A medical expert opinion concerning lumbar syndrome as an occupational disease should only be made if the condition of adequate job-related stress exists. There are no difficulties to diagnose the chronic lumbar syndrome. However, the assessment of the connection in cause may be difficult because of the lack of strong distinctive criterias between job-related degenerative signs and those due to fate. Guidelines for decision-making are demonstrated. The degree of disability due to occupational disease considers the part of the labour market which is closed to the insured person out of functional aspects and preventive reasons. In order to avoid job-related lumbar syndromes, preventive measures at the working place should be the common aim of all involved disciplines in collaboration with the technical service.
The exclusive involvement of the lungs with A lambda-type amyloidosis in nodular dispositions in a case of Sjögren's syndrome is very rare. An immunoglobulin lambda-type light chain, benign, monoclonal gammopathy has been verified as the ethological cause. The urine concentration of paraproteins was below the detection limit of the common examination methods and could only be found immunoelectrophoretically in urine concentrated 100-200 fold. The question of a possible relationship with Sjögren's syndrome is being discussed.
During the past three decades, the use of implants both in urology and other surgical specialties has experienced exponential growth. The development of implantable genitourinary prostheses has similarly grown from simple testicular substitutes to the large group of implantable penile prostheses, artificial urinary sphincters, prostheses in neurology, and possible future developments of artificial bladder and ureteral materials. The majority of urologic prostheses are constructed of silicone, because it is relatively inert, but nevertheless silicone causes some local tissue reactions and deteriorates with time. Currently, much research is underway studying the effects on the human host. Although multiple mechanical malfunctions of these prosthetic devices have occurred, periprosthetic infection is the most disastrous complication which usually leads to removal of the prostheses. This article gives the clinician an overview of common complex urologic implants, especially the current development of prostheses in the field of neurology.
In only 30% of back pain patients an underlying pathology can be found. Rheumatologic causes in a narrow sense are fibromyalgia, osteoporosis and the group of spondylathropathies and reactive arthritis. Infectious disorders of the spine are emergency cases and need immediate and interdisciplinary action. Careful evaluation of signs and symptoms indicate the suspected origin of pain and lead to the use of more specialized diagnostic means. Therapy of specific back pain should be appropriate to the clinical disorders. In acute, nonspecific back pain, the aim is to prevent a chronification of disease by instruction and education of the patient and an early start of physical therapy. The rehabilitation process in chronic cases in complex and may need psychobehavioral methods for pain control. Pharmacologic modalities of treatment-simple analgesics, nonsteroidal antirheumatic drugs, muscle relaxants and antidepressants-should only be used for a limited period and monitored constantly.
Back pain is a wide-spread complaint in modern society and in part an adverse effect resulting from present-day lifestyles. To date, too little attention has been drawn to efficient prevention. The treatment of patients affected with back pain today calls for an in-depth pathophysiological knowledge about the mechanism occurring on the spine. Diagnostic methods and non-operative treatment have been complemented specifically by chirotherapeutic methods. A systematic classification of the vertebragenous pain syndromes and the related treatment strategies have proven to be successful. Irrespectively of that, the individuality of diagnosis and the complaint's progress in each patient should be taken into account at all events. Cost-intensive diagnostic imaging should only be undertaken with a clear indication. Today, the overwhelming majority of back pain patients undergo a non-operative treatment. In case the conservative applications prove inefficient, it is possible to successfully operate on patients a with disc prolaps, degenerative instabilities as well as osseous spinal foraminal stenoses. A precondition is a precise causal diagnosis and a clear indication for operative intervention.
Clinical prevention is defined as the application of all individual practice contacts of patients and physicians during the screening after risky habits or living conditions for the following specific consultation (i.e., aiming for "free of tobacco") and/or induction of specific interventions (i.e., medical check-up, health examination, immunization). All data available up to now are demonstrating that the theoretically accessible options for clinical prevention are realized merely imperfectly by physicians and/or are hardly accepted by the patients. This may be due to the restricted perception and clarification of three problem areas; they are separately discussed: 1. The clinical prevention is also part of a comprehensive "prevention politic" and needs adequate general conditions. I.e., it is generally unclear, who is supposed to take care of the health promotion and prevention: the government with its public health services, the health insurances, the society of panel physicians? 2. Clinical prevention is more distant to a strict outcome orientation than other medical areas. There is a lack of a firm proof of its individual, epidemiological, cultural, and economical effects - namely the positive and negative ones. 3. (Clinical) prevention is especially exposed to ethical tensions. The protection of the patient's (or the client's) autonomy plays a particular role. If it is possible 1. to reduce the fear of physicians and patients for the political implications of clinical and medical prevention more than in the past, 2. to work out and distribute convincing empirical proofs of the desired (and undesired) effects of prevention, and 3. to discuss the ethical tensions typical of prevention as well as to reduce them in each single case, the program of clinical prevention would have a real chance in Germany. Otherwise it has to be feared that there will only be "Medical Prevention Weeks".
The prevalence of back pain is increasing. Usually, back pain is associated with additional vegetative, functional, and mental disorders. Mental factors may contribute to the maintenance of pain and to chronification. The degree of the back pain has a wide variety. According to an international consensus, it is tried to take the view of back pain as a biopsychosocial model. The accordingly derived psychosomatic treatment procedures need a differential indication. Beside the basic psychosomatic treatment, the individual therapy by qualified psycho-therapists and the behaviour therapeutic and depth psychological oriented group therapy by specifically trained physicians belongs to the psychosomatic procedures.
Problems are frequently encountered regarding the terminology, diagnosis, differential diagnosis, and therapy of diseases of thes tendons insertion point (enthesis): Terms such as tendinosis, tenopathy, tendinitis, tendovaginitis, tendoperiostitis, insertions tenopathy, tendomyosis, etc. often are used interchangeably even through they describe anatomically and pathophysiologically different conditions. The term enthesiopathy is used as a generic term in this overview article irrespective of the causality.
Quality circles (peer review) will play an increasing and important role in ambulatory care when they are based on voluntary participation and in a setting of open discussion. Goal is the further qualification of physicians by critical reflections on their practice based on learning processes and the experiences of the participants. Reported are experiences from the unit for primary care and health service research of the Hamburg University on implementing quality circles. Engagement in quality assurance may be helpful in the shaping and professionalisation of general practice.
The results of evaluations proceeding the educational seminar "Psychosomatic Primary Care" in South Baden are presented and analyzed. From 1991 to 1995, approximately 450 physicians took part in these courses. From critical feedback and suggestions for improvement obtained from participants following each course, recommendations for future seminars pertaining to content, structure, process, didactic and evaluation are presented.
The question, whether evaluation of continuing medical education (CME) is necessary, is discussed in Germany for several years. It is frequently criticized that the effects of continuing education on the medical practice and the quality of the patient care are hardly concrete. Evaluation is too often understood as a tool of external control rather than an instrument of self control and feedback for the teachers and organizers of CME events. The evaluation methods in use have many methodological shortcomings, i.e., lack of objectivity, reproducibility, feed back to the students, nearness to practice, and are therefore reason for the missing acceptance of the evaluation by physicians. Evaluation methods make sense if they contribute to efficient learning. They are supposed to aid in correctly assessing both the need and success of learning. These demands are currently most completely fulfilled by the Canadian "Maintenance of Competence Program" (MOCOMP), the applicability of MOCOMP in Germany is now proofed by the German chamber of physicians.
The intervertebral disk, the small vertebral joint, the musculature, and ligamentous apparatus may become the origin of back pain, and, the clinical examination aims for the exact palpation complemented by the functional probe of posture and free mobility. The physiotherapeutic action is orientated according to the main symptom: For acute lumbago, mobilization supported by analgesic measures as soon as possible after the acute painful stage has eased. The blockade of vertebral joints necessitates manual therapy, warmth and/or electrotherapy need to be added for cramped muscles. Infiltration is applied for ligamentous pain, active posture exercises are needed for muscular weakness. If the therapeutic options are limited in the elderly patient, passive measures like segmental massage for muscle relaxation are legitimate.
Dealing with a medical expert assessment requires experience and perseverance of the lawyer. Exact knowledge about the expert opinion itself and the procedural options is of greatest importance due to the decisive impact of the medical expert assessment on the outcome of the lawsuit. The lawyer has to consider at any time of the process whether he can initiate an expert assessment, whether he has to evaluate, criticize or question obtained expert assessments, whether he has to challenge the expert or possibly has to introduce another expert into the lawsuit. The expert witness has to have professional knowledge and the lawyer as well as the court have to absorb this knowledge and use it accordingly.
In view of the wide range of liability claims, expert medical reports constitute part of the basis of the work of liability insurers. However, the very different qualifications of experts often present the so-called "corporate physician" with great problems, since some expert reports are hardly acceptable, as the author discovered during many years of study of a large number of liability files. In addition, the most striking and frequently occurring criteria are discussed.
Acute renal failure accompanied by an increase in retention parameters and oligo-anuria is a common medical problem. The most important medical task in nephrology is a fast diagnostic differentiation between prerenal-, renal- and postrenal failure. Using simple techniques such as case history, medical examination, ultrasound and specific analysis of serum and urine, it is possible to obtain a relatively certain diagnosis. Radiographic techniques with radiocontrast agents are contraindicated because of nephrotoxic side effects. The treatment of acute renal failure is based on the underlying disease. Apart from symptomatic treatment, there are only very few medications available to improve the excretory kidney function and diuresis. Complications like hyperkalemia, hyperhydration, metabolic acidosis and uremia require early renal replacement therapy. Especially in cases of extreme hyperkalemia, an immediate beginning of therapy is important. In the medical practice, emphasis should be placed upon the prevention of renal failure.
Neither the HIV-specialists, the cooperating specialists, nor the family physicians are required to have special qualifications to treat HIV-infected patients. CME-courses don't consider the very different fields of interest of the participants or that the transfer of knowledge is quite important to ensure the quality of medical care. Questionnaires regarding HIV related topics were distributed in nine HIV-CME courses (9/93-5/94) of the DAGNA (German association of panel physicians treating HIV-infected patients) in cooperation with the society of physicians of Germany and the association of public health insurances. The satisfaction of the participants, the topics with regard to their relevance for the task group, the importance for the daily routine, and didactic manners were investigated. Feed-back: 41%. Although the general impression of most participants was "quite satisfying" (87%) there was some critic regarding special aspects. The rating of the courses depended on the level of qualification. Specialists in internal medicine rated the relevance for their medical practice, the topics and the possibility of contribution more positive than other specialists or general practitioners (GP). In general, there was a great difference regarding the rating of the courses among the participants because of their individual level of qualification and knowledge. In order to take the different levels of qualification and demands for topics into account there must be graduated courses: specialists, experts, elementary and beginner courses. The basic courses should contain not only the lectures but also the possibility of an active contribution of the participants. Adequate guidelines have to be developed.
In Saxonia, an agreement of shared care was reached between health insurances and the society of general practitioners with the objective to have a better medical care for patients with diabetes mellitus. This model of shared care means integrated medical care for out-patient diabetics between general practitioner and specialists. It must be accompanied by quality assurance measures. After a training of moderators according to a structured programme of the Central Research Institute for Outpatient Health Care, quality circles started with seven to ten members and two moderators in five Saxonian cities in May 1994. General practitioners interactively improved their medical knowledge about diabetes mellitus during five sessions with two hours each. The regional specialist participated in the first and the last session. He also answered open questions left in a mail box. Based on patient data the following results were achieved: 553 documentations.
A computer diary was developed for physicians to create a portfolio of their self-directed learning. Each item of learning is recorded in the form of a question along with the stimulus, the learning resources used and the outcome planned for the learning. The records of 123 physicians which volunteered to use the diary were analyzed. Their response to the software, elicited by survey, is described. Items of learning were most often stimulated by scanning the literature and while seeking information to manage a patient. The physicians recorded their intent to change their practice as the outcome to learning most often when the learning was stimulated while managing a patient. One-half of the physicians reported that keeping the diary made them think about their patient care.
The introduction of the new German specialist for psychiatry and psychotherapy increased the requirement for more integrated and flexible clinical training programs for residents. The integration of this multitude of more sophisticated diagnostic and therapeutic strategies in an individualized treatment plan for each patient requires new teaching strategies. The instructional method "Cognitive Apprenticeship" in acquisition of treatment planning-competence is discussed within a curriculum framework.
