Back to the future: breast surgery with tumescent local anesthesia (TLA)?

PURPOSE: Breast surgery is usually performed under general anesthesia. Tumescent local anesthesia (TLA) offers the possibility to anesthetize large areas with highly diluted local anesthetic. METHODS: In this paper, the implementation, and experiences with TLA in the field of breast surgery are discussed. CONCLUSION: For carefully selected indications, breast surgery in TLA represents an alternative to ITN.

Rapid effective dose calculation for raster-scanning 4He ion therapy with the modified microdosimetric kinetic model (mMKM).

PURPOSE: To develop and verify effective dose (DRBE) calculation in 4He ion beam therapy based on the modified microdosimetric kinetic model (mMKM) and evaluate the bio-sensitivity of mMKM-based plans to clinical parameters using a fast analytical dose engine. METHODS: Mixed radiation field particle spectra (MRFS) databases have been generated with Monte-Carlo (MC) simulations for 4He-ion beams. Relative biological effectiveness (RBE) and DRBE calculation using MRFS were established within a fast analytical engine. Spread-out Bragg-Peaks (SOBPs) in water were optimized for two dose levels and two tissue types with photon linear-quadratic model parameters αph, ßph, and (α/ß)ph to verify MRFS-derived database implementation against computations with MC-generated mixed-field α and ß databases. Bio-sensitivity of the SOBPs was investigated by varying absolute values of ßph, while keeping (α/ß)ph constant. Additionally, dose, dose-averaged linear energy transfer, and bio-sensitivity were investigated for two patient cases. RESULTS: Using MRFS-derived databases, dose differences ≲2% in the plateau and SOBP are observed compared to computations with MC-generated databases. Bio-sensitivity studies show larger deviations when altering the absolute ßph value, with maximum D50% changes of ~5%, with similar results for patient cases. Bio-sensitivity analysis indicates a greater impact on DRBE varying (α/ß)ph than ßph in mMKM. CONCLUSIONS: The MRSF approach yielded negligible differences in the target and small differences in the plateau compared to MC-generated databases. The presented analyses provide guidance for proper implementation of RBE-weighted 4He ion dose prescription and planning with mMKM. The MRFS-DRBE calculation approach using mMKM will be implemented in a clinical treatment planning system.

Reducing mental health-related stigma among medical and nursing students in low- and middle-income countries: a systematic review.

AIMS: This systematic review compiled evidence on interventions to reduce mental health-related stigma among medical and nursing students in low- and middle-income countries (LMICs). Primary outcomes were stigmatising attitudes and discriminatory behaviours. METHODS: Data collection included two strategies. First, previous systematic reviews were searched for studies that met the inclusion criteria of the current review. Second, a new search was done, covering the time since the previous reviews, i.e. January 2013 to May 2017. Five search concepts were combined in order to capture relevant literature: stigma, mental health, intervention, professional students in medicine and nursing, and LMICs. A qualitative analysis of all included full texts was done with the software MAXQDA. Full texts were analysed with regard to the content of interventions, didactic methods, mental disorders, cultural adaptation, type of outcome measure and primary outcomes. Furthermore, a methodological quality assessment was undertaken. RESULTS: A total of nine studies from six countries (Brazil, China, Malaysia, Nigeria, Somaliland and Turkey) were included. All studies reported significant results in at least one outcome measure. However, from the available literature, it is difficult to draw conclusions on the most effective interventions. No meta-analysis could be calculated due to the large heterogeneity of intervention content, evaluation design and outcome measures. Studies with contact interventions (either face-to-face or video) demonstrated attitudinal change. There was a clear lack of studies focusing on discriminatory behaviours. Accordingly, training of specific communication and clinical skills was lacking in most studies, with the exception of one study that showed a positive effect of training interview skills on attitudes. Methods for cultural adaptation of interventions were rarely documented. The methodological quality of most studies was relatively low, with the exception of two studies. CONCLUSIONS: There is an increase in studies on anti-stigma interventions among professional students in LMICs. Some of these studies used contact interventions and showed positive effects. A stronger focus on clinical and communication skills and behaviour-related outcomes is needed in future studies.

Reducing mental health-related stigma in primary health care settings in low- and middle-income countries: a systematic review.

AIMS: This systematic review compiled evidence on interventions to reduce mental health-related stigma in primary health care (PHC) in low- and middle-income countries (LMICs). Studies targeting PHC staff (including non-professionals) were included. Primary outcomes were stigmatising attitudes and discriminatory behaviours. METHODS: Data collection included two strategies. First, previous systematic reviews were searched for studies that met the inclusion criteria of the current review. Second, a new search was done, covering the time since the previous reviews, i.e. January 2013 to May 2017. Five search concepts were combined in order to capture relevant literature: stigma, mental health, intervention, PHC staff and LMICs. A qualitative analysis of all included full-texts was done with software MAXQDA. Full-texts were analysed with regards to the content of interventions, didactic methods, mental disorders, cultural adaptation, type of outcome measure and primary outcomes. Furthermore, a risk of bias assessment was undertaken. RESULTS: A total of 18 studies were included. Risk of bias was rated as high in most included studies. Only six studies had tested their intervention against a control condition, two of which had used random allocation. Most frequently used interventions were lectures providing theoretical information. Many studies also used interactive methods (N = 9), discussed case studies (N = 8) or used role plays (N = 5). Three studies reported that they had used clinical practice and supervision. Results of these studies were mixed. No or little effects were found for brief training interventions (e.g. 1 h to 1 day). Longer training interventions with more sophisticated didactic methods produced statistically significant changes in validated stigma questionnaires. These results have to be interpreted with caution due to risk of bias. Methods for cultural adaptation of interventions were rarely documented. CONCLUSIONS: More rigorous trials are needed in LMICs to test interventions that target discriminatory behaviours in relationship with patients. Cultural adaptation of stigma interventions and structural/institutional factors should be more explicitly addressed in such trials.

Community cognitive interviewing to inform local adaptations of an e-mental health intervention in Lebanon.

BACKGROUND: Lebanon has a need for innovative approaches to increase access to mental health care to meet the country's current high demand. E-mental health has been included in its national mental health strategy while in parallel the World Health Organization has produced an online intervention called 'Step-by-Step' to treat symptoms of depression that is being tested in Lebanon over the coming years. AIM: The primary aim of this study is to conduct bottom-up, community-driven qualitative cognitive interviewing from a multi-stakeholder perspective to inform the cultural adaptation of an Internet-delivered mental health intervention based on behavioural activation in Lebanon. METHODS: National Mental Health Programme staff conducted a total of 11 key informant interviews with three mental health professionals, six front-line workers in primary health care centres (PHCCs) and two community members. Also, eight focus group discussions, one with seven front-line workers and seven others with a total of 66 community members (Lebanese, Syrians and Palestinians) were conducted in several PHCCs to inform the adaptation of Step-by-Step. Results were transcribed and analysed thematically by the project coordinator and two research assistants. RESULTS: Feedback generated from the cognitive interviewing mainly revolved around amending the story, illustrations and the delivery methods to ensure relevance and sensitivity to the local context. The results obtained have informed major edits to the content of Step-by-Step and also to the model of provision. Notably, the intervention was made approximately 30% shorter; it includes additional videos of content alongside the originally proposed comic book-style delivery; there is less emphasis on total inactivity as a symptom of low mood and more focus on enjoyable activities to lift mood; the story and ways to contact participants to provide support were updated in line with local gender norms; and many of the suggested or featured activities have been revised in line with suggestions from community members. CONCLUSIONS: These findings promote and advocate the use of community-driven adaptation of evidence-based psychological interventions. Some of the phenomena recorded mirror findings from other research about barriers to care seeking in the region and so changes made to the intervention should be useful in improving utility and uptake of 'Step-by-Step'.

[Social support after traumatism]. / Soziale Unterstützung nach Traumatisierung.

The classical concept of social support has recently become of relevance again, particularly in the context of traumatized patient groups, which include refugees and migrants. This article summarizes the evidence from social support research, e. g. different types of positive effects as well as context, gender and cultural aspects. These aspects are highlighted by means of studies stemming from applied healthcare research and thus describe a wide range of health effects, e.g. increased well-being and reduced depressive symptoms, improved functional abilities, better immune status and longevity. Two new trauma-specific differentiations of the social support concept are introduced: societal acknowledgement as a trauma survivor and disclosure of traumatic experiences. Against this background several implications for working with refugees arise: promotion of self-efficacy and posttraumatic maturation as well as the treatment of mental disorders show considerable benefits from focusing on social support. Finally, possibilities emerging from digital communication media are discussed, which are particularly relevant in this context.

[Personalized Internet-based treatment services for posttraumatic stress disorder]. / Personalisierte Internet-Psychotherapie-Angebote für die posttraumatische Belastungsstörung.

Among the most important innovations within the psychotherapeutic care system are the new opportunities in the field of e-mental health. During the past decade, Internet-based and other e-mental health approaches for the treatment of post-traumatic stress disorder and related stress-associated symptoms have been developed in great variety. Solely Internet-based self-help programs are the lowest-threshold approaches in a stepped-care system. By contrast, individualized online psychotherapy and virtual reality programs are at the opposite pole of the spectrum. Approaches in the field of m(obile)-mental health complement these new developments in psychotherapy. The existing evidence supports the clinical efficacy of all the described approaches, although not all have been tested rigorously analog to phase III studies in psychopharmacology. Nonetheless, e-mental health approaches will shape our field more and more in the future.

Comparative validation of single-shot optical techniques for laparoscopic 3-D surface reconstruction.

Intra-operative imaging techniques for obtaining the shape and morphology of soft-tissue surfaces in vivo are a key enabling technology for advanced surgical systems. Different optical techniques for 3-D surface reconstruction in laparoscopy have been proposed, however, so far no quantitative and comparative validation has been performed. Furthermore, robustness of the methods to clinically important factors like smoke or bleeding has not yet been assessed. To address these issues, we have formed a joint international initiative with the aim of validating different state-of-the-art passive and active reconstruction methods in a comparative manner. In this comprehensive in vitro study, we investigated reconstruction accuracy using different organs with various shape and texture and also tested reconstruction robustness with respect to a number of factors like the pose of the endoscope as well as the amount of blood or smoke present in the scene. The study suggests complementary advantages of the different techniques with respect to accuracy, robustness, point density, hardware complexity and computation time. While reconstruction accuracy under ideal conditions was generally high, robustness is a remaining issue to be addressed. Future work should include sensor fusion and in vivo validation studies in a specific clinical context. To trigger further research in surface reconstruction, stereoscopic data of the study will be made publically available at www.open-CAS.com upon publication of the paper.

The current prevalence of child sexual abuse worldwide: a systematic review and meta-analysis.

OBJECTIVES: Systematic reviews on prevalence estimates of child sexual abuse (CSA) worldwide included studies with adult participants referring on a period of abuse of about 50 years. Therefore we aimed to describe the current prevalence of CSA, taking into account geographical region, type of abuse, level of country development and research methods. METHODS: We included studies published between 2002 and 2009 that reported CSA in children below 18 years. We performed a random effects meta-analysis and analyzed moderator variables by meta-regression. RESULTS: Fifty-five studies from 24 countries were included. According to four predefined types of sexual abuse, prevalence estimates ranged from 8 to 31 % for girls and 3 to 17 % for boys. Nine girls and 3 boys out of 100 are victims of forced intercourse. Heterogeneity between primary studies was high in all analyses. CONCLUSIONS: Our results based on most recent data confirm results from previous reviews with adults. Surveys in children offer most recent estimates of CSA. Reducing heterogeneity between studies might be possible by standardized measures to make data more meaningful in international comparisons.

Fluxgate magnetorelaxometry: a new approach to study the release properties of hydrogel cylinders and microspheres.

Hydrogels are under investigation as long term delivery systems for biomacromolecules as active pharmaceutical ingredients. The release behavior of hydrogels can be tailored during the fabrication process. This study investigates the applicability of fluxgate magnetorelaxometry (MRX) as a tool to characterize the release properties of such long term drug delivery depots. MRX is based on the use of superparamagnetic core-shell nanoparticles as model substances. The feasibility of using superparamagnetic nanoparticles to study the degradation of and the associated release from hydrogel cylinders and hydrogel microspheres was a major point of interest. Gels prepared from two types of photo crosslinkable polymers based on modified hydroxyethylstarch, specifically hydroxyethyl starch-hydroxyethyl methacrylate (HES-HEMA) and hydroxyethyl starch-polyethylene glycol methacrylate (HES-P(EG)(6)MA), were analyzed. MRX analysis of the incorporated nanoparticles allowed to evaluate the influence of different crosslinking conditions during hydrogel production as well as to follow the increase in nanoparticle mobility as a result of hydrogel degradation during release studies. Conventional release studies with fluorescent markers (half-change method) were performed for comparison. MRX with superparamagnetic nanoparticles as model substances is a promising method to analyze pharmaceutically relevant processes such as the degradation of hydrogel drug carrier systems. In contrast to conventional release experiments MRX allows measurements in closed vials (reducing loss of sample and sampling errors), in opaque media and at low magnetic nanoparticle concentrations. Magnetic markers possess a better long-term stability than fluorescent ones and are thus also promising for the use in in vivo studies.

Fluxgate magnetorelaxometry for characterization of hydrogel polymerization kinetics and physical entrapment capacity.

Hydrogels have the potential for providing drug delivery systems with long release rates. The polymerization kinetics and the physical entrapment capacity of photo-cross-linked hydroxyethyl methacrylate hydroxyethylstarch hydrogels are investigated with a non-destructive method. For this purpose, superparamagnetic nanoparticles as replacements for biomolecules are used as probes. By analyzing their magnetic relaxation behavior, the amounts of physically entrapped and mobile nanoparticles can be determined. The hydrogels were loaded with five different concentrations of nanoparticles. Different methods of analysis of the relaxation curves and the influence of the microviscosity are discussed. This investigation allows one to optimize the UV light irradiation time and to determine the amount of physically entrapped nanoparticles in the hydrogel network. It was found that the polymerization kinetics is faster for decreasing nanoparticle concentration but not all nanoparticles can be physically entrapped in the network.

[Illness-coping in a population-based representative sample. Situational, sociodemographic and social influences]. / Krankheitsbewältigung in einer repräsentativen Bevölkerungsstichprobe. Situative, soziodemographische und soziale Einflussfaktoren.

In spite of the considerable volume of current coping research there is a noticeable lack of studies based on large representative samples. In this study a sample of 2179 subjects of 16 to 96 years of age that was representative of the entire population of Germany, was asked as to how they now cope, how they have coped in the past or how they would cope with: 1. an existing illness, 2. a past illness and 3. an imagined (non-existent) illness. The instrument used was the questionnaire version of the "Berner Bewältigungsformen" (BEFO), a coping questionnaire with 28 systematically derived coping dimensions that are defined independently of the usual empirical-topographical dimensions (behavioural, cognitive and emotional) of the type of illness. The enquiry was concerned with the influence of varying situational (proximity of illness, subjective evaluation of personal health, psychological symptoms), socio-demographic (age, gender) and social (social support) variables on the choice of coping mechanisms. The results showed that each of these factors influences the repertoire of coping mechanisms to varying degrees. This systematic variability in a representative sample should be taken into account in any evaluation of coping with illness in clinical sub-groups.

Patient-disease characteristics and coping strategies predict hospitalization in emergency psychiatry.

OBJECTIVE: The goal of this study was to analyze how far patient-disease characteristics (sociodemographic variables, previous psychiatric treatment, way of referral, the patient's current diagnosis), and the patient's coping strategies are connected with the consecutive disposition for inpatient or outpatient treatment. METHODS: Data from a one-year intake of the psychiatric emergency service at a University Hospital (N = 1439) were monitored and analyzed with regard to the decision on treatment. Four hundred eighty-one patients were hospitalized and 530 were assigned to outpatient treatment. Two subsamples of twenty-eight patients from each group filled out the Bernese Coping Modes questionnaire before the decision with regard to the treatment disposition was taken. RESULTS: The patient's psychiatric history, the way of referral as well as the current axis I diagnosis made a significant contribution to the treatment decision. Overall, patient-disease characteristics allowed for correct classification of 69.3 percent of cases. However, coping was a comparable predictor of hospitalization. CONCLUSIONS: It is argued that the search for patient-disease characteristics in the psychiatric emergency room should be complemented by a more extensive monitoring of the patients' way of coping with their current crisis.

[Coping--status of knowledge in the 90's]. / Coping--Erkenntnisstand der 90er Jahre.

After a brief historical introduction the literature that has appeared on coping since the middle eighties is reviewed. Theoretically Lazarus' concept of transactional coping has been developed with focus on emotions. Antonovsky's salutogenesis is considered to be innovative. Methodology is discussed in view of instruments, observers time and perspective and need for qualitative evaluation. Clinically it must be concluded from the many cross-sectional comparisons that diseases with comparable demands call for similar coping. Only in long-term studies can stage-dependent differences of efficacy be detected. Active, tackling coping based on social and emotional resources and problem-analysis is significantly superior to passive coping with social withdrawal, ruminating, resignation and self-accusation. More recently interest in coping is extended to families and caretakers of patients. It is concluded that more corresponding with stress-research is needed, methodology should be adjusted and in view of important intervention strategies evaluation of efficacy is necessary.

Coping and psychosocial adaptation: longitudinal effects over time and stages in breast cancer.

OBJECTIVES: This study examined the relationship between coping and psychosocial adaptation in cancer patients over time and across distinct clinical events. METHODS: In a prospective longitudinal study 74 patients with breast cancer were observed for 3 to 5 years at 3- to 6-month intervals. A total of 684 interviews were conducted at different observation points. Three rating scales were used to assess coping and adjustment: first, the Bernese Coping Modes, an observer rating scale devised to elicit 26 coping modes aggregated in this paper as the five Basic Coping Strategies of support, self-control, denial, diverting, and negative-emotional; second, an observer rating scale to ascertain psychosocial adaptation; and third, a self-rating scale as a measure of either emotional distress or well-being. RESULTS: a) When aggregated in illness stages, coping and distress data on the observed clinical time points showed greater variability than time measures alone (analysis of variance (ANOVA) for repeated measures p < .001). b) A significant relationship between the Basic Coping Strategies and psychosocial adaptation was demonstrated using discriminant and correlational analysis. Furthermore, in stage-dependent Pearson r correlations (p < .05 to .001), a clear-cut relationship was found for hospitalization, chemotherapy, and rehabilitation, but not for convalescence and metastasis. c) A positive relationship was demonstrated between psychosocial adaptation and strategies that can be generally categorized as good forms of coping such as support and self-control, and, to a lesser degree, diverting and denial. Conversely, poor coping exerted a negative effect on almost all illness stages and on most criteria of adjustment. CONCLUSIONS: In long-term studies on psychosocial adaptation and coping, stage-related measures should be preferred to time measures alone. The implications of different strategies for the psychological treatment of cancer patients are discussed.

[The Bern Coping Forms BEFO--an instrument for self- and observer rating of coping with illness]. / Berner Bewältigungsformen BEFO-ein Instrument zur Selbst- und Fremdbewertung der Krankheitsverarbeitung.

Coping is an integral part of any illness behaviour, and has major implications inter alia for the doctor-patient relationship, hence, indirectly also for rehabilitation outcome. The Berne Coping Forms BEFO permit coping representation, for one, from the perspective of the observer (observer rating) and, for the other, from that of the patient (self-rating). The instrument is applicable for any diagnostic area or context, whether preventive programme, acute or chronic conditions, rehabilitation, or assessment of stressors in carers or relatives, and many more. The instrument is comprised of 30 categories of coping modes, oriented by three dimensions (action-,cognitive and emotion-related). Numerous studies have demonstrated adequacy of the instrument's psychometric properties. Associations between observer and self-rating are good, as is repeat reliability of the self-rating form, while the required reliability levels are reached in observer repeat ratings. Interrater agreement is good even with minimal previous training. The instrument has stood the test for differentiated assessment of coping modes in varying forms of illness-generated stress. It moreover permits characterization of coping style changes over time, i.e. in the different disease phases. Also, sociocultural differences and coping effectiveness can be substantiated. BEFO interpretation is determined by the research focus at hand, and presupposes differentiated evaluation of illness behaviour. Training and instruction are thoroughly dealt with in a manual, and comparative videos can be made available.

Coping-based intervention strategies.

Coping is explained as a circular process involving three repetitive steps: (1) perception of a change in well-being; (2) cognitive processing of information, in assessing its impact and possible consequences; and (3) coping as such, including many different modes. In general, active, task-oriented behaviour in which patients tackle problems, remain optimistic and seek attention and care is considered favourable. A passive and withdrawn attitude with ruminations, self-accusation and resignation is known to be unfavourable. Based on problem-solving theory, a coping-based intervention strategy is presented as follows: (1) establishing a therapeutic relationship; (2) analysis of the problem (situation and actual coping); (3) definition of problem for patient; (4) defining goals; and (5) working through and modification of coping. A rich body of scientific evidence now exists in almost all areas of medicine that such short and structured interventions contribute significantly to the healing process.