Biomedical subjects
Publications and source records attributed to A Frei.
From 1994 till 1996, the sickness funds represented in the Forum schweizerischer Krankenversicherer are carrying-out a Second Opinion Pilot Program. This program is subject to a scientific evaluation. The objectives and the organisation of the program are presented, and material and methods of the study are described.
In a retrospective investigation we report our experience with alcohol-dependent patients who were hospitalized between 1987 and 1990. There were 58 patients, 29% of them were hospitalized several times. In the middle of 1991 and 1992 we interviewed the family doctors and the social workers who cared for the patients. In 48% of the patients there was improvement, in 24% there was a stabilization, and in 28% we noted a deterioration. There was no difference in patients treated by the family doctor alone or in patients treated by the social workers. Comparing patients taking Disulfiram with patients taking no drug, there was no difference in improvement (48% versus 50%). But the good results in patients not taking disulfiram were nearly exclusively noted for those who had been hospitalized in a special clinic for alcohol-dependent persons. Patients who were hospitalized several times for alcohol withdrawal had a worse chance to improve their situation (-20%). The therapy with disulfiram in alcohol-dependent patients is helpful to cure chronic alcoholics. Programs in a specialized clinic improve also the chance to be cured of the addiction.
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In most cases, evaluations of treatments are restricted mainly to their clinical efficacy. With health resources becoming scarcer, cost-benefit-analyses assume greater significance in the assessment of therapies. The following article introduces a methodological concept for the assessment of costs and benefits in the treatment of mental deterioration. In this concept, data on clinical effectiveness were derived from an existing clinical long term trial. In addition, according to the characteristics of the patients included in the clinical trial, a new sample of similar patients was examined. A cross-sectional analysis was performed in order to measure resource utilization. The clinical trial and the cross-sectional analysis were then combined to assess the cost effectiveness of the treatment. For this purpose, the patients of both the clinical trial and the cross-sectional analysis were classified into groups according to severity of symptoms. The proportions of medically- and placebo-treated patients in the different severity groups were followed up during the long term trial. The costs of resource utilization of each severity group were calculated. Consequently, depending on the course of the illness, direct treatment costs for medical- and placebo-treated patients could be compared. The results show clear differences. Rehabilitation measures and emotional care are provided mainly for patients with moderate symptoms, whereas the services for patients with more severe symptoms concentrate on basic care, such as dressing and undressing, washing, feeding, etc.(ABSTRACT TRUNCATED AT 250 WORDS)
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The present catamnestic study covers 100 petitioners, who either applied for the first time for a driving licence or for readmission to traffic after confiscation of their license by the police. 99 of them were former inpatients or still inpatients at the time of judgement. For all of them, the decision of the police depended upon our expertise. For the judgement we considered our psychiatric investigation, the clinical report and the police traffic record. Normally, our mode of admission was quite generous. The duration of catamnesis lasted at least two years. Our of the 100 petitioners, 88 were considered to be fit for driving; 67 unconditionally and 21 under the condition of regular survey or treatment. Subsequently seven of the petitioners showed a poor probation, i.e. their licenses were taken away by the police, one due to a severe and two due to minor accidents. Nobody was injured. In comparison to the experience of other authors about probation in traffic of former psychiatric inpatients, we think we can report a favourable result. A rather generous mode of admission to traffic seems to be justified in these patients.
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Incidence and mechanisms of cimetidine-induced hypotension were investigated during the first intravenous injection of cimetidine (200 mg over three minutes) in 68 consecutive patients in the intensive care unit. Systolic pressure decreased more than 5 mm Hg (average, 14 mm Hg) in 50 patients, exceeding 30 mm Hg in nine (13%), while heart rate and pulmonary artery pressure (seven patients) did not change. Blood pressure decreased significantly more in patients requiring vasoconstrictor drug support. The arterial vasodilator properties of cimetidine were demonstrated in 12 normal volunteers in whom brachial artery cimetidine infusions caused a significant decrease of forearm vascular resistance. This effect was more pronounced when forearm vessels were preconstricted with dopamine hydrochloride (n = 6) or norepinephrine (n = 6), pointing toward an interference of cimetidine with sympathetically mediated vasoconstriction. Thus, intravenous injection of cimetidine in critically ill patients, presumably through arterial vasodilatation, is frequently associated with decreases of blood pressure, particularly in patients requiring vasoconstrictor drug support.
Two women were admitted for increasing abdominal pain, vaginal discharge, and severe or moderate chronic ascites. Diffuse peritonitis without evidence of liver disease was found in both cases, and in one the ascites and vaginal discharge contained Chlamydia trachomatis. Both patients responded to doxycycline, and this and the laboratory findings pointed strongly to C trachomatis as the aetiological agent. C trachomatis may cause severe peritoneal infections with chronic ascites formation in the absence of liver disease in women with the Fitz-Hugh-Curtis syndrome. Prompt diagnosis and antibiotics lead to rapid cure.
The intravenous 133Xenon method was used to measure regional cerebral blood flow (rCBF) in 20 patients with moderate hypertension. Regional cerebral blood flow under pretreatment, in the placebo period and after 8 weeks of enalapril treatment were compared. The rCBF values [(F1), and initial slope, (IS)] showed no statistical difference during the three periods in spite of significantly higher blood pressure values in the placebo period. It is concluded, that with enalapril good blood pressure control is achieved without any adverse effect on rCBF.
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The evaluation of pathological clinical findings or abnormal laboratory tests in the liver was prospectively investigated. Pathological findings were used for diagnosis or differential diagnosis in only 40% of 102 patients investigated. Further investigations, mainly laboratory tests, resulted in definitive diagnosis only in 20%. The yield of pathological results when routinely ordering liver-specific tests is not more than 20%. Fewer, but perhaps more invasive, investigations would lower costs and improve the diagnostic yield.
Monitoring in an intensive care unit after intoxication with tricyclic antidepressants for 48-72 hours was reevaluated in a retrospective study of 57 patients. As described in the recent literature, severe neurologic (coma grade III and IV, seizure or respiratory insufficiency) or cardiovascular complications (bradycardia, ventricular tachycardia, hypotension, were not found after 24 hours of intensive monitoring. More prolonged monitoring control no longer appears necessary.
The therapeutic possibilities of a day hospital orientated towards active rehabilitation are described. A survey revealed that 11 of the 34 patients were treated with active individual physiotherapy, 8 were attending remedial therapy and 5 regular individual speech therapy. The remaining patients followed physical or occupational therapy in groups. The patients receiving intensive individual procedures were mostly stroke patients with a history of less than two years or patients with chronic joint diseases. The accurate indication for the use of a staff- and time-consuming individual therapy is of great importance both in physiotherapy and occupational therapy. Treatment should be programmed for a carefully defined purpose and has to be adjusted continuously to the changing functional status of the patient.