In 211 bulboscopies 108 normal findings, 29 duodenal ulcers, 44 cases of scar bulb, 4 times erosions of the bulb and 26 times a bulbitis alone (macroscopically) were found. The macroscopic findings duodenitis were confirmed histologically in 85%, the macroscopic findings normal bulbous mucous membrane only in 30% of the cases. In patients with the histological findings duodenitis the bulbous mucous membrane was endoscopically regarded as normal in 70% of the cases. Patients with duodenitis more frequently have an antrum gastritis and less frequently a corpus gastritis than a control group corresponding to age without any macroscopic changes at the stomach and duodenal bulb. On account of its clinico-therapeutic importance is referred to the fact to demarcate the peptic corrosive bulbitis (bulbitis with bulboscopically probable lesion) from the bulbitis without bulboscopic lesion.
In 1% of the patients with cor pulmonale the cause of the high pulmonary artery pressure remains unclear. The underlying severe and mostly progressive pulmonary vascular disease with unknown aetiology is defined as primary pulmonary hypertension (PPH) with three different pathomorphological subtypes, plexogenic pulmonary arteriopathy (PPA), thrombotic pulmonary arteriopathy (TPA) and pulmonary venoocclusive disease (PVOD). The endemic occurrence of PPH after the ingestion of anorexigenic drugs (aminorex fumarate) and toxic rapeseed oil lead to the hypothesis that PPH is a pulmonary vascular reaction to exogenous toxic agents on the base of a genetic disposition. The initial response could be an endothelial cell dysfunction leading to pathological proliferation of vascular smooth muscle cells, vasospasm and local disturbances of haemostasis. The derived therapeutic concepts with vasodilators (high dose calcium channel-blocking therapy, prostacyclin) and with anticoagulant drugs show some encouraging results. The lung and heart-lung transplantation have become real therapeutic options for the patients with PPH considering the mostly still very unfavourable prognosis of PPH.
Numerous surveys have shown that in industrial countries diabetic subjects develop hypertension more frequently than non-diabetic persons. In fact, three typical hypertension forms in these patients can be discerned: essential, renal, and isolated systolic hypertension. In type 2-diabetes (NIDDM) hypertension can be seen in close association with obesity, glucose intolerance, lipid changes, and insulin resistance within the framework of the metabolic syndrome. The increased incidence of hypertension in type 1-diabetes (IDDM) is a result of development of diabetic nephropathy. In the elderly type 2-diabetics particularly frequently isolated systolic hypertension is present which reflects increased arterial stiffness and loss of vascular distensibility. In hypertension progression of both macrovascular disease and microangiopathy is increased whereby interaction of hyperglycemia and hypertension seems to be the main risk factor. In most hypertensive diabetic patients drugs will be necessary to lower blood pressure in a therapeutical range. There are several effective substances available which should be prescribed individually according to the needs and accompanying conditions in these patients.
Most aspects of the nutritional therapy of diabetes mellitus apply equally to IDDM and NIDDM patients and are also appropriate for people with high risk of cardiovascular diseases. A restriction of energy, a reduction of saturated fatty acids as well as of alcoholic drinks and simple sugars are the most important measures. This modification of nutritional intake together with increased fibre consumption is not only appropriate to avoid hyperglycaemia in diabetic patients but has also its benefits in patients presenting with the metabolic syndrome (possible reduction of hyperinsulinaemia, hypertension and hyperlipoproteinaemia). Diabetic patients should have regular screening for microalbuminuria. At first signs of an early stage of nephropathy patients should be advised to restrict their protein intake. About 50% of daily energy intake should be derived from carbohydrates and fat intake should be no more than 35% of total energy (saturated fatty acids less than 10% of energy). Carbohydrate exchange units are usually not necessary in NIDDM patients. In addition diabetes specialty foods are not an essential part of the nutritional therapy. The success of the nutritional therapy in diabetic patients is substantially dependent upon qualified counselling and education of the patients by the physician (as far as possible with the assistance of a dietitian).
The evaluation and management especially of cold thyroid nodules remains an area of controversy. The past decade has witnessed two important advances. The increased availability of fine-needle aspiration of thyroid nodules has altered the clinician's approach to this disease, and provides for the single most precise method for selecting appropriate patients for surgery. The introduction of high-resolution thyroid ultrasonography provides for anatomic definition that is clearly superior to thyroid scintigraphy. However, radionuclide imaging remains critical for determining the functional status of abnormal thyroid tissue. This review attempts to provide a practical approach to the evaluation and management of the thyroid nodule. Only rare data exists concerning the therapeutic approach of cold thyroid nodules and non-toxic nodular goitre. There seems to be a size-reducing effect by thyroxin-treatment, but no data are reported from iodine deficient areas. Concerning the treatment of differentiated thyroid carcinoma total thyroidectomy combined with eradication of remaining thyroid tissue with iodine 131 is usually preferred. In case of smaller or occult carcinoma various modes of uni- or bilateral subtotal resection are used. Chemotherapy is of little use in treating differentiated thyroid carcinoma and remains as a last possibility if usual approaches are no longer effective. To control local-invasive growth of anaplastic thyroid carcinoma combined treatment with mitoxantrone and hyperfractionated irradiation seems to be a successful approach.
Since the late 1970's, diabetes therapy has been revolutionized and, in fact, new treatment strategies have been initiated by patient education and the resulting self-monitoring of the patient. The modern management of the chronic lifelong disease diabetes mellitus not only requires the prescription of the appropriate nutritional and pharmacologic regimen by the physician, but also intensive education and counselling of the patient. It is the diabetic himself who ultimately has to secure the treatment as given by the physician in daily life and--in so doing--has to provide a great deal of self-care and self-control. Meeting the individual treatment goal is largely dependent upon the cooperation and motivation of the patient, with the physician as both the sympathetic and critical counterpart. Today, education is the indispensible prerequisite for the limited well-being and health of diabetics and, at this end, education is equal to therapy.
On the whole, diabetic microangiopathy can be understood as the clinical renal-retinal syndrome. About 10% of all diabetics die of end-stage renal failure, more frequent in IDDM. With an incidence of 14% diabetic retinopathy is one of the major causes of blindness in adulthood. In the non-proliferative state, the pathological changes are limited to the retina, whereas the alterations affect both retina and vitreous in the proliferative state. Photocoagulation is the treatment of choice. If photocoagulatory treatment is not possible because of cataract, vitreous surgery (pars-plana vitrectomy) could improve visual prognosis. The clinical features hypertension, proteinuria and finally renal failure define the term "diabetic nephropathy". The increased intraglomerular pressure is the main pathological alteration of incipient nephropathy. Microalbuminuria essentially determines the prognosis: in IDDM it concerns the incidence of a manifest nephropathy, in NIDDM the excessively increased incidence of cardiovascular mortality. Sonographically, the kidneys are large with bright and wide parenchyma. Along with the development of end-stage renal disease the kidney size diminishes. According to Mogensen, nephropathy is divided into five stages: Stage 1, the early stage, is defined by hypertrophy and hyperfiltration. Stage 2 shows incipient structural changes without any clinical findings. Stage 3 is characterised by persistent microalbuminuria. Stage 4 leads to increasing renal failure and stage 5 to end-stage renal disease and the necessity of dialysis treatment. Incipient nephropathy demands a strict treatment of both hypertension and diabetes. In the meantime, ACE inhibitors are the treatment of choice. In case of dialysis treatment continuous ambulant peritoneal dialysis (CAPD) is usually preferred.
The treatment of type II diabetes should not only concentrate on blood glucose levels but also should take symptoms like insulin resistance, hyperinsulinemia, low HDL-cholesterol, high VLDL, and systemic hypertension into consideration. These symptoms are well described by the metabolic syndrome and are known to be risk factors of macroangiopathy. In obese type II diabetic patients weight loss by caloric restriction is the most essential therapeutic step. Retarding intestinal carbohydrate uptake glucosidase-inhibitors are able to lower postprandial blood glucose levels without stimulating insulin secretion. The biguanide metformin is suitable to diminish peripheral insulin resistance, gluconeogenesis, and intestinal glucose absorption on cellular mechanisms others than betacytotropic effects. In non obese type II diabetic patients sulfonylureas are advantageous because of meal related stimulation of endogenous insulin which runs the physiological way with first pass through the liver. Therefore, sulfonylurea treatment should be continued when secondary failure indicates the need for exogenous insulin. In accordance with the course of type II diabetes in secondary failure insulin should be added to sulfonylureas in as small amounts as possible to ameliorate poor metabolic control. Thus iatrogenic hyperinsulinemia and resulting insulin resistance can be largely avoided. If there is any long term benefit when different oral antidiabetic agents are administered together with insulin has to be evaluated in further clinical studies.
Timely initiation of thrombolytic therapy can achieve coronary reperfusion, a reduction in infarct size, a preservation of left ventricular function and a reduction in mortality. It is therefore an established procedure in acute myocardial infarction. The major drawback is an increased rate of bleeding. As a consequence thrombolytic therapy is at present withheld from many patients with contraindications. Other problems include relative inefficacy of presently available thrombolytic agents and early reocclusion of primarily successfully reperfused vessels. New approaches to optimize the risk/benefit ratio for the patient and to make thrombolytic therapy available to more patients include new antithrombin and antiplatelet agents as adjunctive therapy, synergistic combinations of plasminogen activators, mutants of t-PA and prourokinase, chimeric molecules and antibody-targeted thrombolysis.
Widely differing conditions applied to practice-oriented medical teaching at universities in the various German principalities or territorial states in the 18th century. Initially, the institutions used by professors as "collegium clinicum" belonged either to foundations or were being run on a private basis. It was only in the second half of the 18th century that these institutions became state-supervised, with the inclusion of the discipline of surgery. The results of such reorganization are demonstrated, taking Halle and the work done by Johann Friedrich Gottlieb Goldhagen as examples.
Numerous surveys have shown that in industrial countries diabetic subjects develop hypertension more frequently than non-diabetic persons. In fact, three typical hypertension forms in these patients can be discerned: essential, renal, and isolated systolic hypertension. In type 2-diabetes (NIDDM) hypertension can be seen in close association with obesity, glucose intolerance, lipid changes, and insulin resistance within the framework of the metabolic syndrome. The increased incidence of hypertension in type 1-diabetes (IDDM) is a result of development of diabetic nephropathy. In the elderly type 2-diabetics particularly frequently isolated systolic hypertension is present which reflects increased arterial stiffness and loss of vascular distensibility. In hypertension progression of both macrovascular disease and microangiopathy is increased whereby interaction of hyperglycemia and hypertension seems to be the main risk factor. In most hypertensive diabetic patients drugs will be necessary to lower blood pressure in a therapeutical range. There are several effective substances available which should be prescribed individually according to the needs and accompanying conditions in these patients.
Although there is no evidence of effectiveness of interventional trials concerning macroangiopathy in diabetes mellitus, the focus of primary prophylaxis is based on the treatment of risk factors and optimal adjustment of metabolic parameters. This should contain the prophylaxis of the diabetic foot (foot care, teaching, pressure bearing) in the neuro-ischaemic risk patient. In the secondary prophylaxis acetylsalicylic acid has been proven as effective in the cerebral, cardial, and peripheral vascular regions in different dosages. The aim of the symptomatic therapy is the improvement of the peripheral vascular disease symptoms, which could mean an improvement of the pain-free walking distance or the avoidance of an extremity-threatening ischaemic syndrome. The therapeutic range includes a structured exercise programme, conservative medical treatment, catheter procedures, and bypass surgery as well as amputation. The different procedures are mainly dependent on the general condition of the in many cases multimorbid patients, the clinical stage, the psychological burden and the angiologic status. There should be always an interdisciplinary discussion, which helps to find the right therapeutic decision. All the therapeutic activities should be seen under the guideline of an improvement in the quality of life.
Our investigations carried out in patients with diabetes mellitus revealed oxidative stress loads. The study presented here was to clarify whether a therapy with antioxidants can contribute to an improvement of prognosis. 80 patients affected with a long term diabetic late syndrome were randomised and arranged to 4 groups of n = 20 each. In contrast to a control group these patients received 600 mg of alpha lipoic acid or 100 micrograms of selenium (sodium selenite) daily or 1200 IE of D-alpha-tocopherol respectively for a time of 3 months. In comparison with the control group all groups treated in an antioxidative way showed significantly diminished serum concentrations of thiobarbituric acid reactive substances and of urinary albumin excretion rates. The symptoms of distal symmetric neuropathy measured according to the thermo- and vibration sensitivity also improved in a highly significant manner. The results prove that oxidative stress plays a promoting role in developing of long term diabetic late complications and that a therapy with adjuvant antioxidants may lead to a regression of diabetic late complications.
Goitre defines any enlargement of the thyroid independent of its cause. Worldwide iodine deficiency is the single most common cause of a goitre. However, before iodine deficiency is established, other thyroid diseases need to be ruled out. Very rarely increased production of TSH (secondary hyperthyroidism) or of hormones with TSH activity (e.g. hCG producing tumours), inborn errors of iodine metabolism, and defects of the thyroid hormone receptor (thyroid hormone resistance) are the cause of a goitre. Furthermore, malignancy of the thyroid and autoimmune disease (e.g. Grave's disease) may lead to a thyroid enlargement. Still, worldwide more than 90% of the 200 million patients with goitre suffer from iodine deficiency. In Germany, as in only few other European countries which lack any nation-wide prophylactic iodine supplementation, goitre is endemic with a prevalence of about 25%. The classical concept on the mechanism of iodine deficiency induced goitre is based on decreased thyroid hormone synthesis in the presence of iodine depletion, which leads to increased production of TSH, stimulating thyroidal growth. Recent in vitro findings using thyroid cell cultures expand this concept by demonstrating that TSH regulates the differentiation and function of thyroid cells and may induce hyperplasia, but not cell proliferation. In contrast to TSH, the locally produced growth factors IGF I (insulin-like growth factor I) and EGF (epidermal growth factor) stimulate thyroid cell proliferation. Intrathyroidal iodine antagonises the effects of IGF I and EGF and simultaneously stimulates transforming growth factor beta (TGF-beta), which inhibits thyroid cell proliferation. Thus, intrathyroidal iodine appears to regulate thyroidal growth by controlling proliferation stimulating (IGF I, EGF) and proliferation inhibiting (TGF-beta) growth factors. Though these new insights fill several gaps of the classical concept on the pathogenesis of endemic goitre, open questions remain.
In a retrospective analysis a total of 167 patients with rheumatoid arthritis (RA) who had been treated with the basic therapy formulas of methotrexate (MTX) or sulfasalazine (SUL) were evaluated with respect to therapeutical result and side effects after a period of 12 months. There was no randomization as to either MTX (n = 87) or SUL therapy (n = 80), but deliberate use of therapy according to prior treatment and activity of the illness. Apart from a significantly higher number of inflammatory joint conditions in the MTX group there was no difference in the two patient groups at the beginning of the study. MTX treatment led clearly to a more conspicuous activity decrease of the illness (ESR, joint index) and a more favourable effect on the locomotor function. Furthermore, the sphygmomanometer readings (for grip strength determination), the dose reduction of the concomitant prednisolone medication as well as the doctor's opinion were in favour of MTX. The portion of patients who had to discontinue the therapy because of side effects (= 11%) and lack of effect (= 9%) was exactly identical in both groups of patients. Both substances have shown to be effective basic therapy formulas for rheumatoid arthritis, while methotrexate has a few advantages.
We report on a case of isolated pulmonary valve endocarditis caused by coagulase-negative staphylococci 22 years after total correction of a pentalogy of Fallot. The M-mode and two-dimensional echocardiographic findings are presented, and the patient's clinical progress is described. An overview of the literature shows isolated endocarditis of the pulmonary valve to be an exceptionally rare occurrence. 6 months postoperatively, the patient has not been experiencing a relapse and is now in NYHA stage I.
Even with the new fibrin-specific plasminogen activators thrombolytic therapy remains burdened with numerous side effects, some of them being severe or even life threatening, therapists being horrified if in rare cases the patient dies from severe haemorrhage subsequent to thrombolysis. The incidence and severity of bleeding increase with increasing aggressiveness of the therapeutic regimen and with increasing time during which the thrombolytic state is maintained. Furthermore, side effects related either to the plasminogen activator used (allergic reactions and systemic fibrinogen breakdown e.g.) or related to the underlying disease (pulmonary embolism and reperfusion arrhythmias e.g.) have to be considered. In order not to let thrombolysis become a double-edged sword, the risks of thrombolytic therapy should carefully be weighted against the benefits before thrombolysis is commenced.
As is generally known, the writing movement reacts in a sensitive manner to numerous diseases, medications, stimulants and environmental poisons, as well as to psychic and physical influences. This reaction can occur quite early in the process. Therefore, laboratory data and the physical examination can be supplemented by the handwriting. The graphological analysis is particularly helpful in the following ways: early diagnosis, documenting the course of the disease, evaluating treatment, psychological relationships as well as the problems of old age. This review, presented in three parts, intends to demonstrate to the physician simple and time-saving possibilities, as well as analytical methods, that are most likely to promise success. This needs to be done by a competent graphologist.-Prejudices against graphological methods and exaggerated expectations will be reduced if proper information is presented.
The response to hormone treatment in two patients with dementia due to hypothyroidism was studied prospectively.
Experiments started in 1743 by a working group at the university of Halle marked the beginning of efforts to incorporate electricity into clinical therapy. Very soon this resulted in knowledge that was also taken up elsewhere, leading to a period of intensive research. The creative suggestions that originated in Halle were authored, among others, by Johann Gottlob Krüger, Christian Gottlieb Kratzenstein and Johann Joachim Lange. Their experimental and clinical findings were accompanied by deliberations on the mechanism of action of electrotherapy on which they reported in detail. Due to adverse circumstances this initially leading position occupied by Halle faded out already shortly after the middle of the century.
