnetic stimulation. Analysis at the peripheral nerve.

The optimal stimulus position for a figure-8-shaped coil for magnetic stimulation of the ulnar nerve at the wrist was not coincident with the optimal electrical stimulus point but was shifted 18.3 mm to the ulnar side (P < 0.01). For the median nerve the optimal stimulus site was 9.6 mm radial to the optimal position for electrical stimulation (P < 0.05). This shift of the stimulus point for magnetic stimulation is significantly smaller after interposition of a homogenous electrically conducting medium between coil and arm but not changed after interposition of distilled water. This so-called boundary effect is therefore due to the different conductivities of the medium interposed between coil and nerve. It may also distort precise localisation of other excitable structures such as cranial nerves, nerve roots and cortical areas by means of magnetic stimuli. The amplitudes of the compound muscle action potentials elicited with identical magnetic stimulus strength were larger after the interposition of isotonic solution between coil and skin but not after interposition of distilled water. Consideration of the boundary effect provided an improved response amplitude to magnetic stimulation, but this could not adequately compensate for its poor localisation compared to electrical stimulation.

[Direct and indirect costs of schizophrenia]. / Die direkten und indirekten Kosten der Schizophrenie.

In the present study the costs of schizophrenia in Germany were studied using the "bottom up" prevalence-based method. In a random sample of 180 schizophrenic patients stratified according to the most important care institutions, direct and indirect costs were retrospectively documented for a 12-month period. Depending on the place of recruitment and the extent of care provided, total yearly costs result between about DM 33,000 for a patient treated predominantly on an outpatient basis and about DM 126,000 for a patient requiring hospital care and about DM 135,000 for a patient in job rehabilitation. The direct yearly treatment costs were, as expected, lowest for patients recruited in the private practice of a psychiatrist and predominantly treated on an outpatient basis (DM 5,788), and were the highest in the psychiatric hospital (DM 64,661) and in job rehabilitation (DM 79,996). In the patients recruited in the outpatient domain, doctors' fees and medication together were responsible for only 4.5% of the total costs, whereas the indirect costs (e.g., through work incapacity) were responsible for 87% of the total yearly costs. For methodological reasons the total costs caused by schizophrenic psychoses in Germany per year can at present be estimated only roughly. A conservative estimate is between 8.5 and 18 billion DM per year. The study shows that schizophrenia is a very expensive illness, the direct and indirect costs of which are on the whole comparable to those of the common somatic illnesses. Therefore, also for economical reasons, sufficient financial means should be invested in the research and treatment of this severe illness.