[Recruitment for general practice - relationship between practice-based curriculum and career choice]. / Gewinnung hausärztlichen Nachwuchses - Zusammenhang zwischen praxisorientierter Lehre und Karriereentscheidung.

BACKGROUND: Demographic change and recruitment problems in general practice are increasingly threatening an adequate primary care workforce in many countries. Medical schools play an important role in attracting young physicians to this field. The influence of the general practice curriculum on the career choice of graduates has not yet been sufficiently investigated. METHODS: The present study combines continuously collected data of medical students concerning the participation in miscellaneous general practice courses with data of a later graduate survey. RESULTS: Response rate was 64.2%. Although only 4.7% of the participants preferred a career in general practice at study entry, this specialty was, at 12.3%, the second most frequent career choice. Among the future general practitioners, only 18.5% had initially planned this career. The future general practitioners took part significantly more frequently in all facultative general practice courses. They reported more frequently to have met role models in general practice and to have gained experience in rural areas. Future general practitioners would more often prefer to work in rural areas in the future. CONCLUSIONS: Overall, the present results indicate that a broad and practice-oriented general practice curriculum has the potential to attract medical students to the specialty.

Electric pulse heating device for the analysis of solid/solid phase transformations.

Ohmic pulse heating is applied to investigate diffusion and interface controlled solid-state phase transformations. The developed device uses extensive solid-state electronics providing a high current, low voltage approach that overcomes the limitations of existing setups, most notably the use of sample geometries that allow for the reliable measurement of local temperatures and their assignment to microstructures. Power for heating is supplied by a capacitor array with adjustable voltage, and the process is controlled by microcontrollers and a solid-state relay, which allows for controlled pulses that are adjustable in microseconds. Electric currents of up to 22 kA at 90 V can be realized by the setup. Electric data are monitored and collected during the experiments, and temperature data are captured using a high-resolution infrared camera at high frame rates (1200 fps). The capabilities of the setup are demonstrated by rapid heating (106 K/s) and subsequent cooling of a brass sample. Two distinct areas of the sample are analyzed in detail, showing similar heating, but different cooling curves with rates of 104 and 102 K/s. Local microstructure analysis shows that different phase transformation mechanisms were dominant, and thus, the setup fulfills its purpose.

Results of 115 Rubis II reverse thumb carpometacarpal joint prostheses with a mean follow-up of 10 years.

The aim of this study was to assess the clinical and radiological results of the Rubis II thumb carpometacarpal joint reverse prosthesis, at a mean follow-up of 10 years. Between 1997 and 2008, 253 prostheses were implanted in 199 patients; 115 were reviewed. The survival after a mean of 10 years was 89%. At the last follow-up, 70% of prostheses were painless; the others reported moderate or intermittent pain. The satisfaction rate was 98%. The mean opposition was 9 on the Kapandji scale; the mean QuickDASH score was 30. Wrist, key and tip pinch strengths were comparable with the non-operated side. Of the 115 implants, one was radiologically loose (1%) and 15 had suffered dislocations (13%), 12 of which were caused by an injury. Eleven thumbs had revision surgery. This study confirms that the good clinical results of the Rubis II prosthesis are maintained in the medium and long term, and represents a useful alternative to trapeziectomy for selected patients. LEVEL OF EVIDENCE: IV.

Some observations on psychiatric research.

Principles of sound research design are too often incompletely applied in scientific investigations. Physicians may fail to evaluate journal articles for quality of research, comparability among studies, and clinical relevance. For many investigators quick publishable experiments take precedence over those with rigorous methods. Clinicians and researchers are becoming more aware of these concerns. Students should be taught the skills necessary to interpret scientific reading. Greater attention should be given to correct research design, and authors should fully explain both the procedures of a study, and its relevance. Fewer published articles and more review papers or commentaries might also stimulate better research quality.

Recognition and treatment of rabbit syndrome, an uncommon complication of neuroleptic therapies.

Rabbit syndrome is an uncommon, tongue-sparing, orofacial movement disturbance, rapid and regular in nature and associated with prolonged use of neuroleptics. Two cases reports illustrate how anticholinergic agents successfully treat the disorder. The syndrome is distinguished from tardive dyskinesia, which tends to be exacerbated by anticholinergic agents.

Is lithium bad for the kidneys?

Lithium alters renal physiology (e.g. polyuria) and is nephrotoxic in severe intoxications. With proper precautions, lithium was otherwise presumed safe through the mid-1970's. In 1977, the controversial question arose whether lithium may induce a chronic renal disease documented by biopsy. Later, similar lesions were demonstrated in affective disturbance patients never exposed to lithium. The possible role of lithium as an inducer of kidney damage is undetermined; but concern for the kidney in lithium patients is expressed. Better pre-lithium patient selection and renal work-up, lower serum lithium levels, and closer clinical and laboratory follow-up are advised.

Metrizamide myelography risk factors: a pseudopsychiatric case presentation.

A case of neurologic sequelae from intrathecal metrizamide is presented. The patient had a convulsion, became comatose, and transiently developed mutism and hemiparesis, with eventual full recovery. Metrizamide is generally safe, but side effects do occur, and they may require clinical attention and follow-up.

A practical approach to management of lithium concurrent with hyponatremia, diuretic therapy and/or chronic renal failure.

Lithium therapy concurrent with hyponatremia, thiazides and possibly other diuretics and/or chronic renal failure has generally been avoided. However, despite greater risk for lithium toxicity, such combinations are feasible with appropriate precautions, especially lower lithium dosage and closer follow-up. Under the right circumstances hyponatremia, diuretics, and/or chronic renal failure are only relative lithium contraindications.

Combined trimipramine/phenelzine treatment of depression: case report.

Trimipramine was found safe, effective, and free of complications when used in combination with the MAOI phenelzine in the treatment of a case of refractory depression. Trimipramine co-administration with phenelzine may be an efficacious alternative pharmacotherapy for selected cases when synergistic antidepressant therapies are indicated.

Psychiatric aspects of complex partial seizures: case report.

A patient is described who had a personal and family history of rage attacks, mood disturbance, and epileptiform EEGs. The patient achieved a return to emotional stability with the introduction of anticonvulsant drug therapy. Symptoms relapsed and then remitted as anticonvulsants were stopped and then reinstituted.

Alcohol abuse and attention deficit disorder.

The prevalence of alcohol abuse among the fathers, and ADD in family members, of 22 adult psychiatric patients with persistent attention deficit disorder was found to be significantly higher than in 20 matched controls. Further research is necessary to determine the reasons for, and clinical implications of, these associations.

Adverse behavioral response to clonazepam as a function of Verbal IQ-Performance IQ discrepancy.

Eight of 38 consecutive patients who received clonazepam had significant behavioral side effects. In these 8 patients, the mean absolute IQ discordance between Verbal IQ (VIQ) and Performance IQ (PIQ) was 17.5 points. Thirty of 38 patients had no adverse behavioral side effects while receiving clonazepam. In these 30 patients, the mean absolute VIQ-PIQ discrepancy was 6.5 points. Full neuropsychological testing had been performed on all patients. The only test variable showing a statistically significant difference was the absolute discrepancy between VIQ and PIQ (P less than 0.0001).

Neuroleptic malignant syndrome as a possible postoperative complication: a case report.

Neuroleptic therapy for postoperative agitation in a mentally retarded schizophrenic patient is described. Clinical features consistent with neuroleptic malignant syndrome (NMS) developed. NMS is a dangerous, drug-induced complication of neuroleptic administrations that can be a differential diagnostic problem. Already often misdiagnosed, this syndrome is especially likely to be unrecognized in nonpsychiatric settings, and may occur postoperatively. Failure to recognize NMS may lead to reexposures to the offending agent, with potentially grave consequences.

Implementation of a smoking ban on a locked psychiatric unit.

The purpose of this study was to measure alterations in the level of disruptive patient activity on a locked psychiatric unit after initiation of a smoking ban. Most of the monitored parameters of disruptive behavior remained stable, and/or changes did not reach statistical significance after the implementation of the smoking prohibition. This is in agreement with previous investigations. The only exception was an increase in the amount of p.r.n. medications dispensed specifically for agitated behavior [t(8 df) = -3.07 (p = 0.015)]. Though major clinical disturbances did not occur, it appeared that patients experienced a small yet documentable increase in agitation. Despite there being no major problems in establishing a smoke-free psychiatric service, abolishing tobacco products may create some minor management difficulties. This may be most commonly observed on locked units that treat large numbers of severely disturbed, involuntarily hospitalized individuals.

Emotional adjustment to cardiac transplantation.

Emotional adjustment to cardiac transplantation is a phasic process. Each step is associated with a milestone in the transplantation protocol. The adjustment process is divided into seven distinct stages: 1) transplant proposal, 2) evaluation, 3) awaiting a donor organ, 4) perioperative period, 5) inhospital convalescence, 6) discharge, and 7) post-discharge adaptation. Patient adjustment to transplantation is influenced by the adaptive task of each stage in the procedure, personality factors, previous experience with illness, and social support. Patients need time to adjust to each stage. Do not pressure them into premature acceptance of transplantation. Verbalization of feelings should be encouraged, and adequate support ensured. Contact with already transplanted patients is helpful to surgical candidates. Psychiatric assistance can greatly aid in patient management and emotional adjustment.

Clozapine-induced agranulocytosis and colony-stimulating cytokines.

A case of clozapine-induced agranulocytosis that was treated with a granulocyte colony-stimulating cytokine is presented. The hematological status normalized. Two colony-stimulating factors are marketed for activating bone marrow function. Their utility in clozapine a granulocytoses is not clear, but they offer a potential new therapeutic option.

Consultative psychiatry in both private and public general hospitals.

Most psychiatric patients obtain care in the nonpsychiatric units of general hospitals. Two groups of 100 psychiatric consultation patients in a private hospital setting and in a public hospital were compared. Significant differences were found. Patients in the public hospital were medically, psychiatrically, and socioeconomically more disabled. In the private setting, psychiatric consultants were usually seen as members of a treatment team. The public facility expected consultants to function as psychiatric triage officers. However, both patient groups had a similar frequency of psychiatric illness and had an equal need for psychiatric services.

A two-year follow-up on the effects of a smoking ban in an inpatient psychiatric service.

The effects of prohibiting cigarette smoking on the behavior of patients on a 25-bed psychiatric inpatient unit were assessed immediately after implementation of a smoking ban and two years later. No major behavioral disruptions were observed after the ban. The number of calls for security assistance, physical assaults, instances of leather restraints and of seclusions, and discharges against medical advice did not increase significantly immediately after the restriction on smoking or two years later. Significantly more verbal assaults and prescribing of p.r.n. medications for anxiety occurred immediately after the ban but not two years later.

Drug therapy for depression in the elderly.

Depression is common in the geriatric population, but recovery rates are gratifying. Safe treatment requires attention to the effects of aging on pharmacokinetics and close monitoring. Antidepressants are the drugs most commonly used; to the standard tricyclic drugs have now been added a tetracyclic and a triazolopyridine. Monoamine oxidase inhibitors and lithium are second-choice options; a benzodiazepine is not generally required. Dosages should be lower than conventionally prescribed. Side effects of antidepressant drugs are common, the most important being slowing of cardiac conduction times and the most common being anticholinergic manifestations, such as dry mouth and tachycardia. Some of the more recently introduced antidepressants may have more advantageous side-effect profiles than the older agents.

Lithium's effects on the kidney.

Although lithium was known to cause changes in renal physiology, it was considered safe until reports in late 1977 suggested that it may induce chronic irreversible nephropathy. Later reports documented similar lesions in non-lithium-treated patients with affective disturbances. Thus, the data are inconclusive. Concern for the kidney during lithium therapy is now greater than it was originally, but confidence in lithium's safety is higher than it has been for the past four years. Physician appreciation of the foregoing factors, careful patient selection, and informed consent are important in lithium therapy. An understanding of lithium use in patients in a low-sodium state or on diuretic therapy and avoidance and treatment of lithium intoxication are advocated. Good prelithium workups and closer monitoring of patients on long-term lithium therapy are recommended.