[Psychiatric care in Sachsen-Anhalt: a survey of institutions and services with the "European Services Mapping Schedule" ESMS]. / Psychiatrische Versorgung in Sachsen-Anhalt: Einrichtungen und Dienste im Uberblick - Eine Erhebung mit dem "European Services Mapping Schedule" ESMS -

OBJECTIVE: To describe the availability of outpatient, inpatient and community based psychiatric care in 21 rural districts and 3 cities of Sachsen-Anhalt, one of the federal states of eastern Germany, with rapid changes and developments in psychiatric care over the last ten years. METHOD: Information about services was obtained from files of the "Committee for Issues of Psychiatric Care in Sachsen-Anhalt", which was established in 1992 with six multiprofessional "visitation groups" to perform inspections of all institutions providing psychiatric service to the community. Reports about these regular visits followed semi-standardized protocols. The ESMS was used to classify 365 institutions visited between 1996 and 1998, and numbers of places per 100 000 inhabitants were used to compare the 24 regions of the state. RESULTS: The visitation protocols as the main source of information and the ESMS as a classification tool proved to be useful. The interrater-reliability was high, and the validity of the data was supported by other official statistics. Outpatient care was provided by 4 psychiatrists and 3 psychologists in private practice per 100 000 inhabitants, which is low compared to the German mean. 10 secure beds (forensic psychiatry), 48 acute beds, 13 elective beds and 13 day hospital places per 100 000 inhabitants were available for inpatient care, with a marked shortage of beds in the southern and eastern regions of the state. Non-acute non-hospital residential services with indefinite stay and 24 hour support accumulated to 240 places per 100 000, with regional differences ranging from less than 100 to more than 1000. About 80 % among the residents of these institutions were considered as suffering from "mental retardation", suggesting some persisting institutionalism. All other residential services taken together (time-limited or with less than 24 hour support) came to 24 places per 100 000. Sheltered workshop places corresponded to the number of persons in residential homes. Other facilities offering paid work or work-related activities were scarce; some services providing structured activity or social contact were available in urban agglomerations. The data about the frequency of contacts in outpatient and community services are limited. CONCLUSIONS: Psychiatric care in Germany is fragmentary, as regards providers and funding. Information collected by the "Committee for Issues of Psychiatric Care in Sachsen-Anhalt", taken mainly from visitation protocols, was sufficient to establish a general survey over 24 regions of this federal state. We propose to repeat this approach regularly to monitor developments in the field of social psychiatry for further planning and interventions. Overall, our results show that the aims formulated in the German "Inquiry into Psychiatry" ("Psychiatrie-Enquete") have not been fully accomplished (e.g. the preferential status of outpatient versus in-patient services).

Nerve cell loss in the thalamic mediodorsal nucleus in Huntington's disease.

We estimated the total neurone number, glial number, and glial index (ratio glial cells/neurone) in the thalamic mediodorsal nucleus (MD) in seven patients suffering from Huntington's disease (HD; four males, three females, mean age 52.4 +/- 13.6 years) and age- and sex-matched controls (four males, three females, mean age 53.6 +/- 12.1 years) by means of a stereological protocol. The mean total neurone number (N(T)) in the MD of controls was 2,985,188 +/- 174,710, the mean glial number (G(T); astrocytes, oligodendrocytes) 21,785,008 +/- 2,986,678, and the glial index 7.29 +/- 0.88. In HD, the average neurone number was decreased by 23.8% to 2,275,321 +/- 247,162 (Mann-Whitney U-test P < 0.05), the mean glial number by 29.7% to 15,318,895 +/- 1,722,524 (Mann-Whitney U-test P < 0.05), the glial index was slightly reduced to 6.81 +/- 1.06. Gallyas' impregnation for the demonstration of fibrous astroglia gave strongly positive results in all cases with HD and negative results in the controls. The morpho-functional correlation of the results is complicated because individual variability, presence of segregated and parallel neuronal circuits, and plasticity of the adult human CNS must be considered.

[Design of psychiatric-psychotherapeutic institute ambulatory care: survey to determine need]. / Einrichtung einer psychiatrisch-psychotherapeutischen Institutsambulanz: Umfrage zur Bedarfsermittlung.

OBJECTIVE: In Germany, outpatient care is provided exclusively by physicians in private practice. This privilege is very strictly observed, with only a few exceptions. While psychiatric hospitals are routinely permitted to establish outpatient clinics, psychiatric departments of general hospitals, even if they serve a catchment area, need a formal permission of the organisation of the physicians in private practice. The law requires proof for some kind of "demand". METHOD: In the catchment area of a recently founded psychiatric department of a rural general hospital, 44% of 131 medical practitioners answered a written questionnaire. RESULTS: Psychiatrists and psychologists objected to any kind of outpatient clinic, as expected. All the general practitioners and specialists, however, supported the idea. CONCLUSIONS: Physicians practising in the area do not agree with their organization's policy. Many of them favour the possibility to have selected patients cared for at the psychiatric outpatient clinic of the local hospital.

[Psychotherapy in the day clinic]. / Psychotherapie in der Tagesklinik.

Recently, the importance of psychiatric day hospital treatment is increasing in German psychiatry, as the regionalization and community-orientation of care advance and catchment areas become smaller. When a psychiatric department of a local general hospital is within easy reach of the patient's residence, the means for intensive treatment, as is available in a hospital, can be utilized during the day, while the patient spends a considerable amount of time (in fact, two thirds) in the familiar surroundings of his/her own home. This is applicable for many psychiatric conditions, including neuroses, personality disorders and psychosomatic diseases. As compared to conventional individual outpatient psychotherapy on the one hand and a distinct limited stay in a psychosomatic sanatorium far from home on the other hand, psychotherapy in a day hospital offers a promising additional way to provide effective and lasting professional help early and with a low threshold. The article summarizes the experience gained in a newly founded department of psychiatry and psychotherapy at a general hospital in one district of eastern Germany, where the staff is struggling to meet the needs of the catchment area in spite of a too small number of hospital beds.

[Contribution of psychiatric departments to restructuring inpatient management: the Saxony-Anhalt example]. / Der Beitrag psychiatrischer Abteilungen zur Umgestaltung der stationären Versorgung: Das Beispiel Sachsen-Anhalt.

In 1996, the available number of hospital beds for inpatients care in psychiatry, psychotherapy and psychogeriatrics in Sachsen-Anhalt amounted to approximately 0.4 beds per 1,000 inhabitants. As compared to 1992, when most beds were still concentrated in four large psychiatric hospitals, some decentralisation had been achieved. Now, 13 of 23 catchment areas have clinical facilities of their own, five of which were newly founded. About 800 of 1,346 beds and 245 of 299 day hospital places are now located outside the former large institutions. Some of the recently established facilities, however, are not yet sufficiently equipped to serve their catchment areas, with regard to appropriate size, room, staffing, internal specialisation and authorization to cope with compulsory admissions. Even in general hospitals, psychiatric departments are often separated from the main building, with the spatial distance providing some obstacle to the desired cooperation of psychiatry with other medical specialties.

Nerve cell loss in the thalamic centromedian-parafascicular complex in patients with Huntington's disease.

The centromedian-parafascicular complex represents a nodal point in the neuronal loop comprising striatum--globulus pallidus--thalamus--striatum. Striatal neurone degeneration is a hallmark in Huntington's disease and we were interested in estimating total neurone and glial number in this thalamic nuclear complex. Serial 500-microns-thick gallocyanin-stained frontal sections of the left hemisphere from six cases of Huntington's disease patients (three females, three males) and six age- and sex-matched controls were investigated applying Cavalieri's principle and the optical disector. Mean neurone number in the controls was 646,952 +/- 129,668 cells versus 291,763 +/- 60,122 in Huntington's disease patients (Mann-Whitney U-test, P < 0.001). Total glial cell number (astrocytes, oligodendrocytes, microglia, and unclassifiable glial profiles) was higher in controls with 9,544,191 +/- 3,028,944 versus 6,961,989 +/- 2,241,543 in Huntington's disease patients (Mann-Whitney U-test, P < 0.021). Considerable increase of fibrous astroglia within the centromedian-parafascicular complex could be observed after Gallyas' impregnation. Most probably this cell type enhanced the numerical ratio between glial number and neurone number (glial index: Huntington's disease patients = 24.4 +/- 8.1; controls = 15.0 +/- 5.2; Mann-Whitney U-test, P < 0.013). The neurone number in the centromedian-parafascicular complex correlated negatively, although statistically not significantly, with the striatal neurone number. This lack of correlation between an 80% neuronal loss in the striatum and a 55% neurone loss in the centromedian-parafascicular complex points to viable neuronal circuits connecting the centromedian-parafascicular complex with cortical and subcortical regions that are less affected in Huntington's disease.

[ERWIPA--a standardized inventory for assessment of illness-related insight in patients with schizophrenia]. / ERWIPA--ein standardisiertes Verfahren zur Erfassung des krankheitsbezogenen Wissens bei Patienten mit Schizophrenien.

55 schizophrenic patients answered a 2 x 30 items questionnaire, Item analysis showed a low discriminative power, the initial forms differing with regard to degree of difficulty. Items with discriminative power over 0.30 were arranged into two thematically similar 13 item forms of equal difficulty. The questionnaires ERWIPA-A and ERWIPA-B consist of 2 x 20 items. The first item of each from had been answered correctly by all patients from our sample. We considered six additional items because future research may to different results as far as discriminative power is concerned. The average difficulty of both ERWIPA forms is equal for both the 2 x 13 items and the 2 x 20 items version.

Clinicians' information habits, patients' knowledge of diagnoses and etiological concepts in four different clinical samples.

A total of 230 psychiatric inpatients and their physicians in charge took part in semistandardized interviews. Patients suffering from schizophrenia received information less frequently and less comprehensively than other patients. The label of schizophrenia was often paraphrased or not communicated at all; patients knew their diagnosis less exactly than other subgroups. Asked to indicate the most important cause of their disorder, neurotics tended to name their living conditions (60%), and addicts preferred to blame themselves (73%). Only 26% of the patients with affective disorders or schizophrenia accepted the idea of their disorders as diseases in a medical sense, whereas the psychiatrists favored a biological concept in more than 90% of the cases. The findings stress the need to improve communication between patients and psychiatrists as regards information on illness and treatment.

[Psychiatric aspects of surgical therapy in advanced age]. / Psychiatrische Aspekte bei operativer Therapie im höheren Lebensalter.

Nowadays, in medical treatment of the aged, anaesthesiology and surgical techniques permit extensive operative interventions, whereby there ist no given age limit. Apparently, possible psychic problems which often occur in old age play no role; publications in this area are scarce. Very little research has been carried out concerning the problem of patient's consent for the operation, the risks involved in anaesthesia and operation which are probably increased by brain deficiency, and the patient's reduced ability to cooperate in rehabilitation. So far, there are many questions but few answers.

[Prescription of narcotics to drug addicts? decision aids and guidelines for problem situations]. / Verordnung von Betäubungsmitteln an Drogenabhängige? Entscheidungshilfen und Vorsichtsmassregeln für Problemsituationen.

The proposal is presently being discussed in public that further spread of HIV-infections should be prevented by prescribing substitute drugs. As a rule, no narcotic drug should be prescribed to addicts--to this rule there are a few quite specific exceptions. For instance opiate substitution may be indicated in drug addicts with advanced AIDS who are so debilitated that detoxification measures can no longer be applied, for example by oral long-acting levomethadone. For this particular situation, treatment guidelines are proposed.

[Treatment of drug dependent patients with methadone. 1: Goals, types and results of methadone programs]. / Behandlung drogenabhängiger Patienten mit Methadon. Teil 1: Ziele, Formen und Ergebnisse von Methadonprogrammen.

Is the medical prescription of narcotics an adequate way to treat opiate addiction? This question has been controversial in Germany for the last two decades. In 1987, a clinical trial of levomethadone treatment has been started in North-Rhine-Westfalia. Recently, aspects of public health have come to the fore, as methadone programs are hopefully believed to contribute to the prevention of HIV-infections among intravenous drug users. Principles and models of methadone treatment are briefly discussed, international experiences reported, and major objections reviewed.

[Treatment of drug-dependent patients with methadone. 2: AIDS prevention by drug substitution?]. / Behandlung drogenabhängiger Patienten mit Methadon. Teil 2: AIDS-Prävention durch Drogensubstitution?

On the basis of epidemiological findings, it is shown that methadone programs are unsuitable to prevent the spread of HIV infection, and that the AIDS epidemic among intravenous drug users does not justify the introduction of such programs. Abstinence from all psychotropic substances should remain the overriding aim of all rehabilitation programs for drug addicts.

[Assessment of "coping with disease" in patients with amyotrophic lateral sclerosis (ALS): on the use of an interviewer assessment rating scale]. / Einschätzung der "Krankheitsbewältigung" bei Patienten mit myatrophischer Lateralsklerose (ALS): Zur Anwendbarkeit einer Fremdbeurteilungsskala.

Theories on "Coping" try to explain which resources people use to master crises and conflict situations. Reactions to challenges of life are considered as "coping strategies". In psychosomatic research, the notion of "coping" serves to describe how patients can handle physical or mental illness. Myatrophic (or amyothrophic) lateral sclerosis (ALS) is a rare chronic progressive disease of the nervous system with a gradual loss of motor neurons, resulting in muscular atrophy, weakness and spasticity. Since the etiology is unknown and no curative treatment available, most patients die from respiratory failure within a few years. In a follow-up study on physical disability, medical care and social support in 21 patients with advanced ALS, we tried to address the question how patients get along with such a threatening condition. After semi-standardized clinical interviews with patients and close relatives, two investigators gave independent descriptions of reported or observed "coping strategies" (rated as "not at all-barely-possibly-probably-very probably present"). Considering 17 patients assessed by both raters, significant agreement (Kendall's W) was achieved in three patients only. A comparison of aggregated answers (chi 2-Test) revealed different response sets, since one rater tended to choose extreme scale points, while the other preferred undecided answers. Differences of mean scores were observed in 8 out of 21 items, while significant correlations between investigators were obtained in another 8, including, though, only 2 of those 5 items which both had rated as "probably present" in no less than 50% of the patient sample ("Dejection & Flight-Brooding-Keeping the Situation Open-Distraction-Self-Isolation").(ABSTRACT TRUNCATED AT 250 WORDS)

[Disability in everyday tasks and subjective status of patients with advanced amyotrophic lateral sclerosis]. / Behinderung im Alltag und subjektives Befinden bei Patienten mit fortgeschrittener myatrophischer Lateralsklerose (ALS).

Out of 49 former inpatients diagnosed as suffering from myatrophic lateral sclerosis, 21 with a median illness duration of 33 months and severe physical handicaps took part in follow-up examinations as outpatients (n = 8) or have been visited at home (n = 9) or in nursing institutions (n = 4) another 21 patients had already died from the disease). Investigations included medical history (course of illness), neurological and psychiatric examination and interviews with relatives. Measures of daily living handicaps, quality of medical care, density of social network and amount of social support were obtained. In 16 cases, patients and relatives have been able to answer rating scales concerning patient's physical complaints, present mood, depression and anxiety. According to independent, but corresponding judgements of patients (selfrating), relatives and investigators, three out of four patients suffered from moderate or severe reactive depression. The severity of mood disturbance depended on the degree of physical disability in basic daily functions, rated as "loss of autonomy", and on measures of social isolation (number of relatives available). Handicapped and lonely patients seemed unable to cope with their fate, even if regular care was provided. According to former reports, ALS patients have a reputation of heroic stoicism with a low frequency of depression. Our own findings, obtained in patients with advanced disease, do not support these observations. The medical care--e.g. prescription of specific medication, nursing care, physiotherapy, supply of auxiliary devices and aids, nutrition--could often be considerably improved. Special emphasis is given to the indication and appropriate timing for a gastric feeding tube resp. a percutaneous endoscopic gastrostomy (PEG). A second focus of the discussion is the urgent need for communication devices for paralysed speechless patients.

[Progressive lipodystrophy (Barraquer-Simon syndrome): differential diagnosis and clinical aspects]. / "Lipodystrophia progressiva" (Barraquer-Simon-Syndrom): Differentialdiagnose und Klinik.

"Progressive lipodystrophy" or "partial lipodystrophy of the cephalothoracic type" is a rare, acquired condition of unknown aetiology with onset in childhood and a complete loss of subcutaneous fat of face, neck, trunk and upper extremities. The disease is more common in females than males and causes a disfigurement of the face; that it cannot be regarded only as a harmless variation, is above all due to a typical concomitant disease, membranoproliferative glomerulonephritis with hypocomplementaemia. Laboratory investigations nearly always reveal a complement-activation by the "alternative pathway" with consumption and lack of complement-component C3, a finding which allows a clear distinction between partial lipodystrophy and congenital or acquired forms of total lipodystrophy ("Berardinelli-Seip-Syndrom", lipoatrophic diabetes) and other circumscript lipodystrophies.

[Applicability of digital methods in x-ray diagnosis]. / Anwendungsmöglichkeiten digitaler Methoden in der Röntgendiagnostik.

The significance of digital examination methods continues to grow. Since the introduction of computer tomography, two additional digital imaging modalities-digital subtraction angiography (DSA) and magnetic resonance imaging (MRI)--have been developed. In this paper we present basic techniques of computerized image processing and outline foreseeable future developments. Furthermore, we discuss the possibilities and problems presented by digital picture archiving and communication systems (PACS).