Coordination dynamics of circulatory and respiratory rhythms during psychomotor drive reduction.

A 0.15-Hz rhythm band in cutaneous blood oscillations in awake human subjects was studied in cardiovascular-respiratory time series of five subjects relaxing naïvely or practicing hypnoid relaxation (autogenic training, or AT). Time series analysis used nonlinear algorithms, time-frequency distribution (TFD), postevent scan (PES) method, and linear fast Fourier transform (FFT) algorithm. This 0.15-Hz rhythm band caused phase synchronization with respiration at 1:2, 1:1, and 2:1 integer number (n/m) ratios for extended periods. During wave epochs, the 0.15-Hz rhythm band was amplified, causing the 0.15-Hz rhythm band to also appear in interbeat intervals and arterial blood pressure fluctuations. If phase synchronization of the 0.15-Hz rhythm band with respiration was established at a 1:1 integer number ratio, it was maintained and resulted in consensualization of all cardiovascular-respiratory oscillations at this frequency. Simultaneous cardiovascular and respiratory oscillations at about 0.1 Hz did not affect the appearance of the 0.15-Hz rhythm band in the photoplethysmography (PPG) signal. Recent evidence suggests the emergence of the 0.15-Hz rhythm band and n/m phase synchronization to result from nonequilibrium phase transitions operational in the network of lower brainstem neurons and associated parasympathetic neuronal effectors. These findings corroborate our notion of the 0.15-Hz rhythm band as a marker of the trophotropic mode of operation.

[Diagnosis of trauma sequelae]. / Diagnostik von Traumafolgestörungen. Wie gehen Sie im Verdachtsfall vor?

Traumatic events often trigger acute psychosomatic and psychiatric sequelae, which sometimes show a tendency to become chronic. The post-traumatic stress disorder (PTSD) is a complex syndrome with numerous mental and vegetative symptoms. The diagnosis of trauma sequelae requires a good knowledge of the differential diagnostically relevant comorbid conditions (e.g. anxiety disorders, depressive disorders, and somatoform disturbances). An appropriate management plan is possible only when suitable consideration is given to the traumatic genesis of symptoms. In the treatment of trauma, a stepped approach involving the principles stabilization, trauma processing and psychosocial re-integration has proven value.

[Psychotherapeutic treatment of traumatic stress with the EMDR (Eye Movement Desensitization and Reprocessing) method]. / Traumatherapie mit der Fingerspitze. Die überraschenden Erfolge der EMDR-Methode.

EMDR (Eye Movement Desensitization and Reprocessing) is a method, developed at the end of the nineteen-eighties, for the treatment of the post-traumatic stress disorder (PTSD). The patient is asked to concentrate on certain aspect of the traumatic memory while keeping his eyes fixed on the movements of the therapist's finger. Apparently, this triggers information processing that results in appreciable relief for the patient. The method has proven to be equally as effective as behavioral-therapeutic techniques, and, has in the meantime, been included in national and international guidelines for the treatment of PTSD. The indications for EMDR treatment include not only PTSD, but, increasingly, also other, sometimes more severely chronic, it trauma sequelae. Within the framework of basic care, EMDR must be embedded within a treatment plan and should, where applicable, be combined with other methods.

[Psychological trauma in trauma medicine--the current status of psychological management of trauma victims in Germany]. / Psychotraumatologie in der Unfallmedizin--Zum Stand der psychischen Versorgung von Unfallopfern in Deutschland.

A clinically significant amount of accident victims display psychological disorders as a reaction to the trauma. Outcome studies on multiple trauma emphasize that life quality following severe accidental injury is influenced by early diagnosis and treatment of psychic co-morbidity. In a nationwide survey concerning the state of the art in in-patient treatment of injury patients conducted in Germany, every surgical ward was contacted and physicians were asked about their standard procedures of detecting and treating psychotraumatic complications. The results of the survey indicate that surgeons pay close attention to signs of psychological comorbidity and have good basic knowledge of psychotraumatic disorders. Nevertheless, there are structural deficiencies caused by the fact that only a few wards have staff specially trained in psychotraumatological care. Only a minority of patients is treated for psychotraumatic symptoms. In view of the high prevalence rates for psychotraumatic disorders in the aftermath of severe accidental injuries, the article discusses the need for psychic diagnosis and support as well as the necessary cooperative structures required in the model of Integrative Posttraumatic Acute Care.

[Diagnostic spectrum and treatment requirements of general practice clients. Results of the ADT Panel of the Central Institute of National Health Insurance Management]. / Diagnosespektrum und Behandlungsaufwand des allgemeinärztlichen Patientenklientels. Ergebnisse des ADT-Panels des Zentralinstituts für die kassenärztliche Versorgung.

Results of the ADT-Panel of the Central Research Institute of ambulatory health care in Germany. The ADT-Panel of the Central Research Institute contains the remuneration data that are quarterly collected by office-based physicians and transmitted in anonymous form. These data can be classified according to the status of the insured patient, the diagnoses made or the treatment provided. The Patient Panel does therefore represent an important instrument which allows a rapid scientific analysis (3 to 4 weeks after the end of a quarter) about how patients are treated by different specialists. It might also be used to forecast trends. The Patient Panel does as well allow the demonstration of specialty-related statistics on diagnoses and disease-related treatment provision. The complete publication and some exemplary tables can be found in the DGN Internet (www.dgn.de; Deutsches Gesundheitsnetz). A short summary is available on the home page of the Central Research Institute (www/zi-koeln.de).

[Evaluation of HIV-related continuing education programs for established physicians]. / Evaluation von HIV-bezogenen Fortbildungsveranstaltungen für niedergelassene Arzte.

Neither the HIV-specialists, the cooperating specialists, nor the family physicians are required to have special qualifications to treat HIV-infected patients. CME-courses don't consider the very different fields of interest of the participants or that the transfer of knowledge is quite important to ensure the quality of medical care. Questionnaires regarding HIV related topics were distributed in nine HIV-CME courses (9/93-5/94) of the DAGNA (German association of panel physicians treating HIV-infected patients) in cooperation with the society of physicians of Germany and the association of public health insurances. The satisfaction of the participants, the topics with regard to their relevance for the task group, the importance for the daily routine, and didactic manners were investigated. Feed-back: 41%. Although the general impression of most participants was "quite satisfying" (87%) there was some critic regarding special aspects. The rating of the courses depended on the level of qualification. Specialists in internal medicine rated the relevance for their medical practice, the topics and the possibility of contribution more positive than other specialists or general practitioners (GP). In general, there was a great difference regarding the rating of the courses among the participants because of their individual level of qualification and knowledge. In order to take the different levels of qualification and demands for topics into account there must be graduated courses: specialists, experts, elementary and beginner courses. The basic courses should contain not only the lectures but also the possibility of an active contribution of the participants. Adequate guidelines have to be developed.

Health care for persons with non-insulin-dependent diabetes mellitus. The German experience.

A structured treatment and education program for patients with non-insulin-dependent diabetes mellitus (NIDDM) who are not taking insulin was developed, evaluated, and implemented at the primary health care level throughout Germany. The program is based on the definition of individual and pragmatic therapeutic goals for each patient, primarily using nondrug treatment, which includes systematic glycosuria self-monitoring by the patients and four structured sessions of group education held in a general practitioner's office. After documentation of the program's efficacy in a randomized, controlled trial and several pilot projects, the program has been officially incorporated into the general German health care scheme and includes payment to practicing physicians for each patient treated. More than 12,500 primary health care physicians have participated in special 2-day postgraduate courses given by diabetologists; these courses are a precondition to participating in the program. As part of the primary health care scheme, the NIDDM program will be continuously monitored for quality control and efficiency. Currently, similar structured treatment and education programs targeted to primary health care physicians are being introduced for both insulin-treated NIDDM and arterial hypertension.

[The graduate education project in the new federal German lands "Diabetics--Management in General Practice"]. / Fortbildungsprojekt in den neuen Bundesländern* "Diabetiker-Betreuung in der Praxis".

Supported by the federal ministry of health, the Central Research Institute for Ambulatory Health Care in Germany organised postgraduate courses with the topic "How to take care of diabetic patients" in cooperation with the society of panel physicians. Contents and media of the postgraduate course were developed with the help of experts, a formative evaluation of the curriculum was carried out. In a consensus- and preparatory meeting, diabetologists discussed the medical objectives with experts and were trained under the guidance of educationalists (microteaching with video-monitoring aiming at improving teaching behaviour). Later on, 1315 physicians participated in 38 postgraduate courses. The experiences of this project can provide useful informations how to structure postgraduate medical education.

[Growth in the number of physicians and the structure of medical practice. Has the quality of ambulatory care changed?]. / Die Entwicklung von Arztzahlen und Praxisstrukturen. Andert sich die Qualität der ambulanten Versorgung?

In order to realize a good health policy that, over the long term, combines humanity, effectiveness and efficiency, corrections in the evolution of the number of physicians, changes in the structure of practices, and the preservation of quality in ambulatory care are urgent tasks for the remaining decade of this century. In this connection, the development of medical orientational data and the so-called priority health aims, will be of use. In particular, the system of "health-insurance" doctors is threatened by external influences outside the control and authority of the administrative organs concerned. Here, the influence on the overcapacity of doctors arises in the present constitutional provision which states that all those physicians who wish to work within the health-insurance system, must be allowed to do so. Owing to the increasing "financial bottlenecks" that health-insurance doctors will encounter, the future practicing physician will increasingly become a "businessman", since rising costs and decreasing turnover will exercise a powerful effect on the doctor's practice. In such a situation new practice structures might have a positive effect. In view of all these factors that threaten the independence of the practicing physician, the difficulty arises of preserving the quality of medical care. Already, attempts are being made, on an "outside the medical profession" basis, to ensure quality control, and the proposals made by the expert councils are an indication that this discussion must be intensified among the medical profession itself.