Zeitschrift fur arztliche Fortbildung最新文献

A modular concept for persons members of health insurances: the prevention programme entitled becoming old and remaining healthy. Prevention is sensible in the second half of the life span. In these later years, key objectives include such concrete classical themes like nutrition and mobility as well as prevention of falls and psychosocial support for family care providers. Such prevention requires a multi-step procedure if the goal of a self-determination in health behavior is to be reached. The prevention programme "Becoming Old and Remaining Healthy", an example of such a concept, is presented in this article. Selected components of these programme should give an impression how psychological and educational approaches can be used to help students understand the health implications of their own life circumstances. This paper is to familiarize the reader with the basic concept of prevention and health promotion.

The early recognition of an asthmatic disease is important for optimal treatment and rehabilitation with a long lasting success. The knowledge, that bronchial asthma is always accompanied by a chronic inflammatory process of the airways, necessitates the early application of antiphlogistic substances like glucocorticoids as well as weaker substances like DNCG and nedocromil. Therefore, the basic therapy of patients with asthma of the severity II to III should be a combination of beta-2-agonists and antiphlogistic drugs. The pharmacological therapy has to be accompanied by a practical health training (ashtma and antiobstructive training). This is the only way to accomplish an optimal treatment with a correct inhalation, professional usage of ventilation aids, and a convincing recording of peak-flow-values. Rehabilitation of patients with asthma is team work. Beside physicians, co-therapists like psychologists, dietitians, and trained nurses have to be employed.

Nearly all neurological and neurosurgical diseases can cause lasting disabilities. Therefore, neurorehabilitation is needed. The German Pension Insurance Association has developed a concept of phases working as a chain of treatment, rehabilitation and care. This was confirmed as the one official system by the German Federal Society for Rehabilitation consisting of all social insurances and wellfare sponsors. The goals and tasks of each phase are defined by the functional status of the patients and their requirements for recovery. The costs are mostly determined by the social health or the social pension insurances. Different professions (physicians, nurses, physiotherapists, occupational therapists, speech therapists, (neuro-)psychologists, social workers) have to cooperate as a "therapeutic team" to improve the patient's impairments, disabilities and handicaps and to make full use of their individual resources of recovery. Only this can be the basis for valid prognostic decisions. In the long term treatment and care of the general practitioner, stroke patients are the most important group. Special problems are seen after traumatic brain injuries. Other relevant diagnoses are Parkinson's syndrome, multiple sclerosis, diseases and injuries of the spinal cord or the peripheral nervous system. In many patients, special aids have to be prescribed for several aspects of human living.

In patients with normal gastrointestinal functions, enteral nutrition is safe, efficious and inexpensive. The knowledge of enteral products and the correct selection of application techniques are important for a successful therapy. Long-term enteral nutrition of different subgroups of patients is possible by percutaneous endoscopic gastrostomy (PEG). Many complications may be avoided by changing the modalities of application.

The rehabilitation in gastrointestinal diseases has experienced the introduction of new concepts. Regional health resorts (i.e., mineral springs, climate or mud baths) do not play a role anymore. Today, rehabilitation cliniques are teaching and training centers for chronic patients with multiprofessional teams. The need for rehabilitation cannot be derived from the diagnosis alone or the duration of the illness but from the severity of the symptoms and/or additional psychosocial problems. The order of the application of different techniques during medical rehabilitation differs from patient to patient and necessitates a definition of the rehabilitation goal. Chronic inflammatory bowel disease, chronic pancreatitis, and chronic liver diseases are explained as an example. "Rehabilitation of gastrointestinal or metabolic diseases' is often better described with a model of progression than with the traditional model of disablement. Therefore, a network of clinical and ambulant rehabilitation as well as an entanglement of institutions providing hospital care and after-care is required.

Containing 14,000 beds on wards, the psychosomatic rehabilitation in hospitals has a significant part in the treatment of psychosomatic and somato-psychological diseases where psycho-social parameters play an etiological role. This work may be aggravated by the fact that these diseases are often recognized too late and that the patients are admitted to specialized hospitals in a state of chronic illness. Nevertheless, these hospitals are working with great success especially regarding the reduction of costs in the period after discharge, reduction of the time being incapable to work, in patient days, medication, and medical attendance. Beside these parameters of cost reduction, the success in treatment also contains the improvement of subjective parameters such as satisfaction of living, relationships, and every day life. Psychodiagnostic hints are given for the on time diagnosis of the mentioned disturbances allow an early and adequate treatment.

Concepts and theories of psychology are represented which are suitable to enrich rehabilitation medicine in the outpatient medical attendance. First, the understanding of rehabilitation medicine is discribed as a comprehensive care to ensure handicapped persons remain incorporated in family, society and occupation. Second, special fields of psychology sciences are explained, which contribute to reach these aims of rehabilitation, especially pedagogics and health psychology, medical and clinical psychology and behavioural medicine as well as behavior therapy. Third, there are chances discussed to comprise psychologists in a comprehensive rehabilitative treatment.

This paper reports the results of a representative survey which was performed in cooperation with 145 family physicians and 14 primary care neuropsychiatrists (response rate 83.2%) in the area of Göttingen, Germany. With the use of a standardised interview referring to written sample case histories, we investigated the diagnostic and therapeutic management of memory disturbances in old age. The results showed, that dementia and depression are underdiagnosed in primary care, and that memory disturbances are mainly regarded as consequences of disturbed cerebrovascular perfusion. About 70% of all physicians would prescribe a cognition enhancer, however about a third of them would do it in spite of major doubts about their efficacy. The results underline the necessity of continuing education especially with regard to early diagnosis of dementive and affective disorders in later life. The development of therapeutic standards in this area should take "irrational" motives into account. Appropriate exemplary case histories seem to be a potentially useful tool for the measurement of physicians' competence and its changes.

Since 1994, seminars for the new curriculum in general practice are conducted by the Academy of Continuing Medical Education (consists of the regional medical board and the association of public health insurance in Südbaden). Specialists of different medical disciplines supported by general practitioners in the role of moderators are preparing and teaching a wide range of topics. The general practitioners are supervising the different courses, thus, facilitating the learning process of the participants. Furthermore, the facilitators have to work out the specific needs and requirements of general practice and family medicine. The topics are presented in a form of lessons and clinical cases discussed in small groups (problem-oriented approach). The evaluation of two seminars was carried out in 1994 and 1995 including two thirds of the complete curriculum in general practice. From the positive results of the evaluation, modification and improvement of the didactic concept for future seminars in 1996 are derived.