The influence of persistent bleeding after supracervical hysterectomy on depressive and anxious symptoms: a prospective bicenter study.

PURPOSE: Postoperative spotting is a frequent adverse symptom after laparoscopic supracervical hysterectomy (LSH). The conical excision (eLSH) reduces the postoperative spotting rate, but data in a larger collective are still rare and inconsistent. The influence of persistent bleeding on the anxious and depressive symptoms has not been analyzed yet. METHODS: 311 patients, who underwent a laparoscopic supracervical hysterectomy with conical excision (n = 163), or with straight cervical resection (n = 148) were included. Anxious and depressive symptoms and postoperative spotting were recorded before operation, at 3 month follow-up and at 1 year follow-up in both operative groups using a validated questionnaire (German version of Hospital Anxiety and Depression Scale, HADS-D) and additional questions concerning the frequency and impact of bleeding. Statistical analysis included the impairment of bleeding as well as its impact on depressive and anxious symptoms for both groups. RESULTS: 11.5% after eLSH and 15.5% after LSH reported spotting after 1 year. Supracervical hysterectomy significantly improves depressive and anxious symptoms at 3 and at 12 month follow-up for both groups (p < 0.001) independent on residual spotting. Patients with a preoperative continuous bleeding showed a maximum benefit independent on operative method. CONCLUSION: Laparoscopic supracervical hysterectomy has a positive effect on anxious and depressive symptoms in the short-term and intermediate-term follow-up. The conical excision of the cervical stump reduces postoperative spotting rate, but has no explicit advantage on symptoms of depression or anxiety, irrespective of residual postoperative spotting.

The influence of conventional and extended supracervical hysterectomy on sexuality and quality of life parameters: a prospective bi-center study with a special focus on postoperative spotting.

PURPOSE: Supracervical as well as total hysterectomy are considered to improve postoperative sexuality as well as quality of life, but the benefit of supracervical hysterectomy (LSH) is impaired in up to 20 percent by postoperative spotting. The aim of this study was to analyze the influence of a conical excision of the cervical stump during supracervical hysterectomy on the postoperative spotting rate and its influence on sexuality and in turn quality of life. METHODS: 321 Patients who underwent a laparoscopic supracervical hysterectomy with conical excision (extended laparoscopic supracervical hysterectomy, eLSH, n = 166, Dormagen hospital) or with straight cervical resection (laparoscopic supracervical hysterectomy, LSH, n = 133, MIC Clinics Berlin) were included. Sexual matters, quality of life parameters and additional questions were recorded before operation, at three months of follow up, and at one year of follow up in both groups using a validated questionnaire (German version of International Consultation on Incontinence Questionnaire Vaginal Symptoms Module, ICIQ_VS). Statistical analysis included the impact and impairment of bleeding on sexuality, quality of life in both groups and co-factors such as vaginal symptoms. RESULTS: 11.3% after eLSH and 15.5% after LSH reported spotting after 1 year. Supracervical hysterectomy significantly improves quality of life and sexuality and a conical excision of the remaining stump is associated with a lower but insignificantly reduced spotting rates. Postoperative spotting has no negative influence on sexual matter score of ICIQ_VS, but reduces the postoperative quality of life focusing on vaginal symptoms in a significant way. CONCLUSION: The improvement of ICIQ_VS scores after supracervical hysterectomy is independent of postoperative spotting, but the quality-of-life score is positively influenced by a reduction in the postoperative spotting rate.

[Evidence-based recommendations for the treatment of depressive comorbidity in somatic illness]. / Was ist gesichert in der Therapie depressiver Komorbidität?

BACKGROUND: Comorbid depression is frequent in internal medicine (e.g. in coronary heart disease, congestive heart failure or diabetes mellitus) and impairs quality of life as well as the prognosis of the somatic illness. AIM: To review evidence based recommendations for the treatment of depressive comorbidity in selected somatic disorders. MATERIALS AND METHODS: Selective literature search based on national and international guidelines. RESULTS: In clinical routine, depressive symptoms are often overseen or misinterpreted. Therefore, a specific diagnostic is recommended. Depressive symptoms should obligatory be screened during the clinical interview or by validated questionnaires. When screened positive, further diagnostic steps are mandatory. The treatment of depressive disorders has three main components: basic psychosomatic care, psychotherapy and antidepressant medication. These interventions are safe and effective for reducing depressive symptoms and enhancing quality of life. However, results regarding the effects on morbidity and mortality of the comorbid somatic disorder are still inconclusive. The greatest effects on depression are obtained by a preference-based, stepped-care approach and an optimal cooperation of all professionals ("collaborative care"). CONCLUSIONS: An effective treatment of depressive comorbidity is relevant for quality of life and possibly also for the prognosis of a somatic disease. Integrating a routine screening for depressive symptoms is the first step toward an effective, evidence-based therapy.

"It's Not that Easy"--Medical Students' Fears and Barriers in End-of-Life Communication.

This study aims to assess and improve communication education for medical students in palliative care (PC) with the use of simulated patients (SP) in Germany. More specifically, to explore how students evaluate the use of SP for end-of-life communication training and which fears and barriers arise. A pilot course was implemented. Qualitative content analysis was used to analyse transcribed recordings of the course. Pre- and post-course questionnaires containing open-ended questions ascertained students' motivation for participating, their preparation within their degree programme and whether they felt they had learned something important within the course. Seventeen medical students in their third to fourth year of education (age 22-31) participated in the five-session course and answered the questionnaires (pre n = 17, post n = 12). Students felt insufficiently prepared and insecure. Discussing end-of-life issues was experienced as challenging and emotionally moving. Within the conversations, although students sometimes showed blocking behaviour in reaction to emotional impact, they valued the consideration of emotional aspects as very important. The course was overall highly appreciated and valued as being helpful. The communication situation with the SP was perceived as authentic. Ten out of 12 students confirmed to have learned something important (post course). Our results indicate an urgent need for better communication training for medical students. Due to the fact that bedside teaching in PC is not feasible for all students, training with standardized SP can be a way to generate an authentic learning situation. Techniques to address fears and blocking behaviour should, however, also be considered.

[CorBene: a new model for collaborative care of patients with congestive heart failure]. / CorBene: Ein neues, kooperatives Versorgungsmodell für Patienten mit Herzinsuffizienz.

Congestive heart failure (CHF) is one of the most common medical disorders. The prognosis tends to be unfavorable and the quality of care needs further improvement. The aim of the CorBene project is to improve the health-related quality of life and the prognosis in patients in all stages of CHF and to reduce the hospitalization rate. For this purpose a modern collaborative treatment program involving all relevant health care professionals was developed. The key feature is the close collaboration between family physicians, practicing cardiologists, hospitals and rehabilitation facilities. The CorBene model was launched in Cologne and then spread to North-Rhine/Westphalia and to Saarland. Currently, there is the possibility to offer it in all German states. Preliminary analyses confirm an optimal, guideline-based therapy of CHF.

[The effects of multimodal intervention for the primary prevention of cardiovascular diseases on depression, anxiety, and Type-D pattern: initial results of the randomized controlled PreFord trial]. / Effekte einer multimodalen Intervention zur Primärprävention kardiovaskulärer Krankheiten auf Depressivität, Angst und Typ-D-Muster: Erste Ergebnisse der randomisierten, kontrollierten PräFord-Studie.

Depression, anxiety, and Type-D pattern are associated with the earlier development and faster progression of cardiovascular disease (CVD). The aim of the randomized controlled PreFord trial was to improve multiple biological and psychosocial risk factors in the primary prevention of CVD. A total of 447 women and men with an ESC risk score >5% were randomly assigned to either multimodal or routine care groups. Somatic and psychosocial variables (HADS, DS-14) were assessed before and after the intervention, and annually for 2 years thereafter. The intervention showed no significant effects on the symptoms of depression, anxiety, and type D personality, either in the whole sample or in those with elevated scores at baseline. Thus, our study did not provide evidence that symptoms of depression, anxiety, or Type D personality can be effectively treated by multimodal behavioral interventions for the primary prevention of CVD.

[Anxiety disorders]. / Angststörungen.

With a lifetime prevalence of approximately 17% anxiety disorders are among the most common mental disorders worldwide. The disease progression can take a chronic course leading to a considerable impairment of the affected person. The current medical classification list (ICD-10) by the World Health Organization differentiates between agoraphobia, social phobia, specific phobia, panic disorder and generalized anxiety disorder. The etiology is multicausal comprising an interaction of genetic and psychosocial factors. For treatment, psychotherapy, psychopharmacological treatment and a combination of both methods are eligible. Anxiety disorders are often associated with physical illness either as the causative factor or the consequence. In particular, anxiety has been identified as an independent risk factor for cardiovascular disease. Anxiety disorders associated with somatic diseases are often unrecognized, therefore an optimization of diagnostic and treatment strategies is necessary.

[Transcranial magnetic stimulation for psychogenic tremor - a pilot study]. / Der Einsatz der transkraniellen Magnetstimulation beim psychogenen Tremor - eine Pilotstudie.

Psychogenic tremor is the most common psychogenic movement disorder. Its prognosis is widely held to be poor and strongly depends on the patient's insight into the psychogenicity of the syndrome. The clinical value of transcranial magnetic stimulation (TMS) for (i) establishing the diagnosis with a high level of certainty, (ii) modulating symptom severity and (iii) facilitating patients' insight into psychogenicity was tested in 11 patients with psychogenic tremor of the upper limb. After explaining the psychogenic origin of the syndrome and providing a neurobiological model, 30 TMS pulses were applied over the hand area of the primary motor cortex contralateral to the affected hand(s) at a rate of 0.2 Hz. 15 pulses were administered at intensities of 120 % and 140 % of the resting motor threshold, respectively. Kinematic motion analysis was used to document the effectiveness of the TMS procedure. All patients met the diagnostic criteria of conversion disorder. Time elapsed since symptom onset was on average 48 to 57 months. Tremor affected both hands in 8 patients, one patient had additional head tremor. The TMS procedure caused a significant reduction of tremor frequency and thus established the diagnosis of documented psychogenic tremor according to the criteria proposed by Fahn and Williams (1988) in each patient. The duration of symptom relief was transient in 7 patients, 4 patients had lasting symptom relief. The present pilot study demonstrates that TMS is a helpful tool to (i) establish the diagnosis of psychogenic hand tremor with a high level of certainty, (ii) reduce tremor intensity and (iii) facilitate the patient's insight into the psychogenic origin of the syndrome as a prerequisite to obtain adherence to psychotherapy.

Comparison of social support and psychosocial stress after heart and liver transplantation.

We studied social support, psychological symptoms, and subjective appraisal of quality of life among 233 patients at 1 to 3 years after heart (HTX) or orthotopic liver transplantation (OLT): 78 HTX in 62.8% men and 155 OLT in 51% men. Patients after OLT versus HTX were more often single or divorced (14.4% and 12.3% vs 3.9% and 7.7%), had better school education (68.4% vs 37.8%), and were more often employed (25.5% vs 11.8%). Among the HTX patients, 40.3% had more than 3 inpatient treatments due to complications after transplantation vs only 9.3% of OLT patients. HTX patients had more rejection reactions (55.4% vs 21%). Asked for their appraisal of quality of life, HTX and OLT patients gave comparably good "school grades" (2.6 vs 2.7), describing similar scores of social support in the F-SozU (4.4 vs 4.2). OLT patients, women in particular, reported a significantly higher grade of global psychological stress than HTX patients (67.4 vs 55.1; P < .001). Our results indicated that social support, employment status, and degree of somatic complications cannot sufficiently explain the degree of emotional distress after transplantation. Subjective factors such as making sense of the transplantation in terms of regarding it as a worthwhile operation within the life course are important mediators of psychological stress and perceived quality of life.

[Eating disorders and diabetes mellitus]. / Ess-Störungen und Diabetes mellitus.

Adolescent and young women with type 1 diabetes mellitus demonstrate a more than random coincidence with bulimia nervosa. However, the prevalence of eating disorders that do not fulfil the criteria of bulimia nervosa is also raised in women of this age group yet without diabetes mellitus. The comorbidity of type 1 diabetes and an eating disorder poses a risk factor in the development of diabetic follow-up diseases. Patients with an eating disorder and type 1 diabetes are characterized by an insufficient metabolic control and the early development of diabetic complications such as a retinopathy. The binge eating disorder, according to research aspects initially a new eating disorder entity, may especially be observed in overweight and obesity. Even if a binge eating disorder in persons with a type 2 diabetes does not occur more frequently than in those metabolically healthy persons, it does depict a risk factor for an accelerated weight gain which as rule involves an increase of insulin resistance.

Comorbidity of diabetes and eating disorders. Does diabetes control reflect disturbed eating behavior?

OBJECTIVE: This multicenter study was designed to explore the prevalence of clinical and subclinical eating disorders (EDs), the extent of intentional omission of insulin and oral antidiabetic agents, and its relationship to glycemic control in an inpatient and outpatient population of men and women with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS: Data have been collected from 12 diabetes medical centers in two German cities. In a questionnaire and interview-based study, a sample of male and female patients (n = 341 type 1, n = 322 type 2) was assessed for the following eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. For lack of interview data of several patients meeting the screening criteria, prevalence ranges were calculated. RESULTS: The overall prevalence range of current EDs was 5.9-8.0% (lifetime prevalence 10.3-14.0%). When patients were stratified according to type 1 and type 2 diabetes, there was no difference in prevalence of EDs. However, the distribution of the EDs was different in both types of diabetes, with a predominance of binge eating disorder in the type 2 diabetes sample. Type 1 (5.9%) and type 2 (2.2%) diabetic patients reported deliberate omission of hyperglycemic drugs (insulin or oral agents) in order to lose weight. Compared with control subjects, neither the presence of EDs nor insulin omission influenced diabetic control. CONCLUSIONS: There seems to be no difference in prevalence rates of EDs in both types of diabetes; however, distribution of EDs is different. The findings suggest that neither EDs nor insulin omission are necessarily associated with poor control of glycemia. Binge eating disorder seems to precede type 2 diabetes in most patients and could be one of the causes of obesity that often precedes type 2 diabetes.

Comorbidity of diabetes mellitus and eating disorders: a follow-up study.

OBJECTIVE: There is increasing evidence that the coexistence of diabetes and eating disorders (ED) leads to poor glycemic control and an increased risk of long-term complications. METHODS: In a questionnaire- and interview-based study, a sample of 36 out of originally 38 (94.7%) diabetic patients with an ED (type-1: n=13, type-2: n=23) was assessed after a period of about 2 years in order to determine the course of EDs, body mass index (BMI), glycemic control, and psychiatric symptomatology. RESULTS: Five patients (13.9%) of the total sample showed full remission for at least 12 consecutive weeks. Twenty-two patients (61.6%) showed no change in the diagnosis of the ED. Four patients (11.1%) shifted from subclinical to clinical EDs and five patients (13.9%) vice versa. Of the eight patients who went on to psychotherapy, only one patient (12.5%) showed full remission. Emotional distress of type-2 diabetics was considerably higher compared to type-1 diabetics, which was rather low at baseline. Except interpersonal distrust as one ED-related variable, no significant change of any psychological variable could be observed in the type-1 diabetic sample during follow-up. Of the 13 type-1 diabetic patients with an ED, five patients deliberately omitted insulin in order to lose weight. These patients showed a more serious psychopathology with regard to each measured psychological variable, a higher BMI, and worse metabolic control compared to those without insulin omission. Type-2 diabetics showed a significant increase in drive for thinness and body dissatisfaction. No considerable change could be observed with regard to BMI, glycemic control, and depressive and global psychiatric symptomatology in either diabetic subsample during follow-up. CONCLUSION: EDs tended to persist over time with a considerable shift within the different types of EDs. Insulin-purging in type-1 diabetics was associated with enhanced psychopathology, higher BMI, and worse metabolic control. Both mean body mass and ED-related symptoms such as "drive for thinness" and "body dissatisfaction" increased in the average obese type-2 diabetic sample, illustrating the vicious circle of low self-esteem, enhanced restraint eating, and binge eating in weight control measures.

Diabetes mellitus and eating disorders: a multicenter study on the comorbidity of the two diseases.

Because diet is a key issue in the treatment of diabetes mellitus, it is assumed that these patients are prone to eating disorders. In a multicenter study, we have therefore assessed the prevalence of eating disorders in 662 patients with insulin dependent diabetes mellitus (IDDM) (n = 340) and non-insulin-dependent diabetes mellitus (NIDDM) (n = 322). A two-stage study combining self-rating questionnaires and a standardized interview was carried out. We found a prevalence of eating disorders of 5.9% (lifetime prevalence of 10%), irrespective of gender and type of diabetes; 4.1% of the whole sample reported intentional insulin undertreatment or omission. When patients were stratified according to IDDM and NIDDM, there was no difference in the prevalence of all eating disorders (point prevalence 5.5% vs. 6.5%, lifetime prevalence 10.0% vs. 9.9%). Prevalence of bulimia nervosa (BN) was more frequent in IDDM patients (point prevalence 1.5% vs. 0.3%, lifetime prevalence 3.2% vs. 1.9%) and binge eating (BED) was more frequent in NIDDM patients (point prevalence 1.8% vs. 3.7%, lifetime prevalence 2.6% vs. 5.9%). We conclude that eating disorders seem to be equally frequent in IDDM and NIDDM patients. However, there might be different features of eating disorders in both types of diabetes.

[Chronic fatigue syndrome--a disease entity or an unspecified psychosomatic disorder?]. / Chronisches Müdigkeitssyndrom--eigenständige Erkrankung oder unspezifische Befindlichkeitsstörung?

In spite of its nature as an often severe and disabeling disease, it is still unclear, whether the Chronic Fatigue Syndrome (CFS) is an entire disease of its own right or not. Moreover, there is a growing evidence that patients with CFS belong to an inhomogeneous group with different etiologic constellations. Specific somatic factors, e.g. viruses, seem to be less important for onset than certain personality-traits like depressiveness and workaholism. These traits lead to an increased vulnerability to unspecific psychological or biological stressors that may cause chronic fatigue by complex psychosomatic interferences. Concerning diagnosis, there are no specific methods or results available, the same is true for pharmacological treatment. As a consequence, practitioners should be aware not to miss a somatic disease causing fatigue, and, parallel to this, start right from the beginning talking about the psychosomatic background of CFS. Furthermore, psychotherapy has shown to be effective in CFS.

[Psychocardiology: clinically relevant recommendations regarding selected cardiovascular diseases]. / Psychokardiologie: praxisrelevante Erkenntnisse und Handlungsempfehlungen.

Psychosocial risk factors (work stress, low socioeconomic status, impaired social support, anger, anxiety and depression), certain personality traits (e.g. hostility) and post-traumatic stress disorders may negatively influence the incidence and course of multiple cardiovascular disease conditions. Systematic screening for these factors may help to adequately assess the psychosocial risk pattern of a given patient and may also contribute to the treatment of these patients. Recommendations for treatment are based on current guidelines. The physician-patient interaction should basically follow the principle of a patient centered communication and should gender and age specific aspects into consideration. Integrated biopsychosocial care is an effective, low threshold option to treat psycho-social risk factors and should be offered on a regular basis. Patients with high blood pressure may profit from relaxation programs and biofeedback procedures (however with moderate success). An individually adjusted multimodal treatment strategy should be offered to patients with coronary heart disease, heart failure and after heart surgery. It may incorporate educational tools, exercise therapy, motivational modules, relaxation and stress management programs. In case of affective comorbidity, psychotherapy may be indicated. Anti-depressant pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) in the first line should only be offered to patients with at least moderate severe depressive episodes. Psychotherapy and SSRIs, particularly sertraline, have been proven to be safe and effective with regard to improvements of the patient's quality of life. A prognostic benefit has not been clearly proven so far. Patients with an implanted cardioverter/defibrillator (ICD) should receive psychosocial support on a regular basis. Concomitant psychotherapy and/or psychopharmacotherapy (SSRIs) should be offered in case of a severe mental comorbidity. Generally, tricyclic antidepressants should be avoided in cardiac patients because of adverse side effects.

[Primary prevention-psychosocial aspects]. / Primärprävention-Psychosoziale Aspekte.

Psychosocial risk factors like low socio-economic status, social isolation and lack of social support, chronic work or family stress, depression, and hostility contribute significantly to the development and adverse outcome of coronary heart disease (CHD). The prevention of CHD should therefore include screening for psychosocial risk factors and adequate interventions. Methods to assess psychosocial risk factors are single item questions to be included in the cardiologist clinical interview and/or standardized questionnaires. Recommended interventions include an appropriate physician-patient interaction, multimodal, behavioral interventions with face to face or group counselling, and, in case of clinically significant depression, psychotherapy and medication.

[Psychosocial factors in coronary heart disease -- scientific evidence and recommendations for clinical practice]. / Psychosoziale Faktoren bei koronarer Herzkrankheit -- wissenschaftliche Evidenz und Empfehlungen für die klinische Praxis.

Psychosocial risk factors like low socio-economic status, lack of social support and social isolation, chronic work or family stress, as well as negative emotions, e. g. depression and hostility, contribute significantly to the development and adverse outcome of coronary heart disease (CHD). Negative effects of psychosocial risk factors are conveyed via behavioural pathways including unhealthy lifestyle, e. g. food choice, smoking, sedentary life, inadequate utilisation of medical resources, and psychobiological mechanisms like disturbed autonomic and hormonal regulation: all these factors contribute to metabolic dysfunction and inflammatory and haemostatic processes, which are directly involved in the pathogenesis of CHD. Interventions to improve pychosocial factors are available and have demonstrated positive effects on risk factors and - at least in part - on CHD morbidity and mortality. The prevention of CHD should therefore include screening for psychosocial risk factors and adequate interventions. Recommedations for the screening of risk factors, behavioural change and further management of psychosocial risk factors in clinical practice are pointed out.

[Ectopic pregnancy in intrauterine contraception]. / Ektope Gravidität bei intrauteriner Kontrazeption.

39 patients between 24 and 40 years of age with ectopic pregnancy associated with an IUP comprised 17.9 per cent of ectopics in an 8 year period. The IUP is probably not causal in ectopic pregnancy but does not protect the predisposed patient from ectopic pregnancy.

[Is there is seasonal incidence of acute adnexitis?]. / Gibt es eine saisonale Häufung der akuten Adnexitis?

188 cases of endoskopic proven acute adnexitis were examined regarding to a seasonal accumulation. There was a trend to a higher incidence of the acute adnexitis in general and of the gonorrhoeal one in particular in the sunny months. A gonorrhoea was detectable in 14.9%, and 55% of the patients were nulliparous women. The conclusions related to prophylaxis of infertility are discussed.