["Vocational perspective"--short-term efficacy of a group treatment for patients with extensive work-related problems during medical rehabilitation]. / "Berufliche Zukunft"--Kurzzeiteffekte eines Behandlungsprogramms bei sozialmedizinisch relevanter Problemlage im Verlauf einer medizinischen Rehabilitation.

AIM OF THE STUDY: To analyze the short-term efficacy of the Vocational Perspective programme for patients identified as having extensive work-related problems during rheumatology or orthopaedic inpatient rehabilitation. The primary objectives of the programme on patient level are to convey information about the legal provisions regarding earning incapacity and occupational reintegration, to suggest strategies for dealing with one's own occupational situation, and to strengthen the motivation to stay employed. The programme is explicitly designed for patients who wish to retire or have applied for a pension. On the systemic level, the main goals are to facilitate doctor-patient communication and to increase rehabilitation teams' awareness of occupational problems. METHODS: In a controlled quasi-experimental design, 359 subjects were consecutively assigned to either the control group (CG, n=177) or the intervention group (IG, n=182). The control group received standard care only, whereas the intervention group additionally participated in the 5-part Vocational Perspective programme. Evaluation criteria were assessed by questionnaire at the beginning (t1) and at end of rehabilitation (t2). Survey participation was 92.2% at t2. The socio-medically relevant knowledge status was objectively documented using a specially designed knowledge questionnaire. Aspects of treatment satisfaction were evaluated using individual items, and the subjective prognosis of gainful employment was assessed using the Subjective Prognosis of Gainful Employment (SPE) scale. Facilitation of communication between doctor and patient was operationalized at patient level in terms of patient satisfaction with medical care, and increased awareness of the rehabilitation team was operationalized in terms of the rate of recommendations to apply for vocational reintegration (LTA) services at discharge. Emotional and functional parameters were exploratively analyzed (anxiety and depression using the IRES 3.1 scales, and subjectively experienced pain-related impairment using the Pain Disability Index). RESULTS: Scores for subjective satisfaction with job-related information, medical care, socio-medical assessment, and the overall benefits of rehabilitation were significantly higher in the intervention group than in the control group. IG subjects moreover were better able to use the rehabilitation measure to clarify their occupational situation and exhibited significantly greater improvement of socio-medically relevant knowledge. Age proved to be an important predictor of change in a patient's subjective prognosis for gainful employment (SPE): A positive change in SPE was observed in both groups in subjects under 50, in those aged 50 and older, however, only in the intervention group. No differences between the two groups were observed in terms of functional and emotional parameters (e. g., disability through pain, anxiety, and depression). A total of 60% of the subjects received a recommendation at discharge to apply for vocational reintegration services, the proportion however was significantly higher in the IG. CONCLUSIONS: The Vocational Perspective programme met the patients' high demand for information on relevant socio-medical facilities and services regarding career change and facilitated communication between the doctor and patient by creating greater transparency. The improvement of subjective prognosis for gainful employment observed in the subgroup of older patients indicates that specialized interventions are needed in precisely this disadvantaged group in order to improve their own vocational expectations and thus to improve their chances of reintegration into work life. The high rate of recommendations to apply for vocational reintegration services suggests that rehabilitation teams already have a high awareness of job-related problems even under "usual care" conditions.

["Vocational perspective" - concept and acceptance of a group treatment for patients with extensive work-related problems]. / "Berufliche Zukunft" - Konzept und Akzeptanz eines Behandlungsprogramms bei sozialmedizinisch relevanter beruflicher Problemlage.

BACKGROUND: The treatment programme "Vocational Perspective" was developed for patients with health-related social problems, e. g. long-term sick leave, job loss due to disability, job insecurity and psychosocial disabilities. It intends the patient-oriented imparting of information referring to social system, legal rights, earning capacity and occupational reintegration as well as an early feedback of the sociomedical assessment by the physicians. Participants during in-patient rehabilitation are supported to deal with their occupational situation; motivation to stay employed is strengthened. The group programme contains five psychoeducative modules and an additional sociomedical "ward round". The aim of the study was to examine the acceptance of the newly developed sociomedical vocational therapy module. METHOD: A total of 179 patients participated in 21 "vocational perspective" seminars within the scope of a controlled quasi-experimental trial. In the experimental group the data on acceptance of the treatment was assessed by questionnaire at the end of the intervention. Experiences with implementation of the programme are described in order to complete the patient-related perspective. RESULTS: The identification of a demand for work-related interventions in medical rehabilitation seemed successful: Sociodemographic and socioeconomical parameters of the sample proved high risk in view of the social-medical perspective (poor education, high unemployment rates and long-term sick leave). Self-estimations revealed high suffering of the participants, e. g. due to the occupational situation, anxiety and depression, and confirmed high interest in work-related issues. The patients showed quite high acceptance of the programme (regarding importance of seminar, comprehensibility, usefulness of information, atmosphere of the group, mode and extent of the programme). 82.7% of the participants would recommend the programme to other people with work-related problems. Altogether, the experiences during the implementation of the programme can be described as positive. Nevertheless, organizing took much effort and the treatment was very demanding for the therapists. Finally, it is also necessary that the physicians agree to realize high transparency in the process of sociomedical assessment. CONCLUSION: The sociomedical programme "Vocational Perspective" helps patients to deal with relevant information referring to social system and occupational reintegration. Problematical sociomedical issues can be handled in a therapeutic way during rehabilitation process. Therefore, the programme can be used as meaningful supplement in regular medical rehabilitation. For final conclusions, the results of short-term and follow-up evaluations described elsewhere have to be considered.

[Fractionated inpatient rehabilitation: results from a randomized controlled trial]. / Fraktionierte Rehabilitation: Ergebnisse einer randomisierten, kontrollierten Studie.

The aim of this study was to verify the assumption that fractionated inpatient rehabilitation (three weeks and another week at a future date) is superior to a four-week inpatient treatment for patients with rheumatic diseases (spondyloarthropathies, fibromyalgia, rheumatoid arthritis). This expectation was based on the evidence of only short-term effects of inpatient rehab. Fractionation was intended to prolong and consolidate the effects achieved by the three-week inpatient treatment. Altogether, both groups showed significant positive effects for pain-intensity, activity and state of physical health over a period of more than one year, but there were no statistical effects between the groups. Advantages of fractionated inpatient rehabilitation could not be confirmed.

[Inpatient aftercare in rheumatic diseases--concept, trial, and acceptance]. / Stationäre Nachsorge bei rheumatischen Erkrankungen--Konzept, Erprobung und Akzeptanz.

BACKGROUND: A one-week booster group treatment in rheumatic diseases (rheumatoid arthritis, spondylarthropathies, fibromyalgia) was developed in order to stabilize rehabilitation effects after medical rehabilitation. The program took place in an inpatient setting 3 - 5 months after rehabilitation, aimed at refreshing and deepening already learnt contents as well as teaching new subjects (e. g. about dietetics). Training and educational elements are given priority in this concept. METHOD: A total of 140 patients participated in 19 booster weeks. At the end of each booster week the acceptance was assessed by questionnaire and in a round-table discussion. RESULTS: Comprehensibility and group atmosphere were judged very positively. The course was also considered very helpful, helpfulness being rated with marks about 2 (1 = very helpful, 6 = not at all helpful). Participants especially appreciated the course's framework as a group setting emphasising the exchange of experience with co-patients. At the same time, however, participants wished more individualized treatment such as physiotherapy or massage. With regard to the quantity of the various therapy elements, participants would have preferred more traditional spa therapy, more medical treatment by a physician, more group physiotherapy and sports. They would also have liked more breaks. In general fewer psychological elements, less discussion and reflection but more physical activity was wished for. Little difference was found between the various diagnoses, but the program was rated slightly more positively by the patients with spondylarthropathies. CONCLUSION: Overall, the great number of people participating in the program and their acceptance of the booster week are positive. Patients appreciated the group setting and the possibilities of exchanging experience on a high level. But it was difficult to change patients' traditional expectations concerning medical rehabilitation to a behaviour-orientated course like ours. It is worth thinking about whether this concept should play a greater role in traditional medical inpatient rehabilitation programming.

Mutational activation of the RAS-RAF-MAPK and the Wnt pathway in small intestinal adenocarcinomas.

BACKGROUND: Adenocarcinomas of the small and the large intestine share risk factors and morphological features but both tumor types seem to follow different genetic pathways. The aim of this study on small intestinal carcinomas was to analyze alternative mechanisms of activation of pathways that are typically affected in colorectal cancer. METHODS: Twenty-one sporadic carcinomas were investigated for mutations in KRAS, BRAF, the beta-catenin gene CTNNB1, and the mutational cluster region of APC. Immunohistochemical analysis was performed with a monoclonal antibody for beta-catenin, the transcriptionally active downstream component of wnt signaling. RESULTS: Oncogene mutations were found in 13 (62%) small intestinal adenocarcinomas. Twelve tumors displayed a KRAS mutation, and a novel BRAF mutation at codon 603/604 was seen in one carcinoma without KRAS mutation. One tumor harbored a CTNNB1 mutation consisting of an insertion of 247 nucleotides deriving from chromosome 9. APC mutations were identified in 2 tumors. Immunohistochemistry demonstrated nuclear accumulation of beta-catenin in 5 carcinomas. These carcinomas included the tumor with a CTNNB1 mutation but not those with APC mutations. CONCLUSIONS: Our data show frequent activation of the RAS-RAF-MAPK pathway through mutations of either KRAS or, infrequently, BRAF. Activation of the wnt pathway through accumulation of beta-catenin may have a role in a subset of small intestinal adenocarcinomas but in contrast to colorectal carcinoma, accumulation of beta-catenin is generally not caused by inactivating APC or activating CTNNB1 mutations.

[Costs and benefits of an education program for patients with ankylosing spondylitis as part of an inpatient rehabilitation programs-study design and first results]. / Kosten und Nutzen eines Schulungsprogramms für Patienten mit Spondylitis ankylosans in der stationären RehabilitationUntersuchungsdesign und erste Ergebnisse.

The economic evaluation of a patient education program "ankylosing spondylitis"-based on a randomised controlled prospective multi-center study design-compares program costs and savings in direct and indirect follow-up costs. The collection of health services and cost data was conducted by questioning staff (education programme costs) and patients (follow-up costs). The present study results are: program costs per patient range between 117 euro (10 participants per course) and 186 euro (6 participants per course). Savings in indirect costs (unfitness to work) amount to 2500 euro and thus overcompensate program costs. Currently patient data are verified by sickness fund data and direct follow-up costs and qualitiy of life data are analysed.

[Patient education in practice-a workshop in a small group]. / Patientenschulung in der PraxisWorkshop in der Kleingruppe.

The aim of the workshop was to work out concrete plans and steps for implementing patient education courses in an outpatient setting by the collaborative arthritis centers in Germany. Primarily the patient education model of Lower Saxony was illustrated as an example of successful implementation of patient education programs in practice. In this state patient education courses are run in cooperation between the Arthritis Center of Hannover and the League against Rheumatism in Lower Saxony. Both institutions are in discussion with the health insurance companies for paying the costs for the patient education courses. Then the group discussed several important aspects which have to be considered when establishing patient education courses such as recruiting and motivating the trainers, recruiting the participants, choosing adequate rooms, fund raising and responsibilities. The participants considered the patient education model of Lower Saxony as a transferable model for every collaborative arthritis center in Germany and recommended to follow that path.

[The BASDAI-D--an instrument to defining disease status in ankylosing spondylitis and related diseases]. / Der BASDAI-D--ein Fragebogen zur Erfassung der Krankheitsaktivität bei Spondylitis ankylosans und verwandten Erkrankungen.

OBJECTIVE: Translation and validation of the Bath Ankylosing Spondylitis Disease Activity Index ( BASDAI) for defining disease status in ankylosing spondylitis (AS) and related diseases. METHODS: The German version BASDAI-D was translated with only a few modifications. It contains six 10 cm horizontal visual analog scales to measure severity of fatigue, spinal and peripheral joint pain, tenderness and morning stiffness. A total of 318 patients with AS and other spondarthropathies completed the instrument at the beginning and at the end of their medical rehabilitation. Psychometric evaluation was performed separately for patients with AS corresponding to the modified New York Criteria ( SPA-NY, N=211) and for a second group of patients, which fulfilled the early diagnostic criteria for AS or the ESSG criteria of spondylarthropathies (Fd/Spond., N=86). RESULTS: SPA-NY: Factor analysis yielded one factor explaining 54.8% of variance. The sum score with a standard deviation of 1.94 is nearly symmetrical distributed with mean of 4.7. Reliability analysis yielded high internal consistency (Cronbach's alpha=0.83). Corrected item-total correlations are also high and are large ranging from 0.48 to 0.71. Concerning concordant validity the BASDAI-D showed a substantial correlation with the scale bodily pain of the SF 36 (r = -0.72). There are no correlations with objective clinical parameters. Furthermore the assessment of disease activity by the physician correlates significantly, albeit low with the BASDAI-D. Sensitivity to change yields effect sizes up to 0.60. Fd/Spond.: The results for this group are almost identical with SPA-NY (one factor explaining 53.8% variance, mean 4.6+/-1.75; corrected item-total correlations from 0.50 to 0.75; correlation with the scale bodily pain r = -0.62). Analysis for subgroups showed higher scores for women in both groups SPA-NY and Fd/Spond. CONCLUSION: BASDAI-D ist applicable for patients with AS and likewise for patients fulfilling the early diagnostic criteria for AS or the ESSG criteria of spondylarthropathies. In summary, BASDAID is reliable and valid. Because of its good acceptance and usability BASDAI-D is easy to use in research as well as in clinical practice.

[Basic principles in rheumatologic patient education. Theoretical principles and didactic aspects]. / Grundlagen der rheumatologischen Patientenschulung. Theoretische Grundlagen und Didaktik.

Nowadays, the handling of a chronic disease is seen as a process, influenced by a variety of factors. Case studies, taken from health behavior, help to illustrate the conduct of patients suffering from chronic diseases and develop strategies of how to increase a patient's skills in coping with his illness. The concept of self-efficacy beliefs is of great importance and will be discussed in detail. In addition, possible effects of patient education in the comprehensive treatment of rheumatic diseases will be presented. In teaching methods, equal emphasis is placed on the transmission of information as on the development of practical know-how. They are on a par with emotional support, motivation, assistance in accepting the disease and coping with fear. The special methods and media required will be discussed, along with the framework for training methods and qualification required of the staff in charge of training.