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Background: The benchmark paper of 25 February 2008 and the guideline of 13 September 2010 provide the principles for rehabilitation management (RM) under the German Social Accident Insurance (DGUV) in the DGUV's version of 17 July 2014. Objective: A precise diagnosis and the accident insurer's knowledge of contextual factors influencing the healing process require the timely introduction of RM. Rehabilitation management presents the accident insurer with new challenges. Methods: A rethink by the official authorities regarding customer-oriented service providers is required, which is linked to new demands being made on staff. In addition to the necessary legal knowledge, social competence, communication skills, and medical knowledge are now required. The increased costs incurred by the personal contact required can only be offset by an efficient adminstrative structure and effective data handling. Results: The results of pretesting of the customer survey planned for 2015 show the participants' high level of satisfaction with RM and the rehabilitation managers. Our own analyses of the Wood and Metal Trade Association, in addition to the results of the DGUV's bench mark project 'Efficiency of Case Management,' show that the RM 'pays off.' With expenditure on outpatient and inpatient treatment, which in real terms decreased slightly, periods of sick leave were shortened, invalidity benefit savings were made, and the number of new pensions was reduced. Conclusion: The requirements of the DGUV's new treatment permit better collaboration between doctors and rehabilitation managers of the accident insurers. Case selection fo RM should be investigated. The principles of RM should be transferred to the processing of cases of work-related illness. Important results on the improvement of RM are expected from the customer survey starting in 2015. [ABSTRACT FROM AUTHOR]

In the article "Time required for the vaccination process and organization of COVID-19 vaccination in general practitioner practices," Dr. med. Lucas Spohn describes his own experiences with the vaccination process in his practice. He was able to vaccinate 20 patients per hour and generate a turnover of €480 to €640 per hour. This was made possible through the digitization of his administrative processes. The appointment scheduling was fully automated through an online appointment system, and the patient education and consent were done through the software Idana. Dr. Spohn emphasizes that his patients were highly satisfied and he did not require any paper documents. Prof. Dr. med. Nicola Buhlinger-Göpfarth responds to the reader's letter and explains that the study referred to in the article was conducted before the actual vaccinations in the practices began, and digital processes were not available at that time. [Extracted from the article]

In the article "Time required for the vaccination process and organization of COVID-19 vaccination in general practitioner practices," Dr. med. Lucas Spohn describes his own experiences with the vaccination process in his practice. He was able to vaccinate 20 patients per hour and generate a turnover of €480 to €640 per hour. This was made possible through the digitization of his administrative processes. The appointment scheduling was fully automated through an online appointment system, and the patient education and consent were done through the software Idana. Dr. Spohn emphasizes that his patients were highly satisfied and he did not require any paper documents. Prof. Dr. med. Nicola Buhlinger-Göpfarth responds to the reader's letter and explains that the study referred to in the article was conducted before the actual vaccinations in the practices began, and digital processes were not available at that time. [Extracted from the article]

Background: Huntington's disease (HD) is a progressive neurodegenerative disorder characterized by hyperkinetic movements, psychiatric (e.g. depression and psychosis) and cognitive symptoms (frontal lobe dementia). In Germany approximately 8000 patients suffer from HD. Objectives: The paper reviews the clinical course, epidemiology, genetics, differential diagnoses, pathophysiology, symptomatics and causal treatment options. Methods: Publications on animal and human HD studies and trials and reviews available in Medline have been taken into account. Results: Only genetic testing allows diagnostic certainty. The CAG repeat length influences age of onset, disease course and life expectancy. The mechanism by which mutant huntingtin protein (mHTT) causes HD is complex and poorly understood but leads to cell death, in particular in striatal neurons. In clinical trials antioxidants (e.g. coenzyme Q10), selisistat, PBT2, cysteamine, N-methyl-D-aspartate (NMDA)-receptor antagonists and tyrosine kinase B receptor agonists have been studied in HD. Conclusion: No disease-modifying therapy is currently available for HD; however, gene silencing, e.g. through RNA interference, is a promising technique which could lead to effective therapies in due course. [ABSTRACT FROM AUTHOR]

The present paper summarises the changes of the International Classification of Sleep Disorders, (ICSD-3, published in 2014) in comparison to its predecessor, ICSD-2 (2005). Changes within sleep-related breathing disorders are described in the article by Stuck and Weeß in this issue. Polysomnographic recordings and sleep scoring in the diagnostic process should always use the most recent version of the AASM manual. Insomnias are newly classified as either chronic or short term. Chronic insomnia includes all former insomnia forms with the exception of adjustment insomnia (acute insomnia). The minimal duration is now defined as 3 months. Non-restorative sleep no longer constitutes an insomnia-specific symptom. The term 'hypersomnias of central nervous origin' has been replaced by 'disorders of hypersomnolence'. Hypersomnolence is understood as excessive daytime sleepiness. The new classification of narcolepsy differs between narcolepsy type 1 (with cataplexy or with hypocretin-1 deficiency) and narcolepsy type 2 (without cataplexy). The circadian rhythm sleep-wake disorders have barely changed. The group of parasomnias now includes 'sleep-related eating disorders'. The former diagnosis 'sleep drunkenness' in the category confusional arousal was replaced by 'confused awakening'. The criteria for the diagnosis of 'nightmares' have been operationalized for the first time. The diagnosis 'periodic limb movement disorder' should no longer be used when either RLS, narcolepsy, REM sleep behavior disorder or untreated sleep apnea syndrome coexists. Isolated symptoms and normal variants are now directly associated with each diagnostic category. [ABSTRACT FROM AUTHOR]

Fractures of the distal humerus are rare and account for only a small proportion of fractures in adult patients. Due to demographic changes surgeons will be faced with an increasing number of complex multifragment fractures with diminished bone quality in geriatric patients. As conservative treatment frequently leads to limited and painful elbow function, open reduction and stable internal fixation with early range of motion exercises are considered the gold standard. However, in combination of comminution and an osteoporotic bone stock, complication rates remain considerably high and stable fixation might be impossible. In these patients primary total elbow arthroplasty has become increasingly popular in recent years. Since Cobb and Morrey published their landmark paper on the use of total elbow arthroplasty for distal humeral fractures it has become accepted that this technique is a valuable treatment option. Detailed knowledge and understanding of the technical aspects of total elbow arthroplasty are the key factors for a successful procedure and patient satisfaction. This articles highlights the history of total elbow arthroplasty for trauma fractures, provides detailed information on the correct indications, the operative procedure, results and complications. [ABSTRACT FROM AUTHOR]

Background: Tendon injuries of the foot are often not recognized and are usually not immediately diagnosed correctly. The resulting loss of function often requires that surgical reconstruction be performed. Causes and promoting factors: Injuries of the anterior tibial and posterior tibial tendon are usually due to pre-existing degenerative damage, whereas luxation of the peroneal tendon is usually caused by trauma. Thus a differentiated approach is required, depending on age of the patient, the physical activity and the location of the injury. Conclusion: This paper gives an overview of the injuries and pathologies of the anterior tibial, posterior tibial and peroneal tendons and recommendations for further treatment strategies. [ABSTRACT FROM AUTHOR]

Because of an ageing population and a relative lack of professionals, the German health system is under great pressure. In rural regions in particular, anesthesiology is also affected − nursing staff, anesthetists, intensive care physicians, and emergency physicians often have to be supported by freelancers from other regions and from abroad − at least periodically. In addition to the increasing number of treatments, the potential quality of therapy is also increasing owing to progress in medical research. Against this background the need for resources is increasing to ensure the optimal quality of treatment. This applies to all clinical disciplines, including all sections of anesthesiology − especially in economically underdeveloped regions where highly qualified experts are lacking. In various cases it is not the physical attendance or manual skills of experts that is primarily requested on-site, but rather their medical expertise and experience. Therefore, telemedicine systems are suitable for closing these gaps very effectively and efficiently. In the various anesthesiological sub-sections the number of scientific papers published to date varies. For anesthesia and pain therapy only a few telemedical applications or concepts have been reported in the literature. However, in tele-intensive care medicine and tele-emergency medicine several national and international research projects have successfully been carried out, leading to established routine systems in some cases. [ABSTRACT FROM AUTHOR]

Because of an ageing population and a relative lack of professionals, the German health system is under great pressure. In rural regions in particular, anesthesiology is also affected - nursing staff, anesthetists, intensive care physicians, and emergency physicians often have to be supported by freelancers from other regions and from abroad - at least periodically. In addition to the increasing number of treatments, the potential quality of therapy is also increasing owing to progress in medical research. Against this background the need for resources is increasing to ensure the optimal quality of treatment. This applies to all clinical disciplines, including all sections of anesthesiology - especially in economically underdeveloped regions where highly qualified experts are lacking. In various cases it is not the physical attendance or manual skills of experts that is primarily requested on-site, but rather their medical expertise and experience. Therefore, telemedicine systems are suitable for closing these gaps very effectively and efficiently. In the various anesthesiological sub-sections the number of scientific papers published to date varies. For anesthesia and pain therapy only a few telemedical applications or concepts have been reported in the literature. However, in tele-intensive care medicine and tele-emergency medicine several national and international research projects have successfully been carried out, leading to established routine systems in some cases. [ABSTRACT FROM AUTHOR]

Unilateral cerebral ischemia of the hippocampus is very rare. This paper reviews the literature and presents the case of a 59-year-old woman with an amnestic syndrome due to a left hippocampal stroke. The patient suffered from retrograde amnesia which was most severe over the 2 days prior to presenting and a slight anterograde amnesia. In addition, a verbal memory disorder was confirmed 1 week after admission by neurological tests. As risk factors, arterial hypertension and a relative hyper-beta lipoproteinemia were found. This case shows that unilateral amnestic stroke, e.g. in the hippocampus region, may be the cause of an amnestic syndrome and should be included in the differential diagnostics. [ABSTRACT FROM AUTHOR]

This article questions why medicine fails to provide a general concept of disease for use by doctors, patients and society because the lack of such a unified concept inhibits any definitive distinction between 'deviant' and 'disease'. By providing an historical overview of the particularities related to this question the authors demonstrate that the ever-changing concepts of disease were not driven by the process through which medicine became a science. In contrast to naturalistic concepts of disease, anthropological, sociocultural and psychosomatic concepts are grounded in an understanding of disease that cannot be determined, described and categorized by pathology alone. As a consequence, disease can only be determined or defined in relation to social and scientific frames of reference, as illustrated by an example from the Berlin Nervenklinik (psychiatric clinic) in the early twentieth century. The ways in which the definition of a disease concept represents a normative interpretation can be observed. The authors of this paper argue for the acceptance of this normative definition as a matter of societal agreement. Consequently, transparency is required in the shaping of general disease concepts. [ABSTRACT FROM AUTHOR]

Many aspects of Bion's theory of thinking have come to be widely recognized. Concepts like 'containment' and 'communicative projective identification' turn up in almost every clinical discussion. Bion's ideas regarding the development of thinking and disorders in thought have received less attention, for the simple reason that his writing on these topics is often hard to read. In the hope of making observable phenomena more communicable, he abstracts them into mathematical symbols. In addition, he occasionally chooses ambiguous or polysemic terms in order to retain the wide range of associations they offer. In this manner he deliberately confronts the reader with the kind of uncertainty which, he says, the analyst working with an analysand must be able to endure. This paper explains Bion's various models for the development and the use of thought: psychosomatic digestive tract, alpha function, container-contained, and the genesis of concept through the meeting of preconception with realization. Special weight is given to the case vignettes that alternate with theoretical passages, serving two purposes. On the one hand they show how Bion conceptualized specific problems as he built his theory of thinking. On the other hand they give intuitive access to Bion's abstractions, and show how tracing Bion's thought processes can help in the grasp of clinical phenomena and in the understanding of patients. One case serves to show how giving a name to emotions helps open the door to thought and communication. Additional examples clarify the manner in which thought functions become disturbed as a result of the avoidance of unbearably painful external or psychic reality. [ABSTRACT FROM AUTHOR]

Complications of implant removal: Fractures during removal of implants are rare (0-1.5 %) but serious complication, particularly because these procedures are thought to be the end of primary treatment, but if this occurs, then the patient will be back at the beginning of therapy. Furthermore 50-60 % of implant removals are highly elective surgeries on healthy patients. Due to the increasing number of operative fracture fixation procedures, the number of patients requesting implant removal will also increase in the upcoming decades. In this paper, an overview of the different causes for fractures based on implant removal procedures (intraoperative vs. postoperative) is given. Finally, the data in the literature are reviewed for long bones and recommendation are made to prevent such complications. Conclusion: Errors leading to fractures during implant removal may happen during initial fracture fixation, as well as during all stages of the implant removal procedure, e.g., assessment of indication, planning and performing the operative procedure, as well as operative after care. Based on the published literature, no evidence-based recommendations for implant removal can be given and each decision has to be made on an individual basis after critical evaluation. [ABSTRACT FROM AUTHOR]

The assessment of legal capacity and testamentary capacity require thorough knowledge of the legal framework and the relevant case law. This paper explains the concept of the legal capacity to contract and the concept of testamentary capacity with respect to German civil law. The relevance of major mental disorders for the assessment of legal capacity and testamentary capacity is discussed. [ABSTRACT FROM AUTHOR]

By restoring the immunological function the modern antiretroviral treatment of human immunodeficiency virus (HIV-1) infection has considerably lowered the incidence of opportunistic infections. As opposed to the classical manifestations of HIV-induced immunosuppression the incidence and prevalence of HIV-associated neurocognitive disorders (HAND) has not noticeably decreased and HAND continues to be relevant in daily clinical practice. At present, HAND occurs in earlier stages of HIV infection, and the clinical course differs from that before the introduction of combination antiretroviral treatment (cART). The predominant clinical manifestation is a subcortical dementia with deficits in the domains attention, concentration and memory. Signs of central motor pathway lesions have become less frequent and less prominent. Prior to the advent of cART the cerebral dysfunction could at least partially be explained by the viral load and by virus-associated histopathological findings. In patients with at least partially successfully treated infections, this relationship no longer exists, but a plethora of poorly understood immunological and probably toxic phenomena are under discussion. This consensus paper summarizes the progress made in the last 12 years in the field of HAND and provides suggestions for the diagnostic and therapeutic management. [ABSTRACT FROM AUTHOR]

Heinrich von Kleist (1777-1811) was a German poet and dramatist. During the celebrations marking the 200th anniversary of his death in November 2011, his double suicide with Henriette Vogel on the shores of the Kleine Wannsee near Berlin was extensively and publicly debated in the German. The meticulous reconstruction of his suicidal condition demonstrates that often only a few aspects of this condition are highlighted in German-speaking feuilleton or biographies. Contrasting the popular stylization of Kleist's suicide as a 'well-defended deliberate self-killing' or a 'romantic double suicide' it is argued that: (a) retrospective psychiatric diagnosis or psychological models of explanation are necessarily questionable (so-called pitfall of pathography), (b) Kleist's mental narrowness regarding suicide as a behavioral option was multifactorially motivated and (c) his sentence 'The truth is that on earth no help was possible for me' clearly expresses his desperation but delivers no justification for his suicide. On the contrary, from a clinical ethical point of view suicide can only be justified if no improvement of the condition is objectively possible. Even if this would have been the case in Kleist's time, nowadays modern psychotherapeutic and pharmacological means are reliably and easily able to help people in comparable situations. With a discussion and meticulous reconstruction this paper increases the understanding of Kleist's suicide and opens a clear view on his life and works. [ABSTRACT FROM AUTHOR]

The conceptual history of 'anancasm' in psychiatry remains almost unexplored and this article will help to remove this deficit. It was the Budapest-based neuropsychiatrist Gyula Donáth (1849-1944) who first proposed this Greek-rooted term in 1897 as an international term for compulsive symptoms and as an independent mental illness similar to present-day obsessive compulsive disorders (ICD-10). By suggesting this term Donáth wanted to extend the concept of compulsion as proposed by his teacher Carl Westphal to other compulsive phenomena, psychomotor impulses and restrictions including echolalia, coprolalia, echokinesis, echopraxia, contemporary maladie des tics (present day Tourette's syndrome) and even intermittent dipsomania (craving for alcohol), paraphilias, sexual fetishes and homosexuality. In 1923 Kurt Schneider used this term for a subgroup of psychopathic personalities, the so-called insecure anancastic psychopaths. His concept was much different to that suggested by Donáth, with the only thing in common being the compulsory component. Schneider's anancasts suffered from feelings of insecurity and insufficiency and were forced to try to overcompensate by being excessively careful, meticulous and hyper-correct. Based on Schneider's concept anancasm has survived as a name for a subdivision of compulsive personality disorders in ICD-10; however, these rather complex personality defects were not what Donáth had in mind when he first suggested the term anancasm. The paper discusses further discrepancies between Donáth, Schneider and ICD-10. [ABSTRACT FROM AUTHOR]

'Beware of understanding!' Lacan's structural analysis: theory and practice of interpretation. This paper investigates the relationship of understanding and countertransference analysis in the process of analytical interpretation. Here self-image of the analyst is crucial concerning the direction of the analysis. As field and function of speech are pivotal, they will be briefly sketched to clarify the structural-analytic starting point of the following arguments. The basis of the ideas is a definition of the unconscious as what is not conscious available. Should the analyst see himself as the 'knowing' one, as his patient also assumes, a false assurance will result and the analysis will lead nowhere. This is typical of a 'forced' transference analysis in the here and now. The alternative is a strategy of hints, whose premise is, that we do not know. This assumption makes it unnecessary to rely on countertransference analysis. Instead, the spoken word and its contradictions are in the focus. This analytical attitude makes listening to the 'subject of the unconscious' possible by means of the analyst and his hints. [ABSTRACT FROM AUTHOR]

In this paper I want to explore whether it is possible to establish a correlation between different levels of pathology and the distortions of some unconscious functions necessary for good mental functioning. My hypothesis is that mental health depends on the possibility to use an apparatus that allows us to contain and keep our emotions alive as well as to give meaning to them. This apparatus functions all the time, beyond individual consciousness. Some patients have this apparatus or have at least the potential to develop it whereas others, such as borderline and psychotic patients seem to be lacking it completely, hence the difficulty of analyzing these kinds of patients. [ABSTRACT FROM AUTHOR]

In October 2011 the Task Force Therapeutic Drug Monitoring of the Association for Neuropsychopharmacology and Pharmacopsychiatry (AGNP) published an update (Pharmacopsychiatry 2011, 44: 195-235) of the first version of the consensus paper on therapeutic drug monitoring (TDM) published in 2004. This article summarizes the essential statements to make them accessible to a wider readership in German speaking countries. [ABSTRACT FROM AUTHOR]

With a lifetime prevalence of 13 % social phobia (social anxiety disorder) is a common and serious condition that should not be played down because of the burden associated with the disorder, an increased suicide rate and the frequent comorbidity with substance abuse disorders. Social phobia is characterized by the excessive and unrealistic fear of being scrutinized or criticized by others. The disorder often begins in adolescence. Symptoms of social phobia can be effectively treated with evidence-based treatment, including cognitive behavior therapy (CBT) and psychopharmacological medications. In the present paper, treatment recommendations are given, which are based on a systematic review of all available randomized trials for the treatment of social phobia. Among psychological therapies, variants of CBT have been proven to be effective in controlled studies. Selective serotonin reuptake inhibitors (SSRIs) and the selective serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine are among the drugs of first choice. [ABSTRACT FROM AUTHOR]

Background: Systemic mast cell activation disease (MCAD) is characterized by an increased and unregulated release of mast cell mediators which can evoke a multifaceted clinical picture often resembling irritable bowel syndrome or fibromyalgia. Because of the considerable prevalence (~ 17 %) of MCAD surgeons are frequently unwittingly confronted with MCAD patients in whom unexpected intraoperative and postoperative complications may occur. Therefore, knowledge of the particular requirements is of relevance for surgical treatment of MCAD patients. Objective: The present paper outlines a concept of surgical treatment of MCAD patients based on the literature which is illustrated by a case report on emergency laparoscopic cholecystectomy. Conclusions: Due to the high prevalence of MCAD in the general population it can be assumed that the frequency in the surgical patient population is similar. If a patient has MCAD, specific characteristics should be taken into account in the surgical procedure to avoid increased operative and complication risks resulting from MCAD. [ABSTRACT FROM AUTHOR]

Diagnosis and treatment of sleep disordered breathing (SDB) undergo substantial changes, both in terms of increasing scientific knowledge and also in terms of patient provision and socio-economic aspects. Increasing evidence shows the relevance of SDB on morbidity and mortality of affected patients. The precise differentiation of different phenotypes of SDBs has improved substantially in recent years. These proceedings influence the approach to the patients suspected of suffering from SDB. The scientific advances on the one hand are facing intentions to simplify diagnostical processes and treatment initiation and intentions to translate duties of physicians to non-medical personnel on the other hand. This consensus paper presents the principals of diagnosis, treatment initiation and provision, including the role of different participants of the healthcare system, and compares different treatment options. Major aspects include the differentiation of the diagnostical process in screening, affirmation of diagnosis and differential diagnosis. In addition, it focusses on the relevance of the pretest probability and describes a therapeutical algorithm. [ABSTRACT FROM AUTHOR]

Background: Assessment of the severity of paraphilic disorders is an important aspect of psychiatric court reports for assessing criminal responsibility and placement in a forensic psychiatric hospital according to the German penal code (§§ 20, 21, 63 StGB). The minimum requirements for appraisal of criminal responsibility published by an interdisciplinary working group under the guidance of the German Federal Court of Justice define the standards for this procedure. Objectives and methods: This paper presents a research concept that aims to assess the severity of paraphilic disorders by using items of standardized prognostic instruments. Results and conclusions: In addition to a formal diagnosis according to the international classification of diseases (ICD) and the diagnostic and statistical manual of mental diseases (DSM) criteria, the items 'deviant sexual interests' and 'sexual preoccupations' from the prognosis instrument Stable 2007 are used to assess the severity of paraphilic disorders. Other criteria, such as 'relationship deficits' are used to support the appraisal of the severity of the disorder. The items 'sexual preoccupation', 'emotional collapse' and 'collapse of social support' from the prognosis instrument Acute 2007 are used to assess the capacity for self-control. In a next step the validity and reliability of this concept will be tested. [ABSTRACT FROM AUTHOR]

This paper confirms a marked change in developmental context and serious delays in identity development in all age groups, which have consequences for relationships in general and therapeutic relationships in particular. These changes in identity development have led to a depathologization of the prolonged transition to adulthood. In addition, it became obvious how much parents may hinder identity development. Recent societal changes leading to a more precarious life are responsible for an increase in reactive identity disturbances. In psychotherapy the endless search for identity, a difficulty to balance individuality and attachment and, considering transference, a too supportive relationship are important issues. Furthermore, it might be useful to discriminate between identity crisis, identity conflict and identity diffusion. [ABSTRACT FROM AUTHOR]

Background: Calcaneus fractures are still regarded as one of the most complicated fractures. In this paper, the current classifications and the status quo of therapy options for calcaneal fractures are provided. Classification: Although a large number of classifications are available, no uniform classification is used in the clinical setting. Therapy: Various options for treatment and concepts for follow-up treatments are reviewed and evaluated in an evidenced-based manner. While it appears that surgical treatment of complex fractures of the joint is superior to conservative therapy, the optimal surgical procedure remains unclear. Intraoperative evidence of the joint′s reposition is desirable. Conclusion: Due to the difficulty and complexity of treatment, treatment in hospitals with high case loads of calcaneal fractures is likely to be beneficial for the patient. [ABSTRACT FROM AUTHOR]

The general approach to the initial resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely injured patients. After initial stabilization of vital functions patients are evaluated based on the symptoms and critical care interventions are initiated as and when necessary. Adequate structural logistics and personnel organization are crucial for the treatment of non-trauma critically ill patients although there is currently a lack of clearly defined requirements. For severely injured patients there are recommendations in the S3 guidelines on treatment of multiple trauma and severely injured patients and these can be modeled according to the white paper of the German Society of Trauma Surgery (DGU). However, structured training programs similar to the advanced trauma life support (ATLS®)/European resuscitation course (ETC®) that go beyond the current scope of advanced cardiac life support training are needed. The development of an advanced critically ill life support (ACILS®) concept for non-trauma critically ill patients in the resuscitation room should be supported. [ABSTRACT FROM AUTHOR]

The general approach to the initial resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely injured patients. After initial stabilization of vital functions patients are evaluated based on the symptoms and critical care interventions are initiated as and when necessary. Adequate structural logistics and personnel organization are crucial for the treatment of non-trauma critically ill patients although there is currently a lack of clearly defined requirements. For severely injured patients there are recommendations in the S3 guidelines on treatment of multiple trauma and severely injured patients and these can be modeled according to the white paper of the German Society of Trauma Surgery (DGU). However, structured training programs similar to the advanced trauma life support (ATLS®)/European resuscitation course (ETC®) that go beyond the current scope of advanced cardiac life support training are needed. The development of an advanced critically ill life support (ACILS®) concept for non-trauma critically ill patients in the resuscitation room should be supported. [ABSTRACT FROM AUTHOR]

Background and objectives: The German health interview and examination survey for adults (DEGS1) with the mental health module (DEGS1-MH) is the successor to the last survey of mental disorders in the general German population 15 years ago (GHS-MHS). This paper reports the basic findings on the 12-month prevalence of mental disorders, associated disabilities and self-reported healthcare utilization. Methods: A representative national cohort (age range 18-79 years, n = 5,317) was selected and individuals were personally examined (87.5 % face to face and 12.5 % via telephone) by a comprehensive clinical interview using the composite international diagnostic interview (CIDI) questionnaire. Results: The overall 12-month prevalence of mental disorders was 27.7 % with substantial differences between subgroups (e.g. sex, age, socioeconomic status). Mental disorders were found to be particularly impairing (elevated number of disability days). Less than 50 % of those affected reported to be in contact with health services due to mental health problems within the last 12 months (range 10-40 % depending on the number of diagnoses). Conclusions: Mental disorders were found to be commonplace with a prevalence level comparable to that found in the 1998 predecessor study but several further adjustments will have to be made for a sound methodological comparison between the studies. Apart from individual distress, elevated self-reported disability indicated a high societal disease burden of mental disorders (also in comparison with many somatic diseases). Despite a relatively comprehensive and well developed mental healthcare system in Germany there are still optimisation needs for treatment rates. [ABSTRACT FROM AUTHOR]

Summary: Background: Complex regional pain syndrome (CRPS) constitutes an enigmatic post-traumatic pain disorder. Aim of the study: The paper provides state of the art knowledge about CRPS. Results: The typical constellation of symptoms of CRPS includes pain, sensory disturbances, motor symptoms, disturbances of the autonomic control of the limbs and trophic changes. These symptoms generalize distally and go beyond single nerve innervation territories. Diagnosis is made based on clinical findings. Three-phase bone scintigraphy may be the best supporting technical investigation. Symptoms typically change during the course of CRPS. In the acute stage inflammatory symptoms prevail and during chronic stages the most expressed findings are related to central neuroplasticity. These findings include hyperalgesia, sensory loss, CRPS movement disorder, body perception disturbances and autonomic symptoms. Medical treatment with anti-inflammatory agents (steroids) or bisphosphonates is most effective in the early stages and DMSO cream might also be beneficial. Administration of i.v. ketamine has been proven effective against CRPS pain and physical therapy with behavioral components, such as pain exposure helps to overcome central reorganization and functional impairment. Psychotherapy should be offered if there are significant comorbidities. All other forms of treatment are more or less empirical. Invasive treatment should be restricted to selected cases and should only be offered in specialized centers. Discussion: If these recommendations are followed the prognosis for CRPS is not as poor as commonly assumed. Whether this means a return to the previous quality of life is unclear and often depends on very personal factors. [ABSTRACT FROM AUTHOR]

Based on the analytic work on colleagues the author investigates a writer’s block of German psychoanalysts when writing about their patients. In the process of their own therapeutic analysis, an inhibition of association in these psychoanalysts comes to the fore by them falling into the professional role and talking about their patients. The accounts of these colleagues on their own patients function as a doubled imago revealing the unconscious conflicts of the patients as well as acting as a proxy of the psychoanalysts’ impulses, affects and foreclosed memories in their own analysis. The inhibition of thinking, leading to a writer’s block, is the result of the correspondence of the trauma of the patient with the trauma of the analyst when the transference-countertransference relationship evokes annihilation anxieties in the psychoanalyst. Therefore the writer’s block of these psychoanalysts is rooted in their professional work and is the result of the internalization of precarious emotional contents of their patients. The author examines the role of institutionalized psychoanalysis in developing a professional writer’s block, and the results of the paper highlight the need of an emotionally supporting professional environment for the psychoanalyst during his training and his practice work. [ABSTRACT FROM AUTHOR]

This article is the third part of an originally unplanned trilogy caused by the internal logic of the research process on psychosomatic theories. On the background of Freud’s difficulties with the illness and disease theory the fragmentation of the field of psychosomatic medicine has been described and presented in the two previous parts as an attempt to explain its tortuous developmental course. In the first part of this current paper the author tries to understand both the ideas and sociopolitical forces that were involved in the historical development of psychosomatic medicine. The scope of the field as well as the models used oscillated greatly. Psychoanalysis has played an important role in this development even if the mainstream psychoanalysts showed relatively little interest. Psychosomatics also required therapeutic approaches that were foreign to the accustomed psychoanalytical setting. Occasionally the influence of various physiological models was strongly displayed (e.g. Selye’s stress model and the influence of the immune system). The deepening of the psychological understanding is nevertheless due to original marginal psychoanalytic thinkers, such as Ferenczi and Groddeck. Under the influence of Ferenczi the unconventional search was completed by Balint to some extent either through development of the psychotherapeutic technique or by the influence of listening to the doctors in their interaction with patients. [ABSTRACT FROM AUTHOR]

Background: Patient data management systems (PDMS) enable digital documentation on intensive care units (ICU). A commercial PDMS was implemented in a 25-bed ICU replacing paper-based patient charting. The ICU electronic patient record is completely managed inside the PDMS. It compiles data from vital signs monitors, ventilators and further medical devices and facilitates some drug dose and fluid balance calculations as well as data reuse for administrative purposes. Ventilation time and patient severity scoring as well as coding of diagnoses and procedures is supported. Billing data transferred via interface to the central billing system of the hospital. Such benefits should show in measurable parameters, such as documented ventilator time, number of coded diagnoses and procedures and others. These parameters influence reimbursement in the German DRG system. Therefore, measurable changes in cost and reimbursement data of the ICU were expected.Material and Methods: A retrospective analysis of documentation quality parameters, cost data and mortality rate of a 25-bed surgical ICU within a German university hospital 3 years before (2004-2006) and 5 years after (2007-2011) PDMS implementation. Selected parameters were documented electronically, consistently and reproducibly for the complete time span of 8 years including those years where no electronic patient recording was available. The following parameters were included: number of cleared DRG, cleared ventilator time, case mix (CM), case mix index (CMI), length of stay, number of coded diagnoses and procedures, detailed overview of a specific procedure code based on daily Apache II and TISS Core 10 scores, mortality, total ICU costs and revenues and partial profits for specific ICU procedures, such as renal replacement therapy and blood products.Results: Systematic shifts were detected over the study period, such as increasing case numbers and decreasing length of stay as well as annual fluctuations in severity of disease seen in the CM and CMI. After PDMS introduction, the total number of coded diagnoses increased but the proportion of DRG relevant diagnoses dropped significantly. The number of procedures increased (not significantly) and the number of procedures per case did not rise significantly. The procedure 8-980 showed a significant increase after PDMS introduction whereas the DRG-relevant proportion of those procedures dropped insignificantly. The number of ventilator-associated DRG cases as well as the total ventilator time increased but not significantly. Costs and revenues increased slightly but profit varied considerably from year to year in the 5 years after system implementation. A small increase was observed per case, per nursing day and per case mix point. Additional revenues for specific ICU procedures increased in the years before and dropped after PDMS implementation. There was an insignificant increase in ICU mortality rate from 7.4 % in the year 2006 (before) to 8.5 % in 2007 (after PDMS implementation). In the following years mortality dropped below the base level.Conclusion: The implementation of the PDMS showed only small effects on documentation of reimbursement-relevant parameters which were too small to set off against the total investment. The method itself, a long-term follow-up of different parameters proved successful and can be adapted by other organizations. The quality of results depends on the availability of long-term parameters in good quality. No significant influence of PDMS on mortality was found. [ABSTRACT FROM AUTHOR]

Background: Patient data management systems (PDMS) enable digital documentation on intensive care units (ICU) and have positive effects on completness, quality and quantity of documented information. A commercial PDMS was implemented in a 25-bed ICU replacing paper-based patient charting. The ICU electronic patient record is completely managed inside the PDMS. IT compiles data from vital signs monitors, ventilators and further medical devices and facilitates some drug dose and fluid balance calculations as well as data reuse for administrative purposes. Ventilation time and patient severity scoring as well as coding of diagnoses and procedures is supported. Billing data transferred via interface to the central billing system of the hospital. Such benefits should show in measurable parameters, such as documented ventilator time, number of coded diagnoses and procedures and others. These parameters influence reimbursement in the German DRG system. Therefore, measurable changes in cost and reimbursement data of the ICU were expected. Material and methods: A retrospective analysis of documentation quality parameters, cost data and mortality rate of a 25-bed surgical ICU within a German university hospital 3 years before (2004–2006) and 5 years after (2007–2011) PDMS implementation. Selected parameters were documented electronically, consistently and reproducibly for the complete time span of 8 years including those years where no electronic patient recording was available. The following parameters were included: number of cleared DRG, cleared ventilator time, case mix (CM), case mix index (CMI), length of stay, number of coded diagnoses and procedures, detailed overview of a specific procedure code based on daily Apache II and TISS Core 10 scores, mortality, total ICU costs and revenues and partial profits for specific ICU procedures, such as renal replacement therapy and blood products. Results: Systematic shifts were detected over the study period, such as increasing case numbers and decreasing length of stay as well as annual fluctuations in severity of disease seen in the CM and CMI. After PDMS introduction, the total number of coded diagnoses increased but the proportion of DRG relevant diagnoses dropped significantly. The number of procedures increased (not significantly) and the number of procedures per case did not rise significantly. The procedure 8-980 showed a significant increase after PDMS introduction whereas the DRG-relevant proportion of those procedures dropped insignificantly. The number of ventilator-associated DRG cases as well as the total ventilator time increased but not significantly. Costs and revenues increased slightly but profit varied considerably from year to year in the 5 years after system implementation. A small increase was observed per case, per nursing day and per case mix point. Additional revenues for specific ICU procedures increased in the years before and dropped after PDMS implementation. There was an insignificant increase in ICU mortality rate from 7.4 % in the year 2006 (before) to 8.5 % in 2007 (after PDMS implementation). In the following years mortality dropped below the base level. Conclusion: The implementation of the PDMS showed only small effects on documentation of reimbursement-relevant parameters which were too small to set off against the total investment. The method itself, a long-term follow-up of different parameters proved successful and can be adapted by other organizations. The quality of results depends on the availability of long-term parameters in good quality. No significant influence of PDMS on mortality was found. [ABSTRACT FROM AUTHOR]

The treatment of rectal cancer has evolved significantly in recent decades. Both modern radiotherapy treatment concepts and surgical techniques have been able to improve oncological as well as functional outcomes for rectal cancer patients. Large-scale, multicenter, randomized trials have been able to demonstrate the benefits of neoadjuvant treatment over adjuvant radiotherapy. In addition, local tumor control is improved by neoadjuvant irradiation. Conversely, patients receiving a total mesorectal excision showed no survival advantage following irradiation vs. only surgically resected patients. In addition, radiation therapy is associated with a certain morbidity and mortality. This paper summarizes the available evidence regarding postoperative morbidity, mortality, and long-term chronic effects of neoadjuvant radiotherapy. [ABSTRACT FROM AUTHOR]

Background: Risk of postoperative infection in ambulant surgery must not exceed the respective patient's risk in the hospital setting. Therefore, identical regulations for hygiene are applied. Aim: This article summarizes the legal and professional basics for ambulant surgery. Problems evident during infection control visits of the public health departments are illustrated. Results: Because most operations were classified as invasive surgeries, the spatial requirements were met, although a shortage of rooms was often observed, which hampered hygienic procedures. The most common problems were associated with hand hygiene (sink with overflow and drain directly connected with the waste water system; lack of a soap dispenser, hand disinfection liquid, and paper towels). The most severe problems were observed in reprocessing medical devices (e.g., surgical instruments), with risk assessment and standard operation procedures as well as professional education of the personnel reprocessing medical devices being found, incorrect manual reprocessing or reprocessing by cleaning and disinfection machines and sterilizers which were not properly tested or validated. Conclusion: Practical tips for observing hygiene requirements in the ambulatory setting are given. [ABSTRACT FROM AUTHOR]

Indications: After serious injuries of the hand which can include tendon damage, infections or other injuries that have already been treated but still have loss of function or after surgical treatment with the appearance of new functional deficits, tendon reconstruction is indicated. Procedure: The decision for the treatment is associated with the location, the extent of the damage, the time elapsed since the injury and soft tissue coverage. The quality of postoperative physiotherapy and occupational therapy after surgical treatment of tendon injuries cannot be underestimated. Thus, exact planning of the surgical procedure and a well-informed, cooperative patient are necessary for successful reoperation. It must be taken into consideration that secondary tendon repair is generally more difficult than primary treatment, due to the existence of adhesions and scars. Conclusion: This paper gives an overview of various possibilities for secondary tendon reconstruction and functional restoration after hand injuries. [ABSTRACT FROM AUTHOR]

Gottfried Ewald (1888-1963) had been director of the State Hospital and Nursing Home and the University Clinic for Psychiatry from 1934. In August 1940, he refused his cooperation as a medical expert in the National Socialist's 'euthanasia' operation during a discussion of the 'Reich Cooperative for State Hospitals and Nursing Homes' (Reichsarbeitsgemeinschaft Heil- und Pflegeanstalten) in Berlin. Shortly afterwards Ewald wrote a comprehensive position paper against the operation which was sent to Werner Heyde, head of the 'T4' medical office, and Leonardo Conti, 'Reich physician leader' (Reichsärzteführer), among others. While Ewald's protest remained unsuccessful, it did neither result in any disciplinary consequences. By his own account, he decided to remain in his position on order to be able to rescue at least some of the patients of the State Hospital and Nursing Home destined for transport to the 'T4' killing centres. In cooperation with colleagues at the hospital and the Provincial Association in Hanover, he partly succeeded to meet this aim through deferrals, leaves of absence, re-assessments and releases. These strategies were, however, not used to prevent the deportation of Jewish and compulsory detention patients. Thus, Ewald's protest was a partial, pragmatic circumvention of the National Socialist's 'euthanasia' operation. [ABSTRACT FROM AUTHOR]

Extreme and complex traumatisation represents a severe problem in today's world. There is a need to develop treatment approaches that are efficient for traumatised persons who often live under very difficult circumstances. There are moreover certain societal conditions that are important for the treatment and rehabilitation of the traumatised patient. The paper will discuss how psychoanalytic therapy may be helpful for severely traumatised patients and what are the mechanisms of change in the therapeutic process. A focus is on how traumatic experiences are actualised in the transference and brings the analyst in a situation where enactments inevitably occur. It will be demonstrated how these processes may lead to symbolisation of these traumatic experiences. What are the therapeutic and societal preconditions for treating traumatised patients? [ABSTRACT FROM AUTHOR]

Developments and consequences of school profiling in general-education schools in selected European countries and perspectives for implementation in Germany - The development of a school programme, e.g. by way of forming a profile in the field of music or sports, is part of everyday school life in many European state and private schools today and even statutory in some countries and states. This paper focuses on the background and the significance of this development in school politics but also on the potential and the challenges which come with the profile formation of schools on an individual as well as systemic basis. Furthermore, the author introduces and discusses examples for the profile formation of schools and classes by looking at concrete projects. After that, recommendations are given for school programme work in individual schools. The focus is especially on German-speaking countries such as Germany, Austria and Switzerland. [ABSTRACT FROM AUTHOR]

The paper discusses the migration of German Jewish psychiatrists from Nazi Germany to Palestine during the 1930s. It focuses on their special assimilation process as immigrants who belonged to a culture different from the dominant Eastern European socialist Zionism and as a professional group which belonged to a marginalized discipline. [ABSTRACT FROM AUTHOR]

This paper reviews the concepts, evidence and implications regarding mental health at the workplace. The theoretical background with the most common theories (e.g. effort-reward imbalance model and job-demand control model) are briefly reviewed and findings from systematic reviews and from a meta-analysis regarding psychosocial factors at the workplace and common mental disorders, which indicate that psychosocial factors increase the risk of mental disorder are outlined. Implications for primary prevention as well as early intervention and treatment following a stepped care model including a variety of agents from different backgrounds are discussed. Implications to enhance research in the field are outlined. [ABSTRACT FROM AUTHOR]

Background: The German National Surgical Trial Network (CHIR-Net) which has been funded since 2006 by the Federal Ministry of Education and Research (BMBF, funding code 01GH1001A-01GH1001F, 01GH0702) is made up of eight regional surgical centers. The aim of the CHIR-Net is the design, implementation and publication of prospective, randomized, multicenter trials to support evidence-based medicine in surgery. Two main pillars of the CHIR-Net are the surgeon on rotation program and the flying study nurse program. With these two programs the surgical hospitals are supported in their trial working by educating competent investigators and the infrastructural support of flexible and mobile study nurses. Methods: The surgeon on rotation program and the concept of the flying study nurse are presented descriptively. Furthermore, this paper provides reports of experiences of a surgeon on rotation and a flying study nurse of the CHIR-Net. Additionally, the results of an on-line evaluation of the regional surgical hospitals (belonging to the regional surgical center of the universities Witten/Herdecke and Cologne) regarding the needs and requirements of the regional surgical hospitals are presented. Results: The surgeon on rotation program of the CHIR-Net offers investigators the possibility to acquire the basics of designing, developing and implementation of high quality clinical trials. In addition, their own study projects could be intensively driven forward. The flying study nurse program enables in particular non-university surgical hospitals to be supported competitively in performing their own study projects and participating in muliticenter clinical trials. The success of these two programs has been confirmed by the conducted evaluations and the presented field reports. Conclusion: The CHIR-Net is able to develop a high quality study culture in Germany with its surgeon on rotation and flying study nurse program. In addition to the funding period by the BMBF, the continuance of the CHIR-Net should be a primary aim of further measures. [ABSTRACT FROM AUTHOR]

The Deutsche Zeitschrift fuer Nervenheilkunde (German Journal for Neurology) was founded as a specifically neurological journal at the end of the nineteenth century and soon became a European platform for scientific discussion of neurological topics. Papers also came from the USA, Scandinavia and Russia. The difficulties of the diagnosis and definition of clinical entities are illustrated in cases of botulism, myotonic dystrophy and myasthenia gravis. [ABSTRACT FROM AUTHOR]

Muscular problems in leisure and elite sports represent the most common causes for training and competition breaks. This includes not only simple strains, but also complicated injuries. Thus, early recognition of the injury pattern and magnitude is key to successful treatment. The diagnosis is based on the anamnesis and clinical examination, which can be complemented by imaging results. There is currently no general consensus concerning the treatment of muscle injuries and no scientific evidence for the efficacy of various treatment options. The focus of the present paper is injection treatment of muscle lesions. Its use in the relief of pain is part of sports medicine. However, there are currently few publications; in particular studies with larger numbers of cases and randomized studies are needed. An improved scientific database is urgently necessary before a recommendation can be given for further patients. [ABSTRACT FROM AUTHOR]

Complications of implant removal: Fractures during removal of implants are rare (0-1.5 %) but serious complication, particularly because these procedures are thought to be the end of primary treatment, but if this occurs, then the patient will be back at the beginning of therapy. Furthermore 50-60 % of implant removals are highly elective surgeries on healthy patients. Due to the increasing number of operative fracture fixation procedures, the number of patients requesting implant removal will also increase in the upcoming decades. In this paper, an overview of the different causes for fractures based on implant removal procedures (intraoperative vs. postoperative) is given. Finally, the data in the literature are reviewed for long bones and recommendation are made to prevent such complications. Conclusion: Errors leading to fractures during implant removal may happen during initial fracture fixation, as well as during all stages of the implant removal procedure, e.g., assessment of indication, planning and performing the operative procedure, as well as operative after care. Based on the published literature, no evidence-based recommendations for implant removal can be given and each decision has to be made on an individual basis after critical evaluation. [ABSTRACT FROM AUTHOR]

Although psychodynamic concepts may be helpful in identifying the complex interpersonal and manipulative processes that occur between inmates and therapists and to transform them into the therapeutic process they are hardly ever applied in a correctional setting. The author provides an insight into the psychotherapeutic work conducted in prison. The first part of the paper outlines the special conditions in which psychodynamic psychotherapy occurs in a social therapeutic intervention institution within the German prison service. Characteristic transference and countertransference constellations are described. Based on a verbatim report an account is provided of a therapy session with a serious violent offender. In his reflections on the session the author focuses on the effects on the transference process of, in the offender's eyes, being both therapist and assessor at the same time. [ABSTRACT FROM AUTHOR]

Scientific prognoses augur the advent of 'Peak Oil', or maximum possible global oil production, in our time. After this maximum, production rates will begin to drop due to increasing capillary pressure in rock deposits, and new discoveries will be unable to compensate for the additive drop in production rates. At the same time, a global increase in energy consumption is also predicted. It is to be expected that the discrepancy between production and demand (heat, mobility, oil-based chemicals) will lead to political destabilisation not only between the 'industrial' and 'developing' nations, but also in democratic systems. Like the biblical 'mene tekel', 'Peak Oil' may be interpreted psychoanalytically as another ecological omen which should arouse civilization to ward off coming disaster. Up to now, psychoanalysts have dealt only sparingly with this perspective. The wake-up call of scientists and publicists in the media has prompted little reaction among consumers and decision-makers. Instead, utopian and/or apocalyptic visions of the future are the order of the day. In correspondence with the Airbus motto: 'We must use the air to preserve the earth', a project of the Max Planck Society is working on 'flying automobiles'. In view of these phenomena, our paper presents for discussion the hypothesis of a collective manic denial with splitting of the ego. We try here to limit psychoanalytic speculations with a clinical vignette. It may be asked to what extent the psychoanalytic method - in matters of ecological reality - runs the risk today of entering into collusion with the above-mentioned collective denial, instead of working through it lege artis on the basis of the reality principle. [ABSTRACT FROM AUTHOR]

Massive bleeding with coagulopathy and hemorrhagic shock poses a potential threat to life in numerous clinical settings. Optimal treatment including the prevention of exsanguination necessitates a standardized and interdisciplinary approach. Several studies have shown the importance of massive transfusion protocols and standardized coagulation algorithms to improve survival of severely bleeding patients and to avoid secondary complications. Thus, the Helsinki declaration for patient safety in anesthesiology demands the implementation of clinical practice guidelines for the treatment of patients requiring massive transfusion. This paper introduces a standardized algorithm for the treatment of patients with massive bleeding which was developed in consensus with the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). [ABSTRACT FROM AUTHOR]

Massive bleeding with coagulopathy and hemorrhagic shock poses a potential threat to life in numerous clinical settings. Optimal treatment including the prevention of exsanguination necessitates a standardized and interdisciplinary approach. Several studies have shown the importance of massive transfusion protocols and standardized coagulation algorithms to improve survival of severely bleeding patients and to avoid secondary complications. Thus, the Helsinki declaration for patient safety in anesthesiology demands the implementation of clinical practice guidelines for the treatment of patients requiring massive transfusion. This paper introduces a standardized algorithm for the treatment of patients with massive bleeding which was developed in consensus with the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). [ABSTRACT FROM AUTHOR]