[Telemedicine in stroke-pertinent to stroke care in Germany]. / Telemedizin in der Schlaganfallversorgung ­ versorgungsrelevant für Deutschland.

BACKGROUND AND OBJECTIVE: Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution. METHODS: The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks. RESULTS: Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states. CONCLUSION: Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

[Delta(9)-tetrahydrocannabinol and the opioid receptor agonist piritramide do not act synergistically in postoperative pain]. / Keine synergistische Wirkung der Kombination von Delta(9)-Tetrahydrocannabinol und Piritramid bei postoperativen Schmerzen.

BACKGROUND: It is concluded from animal experiments that cannabinoid receptor and mu-opioid receptor agonists act synergistically with respect to antinociception. In order to demonstrate this effect under clinical conditions, we conducted a randomized double blind trial with patients after radical prostatectomy. PATIENTS AND METHODS: From the evening before the operation until the morning of the second postoperative day, all patients received eight oral doses of either placebo or 5 mg Delta(9)-tetrahydrocannabinol (dronabinol). Postoperatively patients had access to patient-controlled analgesia with the micro-opioid agonist piritramide for 48 h. We expected patients receiving dronabinol to require significantly less piritramide compared to patients on placebo. RESULTS: The consumption of piritramide was recorded in 100 patients after radical retropubic prostatectomy with regional lymphadenectomy. Patients in the placebo group consumed 74 mg (median), interquartile range (IQR) 44-90 mg, patients in the verum group consumed 54 mg (median) IQR 46-88 mg. The difference between groups was not statistically significant. Plasma concentrations of Delta(9)-THC were measurable in all patients in the verum group. The levels (median) were 1.5 ng/ml (IQR 0.6-2.3), 1.3 ng/ml (IQR 0.5-2.2) and 1.9 ng/ml (IQR 0.8-2.7) on the day of operation, the first and second postoperative day, respectively. CONCLUSION: We found neither a synergistic nor even an additive antinociceptive interaction between Delta(9)-tetrahydrocannabinol and the micro-opioid agonist piritramide in a setting of acute postoperative pain.

Development and initiation of computer generated documentation for burn patient care.

Burn care is costly, complex, and poorly reimbursed. Capturing evaluation and management codes is an essential step in obtaining reimbursement for services rendered. For surgeons used to billing on the basis of Current Procedural Terminology codes, this represents a significant paradigm shift. In an effort to document the care provided and increase compliance with billing standards, we created computerized history and physical examination notes and progress notes specifically for burn patients. Drop down menus are included to answer directed queries, which allows the majority of the documentation to be completed with a point and click of the mouse. The note is completed by the house staff except for the "assessment and plan," which are entered by the attending physician who reviews and then electronically signs the note. A log of electronically signed notes is generated weekly for billing purposes. The use of these computerized documents has been reviewed and approved by the coding and quality assurance specialists within our billing organization. We believe these tools maximize the efficiency of documenting burn patient care, while minimizing the effort necessary to comply with evaluation and management guidelines. The aim of this study was to test the new computerized method at our institution to see whether it would improve documentation for evaluation and management services provided to burn patients. The results prove that this new system accomplished the goal we had set.

Life's many pieces: the identity of the group psychotherapist.

The American Group Psychotherapy Association (AGPA) and its members are experiencing a trauma in response to the changes in health care imposed by the managed care industry. Although the economic threat is frightening, the threat to professionals' and AGPA's identities is even more damaging. The increasingly rapid, society-wide rate of change and factors related to the aging of AGPA's membership complicate its ability to cope with the trauma. The author recounts personal trauma and professional experiences in treating traumatized individuals, and proposes that when certain needs are met, growth can occur as part of a healing process: getting through the trauma, finding safety, self-soothing, and achieving mastery. AGPA resources for being safe, self-soothing, and achieving mastery are described. AGPA has been successful in reaching out via new accomplishments in regard to visibility, although the understandable impulse to withdraw may be impeding efforts to diversify the membership body. The author urges fighting against the pull to withdraw and expresses hope that the AGPA will cope well with the trauma by using its significant resources and will ultimately experience a beneficial change in its identity.

Acetyl-boswellic acids are novel catalytic inhibitors of human topoisomerases I and IIalpha.

Acetyl-boswellic acids (acetyl-BA) are pentacyclic triterpenes derived from the gum resin of frankincense. We have previously shown that these compounds are effective cytotoxic agents, acting through a mechanism that appears to involve the inhibition of topoisomerase activity. We have now investigated the mechanism of action of acetyl-BA and show that these compounds are more potent inhibitors of human topoisomerases I and IIalpha than camptothecin, and amsacrine or etoposide, respectively. Our data demonstrate that acetyl-BA and, to a lesser extent, some other pentacyclic triterpenes, such as betulinic acid, ursolic acid, and oleanolic acid, inhibit topoisomerases I and IIalpha through a mechanism that does not involve stabilization of the cleavable complex or the intercalation of DNA. Surface plasmon resonance analysis revealed that topoisomerases I and IIalpha bind directly to an immobilized derivative of acetyl-BA. This acetyl-BA derivative interacts with human topoisomerases through high-affinity binding sites yielding K(D) values of 70.6 nM for topoisomerase I and 7.6 nM for topoisomerase IIalpha. Based on our data, we propose that acetyl-BA inhibit topoisomerases I and IIalpha through competition with DNA for binding to the enzyme. Thus, acetyl-BA are a unique class of dual catalytic inhibitors of human topoisomerases I and IIalpha.

Enantioselective high-performance liquid chromatography assay of (+)R- and (-)S-alpha-lipoic acid in human plasma.

A specific plasma level assay for the enantiomers of alpha-lipoic acid is described. It makes use of liquid-liquid extraction, chemical reduction to the dithiol enantiomers, and their precolumn chiral derivatisation with o-phthalaldehyde in the presence of D-phenylalanine. The two diastereomeric derivatives are separated by reversed-phase HPLC with fluorescence detection. The working range of the assay is between 15 ng/ml (lower limit of quantitation) and 1,000 ng/ml for either enantiomer.

Fluorescence detection of cardenolides in reversed-phase high-performance liquid chromatography after post-column derivatization.

Methods for the fluorescence derivatization of cardiac glycosides with concentrated acids from TLC are adopted to HPLC for post-column derivatization. The column effluent is blended with concentrated acids in a knitted tube reactor, which enables derivatization with negligible increase in chromatographic peak width. The selectivity of the reaction is temperature-dependent and influenced by the respective acid. Reactivity increases from H3PO4-->CH3SO3H[symbol: see text]H2SO4. The conversion of digoxigenin, digitoxigenin and their digitoxosides is accelerated by Cu(II) acetate or Co(II) nitrate in H2SO4. Combined with a new two-mode, single-column solid-phase sample preparation, cardiac glycoside levels of less than 100 pg/glycoside in 1 ml plasma are detectable.

Can we be both women and analysts?

The authors, candidates at a psychoanalytic institute that has not had a woman training analyst for more than 20 years, have a unique vantage point from which to examine the woman's development as an adult female and as a psychoanalyst. Our group has engaged in a series of discussions asking: Can we be both women and analysts? Comparing and contrasting our experiences with feedback from colleagues across the United States and abroad, we had to accept that our unique situation could not be a foil for the training dilemmas facing women. Our insights into the challenges involved with training, expression of sexuality, family ties, formation of an analytic identity, creative contributions to the field, and career progression have caused us to arrive at some sobering observations and hard-hitting questions which we present here. We hope that as we describe our discussions about the woman analyst's experience an active dialogue will arise within the reader's mind, and subsequently with colleagues.

Etiology and management of anger in groups: a psychodynamic view.

The author postulates that theoretical explanations of the etiology of anger and aggression inform the group therapist's interventions. Four psychodynamic schools of thought--drive theory, ego psychology, object relations theory, and self psychology--are discussed. Choice of the best-suited theory to increase understanding may vary according to the particular patient and/or set of group circumstances. A pitfall to be avoided is forcing any given individual, event, or process into a specific school of thought. In the group, special issues related to anger exist: the therapist's vulnerability to narcissistic injury if made the focus of anger, the increased intensity and force of anger that can be mustered in a group, and the safety afforded patients as they, outnumbering the therapist(s), express anger.

Innovative uses of psychodynamic group psychotherapy.

Psychodynamic group psychotherapy is gaining renewed attention as an effective form of treatment, due in part to increasing economic constraints that make other forms of treatment less accessible. The author highlights some innovative applications of both extended and time-limited groups. She also describes specific issues that can be addressed effectively in homogeneous time-limited group therapy.

Group psychotherapy for persons with multiple personality and dissociative disorders.

Group psychotherapy is a valuable part of the treatment of patients with multiple personality and dissociative disorders. After reviewing the sparse literature on the subject, the author describes the use of group psychotherapy with these patients alone, as well as with two types of groups in which these patients may participate: incest survivors and general group therapy patients. She concludes by emphasizing the need for expert training for therapists who conduct group psychotherapy with multiple personality and dissociative disorder patients.

Incest perpetrators in group therapy: a psychodynamic perspective.

Patients who have been sexually abusive toward children in their family often have guarded prognoses. However, the legal system's promotion and support of treatment elicits cautious optimism; even limited progress can make a significant difference in the lives of these persons and their families. The authors report on their work with incest perpetrators in a psychoanalytically oriented psychotherapy group with 20 incest offenders (selected after evaluation of 50), describing major obstacles (i.e., patients' lack of motivation and countertransference) and frequent clinical issues (i.e., perversion, psychopathic tendencies, low self-esteem, and substance abuse).

Altered spatial perception following harvest of a posterior auricular skin graft.

A 57-year-old man blind since an early age lost significant ability to orient himself in space regarding surrounding objects after his left ear was retropositioned to close a retroauricular full-thickness skin graft donor site. Release of the ear to its former position corrected the disability. We warn readers that long-time blind persons develop alternate methods to vision and a seemingly insignificant change of ear position may alter spatial orientation.

Use of an absorbable mesh to repair contaminated abdominal-wall defects.

When polypropylene mesh (Marlex) is used to repair contaminated abdominal-wall hernias, a high incidence of mesh-related chronic infection, drainage, erosion, and bleeding is noted. As an alternative to placing polypropylene mesh in a contaminated field, in the past 18 months we have used an absorbable polyglycolic acid mesh (Dexon) to repair contaminated abdominal-wall defects in eight patients--three with necrotizing abdominal-wall infections, one with an extensive electrical burn of the abdominal wall, three with infected polypropylene mesh from a previous repair, and one whose hernia was covered by a chronically infected scar. In seven of the eight cases, a single sheet of polyglycolic acid mesh was sewn to the fascial margins. In four cases, skin was closed over the mesh; wound packing and subsequent skin grafting were required in the other four. In follow-up studies that ranged from three to 18 months, six of the eight patients developed abdominal-wall hernias at the site of absorbable mesh placement. None of the patients required an abdominal binder. Postoperative hernia development is probable in patients whose defects are repaired with absorbable mesh. However, this complication is balanced against the more serious complications of fistula, bleeding, skin erosion, drainage, and chronic infection, which require removal of the more rigid nonabsorbable meshes in 50% to 90% of cases when the latter are placed under contaminated conditions. Placement of absorbable mesh for temporary abdominal-wall support until wound contamination resolves enhances the likelihood of subsequent successful placement of a permanent mesh.