[Changes in treatment of squamous cell carcinoma over time. A process analysis]. / Adaptierte Behandlungsmodalitäten bei Patienten mit Plattenepithelkarzinomen im Wandel der Zeit. Eine Prozessanalyse.

BACKGROUND: The incidence of squamous cell carcinoma is rapidly increasing and requires process-optimized treatment dependent on the course of the patient's individual disease. Patient-based data on squamous cell carcinoma were used to analyze the treatment modalities before DRGs were introduced, after their introduction and after discussion about process-optimization in context of clinical pathways. PATIENTS AND METHODS: From the recorded data in the department of dermatology, all squamous cell carcinoma cases were identified and evaluated. In addition to patient characteristics, parameters describing the process, for example, length of stay in hospital, pre- and post-interventional days, were collected. RESULTS: Between 1998-2002, 2004-2006 and January to June 2007, 658 patients were treated for squamous cell carcinoma. In contrast to the times before DRGs, the treatment process has been significantly optimized, reducing the pre- and post-operative days and thus the duration of stay. Analysis of clinical pathways as part of the continuous improvement process was hardly able to detect further improvement. However, the weekly distribution of the admitted patients has been improved. CONCLUSIONS: Patients with squamous cell carcinoma requiring surgical excision benefit from an optimized process, just as do impatient facilities. However, optimized treatment modalities carry hardly any potential of improvement by the invention of clinical pathways.

[Health economics studies in dermatology]. / Gesundheitsökonomische Studien in der Dermatologie.

Because of reduced resources for health care, provision of modern effective dermatologic care for patients with German public health insurances has become more and more difficult. This survey is designed to aid in the assessment of published health economic studies as well as encourage participation in health economic evaluations. These studies should analyze and optimize the allocation of the available resources. Four main approaches can be used to calculate the incidental expenses; they differ in their methods of evaluation and assessment of health services. They all offer methods to calculate the anticipated costs and consequences. The methods include cost minimization analysis (CMA), cost effectiveness analysis (CEA), cost utility analysis (CUA) or cost benefit analysis (CBA). Many subgroups also exist. Important criteria for the evaluation of health economic trials and hints for the publication of the results are provided on the basis of the recommendations for health economic evaluations.

Are endoscopic antireflux therapies cost-effective compared with laparoscopic fundoplication?

BACKGROUND AND STUDY AIMS: A number of endoscopic antireflux therapies (EATs) have emerged as potential nonmedical treatment options for patients with gastroesophageal reflux disease (GERD). Concerns about clinical efficacy and costs have given rise to debate about their role in GERD management. The costs of laparoscopic fundoplication (LF) were compared with the costs of EAT when used in a sequential strategy that reserves the option of LF for EAT failure. METHODS: A simple mathematical criterion of direct medical costs was applied. Published articles concerning EAT were reviewed to assess its effectiveness, durability and costs, in order to estimate the parameters of the model. The costs of EAT and LF were evaluated from the perspective of a German third-party payer. Only direct medical costs were considered. RESULTS: Assuming that EAT has no impact on potential LF later on, the outcome of both strategies (LF, or EAT first with LF in case of failure of EAT) is identical and preference is a simple question of costs. The sequential strategy in nonmedical GERD treatment would be preferable if the long-term relief rate with EAT exceeds the ratio of the cost of EAT to the cost of LF. Long-term success rates of EAT do not exceed 0.65. At current prices EAT is clearly not cost-effective in Germany. CONCLUSION: Our simple criterion indicates that EAT would only be cost-effective and beneficial in a sequential strategy if the costs of EAT were to be decreased to around 30 % of current retail prices. However, long-term studies and randomized controlled trials are necessary to finally determine the role of EAT in GERD treatment, and the preference may change in either direction.

[Skin and knife. Attributes of St. Bartholomew]. / Haut und MesserAttribute des heiligen Bartholomäus.

St. Bartholomew, who was born in Kana/Galilee in the first century, is known as one of the twelve apostles of Jesus and is associated with skin diseases due to the attribute "skin" which he carries over his arm like a coat or blanket. Curing the daughter of King Polymios in Armenia led to his doom. He was flayed alive and subsequently crucified. Michelangelo's Last Judgment (1536-1541) in the Sistine Chapel of the Vatican shows him as flayed and holding his own skin in his hand. Today he is regarded as the patron saint of dermatology because of his association with the skin.

[Drug reaction to terbinafine simulating an acute generalized exanthematous pustulosis]. / Arzneimittelreaktion auf Terbinafin unter dem Bild einer akuten generalisierten exanthematischen Pustulose (AGEP).

Oral terbinafine (Lamisil) is a widely used and effective therapy of dermatophyte infections. A 20-year-old patient was treated with oral terbinafine for an inguinal-scrotal fungal infection and developed an acute generalized exanthematic pustulosis (AGEP) and fever. Histological examination of skin biopsy revealed subcorneal and spongiform pustules. The diagnosis of an AGEP induced by terbinafine was established based on the history, clinical manifestations, and laboratory findings. Clinical features, differential diagnosis, causative drugs, and the therapy of AGEP are discussed and the literature on cases of terbinafine-induced AGEP is reviewed.

Immunomodulators in the treatment of cutaneous lymphoma.

BACKGROUND: Cutaneous lymphoma involves clonal proliferation of immunocompetent cells. Immunointerventional strategies are a rational approach to the treatment of cutaneous lymphoma given the pathophysiological aspects of the disease. OBJECTIVE: Immunomodulatory therapies in cutaneous lymphoma are reviewed, including interferons, interleukin-2, cyclosporin A, monoclonal antibodies, autologous bone marrow transplantation, fusion toxins, thymopentin and extracorporeal photopheresis as well as recently reported methods such as vaccination therapy, mycophenolate, and new retinoids. RESULTS/CONCLUSION: Cutaneous lymphoma is sensitive to immunointerventions. This approach should be used in early stages of the disease when it is more susceptible and benefits better from immunomodulatory treatment modalities.

Imbecility, pauperism, and crime: an appraisal of their relationship to substance use, abuse, and dependence.

Freud had stated that human judgments of value "follow directly ... wishes for happiness--that, accordingly, they are an attempt to support ... illusions with arguments." This paper argues that substance use/abuse/dependency treatment has been a failure because we understand little about eradicating the significant concerns associated with the use of chemicals that haunt mankind: ignorance, poverty, and crime. While technologies advance at dizzying speed, the human capacity to integrate new information and to achieve a quality life seems to evade many. The author presents her treatment regime which has helped some patients. But the psychologist is only one contributor to psychotherapy, habilitation and rehabilitation. It is advisable that each member of the professional and lay communities "tend to their own garden."

Domestic abuse by male alcohol and drug addicts.

Sixty-three male inpatient alcohol and drug addicts and 34 of their female partners participated in a study of variables associated with physical and nonphysical abuse of women. Results suggest that domestic abuse by male addicts is not directly related to experience of violence or addiction in the family of origin, external locus of control, or severity of alcohol abuse. Correlates of domestic abuse were an early onset of drug/alcohol-related problems; low income; a history of nonalcohol drug use, particularly cocaine; and a history of arrest and outpatient counseling.

The political process and its relationship to the psychotherapy of substance misusers: an historical perspective.

There are massive changes underway in the allocation of funds for health care in the United States which will impact upon services provided for users and misusers of intoxicating substances. Recent findings suggest that conditions in the marketplace and the development of professions have effected standards of care rather than a reasoned analysis of need and outcome. Psychologists question to what extent they will be involved in public policy issues including what is clinically and socially relevant. The goal of this paper was to determine if an historical perspective upon federal regulation of intoxicating substances (tobacco/alcohol/drugs) would enlighten the psychotherapy scientist in the pursuit of standards for service. The methodology included a review of the economic and social structure of colonial America which included tobacco plantations, breweries, and distilleries as well as a review of the formation of the federal government and political system in which men, women, and slaves were each assigned different performance standards/roles and economic rewards within the community. The implication is that potential for self-regulation and psychological development is based upon the legacy of our forefathers.

The Addiction Severity Index: predicting relationship to a hospital and a professional.

The Addiction Severity Index was developed to be a useful instrument in treatment planning for the substance abuser. Multivariate statistical tests were conducted on the questionnaire for a clinical sample of 190 males at a Veterans Administration hospital. When the desire for psychological treatment with a specific person was taken into consideration, the overall predictive validity of the instrument in designating discharge accounted for 69% of the variance rather than 24% of the variance. This finding could challenge the myth that substance abusers and patients from lower socioeconomic levels are not psychologically minded and not capable of being engaged in psychological process treatment. This finding is also relevant to governmental concerns for quality assurance and cost effectiveness, since it can be utilized to both improve treatment planning and delete irrelevant documentation and assessment procedures.

Attrition within a detoxification unit: patient response to policy and psychological intervention.

Professional psychological consultation with selected substance abusers was found in earlier work to stabilize patients as well as create organizational change. All patients subsequently were to undergo a psychological consultation. Three consecutive 10-month samples of male veterans (N = 254, 309, and 261) undergoing inpatient detoxification showed characteristic rectilinear decay curves while those refusing psychological consultation showed poisson-like negatively accelerating decay curves. Distributions clearly reflect (a) treatment contract, either 14- or 21-day length of stay; (b) presence or absence of a psychological consultation; and (c) an unknown factor. It is hypothesized that in addition to policy, the psychological focus upon self-experience rather than behavior had become internalized by the treatment team, thus creating a calmer interpersonal atmosphere, one more able to sustain the irritability, demandingness, and negativism of substance abusers, though with emotional cost to those involved. It is suggested that enlightened mental health policy be introduced on a wider scale.

Factor structure of the Addiction Severity Index in an inpatient detoxification sample.

This study examines the factor structure of the Addiction Severity Index for a clinical sample of 190 males in an inpatient detoxification unit at a Veterans Administration hospital. Factor analysis revealed a four-factor solution rather than the six-factor solution originally suggested. These four factors (accounting for 22% of the common variance) were labeled chemical addiction, criminality, psychological distress, and health-related problems. Overall results suggest that considerably more work must be expended in developing standards for an interview schedule applicable to the chemically dependent.

Psychological consultation with substance abusers.

Previous work has documented that compliance rates of substance abusers undergoing inpatient detoxification could be influenced by professional psychological consultation. The administrative structure has been previously described as well as a clinical/humanistic component within the administrative structure. This report describes the individualized psychological consultation. This consultative intervention is in accord with the tripartite model of mental health which views the assessment of pathology from the perspectives of the mental health practitioner, the patient, and the culture; and the recent advances within self-psychology. A self-psychological model is suggested to understand the detoxifying substance abuser, from a stage of loss of cohesiveness to one of personality stabilization. The hospital environment and persons within the environment provide both a framework and self-object functions (mirroring, idealizing, and alter ego) during detoxification. Research recommendations are made to collect empirical data on the psychology of the detoxifying addict.

An educational program for the assessment and development of psychological-mindedness in the chemically dependent.

Substance abusers can be conceptualized as alexithymic (Sifneos), psychically traumatized (Krystal), without internalized standards (Wurmser), and narcissistically defective (Kohut). Each of these theoretical systems conveys an important vantage point from which to view the rise of substance use and abuse and personality deterioration within the international community during this time of cultural fragmentation. Culture has been described as contributing to aspects of internalized psychic structure (Horney), to the maintenance of that structure (Bion), and to its members' performance of ongoing functions of mirroring and idealizing (Kohut). A detoxification program is described within which a psychological component has been found effective in stabilizing patients, in developing psychological-mindedness, in preparing some for psychic structural development, and in the creation of a facilitating, humanistic environment.

Professional psychotherapy and its relationship to compliance in treatment.

Compliance rates over a 21-month period for 57 drug-abusing patients receiving individual professional psychotherapy in addition to paraprofessional counseling were compared to compliance rates for patients not receiving individual professional psychotherapy. Compliance was defined as remaining in the treatment environment for an agreed upon time and neither leaving the hospital against medical advice nor being given a disciplinary discharge for illegal drug use, stealing, or fighting. Patients receiving professional psychotherapy had been assessed as having either higher levels of psychiatric symptoms or a history of a psychiatric diagnosis, or being potential management problems. Patients who received psychotherapy more likely remained stabilized in the treatment environment and in their role as patient. An additional finding was that clarity of the therapist's role in the ward environment affected the patient's stabilization. This study supports recent findings that professional psychotherapy can be effective for drug abusers. It suggests that individual psychotherapy/consultation with distressed and difficult patients experiencing disequilibrium in the hospital milieu can be an effective means of restoring that equilibrium.

Effect of the hypnotic flurazepam on the sleep of pentazocine and heroin addicts during withdrawal.

Fourteen male heroin addicts being detoxified on methadone and 14 male pentazocine addicts being detoxified drug-free were observed over a 24-hour period for 2 weeks in their sleeping patterns to assess the effects of flurazepam upon sleep during withdrawal. Results of objective and subjective measures find that flurazepam use is associated with more objective nighttime arousals and less total sleep for the heroin group compared to the pentazocine group. Heroin patients felt they had a poorer quality of sleep and took flurazepam more frequently than did the pentazocine patients. Heroin patients' assessments of their sleep and number of arousals correlated poorly with observations.

Predicting treatment dropouts from a drug abuse rehabilitation program.

Seventy-five drug addicts who completed an opiate detoxification program were compared with 75 addicts who dropped out prematurely on 14 variables. Results showed that patients were more likely to complete detox when the number of staff absences and primary therapist absences increased, when more patients were admitted during their hospitalization, and if they were prescribed methadone. A discriminant function analysis successfully classified 88% of the sample into stay/leave categories. The results were cross-validated on an independent sample of 25 completers and 25 dropouts, resulting in 75% classification accuracy. Primary drug of abuse (heroin/Talwin) was not a factor on any measure. Results indicate that treatment dropout among drug addicts is based more on situational interactionism than on individual determinism.