[Medical documentation exemplified by neurology. 20 years' experience--current challenges--future prospects].
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Diagnosis, Differential↗
Biomedical subjects
G S Barolin
Publications and source records attributed to G S Barolin.
[Headache: interdisciplinary cooperation].
Tendency towards subspecialization in medicine, especially in medical literature, endangers the patient who does not fit in one of the specialities. Hence he may be treated badly or not at all. Headache forms an interdisciplinary meeting point and shows this in high grade. Four following reviews of books on headache will demonstrate it. Each of it claims a good deal of competence and authority. In itself however the four books are widely contradictory. Our concept of multidimensional classification in headache builds up a planned polypragmasy using target symptoms. This is an attempt to evade such dilemma. Further seems to be needed: better knowledge of the marginal territories in our specialization, closer interdisciplinary cooperation and maybe a new organisation of medical system.
Austria↗
[Illness, anxiety and the physician. An example from neurology and neurorehabilitation].
There are rationally treatable fears arising from the acute situation (especially in rehabilitation patients) as well as the irrational anxieties of the mainly endogenous depressive. In the condition which we have come to call "concomitant depression", especially in neuro-rehabilitation, we can find both types of fear and anxiety, often in the same patient with mutual overlapping. In dealing with the fears of the incurably ill patient it is essential to know the phase-related progression in order to give empathy and help in entering the further phases at the appropriate times. It is important to know the "typical anxieties of the elderly" and to take them into account in concomitant psychotherapy, whereby group therapy has proved to be especially useful. On the other hand, the anxieties of the doctors themselves have to be dealt with, which opens a wide field for psychodynamic supervision and the Balint-groups. Apart from psychodynamic components there should however be a distinctly defined teaching program for the health profession, as well. On the therapeutic sector, we have to mention the organismic therapies, which have a good anxiolytic quality (therapy by hypnoid states and/or relaxation). Anxiety is by no means the only known contra-productive psychodynamic factor, but it is a point of onset for a desirable integrative approach in medicine, as a counterbalance against present tendencies towards over-specialisation, which at time can be counter-productive and detrimental to the patient. To achieve this, psychotherapy has to leave its ivory tower in order to radiate into all medical disciplines. It is not our task to eradicate anxiety in its pathological overflow by therapy; but to recognize and acknowledge it as an existing human dimension, thereby preventing it from turning into counter-productive moxiousness. Essential in this process are self-reflexion, empathy, training and systematic application of therapeutic techniques in efficient combination.
Anxiety Disorders↗
[Seizures in old age].
The important differential diagnosis between epileptogenic versus non-epileptogenic attacks becomes increasingly difficult with elderly patients: 1) Vasovagal syncopes may occur abruptly, not infrequently with injuries caused by the sudden fall ("Blitz-Synkope"). Other generalized non-epileptic seizures include drop-attacks, amnesic episodes, prolonged syncopes, and seizures caused by faulty metabolism. 2) Focal non-epileptic seizures in advanced age are mainly TIA and prolonged TIA (PRIND). Complicated migraine is more typical for the younger age group. In this connection it must be kept in mind that 10% of TIA are caused by brain tumor, 20% can be traced to cardiac origin. 3) In connection with the non-epileptic seizures mentioned above there may appear singular irregular cloni without any rhythmical sequence. We have come to call this type of attacks "incidental convulsions". Especially in these cases differential diagnosis is of great importance with respect to basically different therapeutic measures. 4) First manifestations of epilepsy in advanced age are--regarding etiology--in the first rank symptoms of cerebral vascular disease or of intracranial tumors. 5) In the diagnostic approach it is necessary to keep in mind all the above-mentioned possibilities and to exploit every possible access to anamnestic exploration, with the patient as well as with his family, friends and colleagues. Essential auxiliary diagnostic methods include EEG, computed tomography, Doppler-sonography, occasionally long-time EEG or ECG, in some cases NMR.
Aged↗
[The expertise situation as pathoplastic factor].
Underlying attitudes of apprehension or desire have an essential pathoplastic function, especially in the situation of medical assessment. The functionality of symptoms and complaints requires a diagnostic approach which is not oriented simply towards the "exclusion of organic causes". Interaction between somatogenic and psychogenic factors is by far more common than sheer functionality. Although widely neglected in our medical teaching and literature, these problems are not confined to the mere assessment of temporary or permanent invalidity, but are of great importance for the entire medical sphere, including manifestations and course of a disease, therapeutic success etc. In Austria, the population of foreign workers is in a special position due to socio-economic preconditions, partly due to short-sighted policy devoid of psycho-hygienic considerations. This situation requires thorough analysis free of emotions, which should lead to the development of sensible, although in some respects belated, measures. The latest economical recession has revealed several faulty courses of development in our system of social and health insurance, which needs revision urgently lest it should collapse. In this respect, the medical profession is called upon to contribute to a necessary curtailment of excessive misuse within a system that has become inflexible during the past decades, thereby endangering the valuable achievements of social medicine.
Adult↗
[Seizures and driver's licence].
Legislation leaves a wide margin of freedom of judgement to the medical expert in the forensic assessment of a person's suitability for holding a driver's license. We have to make use of this freedom very cautiously with regard to social aspects as well as to the presently accepted state of scientific knowledge. In cases of first manifestations of epilepsy we must postulate--as a rule of thumb--a seizure-free period of two years with regular medication and clinical and electro-encephalographic checkups. The (epileptic or non-epileptic) "accidental seizure" is characterized by the releasing influence of powerful external noxious factors. In these cases, the patients should be seizure-free for at least six months before driving can be resumed. In all cases, the evaluation depends on the continuous observance of the patients, taking into account any underlying primary illness (alcoholism, cerebral vascular disease, conditions following brain surgery or trauma). The organic brain syndrome is an essential additional factor, together with the feasibility of treatment and the patient's compliance. Evaluation of the clinical picture is of foremost importance, support by EEG-findings, serum levels and psychological tests. Knowledge of cumulative factors, elimination and side-effects of anticonvulsive drugs is essential. According to the present view, medication should be continued over a period of many years. Curative medicine and medical assessment are not mutually exclusive, but require a distinct differentiation in every single case.
Adult↗
[Valduna Rehab Scale in evaluating the correlation of clinical outcome and laboratory values in follow-up of encephalomalacia].
The clinical outcome of 65 patients with malazia alba of the brain was documented by the use of our "Valduna-Disability-Score" examining the patients at defined points of time. Simultaneously several rheological parameters of venous blood gained by punction of the cubital veine were examined before and after hemodilution therapy using dextran 40. The items or progress concerning clinical outcome and changes of the rheological parameters were correlated. There was not found any significance. We conclude, that the changes of rheological parameters in venous blood are not able to predict the clinical outcome after hemodilution therapy. The important role of disability scores--in our case the "Valduna-disability-score"--is to be stressed.
Activities of Daily Living↗
[Ten years neurologic follow up--part of the "Vorarlberg Rehabilitation Model"].
Within our framework of "comprehensive and permanent" rehabilitation, the follow-up neurological rehabilitation service is an important element. Based on the findings of an anterospective computerized documentation, a ten year survey is given concerning more than 600 patients and over 15,000 home visits. Aside general epidemiologic data, such as age, gender distribution, etc., our findings above all show that improvements in rehabilitation profiles can be achieved even after prolonged periods of time (i.e., 12 months and over) after onset. This, for one thing, may help in countering a widespread rehabilitation pessimism and, for another, serve in motivating the responsible cost-carrying agencies to pay increased attention to the field of neuro-rehabilitation. Literature concerning systematic assessment of long-term rehabilitation outcomes is sparse and fragmental. Available data to a large extent are in line with our findings. Further accompanying rehabilitation research into these respects is urgently needed. A number of important service delivery/organizational aspects have in addition been traced, which we are already trying to implement within our Vorarlberg rehabilitation model.
Activities of Daily Living↗
[Predictors of multiple sclerosis development trends with special reference to "questionable initial manifestations"].
Within 10 years we have had evidence in our department of 173 cases of proven multiple sclerosis (MS) and 63 cases which primarily were called by us: "bland entzündliches Geschehen" (BEG) instead of "possible first onset of multiple sclerosis". 44% of these cases remained as a singular manifestation, whereas 56% developed to established MS. This underlines our proposition of a new classification which does not call such questionable first symptoms as "possible first onset of MS" but as "bland entzündliches Geschehen". This is much less severe and prejudicatory for the bearers of such symptoms. Furthermore we could demonstrate clear correlations between clinical and laboratory findings and the probability of development of MS and the improbability of such a development, respectively. We could not find such predictors up till now in the literature. The several laboratory parameters, relevant for MS (not only with regard to BEG, but also to the whole population which clinically proven MS) could be tested regarding their sensitivity. As a remarkable result, to our knowledge not mentioned so far in the literature, we could demonstrate the flicker-fusion-analysis to be the leading laboratory test. In addition it is a very simple laboratory method, as far as time and money are concerned. It is at least as valid as visual evoked potentials which in the literature are considered to be the most sensible test. Taking into account the few cases examined with the magnet resonance tomography until today, this method, seems to be less sensitive than flicker-fusion-analysis. We do not have a 100% laboratory method at our disposal.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Medical graduate and basic education in Austria: emergency or surplus? Objective evaluation or bureaucratic regimentation?].
If there is a reform of medical school, it will be desirable to keep the positive aspects of our tradition, while adding favourable aspects out of international experience. We will need to shorten unprofitable ballast, which means theory in excess, seeking for more practical and well accessable knowledge capability of independent work and decisionmaking. We need better communication ("humanization") in medicine. It is necessary to take the whole education system into consideration: college up to professorship, as they are linked together. We cannot recommend to increase the number of exams, but we support a continuating control, working in small groups promoting the motivation of the students. They must see more sense in their studies. Rather intensify the control and supervision of the system of instruction than to reinforce the learning control of students by exams. We reject to explain all failures and disappointments in medical school by lack of financial means or because of competences which overlap each other. Many things could be changed within existing laws. Partly they have to be changed by altering laws. A number of practical possible ways to reach this target are pointed out here.
Austria↗
[Physician consultation: a main medical factor].
The patient's rating remains largely uninfluenced by the physician's quality as such--it is mostly the quality of the interpersonal contact, which counts, along with banal circumstances, such as the daily menu. It is conversation with the patient, which ought to be re-discovered as an important medical function, particularly in view of trends for medicine to become increasingly technical and specialised. This holds true for clinical routine as well as for medical education and training. We envisage an organic and systematic development from primary contact with the patient (including non-verbal and behavioural aspects) and spontaneous conversation towards basic psychotherapy. All medical and nursing staff ought to be included in this approach. Thereby the ground would be prepared for special psychotherapeutic techniques which might be applied later (not discussed here). A rather critical item is instruction at the patient's bedside, which we continue to regard as necessary, but which requires observation of special rules and enhanced attention, in order not to have detrimental effects. Also highly important are well-controlled contacts with the relatives of the patient. While these factors tend to be regarded as incidental, they have the potential for becoming rather important: By way of the emotional condition they can become relevant for healing and rehabilitation. Since neither medical routine nor education and training do currently pay enough attention to them, it is indicated to point this out more regularly.
Austria↗
[Rehabilitation in relation to terminology from the neurologic viewpoint ("neuro-rehabilitation")].
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Adaptation, Psychological↗
[Post-traumatic headache].
Acute and increasing headaches after traumatism may be a signal for important complications, namely: subarachnoid hemorrhage, infections from the sinus, subdural hematoma. In chronic posttraumatic headaches we do not see one single clear cut entity of "posttraumatism". The trauma acts mainly (pathophysiologically) via vasolability and via cervical spine. The important role of cervical spine for posttraumatic headaches is greatly underestimated, especially if the cranial trauma is looked at isolated, just by valuing X-rays and duration of unconsciousness. If we look at traumatism as a triggering respectively modifying factor it makes clear that we can not postulate an everlasting causation of headache by traumatism, but have to see posttraumatic headache in a fluent transition from trauma-etiology to a constitionally caused personality-etiology. Difficulties arise in giving a clear cut limit between the two causations. A time span of about two years is a ruff measure. Our multidimensional concept of headache etiology demands a clear analysis of the different factors. On the basis of this we can build up a polypragmatic way of therapy that acts as specific and complex as possible. This creates higher efficacy.
Adult↗
[Pain therapy other than with drugs with special reference to headache].
Pain-control and pain-therapy becomes most efficient within a systematic polypragmasy combining pharmacological and non-pharmacological means. the non-pharmacological means as well have to be combined in a rational (not casual) way. Plurality of methods should be controlled by a holistic medical view, not to become monomaniac. On the other hand specialized development in methods must be stimulated. Within our own working group we have developed a special model of group therapy combining autogenic training and analytical approach. We also apply respiratory feedback combined with suggestive formula implanted into the hypnoid state.
Acupuncture Therapy↗
[Virus diseases of the nervous system in selected patients at a neurologic specialty unit during a 9-year period].
During a 9-year period an unselected population of 377 patients with clinically suspected viral diseases of the nervous system were hospitalized. Due to the serological findings a definite viral etiology could be established in 123 (33%). With respect to clinical syndromes serological evidence of viral etiology was found in 74% of mono- respectively oligoneuritides, 43% of meningoencephalitides, whereas in polyneuritis only in 18%. Concerning different virus strains varicella zoster virus appears to be largely ahead (65 cases), then come the enterovirus and herpes simplex virus. Clinical features are presented, some exceptional features are discussed. As regards severity of clinical symptoms and course nearly all patients made a good recovery. Only 2 patients died due to complications of the viral infection. In some cases it seems worth noting the association of another virus to a well determined etiology, this occurring simultaneously.
Antibodies, Viral↗
[Neuroborreliosis].
The principles of certain clinical symptoms first described at the beginning of the century are rediscovered again: Erythema chronicum migrans after tick-bite followed by numerous neurological manifestations. Meningopolyneuritis Garin-Bujadoux-Bannwarth is recognized to be a central nervous system-manifestation of Borrelian infection transmitted by tick-bites. In a period of 2 years we evaluated 15 patients with diagnosis neuroborreliosis. There is a good improvement after treatment with penicillin or ceftriaxone but there are also some cases with recidives and permanent lesions. We can also present a case report of a progressive borrelian encephalomyelitis.
Adult↗
[Consultation with the neurologist in transplantation medicine].
The neurological committee in the transplantational team not only has got to determine the exact physical point of death but also has to integrate the whole environment especially in having precise talks with intensive care staff and relatives. This procedure requires knowledge in law as well as tact and a specific medical training in this sort of conversations. The 3 major issues for determining the point of death should remain together as they used to, i.e. clinic plus zero wave EEG plus angiography. This fact is stressed by 12% of patients being "problematic cases" within a number of 50 patients who have been seen by us and considered for transplantation. In those 12% there were discrepancies in the 3 major criterias. Therefore we are not confirmed with today's tendency in which mere angiography suffices as criteria of the point of death. The above all existing ethical principle which permits to take away organs only after the death of the brain may not be confused with an unfavourable prognosis. The inclining need of organs for transplantations should not be prevented through a time spending and exact determination of the point of death. Better and ubiquitous organisation of transplantational teams is required - although exact criterias got to be obeyed - in order not to lose precious organs, which can still happen in hospitals, whereas patients in need of transplantation painfully await them respectively still die without them. In this complexity the neurological cooperation in the transplantational committee is an activity which requires high skills, time and exactness but, despite all effort offers satisfying and meaningful work.
Adult↗
[Amnestic episodes].
Amnesic episodes, by no means infrequent occurrences, are likely to trigger off anxiety in the patient and to evade adequate diagnostic interpretation. They consist of an isolated disturbance of short-term memory, manifesting itself as a permanent memory gap. The clinical features may vary from a conspicuous behaviour with stereotype repetition of questions to a completely inconspicuous picture with flawless execution of even highly differentiated behaviour patterns. The vegetative state may either be completely undisturbed or vary from mild impairment with nausea and vertigo to marked vegetative disorder. We are advocating a classification in 3 groups: a) "Genuine" amnesic states as symptoms of impaired blood flow in the basilar system in the absence of other etiological clues. b) "Symptomatic" amnesic episodes with tangible pathogenic factors, such as injury of the head and cervical spine, epilepsy, intoxication with various agents. The "genuine" amnesic states can also be regarded as transitory ischemic attacks of the basilar system. They show the following criteria: preponderance in females beyond middle age, duration of several hours, relatively high frequency of vascular risk factors and degenerative changes in the cervical spine, often triggered off by stress on the cervical spine, low tendency towards recurrence, general clinical benignity. In consequence, we stress the importance of etiological clarification before the onset of therapy. After the diagnosis of "genuine" amnesic state has been established, treatment has to be in accordance with the principles of basilar stroke therapy with subsequent vascular prophylaxis. Nevertheless, because of possible therapeutic or forensic consequences, the "symptomatic" states have to be kept in mind.
Adult↗