[Vocational inpatient and post-treatment proposals in cardiac rehabilitation patients (BERUNA): results of a randomized controlled trial]. / Berufsbezogene Rehabilitation und Nachsorge in der kardiologischen Rehabilitation (BERUNA): Ergebnisse einer randomisierten Kontrollgruppenstudie

BACKGROUND: The "Verband Deutscher Rentenversicherungsträger (VDR)" required the intense focus on vocational rehabilitation of medical problems since the early 1990s. By integrating elements of the working environment in the structures and processes of medical rehabilitation, vocational problems can be identified early in order to take appropriate countermeasures. Posttreatment proposals off er a way to provide a reliable long-term success. OBJECTIVE: The intention of this study is the implementation and the investigation of effectiveness of an intensified vocational program that integrates besides the in-patient rehabilitation post-treatment proposals as well. METHODS: Cardiac rehabilitation patient occurring special vocational problems participe. The recruited patients were randomized to either the vocational program or the common cardiac rehabilitation.Primary outcome was the vocational reintegration 12 months after the end of rehabilitation.The database was collected through a query of the pension insurance accounts and questionnaires. RESULTS: 306 people were included to the study at the beginning of rehabilitation. Rates of response:95 % of the survey to the end of rehabilitation,77 % of the survey 6 months and 73 % of the survey 12 months after the end of rehabilitation.The sample was characterized by great interferences of their professional involvement and a high demand for vocational treatments. At the beginning of the rehabilitation 50 % of study participants intended to make an application for reduction-pension. Nevertheless, one year after the end of rehabilitation a surprisingly high rate of vocational reintegration by over 70 % in both groups (IG: 72 %, KG: 75 %, p < 0.929) was indicated.The majority of the unemployed patients at the beginning of rehabilitation remained in the unemployment (IG: 69 %, KG: 65 %, p < 0.757). The participation rate at the post-treatment proposals was 42%. CONCLUSION: The results show that vocational programs in rehabilitation need to be revised, including with regard to the question, whether and in what way post-treatment proposals must be changed.

[Protect employability: effects of prevention programs offered by the German pension scheme]. / Beschäftigungsfähigkeit teilhabeorientiert sichern (Betsi): Ergebnisse der Einjahreskatamnese von Prävention-s-maßnahmen der Deutschen Rentenversicherung.

A pilot study was carried out in 4 medical rehabilitation centers to examine the practicability and effectiveness of preventive life-style interventions for employees with risk factors. The programs were developed in cooperation with the German pension scheme and employers. Selection criteria were risk factors as lack of physical activity, overweight, dorsal pain or job strain. The results demonstrate that preventive programs, which are conducted in addition to the normal working hours on the job, can be implemented successfully in rehabilitation units. The participation in the multimodal prevention program goes along with a stable reduction of risky health behavior: increased physical activity, stress coping, dietary change und weight reduction. The healthier life-style is reflected in an enhanced state of health and has also positive impact on the occupational field scale: The percentage of employees who believed to be able to work until their old-age pension, could be increased significantly (p<0.001) from 47% to 74%. Work-related risk behaviors like excessive demands on oneself were reduced and protective strategies were -developed.

[DGRW update: rehabilitation in cardiovascular diseases. what's new in cardiac rehabilitation?]. / DGRW-Update: Rehabilitation bei Herz-Kreislauferkrankungen. Was gibt es Neues in der kardiologischen Rehabilitation?

BACKGROUND: A quality goal of medical rehabilitation is ongoing and continuous development of service standards orientated by the patient and new research findings. Because of the stark increase of research findings in the field of rehabilitation, it becomes difficult for the responsible rehabilitation providers to keep up to date on new findings and to realize the transfer of knowledge. Hence, the aim was to establish a literature research which surveys current national and international results in cardiac rehabilitation. METHODS: The literature search was undertaken using the electronic databases OVID and includes publications from 2009 and the first 2 months of 2010. The selection of studies was performed in a team of experts based on the criteria of relevance, usefulness and methodological quality of research for rehabilitation. RESULTS: 26 primary sources were selected, mainly focusing the fields "Cardiac rehabilitation: indications", "Risk factors and prevention", "Job-related reintegration", "Rehabilitation of specific medical disease patterns" and "New rehabilitation models". CONCLUSION: The studies examined show very clearly that cardiac patients can benefit from participation in cardiac rehabilitation treatment and that prevention represents a central task of medical care in the long-term treatment of coronary diseases. There is a need for further research, especially concerning the topics "New rehabilitation models" and "Job-related reintegration". The DGRW Update intends to depict current developments and to promote evidence-based medicine in rehabilitation.

[Pain and pain-related behavior during orthopedic rehabilitation]. / Schmerzempfinden und -verhalten während der orthopädischen Rehabilitation.

BACKGROUND: Problems concerning the sustainability of medical rehabilitation are well known. Persistent avoidance behavior might be a potential cause. The present study is designed to determine the relationship between pain and pain-related behavior (resignation, distraction, avoidance) during the rehabilitation process. In addition, the impact of gender, age, level of chronicity, and location of ailments are investigated. METHODS: Pain (German pain perception scale, SES) and pain-related behavior (German pain control questionnaire, FSR) were measured in 309 orthopedic rehabilitation patients. RESULTS: Affective pain, resignation and distraction are more pronounced in women than in men. Participants with highly increased levels of chronicity have more affective and sensory pain and higher values of avoidance and resignation. During the rehabilitation process, there was a decrease in affective pain, sensory pain and resignation. The difference values correlate significantly. CONCLUSION: Rehabilitation is effective for pain reduction. However, only limited changes in pain-related behavior were detected.

[Improvement of worklife participation through vocationally oriented cardiac rehabilitation? Findings of a randomized control group study]. / Lässt sich die Teilhabe am Arbeitsleben durch eine berufsorientierte kardiologische Rehabilitation verbessern? Ergebnisse einer randomisierten Kontrollgruppenstudie.

PURPOSE: Although acute medical care of cardiac patients has clearly improved, vocational integration and vocational outlook of patients after MI and/or cardiac surgery did not improve substantially over the last few decades. This study is intended to evaluate a programme aimed at enhancing the return to work of cardiac rehabilitands. The programme is applied in addition to the usual rehabilitation programme and includes job-related interventions by the Social and Psychological Services as well as standardized application of the functional capacity evaluation (FCE). METHODS: This prospective randomized controlled trial is intended to evaluate the effects of the intervention programme on return to work. 150 patients who received the job-related programme (the intervention group) were compared to 150 patients who received the usual rehabilitation interventions (the control group). The study includes cardiac patients insured under the workers' pension insurance scheme and not older than age 56. Before coming to the clinic they had been unable to work, and problems with their returning to work were anticipated. Exclusion criteria were heart surgery less than three months ago, a cardiac capacity below 75 Watt, and reduced left-ventricular function. Follow-up data collection was performed 12 months after rehabilitation using a mail questionnaire. RESULTS: At the beginning of the rehabilitation programme, comparison of the groups showed no significant differences in biological, psychological and social variables. At 12-months follow-up, the data of 212 participants (70.6% of the participants) were available. Up to this time, 79.1% of the patients from the intervention group had returned to work, whereas in the control group only 62.9% had returned to work (chi(2) test, p<0.05). CONCLUSION: The results of the 12-months follow-up underline the positive effects of a job-oriented rehabilitation programme for patients' return to work.

[Depression in cardiac patients undergoing rehabilitation--a study for investigating the correlations between depression and occupational groups]. / Depressivität bei kardiologischen AHB-Patienten--eine Studie zur Uberprüfung von Zusammenhängen zwischen Depressivität und Berufsgruppenzugehörigkeit.

The results of many studies show that physical recovery and social integration of cardiac patients are negatively influenced by a persistent depressive disorder. For this reason issues of occupational integration should be considered from this point of view, too. Correlations between various occupational groups and depression were investigated with 907 cardiac patients at the beginning and at the end of a follow-up treatment. The results were compared to those for 756 persons in corresponding age groups from the general population. We found that at the beginning of rehabilitation the depression values of the HADS did not show any significant differences between the various occupational groups, however, their values were significantly higher than those found in the general population. During rehabilitation the HADS values decreased significantly. At the end of rehabilitation, unskilled and semi-skilled workers had significantly higher depression values than skilled workers and persons in higher positions. Consequences for medical rehabilitation are discussed.

Routine disinfection of the total dialysis fluid system.

The importance of bacteria and endotoxin free, sterile dialysis fluid for long term, high quality haemodialysis treatment is obvious and very much demanded (1,2). Dead spaces and connections between units (segments) of fluid production and delivery in elder systems are a continuous source for bacteria growth, biofilm generation and endotoxin release (3). After varying success with routine disinfection of system components showing partly fast recovery and growth of bacteria (i.e. < 48 hours) we changed to routine disinfection of the entire fluid production and distribution system. We call this'system disinfection'. We report the methods and results from observation of practice over 28 months of disinfection. The fluid system is composed of a soft water tank, reverse osmosis (double RO), RO fluid loop, central bicarbonate production and delivery system and dialysis stations with and without ultrafilter and citric-thermal disinfection before and after each haemodialysis. The system disinfection is carried out bimonthly with peracetic acid 3.5% in > 0.1% solution at a mean temperature of > 15 degrees C and at a minimum of 60 minutes of disinfection time. Samples for microbiological testing and endotoxin measurement were assessed 3-4 monthly at 7 measurement points. The tests were carried out 7 times on the 11th day (mean value [MV]) after routine system disinfection. The result was in 0.2 CFU/ml (MV) in 40 tests. The endotoxin levels (IU/L) were all < 0.25 except one at 0.325 in RO water. Endotoxin was assessed 5 times in 26 tests over 28 months. Samples were taken at 10.5 (MV) days after system disinfection. The Gel Clot or turbometric method was used. Efficient and preventive routine system disinfection of an entire dialysis fluid production and distribution system as standard in modern equipment - can support sufficient quality in dialysis fluid produced and distributed by elder and composed systems.

[Outpatient cardiological rehabilitation--acceptance and conditions related to choice of setting]. / Teilstationäre kardiologische Rehabilitation - Akzeptanz und Bedingungskonfigurationen für die Settingentscheidung*

In view of the increasing demands for more co-operation and integration among health care providers and "uninterrupted" care delivery processes increasing attention is being paid to establishing the determinants of a more flexible form of rehabilitation setting. Interest is focused particularly on determining at what stages and under what conditions specific choices of rehabilitation setting are made. In 1838 patients admitted consecutively to a cardiological rehabilitation clinic, the study investigated how many patients opted for outpatient rehabilitation and what factors influenced the patients' choice of rehabilitation setting. A total of 165 (9 %) of the 1838 patients chose outpatient rehabilitation. Patients who prefer outpatient rehabilitation are mainly male, belong to a higher social class and are younger. Patients who choose inpatient treatment feel more restricted by their illness. This is also revealed in the difference in coping strategies employed. Patients who prefer the inpatient setting show a greater tendency towards rumination than outpatients. It is thus comprehensible that these patients hope to gain a greater distance from their day-to-day problems. The results indicate that patients' willingness to take advantage of outpatient forms of rehabilitation is moderated both by sociodemographic, psychosocial and disease-related variables as well as by context variables. It is embedded in the complex biopsychosocial conditions governing rehabilitation. One consequence for managing the introduction of more flexible modes of rehabilitation could be to avoid dirigistic and unidimensional control parameters. The results indicate that more flexible disease management cannot follow fixed rules, but rather that the planning of individual requirements should be taken into account.

[Intensified after-care--a method for improving occupational reintegration after myocardial infarct and/or bypass operation]. / Intensivierte Nachsorge (INA)--ein Verfahren zur Verbesserung der beruflichen Reintegration nach Herzinfarkt und/oder Bypassoperation.

Occupational reintegration after coronary heart disease of patients who are insured by the German workers pension (Arbeiterrentenversicherung) succeeds in 40-60% of the recorded cases. Patients who were not able to return to work after finishing their regular cardiac rehabilitation took part in a program called "Intensivierte Nachsorge (INA)". INA is an interdisciplinary support program, taking place twice a week for a whole day over a period of six weeks. On the remaining three days patients were either progressively reintegrated into their working place or stayed at home. The results of the INA group were compared to those of a control group. Two years after patients had terminated the cardiac rehabilitation, statistically significant effects could still be found: 70.2% of the INA group had returned to work compared to 52.6% of the control group. This is a difference of 17.6%. After the results had been corrected by considering age differences between the two groups, the control group had a recalculated return to work rate of 57.4%. A significant difference of 12.8% could still be identified with respect to the INA group. Support programs which follow regular cardiac rehabilitation seem to be specially suitable for older patients with highly perceived job strain, because our results showed that these patients had lower return to work rates. 44.2% of the INA group and 21.9% of the control group were progressively reintegrated into their work place. Two years after their regular rehabilitation 36.3% of the INA group patients took part in ambulatory heart groups compared with 10.4% of the control group. It was also found that patients of the INA group showed improvements in activities of daily life. The INA program however does not seem to have an influence on behavioral components such as eating habits, relaxation, and smoking as well as on the psychological status. The physical fitness measured in watt x min at the beginning of the INA program (T1) was 589.46 +/- 255.03 in the control group. This number increased to 598.32 +/- 276.01 six months after regular rehabilitation (T3) and continued to rise to 661.15 +/- 362.01 after two years (T4). In the INA group the numbers were as follows: 658.13 +/- 263.63 at T1, 751.83 +/- 318.15 at T3, and 717.93 +/- 336.76 at T4. The differences between the groups are significant at T1 and T3, whereas at T4 there is no significant difference. It should also be stated that the lipid parameters indicated no differences between the groups except for the triglyceride values which were significantly lower statistically in the INA group than in the control group.

Chronic poisoning by copper in tap water: I. Copper intoxications with predominantly gastointestinal symptoms.

Copper can induce acute and chronic intoxications in humans. Copper in tap water has caused a series of severe systemic diseases in Germany in recent years (copper induced liver cirrhosis). Besides cirrhosis, another type of disease with predominantly gastrointestinal symptoms has occurred which likewise appeared to be induced by copper in tap water. - In a retrospective investigation we looked for additional indications and proof that chronic copper poisoning has been the cause of the observed gastrointestinal diseases. All patients suffering from this type of disease had copper plumbing in their houses. - The patients (children and adults) suffered from nausea, vomiting, colic, and diarrhoea. In the group of infants, one refused formula milk (prepared with tap water) and the others suffered from persistent restlessness, unexplainable screaming (especially at night) and/or long lasting diaper rash. - We accept the diagnosis of chronic copper intoxication as the cause of the gastrointestinal symptoms when at least one of the following criteria were fulfilled: 1. first manifestation, remission and relapse of the disease depend on intake and a non-intake of water containing copper, respectively. 2. hypercupric state of the patients (i.e. pathological high concentrations of the non-ceruloplasmin-bound copper in serum and/or elevated copper levels in urine) 3. signs of systemic copper intoxication in the same patient 4. signs of systemic copper intoxication or hypercupric states in members of the patient s family or in his neighbourhood (non-relatives) - We found that the disease can even be caused by copper concentrations below the allowed concentration given by the German Guidelines for Drinking Water (Trinkwasserverordnung). - The data prove that copper in drinking water can cause gastrointestinal diseases and not only the better known systemic diseases (i.e. copper induced liver cirrhosis). Copper poisoning must be considered as a possible cause of chronic gastrointestinal diseases in those countries in which copper plumbing is common.

Chronic poisoning by copper in tap water: II. Copper intoxications with predominantly systemic symptoms.

Copper can induce acute and chronic intoxications in humans. Copper in tap water has caused a series of severe systemic diseases in Germany in recent years (chronic copper poisoning, CCuP). From the clinical point of view it has been difficult to establish the diagnosis on the basis of clinical and laboratory methods. In a retrospective study, we therefore looked for essential clinical signs as well as laboratory findings which might be typical and essential for the diagnosis of CCuP. - We observed that in patients with severe systemic CCuP not only the liver but also several other organs have been the target of copper. As a proof copper overload has been measured. The latter results are presented here. - During or shortly after exposure "free" serum copper (= non-ceruloplasmin-bound copper) was significantly elevated in all patients (range 5.1 to 47.1 micromol/l, or 25.7 to 56.2 % of total serum copper). The normal upper limits in infants according to Salmenperä (8) are: 0.3 micromol/l, or 1.6 % of total serum copper. - Total serum copper was elevated in 14/16 patients: 13.7 to 30.1 micromol/l in sick infants (normal upper level: 12.6 micromol/l), and 17.0 to 27.2 in sick children (normal upper level for children and adults: 21.4 micromol/l). - Urine copper excretion was found elevated in 9/10 patients, with a range of 11 to 456 microg/dl (normal upper level in adults: 15 microg/dl). - Our results show that patients with systemic CCuP are in a "hypercupric" state. The data thus firstly prove that indeed the putative agent copper is found in excess in the patients and secondly show that the estimation of "free" copper in serum and the measurement of copper in urine are reliable diagnostic methods. Elevation of total serum copper (even though not specific) can give a first hint to the diagnosis. - The hypercupric state of systemic CCuP can be differentiated from that of Wilson's disease by (1) normal levels of ceruloplasmin and (2) the observation that values for free copper in serum or urinary copper normalize in an environment without copper in tap water, for instance in a hospital.

[Identification of psychologically impaired patients in cardiologic rehabilitation]. / Identifikation psychisch auffälliger Patienten in der kardiologischen Rehabilitation.

As psychological factors have a substantial influence on the further medical, psychological and occupational career of a patient with somatic disease, early identification of patients with psychological disturbances is of special importance in medical rehabilitation. The share of psychologically disturbed patients in a cardiac rehabilitation clinic has been screened. Different methods for identification of anxious and depressive patients (by medical and psychological staff as well as a screening instrument) are compared. Concluding, the benefit of introducing a screening instrument as a routine procedure is discussed under the aspect of effectivity.

[Occupational therapy in neurology--results of 7 years' experience]. / Arbeitstherapie in der Neurologie--Ergebnisse 7jähriger Erfahrungen.

Indications, mode of referral, therapeutic methods, and documentation of the functional occupational therapy practised in the field of neurology are presented and experiences hitherto existing discussed. For many of neurological diseases, the occupational therapy may be regarded as an equivalent method to the medication and to the physiotherapeutic treatment. When carrying-out as group therapy, it is an economical way of treatment, and most of the patients take this kind of therapy in a positive manner. In addition to this, the occupational therapy renders possible that the state of the rehabilitation can be sized up.

[Legal aspects of traumatic cerebrovascular lesions]. / Gutachterliche Aspekte bei traumatischen Hirngefässläsionen.

The paper opens with an account of what may be entailed in traumatic damage to cerebral vessels and cervical vessels, and its pathomechanism. There follows an account of two cases involving traumatic cerebral infarction and the resulting problems for the expert witness. Ascertainment of the relationship between external trauma and cerebral infarction depends on the nature and degree of the traumatic violence (precise trauma anamnesis), the reaction of the organism thereto, and the seriousness of previous complaints (arteriosclerosis, causes of cerebral embolism).

[Atlanto-axial dislocation in Down syndrome and os odontoieum. Case report and review of the literature]. / Die atlanto-axiale Dislokation bei Down-Syndrom und Os odontoieum. Fallbericht und Literaturüberblick.

A case is reported of the rare coincidence of mongolism and os odontoideum in an eleven-year-old child, leading to compression myelopathy in consequence of atlantoaxial dislocation, and an overview of literature to the present time is given. Recommendations on diagnostic and prophylactic measures are offered designed to counteract as early as possible the spinal complications of atlantoaxial instability.

[Psychopathology of progressive paralysis. Remarks on some personal cases]. / Zur Psychopathologie der Progressiven Paralyse. Bemerkungen zu eigenen Fällen.

Four of our own cases that presented a clinical picture of dementia are discussed. A study of the relative literature has failed to reveal any "swing" in the pattern of the clinical condition: Just as it did ninety years age, paralytic dementia accounts today for well over 60% of all cases, those clinical pictures erroneously regarded as "typical" "classic", accounting for a mere 10%-15% of cases. The need for routine lues serology is pointed out.