Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors: Part D Basic conditions supporting drug treatment.

Physiological changes in old age: loss of muscle mass; reduction in bone mass; percentage of fat increased; lower amount of body water; lack of thirst; diminishing kidney function (caution: sufficient intake of fluids: 1.5-2 l and moderate intake of protein 8 g/kg body weight); reduced secretion of digestive enzymes, delayed emptying of stomach (which means premature feeling of repletion). Lack of fluids and nutrition is therefore likely. Daily intake of 1,500 kcal and 1.5-2 l fluids is necessary. An indicator for malnutrition is low body weight (defined for persons older than 65 years of age as BMI < 20) and a protein serum concentration < 35 g/l. Malnutrition carries an increased risk of infections, falling and fractures, bed sores, anemia, decompensation of chronic diseases. 10-20% of subjects over 80 years of age show signs of malnutrition, 40-60% of subjects in care institutions or hospitals. There are regressive changes in the locomotor and the nervous system of the elderly which have an effect on physical fitness. These changes reduce strength, endurance, proprioceptive capacity (e.g. coordination, balance) and mobility. Exercise in the old and very old should increase skeletal muscle strength in particular and improve coordination and balance. Regular physical exercise and moderate training has a positive effect on mobility and thereby improves independence and reduces falls. Moreover, it has a positive effect on cardiac output, maximum heart rate, stroke volume and the risk of a cardiovascular event and mortality can be reduced. Moreover, moderate physical exercise is often more effective in treating chronic disease than drug therapy e.g. heart failure, coronary heart disease, asthma/COPD, stroke, diabetes mellitus Type 2, degenerative diseases of the joints, depression and others. Examine cardiovascular risks in persons over the age of 50 before beginning physical exercise. Avoid maximum stress levels.

Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors - Part C Special Pharmacology.

This article contains the 4th part of the Pharmacotherapy Guidelines for the Aged by Family Doctors for Family Doctors. Part 4 is dedicated to fecal incontinence and chronic constipation. The diagnostic categories are divided according to severity and dysfuntion of bowel and pelvic floor, sphincter and neural control. Therapy is also outlined. Importance is given to patient history, in particular the use and abuse of drugs that stimulate peristalsis and promote constipation. Therapy in the elderly is guided by the maxim: use the most conservative therapy possible, where stool training has considerable importance. Drug therapy based on symptoms can only be recommended when non-drug measures continue to fail. In patients with fecal incontinence: 1) opiates (which reduce colonic motility), 2) loperamide (which has the capacity to dilate the rectum) and 3) anion exchangers which have the capacity to prevent cholonic diarrhea. In patients with chronic obstipation: 1) trial: stool-forming laxatives (ensure intake of sufficient amount of fluids) 2) trial: laxatives with an osmotic effect and 3) trial: stimulating laxatives (beware abuse, do not use in cases of acute abdomen).

Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors.

Part C of the guideline is preceded by Part B General Pharmacology IJCPT. 2008; 46: 600 - 617. Included in Part C are practical guidelines for improving the therapy of some age-specific diseases and problems commonly encountered in general practice. The article in this issue is dedicated to the therapy of Dementia and M. Parkinson. Further guidelines for the other age specific diseases and problems named above will be published in the following issues of IJCPT. An important feature of these guidelines are the inclusion of Levels of Evidence and of the Strength of Recommendations for the therapy which are shown when reliable studies are available. (For both see levels of evidence at the end of this article.).

Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors: part C--Special pharmacology.

The part "Special pharmacology of the aged" of this guideline contains recommendations for typical conditions in the family doctors practice: in the January issue 2009 dementia and Morbus Parkinson, in this issue osteoporosis and urinary incontinence and in the next issue rectal incontinence and obstipation. This issue of the IJCPT contains the third part of the Pharmacotherapy guidelines for the aged by family doctors for family doctors. Part 3: Osteoporosis and urinary incontinence. Osteoporosis is a systematic disease characterized by low bone mass and declining bone structure. Exercise, adequate diet, nicotine abstinence as well as reduction of alcohol consumption may counteract the progression of the disease. Osteoporosis manifests in bone fractures with minimal trauma. Attention must be given to the risk of falling, e.g., by avoiding drugs that increase the risk of falling: e.g., psychotropic agents, analgesic drugs and antiarrhythmic agents. Specific osteoporosis medication e.g. calcium, vitamin D, biphosphonates and SERM (selective estrogen receptor modulators) is evaluated by family doctors according to indication, dosage, contraindications, long-term therapy and nature of any fracture. Duration of therapy is at least 3 - max. 5 years followed by reassessment of indication. There are 3 types of urine incontinence (urge-, stress-, and overflow-incontinence). Another standardization of urinary incontinence follows dysfunctions of the pelvic floor: detrusor muscle-dependent, due to sphincter spasm, prostate gland dependent. Urge incontinence with a dysfunction of the detrusor muscle is the most common type. Mixed types are frequent. Non-drug measures (e.g. pelvic muscle training, bladder training, toilet training are first choice treatments. Drug therapy (estrogen, imipramine) are without proven effect.

Suppression of cell-mediated immunity in rats transplanted with kidneys from donors compatible at the major histocompatibility complex.

In order to study the immunological status of rats transplanted with H-1-compatible kidney allografts, LEW rats were grafted with F and (Fischer X Lewis)F1 (FLEWF1) kidneys. Most of the F kidneys were rejected within 55 days, only 4 of 24 surviving for more than 4 months. However, two-thirds of the FLEWF1 recipients survived for more than 4 months, the others having died within 64 days. During the first postoperative week, high levels of serum lymphocytotoxic antibodies were found in recipients of F kidneys, and thereafter there was little change. In this respect these rats did not differ from recipients of kidneys with major histocompatibility differences. However, recipients of FLEWF1 kidneys had low haemagglutinating and lymphocytotoxic antibody titres. No serum-blocking factor could be found in kidney of recipients by use of the microcytotoxicity assay (MCA) or inhibition of allorosette formation. Cellular immunity, which was studied by means of the graft-versus-host reaction (GVHR) and the microcytotoxicity assay, was detected in the first postoperative week. This immunity gradually declined, and after 6 weeks it was no longer detectable. The immunological status of the long-term surviving kidney recipients remained unchanged, even when they were provided with further antigenic challenge in the form of two successive donor strain skin grafts.

New methods for determining pre-operative and postoperative skin disinfection.

A comparison was made of the Thran pressurized spray gun and scrubbing with cotton swabs on the removal of organisms from the skin. Both methods showed similar results but sometimes considerable differences in counts were found on adjacent skin areas. The cotton swab method was used to compare the effect of 60 or 70% isopropanol and 10% povidone-iodine on the flora of the outer side of the upper arm over 24 h. With the exception of one test person, no significant difference was found between the disinfectants.

[The efficacy of a combination herbal medicine in the treatment of functional dyspepsia. Meta-analysis of randomized double-blind studies on the basis of a valid gastrointestinal symptom profile]. / Wirksamkeit eines pflanzlichen Kombinationspräparats bei funktioneller Dyspepsie. Metaanalyse randomisierter Doppelblindstudien auf Basis eines validen gastrointestinalen Symptomprofils.

BACKGROUND AND AIM: Functional dyspepsia is a heterogeneous clinical entity of incompletely known etiology. Overall, four randomized double-blind studies from the nineteen-nineties investigating acute treatment of this condition with the combination herbal medicine Iberogast, are available. A meta-analysis of the studieswas carried out to evaluate the overall therapeutic effect. PATIENTS AND METHODS: In all four, triple-arm, controlled multicentre studies, the efficacy of 4 weeks of treatment with 3 x 20 drops daily, applied after a washout phase, was investigated, the primary efficacy parameter being a specific gastrointestinal symptom score. Of the 592 participants in the studies, 196 were treated with Iberogast, 131 with placebo, and 61 with cisapride as positive control. The remaining 204 patients, who were treated with an experimental herbal preparation of similar composition, were not admitted to the final analysis. RESULTS: While overall appreciable improvement of the clinically relevant symptoms of moderate severity was seen under treatment with the combination herbal preparation, the individual studies differed in terms of the statistical significance of the results obtained. The meta-analysis of studies revealed a clear therapeutic effect for the herbal medicine (p < 0.0001). CONCLUSION: The clinical experience with the combination preparation for the treatment of functional dyspepsia was confirmed by the meta-analysis of the modern double-blind studies.

[Assessment of the efficacy and safety of the phytopharmacon STW 5 versus metoclopramide in functional dyspepsia--a retrolective cohort study]. / Wirksamkeit und Unbedenklichkeit des Phytopharmakons STW 5 versus Metoclopramid bei funktioneller Dyspepsie unter Praxisbedingungen--eine retrolektive Kohortenstudie.

AIM: The objective of this study was to assess the efficacy and safety of the phytopharmacon STW 5 versus metoclopramide in functional dyspepsia. METHODS: A retrolective, epidemiological cohort study with parallel groups in 23 randomised centres where both drugs were used routinely was performed. The main outcome variable was improvement of 10 dyspepsia-specific symptoms of a valid gastrointestinal symptom score (GIS) during therapy. For inclusion, patients had to suffer from at least three of these symptoms before therapy. Secondary outcome variables were change of single symptoms, time till complete symptom relief, investigators' judgement of efficacy and tolerability, duration of inability to work and occurrence of adverse events. RESULTS: The per protocol collective comprised 490 STW 5 and 471 MCP patients. Anamnestic data were comparable. 439 of patients had taken MCP as drops. There was no relevant difference in median treatment duration. Significantly more patients were symptom-free after STW 5 treatment (71.6 vs. 62.8% p = 0,012). Additionally, the extent of symptom improvement (excluding nausea and vomiting) and median duration of inability to work (1 vs. 3 days) were significantly different in favour of STW 5. More physicians assessed STW 5 as effective (71.6 vs. 63.1% p<0.01) and very well tolerated (90 vs. 70.6% p<0.001). Adverse drug reactions were documented only under MCP. CONCLUSION: The present study illustrates a comparable to higher efficacy of STW 5 vs. MCP with better tolerability in treating functional dyspepsia under practice conditions, especially regarding complete symptom improvement, symptom duration and quality of life. The study confirms the results of prospective trials for STW 5 as being an appropriate alternative to the frequently administered antacids and prokinetics.

Phytotherapy for functional dyspepsia: a review of the clinical evidence for the herbal preparation STW 5.

Functional gastrointestinal disorders such as functional (or non-ulcer) dyspepsia are characterized by a broad spectrum of symptoms referred to the upper abdomen without a detectable cause utilizing routine diagnostic measures. It is now believed that disordered gut function (including abnormalities like disturbances of motility such as postprandial fundic relaxation, gastric emptying and disturbed visceral sensory function) play a key role for the manifestation of these disorders. The underlying pathophysiology is not yet fully understood. However, the available data suggest that a number of factors may contribute to the manifestation of symptoms. These factors include environmental factors such as acute infections as trigger event, psychological stressors that may precede acute exacerbations and a genetic predisposition. Considering the large number of mechanisms, a treatment targeting a single mechanism is unlikely to be effective in all patients. Indeed, chemically defined treatments usually gain a 10-15% superiority over placebo. In recent years placebo-controlled studies have demonstrated superiority of a commercial multicomponent herbal preparation, STW 5, with the trade name Iberogast, for the treatment of patients with functional dyspepsia and irritable bowel syndrome. This phytopharmacon is a combination of nine plant extracts each with a number of different active constituents. Pharmacological studies have shown different effects of the single plant extracts on the (molecular) mechanisms which are discussed as underlying the manifestation of symptoms. Various well-controlled clinical trials have independently confirmed clinical efficacy and safety. The clinically efficacy of this multicomponent herbal preparation questions the current trend of highly targeted drug molecules that usually target one single receptor population while it has not been shown that a single receptor group plays a pivotal role for the control of symptoms. Herbal medicines are obtained from various plants and contain complex extracts with a large number of different active substances. While there are only limited head-to-head comparisons with conventional chemically defined medications, the combination of extracts with various gastrointestinal active ingredients appears to be advantageous for a heterogeneous condition such as functional dyspepsia.

[Hand, skin and mucous membrane disinfection in medical and dental practice]. / Handreinigung, Haut- und Schleimhautdesinfektion in ärztlicher und zahnärztlicher Praxis.

Disinfection of hands, skin or mucous membranes or the mere cleansing of hands have different functions, which should be differentiated clearly. With different cleansing methods dirt will be removed, whereas disinfection methods will eliminate microbial contamination or reduce the resident skin flora. Cleansing of hands removes only a very limited amount of microorganisms and cannot replace disinfection. Skin has to be disinfected when the integrity of the body is harmed. Depending on the tasks which are to be performed, sometimes an immediate onset of action and not a long duration of effect can be desirable. In other cases it is just the prolonged action, even with slow onset, that is required. Furthermore a long-lasting effect can be useful, when recontamination takes place later on. Skin disinfectants can be applied by spraying or swabbing. There are only limited data known over disinfection of mucous membranes and till now there exist no suitable test-methods. Experimental studies have shown no really convincing results, even though sometimes a sufficient disinfection could be seen in clinical practice. This is partly due to the bacteriostatic effect. The problematical nature of recontamination of mucous membranes is naturally very serious, but the adhesion of disinfectants due to the special conditions on mucous membranes usually rather bad. Which procedures have to be applied in particular cases has to be decided after weighting the risks against each other.

[Requirements for ambulatory operations from the point of view of hygienists]. / Anforderungen bei ambulanten Operationen aus Sicht des Hygienikers.

Not least because of possible cost reduction ambulatory operations are being performed increasingly in hospitals and in accordingly equipped surgical practices. From the hygienic point of view infection control is just as important as with inpatients, i.e. requirement have to be the same in principle. This applies to constructional requirements, i.e. structure of operation areas including technical equipment and ventilation system, as well as to organizational requirements. On the other hand particularly operations in surgical practices have special features that have to be taken into account. One has to consider several factors like the lower probability of patients to be colonized by hospital specific bacteria, the as a rule relatively low number of operations and the small group of persons involved with operations, so that often staff discipline can be improved more easily than in big hospitals. Problems can arise with the supply of sterile goods, as facilities comparable to those of sterilization centers in hospitals are usually lacking. In these particular cases hygienically perfect solutions that consider all special features of a practice should be sought in cooperation with a hygienist.

[Clinical hygiene: practice vs. theory (author's transl)]. / Was ist in der Krankenhaushygiene praktikabel und was ist reine Theorie?

The purpose of clinical (hospital) hygiene is to prevent health hazards, above all hospital-acquired infections, and thereby to support the clinician. Its measures are always applicable in hospitals and clinics where clinical hygiene is considered important. Clinical hygiene procedures are not practical if the necessary though inconvenient changes in personnel practices have not been established. Personnel requirements are hard to meet in that there is still a shortage of qualified individuals, i.e., hygienists, etc. Expensive constructional changes are worthwhile only if the clinical staff is prepared to observe the hygiene measures as closely as possible.