Occupational therapy for elderly. Evidence mapping of randomised controlled trials from 2004-2012.

OBJECTIVE: Previous systematic reviews on occupational therapy for elderly included studies until 2003. The present evidence mapping summarizes recent evidence for the efficacy of occupational therapy with older persons based on randomised controlled trials from 2004-2012. METHOD: An electronic search in Cochrane and Medline databases identified publications of randomised controlled trials on occupational therapy interventions for persons≥65 years old. Two raters independently extracted data and analysed the quality of samples, interventions and outcome evalutations according to PRISMA criteria. RESULTS: In all, 136 abstracts were identified and 48 studies analysed, from these 12 on stroke, 15 on falls and mobility, 7 on dementia, 4 on prevention and 10 on other conditions. Reports of adverse events and evaluations of costs and long-term outcomes are frequently lacking. CONCLUSION: The most promising fields for further research are primary and secondary prevention in persons with stroke, falls or mobility problems and tertiary prevention in persons with dementia. Future trials should be conducted and reported according to consented reporting guidelines of the equator network.

[CT-guided electrode placement for sacral nerve stimulation in the treatment of faecal incontinence (cSNS)]. / CT-gesteuerte Elektrodenplatzierung zur Sakralnervenstimulation bei Stuhlinkontinenz (cSNS).

BACKGROUND: The sacral nerve stimulation (SNS) can be performed in the screening phase under local anaesthesia. Implantation of the tined-lead electrodes is usually performed in an inpatient setting under general anaesthesia. An outpatient procedure for both PNE and implantation of the electrodes offers decisive advantages with respect to the accuracy of electrode placement. MATERIALS AND METHODS: From 2006 to 2011 a total of 51 patients was treated with SNS in an outpatient setting. RESULTS: Of 51 patients having the PNE, in four patients the procedure could not successfully be completed. In 39 of the 47 patients screened, the testing was positive. Eight times the screening was negative. The functional results show a significant decline in the Cleveland scores from 14.9 to 6.4. The manometric resting pressure improved from 23.4 mmHg to 43.81 mmHg, the squeezing pressure improved from 42.2 mmHg to 76.12 mmHg. Due to patients' perception and according to the response on the stimulus, the electrodes were placed on the left in S4 11 times, 23 times in the left S3, 3 times in the right S3, once in the left S2 and once in the right S2. CONCLUSION: CT-guided electrode placement is safe for temporary (subchronic) and permanent (chronic) sacral nerve stimulation and provides a valuable means for placement of the stimulating material.

Cooperate concept of metastasis: site-specific requirement of activated differentiation and dynamic deterioration.

Cancer metastasis results from positive and negative cellular events such as constitutive activation of oncogenes (cOA) or genetic losses (GL) being modulated by downstream signals of epithelial-mesenchymal or mesenchymal-epithelial transition, thus constituting master programs of metastatic phenotype and site specificity. To address the complex nature of these programs, we introduced clinical and phenotypic markers like tumor size, grade, cellular shape, or expression of E-cadherin in 27 colon cancer (CC) patients (cOA and GL), and 41 patients with gastrointestinal stromal tumors (GIST, cOA) to produce scores of cOA and GL. Scores of cOA were highest in case of hepatic and lower in case of an isolated peritoneal spread (GIST), or (CC) of both, cOA and GL, highest in case of a combined hepatic and peritoneal spread and lower in case of an isolated peritoneal spread; but in case of an isolated hepatic spread, scores of cOA were high and low of GL. This indicates a differential contribution of cellular dissociation and recognition in site-specific metastasis, of cOA predominantly in production of hepatic and in the case of GL of serosal spread.

[Sacral nerve stimulation (SNS) in the treatment of faecal incontinence]. / Die sakrale Nervenstimulation im Behandlungskonzept der Stuhlinkontinenz.

Sacral nerve stimulation (SNS, sacral neuromodulation) has become an important tool in the treatment of incontinence. Idiopathic, muscular as well as neurogenous disorders can be treated successfully with this method. Possible complications like infections, cable breaks and electrode displacements may be treated very well conservatively. However, in some patients a surgical revision or removal of the stimulation system may be necessary.

[Treating vaginismus in Turkish women]. / Vaginismusbehandlung bei türkischen Frauen.

OBJECTIVES: Vaginismus is a sexual dysfunction involving various branches of medicine, including psychiatry and gynaecology. Psychiatric help is sought in only a small proportion of cases, although it is probable that the psychopathological aetiology is more frequent than generally recognized. This article deals with the causes and psychological circumstances in four Turkish couples who presented with unconsummated marriage for 3 to 7 years. Vaginismus F52.5 to the ICD-10 is a sexual dysfunction characterised as: deep anxiety about coitus leading to extreme spasm of musculature making coitus impossible or extremely unpleasant and painful. PATIENTS AND METHODS: Four Turkish couples with unconsummated marriage due to the female partners' penetration phobia were included to this study. A patient-oriented multidimensional individual treatment (combination therapy) is a cost effective, short-term (typically 10- to 12-week) treatment model for both partners. It includes some elements of cognitive behavioural therapy and systemic partner therapy which were considered not radically different from previous therapeutic strategies. RESULTS: Results were successful in all cases; the couples were extremely satisfied with having a normal sex life for the first time. This led to desired pregnancies and avoiding of possible breakdown of their families. DISCUSSION: The couples did well with combination behavioural therapy. This methodology is discussed in its various aspects and with a cultural background. We also emphasise the need for physicians to be mindful of cases of vaginismus requiring psychiatric intervention rather than gynaecological treatment.

Unmet needs in the diagnosis and treatment of dyslipidemia in the primary care setting in Germany.

OBJECTIVES AND METHODS: DETECT is a cross-sectional study of 55,518 unselected consecutive patients in 3188 representative primary care offices in Germany. In a random subset of 7519 patients, an extensive standardized laboratory program was undertaken. The study investigated the prevalence of cardiovascular disease, known risk factors (such as diabetes, hypertension and dyslipidemia and their co-morbid manifestation), as well as treatment patterns. The present analysis of the DETECT laboratory dataset focused on the prevalence and treatment of dyslipidemia in primary medical care in Germany. Coronary artery disease (CAD), risk categories and LDL-C target achievement rates were determined in the subset of 6815 patients according to the National Cholesterol Education Program (NCEP) ATP III Guidelines. RESULTS: Of all patients, 54.3% had dyslipidemia. Only 54.4% of the NCEP-classified dyslipidemic patients were diagnosed as 'dyslipidemic' by their physicians. Only 27% of all dyslipidemic patients (and 40.7% of the recognized dyslipidemic patients) were treated with lipid-lowering medications, and 11.1% of all dyslipidemic patients (41.4% of the patients treated with lipid-lowering drugs) achieved their LDL-C treatment goals. In conclusion, 80.3% of patients in the sample with dyslipidemia went undiagnosed, un-treated or under-treated.

Cardiovascular risk factors in primary care: methods and baseline prevalence rates--the DETECT program.

OBJECTIVES: DETECT is an epidemiological study in primary care to examine (a) the prevalence rates and comorbidity of diabetes mellitus, hypertension, hyperlipidaemia and coronary heart disease (CHD), and associated conditions; (b) the frequency of behavioural and clinical risk factors for onset and progression; (c) the 12-month course and outcome; and (d) the met and unmet needs for these patients. METHODS: Three-stage, cross-sectional clinical-epidemiological study with a prospective-longitudinal component in a nationally representative sample of N = 3795 primary care settings [response rate (RR): 60.2%] and N = 55518 patients (RR: 95.5%). Patients completed a standardized assessment, including questionnaires for patients and the physician and diagnostic screening measures (i.e. blood pressure, heart rate, body mass index and waist circumference assessments). A subsample of patients (N = 7519) also completed a standardized laboratory screening program and was followed-up after 12 months. Data were weighted to adjust for non-response, regional distribution and attrition. RESULTS: (1) Doctors and patients sample can be regarded as representative for primary care settings in Germany. (2) The clinician-rated point prevalence of hypertension is highest (35.5%), followed by hyperlipidaemia (29.1%), diabetes (14.1%) and CHD (12.1%); prevalence rates of each disorder as well as their co-incidence rates increase markedly with age. (3) The vast majority (78%) of all patients revealed multiple (3+) behavioural and clinical risk factors. CONCLUSION: The findings of DETECT underline the considerable burden for primary care doctors in managing a highly morbid patient population, with predominantly complex risk factor constellations, in routine care. Our data provide, in unprecedented detail, a basis for calculating age-, gender- and risk-group-adjusted risk-factor profiles in routine care.

Development of angina pectoris pain and cardiac events in asymptomatic patients with myocardial ischemia.

A total of 389 patients with angiographically determined coronary artery disease, who exhibited a complete absence of angina pectoris in the presence of reproducible myocardial ischemia, were studied in a follow-up investigation. After an initial coronary angiogram, anti-ischemic medication was prescribed as treatment. After a mean follow-up time of 4.9 years (maximum 13.4 years) patients were sent a questionnaire that assessed any new development of angina pectoris pain and cardiac events. In 48 of these patients a second angiogram was recorded after a mean period of 4.2 years. Asymptomatic patients had a worse prognosis than an age-adjusted normal population. After 5 and 10 years, 9 and 26% of the patients, respectively, had died, nonfatal cardiac events (myocardial infarction, bypass surgery or percutaneous transluminal coronary angioplasty) occurred after 5 and 10 years in 19 and 46%, respectively. A large number of initially asymptomatic patients developed angina pectoris pain over the follow-up period (34% after 5 years, 58% after 10 years). Novel angina pectoris pain often preceded cardiac events by months to years. Multivariate analysis indicated that vessel disease (p = 0.0001) and degree of ischemia (defined by ST-segment depression free exercise tolerance, p = 0.04) proved to have independent predictive value with respect to mortality rate. Newly developed angina pectoris was associated with an increase in objective signs of myocardial ischemia and a progression in coronary stenosis. The results indicate that patients who originally had myocardial ischemia with a marked absence of pain can develop angina pectoris over the course of years and that newly developed pain often precedes cardiac events.

Short-term hemodynamic, anti-ischemic, and antianginal effects of pirsidomine, a new sydnonimine.

Pirsidomine is a new sydnonimine compound in clinical development. As a prodrug, it is transformed into a nitric oxide-releasing metabolite in vivo. In animal tests there were no signs of tolerance with repeated administration. The short-term effects of 10, 20, and 40 mg of the drug on pulmonary hemodynamics and ischemic parameters were examined at rest and during exercise in a double-blind, randomized, placebo-controlled study. The study included 48 patients with documented coronary artery disease and exercise-induced ST-segment depression. Compared with the baseline test, there was a reduction of diastolic pulmonary artery pressure with pirsidomine at rest (placebo: -0.4 +/- 0.5 mm Hg; 10 mg: - 1.5 +/- 2.4 mm Hg; 20 mg: - 1.4 +/- 1.1 mm Hg; 40 mg: - 2.3 +/- 1.3 mm Hg [p < 0.05 ]) and at the highest comparable workload (placebo: -2.8 +/- 1.9 mm Hg; 10 mg: -7.3 +/- 6.8 mm Hg; 20 mg: -8.4 +/- 7.9 mm Hg [p <0.05]; 40 mg: -13.8 +/- 7.1 mm Hg [p <0.05]). ST-segment depression decreased at the highest comparable workload (placebo: -0.33 +/- 0.49 mm; 10 mg: -1.33 +/- 1.37 mm [p <0.05]; 20 mg: -1.33 +/- 0.83 mm [p <0.05]; 40 mg: -1.96 +/- 0.86 mm [p <0.05]) and total exercise time increased (placebo: 15 +/- 48 s; 10 mg: 98 +/- 126 s; 20 mg: 165 +/- 251 s [p <0.05]; 40 mg: 155 +/- 174 s [p <0.05]). Of 40 patients who complained of angina pectoris symptoms in the baseline test, 15 became free of angina pectoris with pirsidomine. Compared with placebo, blood pressure, heart rate during exercise, and cardiac output during exercise showed no significant change. Plasma concentration response relations of the metabolite revealed concentrations that caused a half-maximum effect of 6 ng/ml, 13 ng/ml, 20 ng/ml, and 28 ng/ml in reduction of ST-segment depression, reduction of diastolic pulmonary artery pressure, relief of angina pectoris symptoms, and an increase in exercise duration, respectively. Thus, pirsidomine is an effective anti-ischemic and antianginal agent. A significant preload reduction was obtained with plasma metabolite concentrations lower than those necessary to achieve a satisfactory antianginal effect.

In vitro enzymatic methylation of DNA modified with the mutagenic amine: 3-N,N-acetoxyacetylamino-4,6-dimethyldipyrido(1,2-a:3'2'-d )imidazole.

Both the initial velocity and the overall methylation of DNA modified by acetylamino-4,6-dimethyldipyrido(1,2-a:3',2'-d)imidazole (A-Glu-P-3) by rat liver DNA-(cytosine-5-)-methyltransferase are decreased as compared to native DNA. A-Glu-P-3 bound to guanine residues may block the movement of the enzyme along the helix. The modified DNA does not inhibit the enzymatic methylation of native DNA. The enzyme has a lower affinity for the modified DNA than for native DNA. The hypomethylation caused by this carcinogen could have a significance in gene activity, cellular differentiation and cancer induction.

Complete remission of Crohn's disease after high-dose cyclophosphamide and autologous stem cell transplantation.

In a 36-year-old male with ileocolic Crohn's disease (CD) no long-lasting remission was obtained by treatment with corticosteroids, mesalazine, azathioprine and antibiotics. Surgical interventions due to relapsing fistulae and abscesses resulted in the removal of >1.5 m of small bowel and left only 40 cm of large bowel. In July 2000, a new fistula and abscess developed. The combination of corticosteroids, mesalazine, ciprofloxacin, metronidazol, azathioprine, formula diet and anti-TNF-alpha antibody largely reduced clinical activity, and resection of fistula and abscess were successful. Despite clinical remission, histology showed activity in the small bowel and the colon. In March 2001, stem cell mobilization chemotherapy with cyclophosphamide was performed. It induced an endoscopic remission for 9 months, which was maintained on azathioprine and corticosteroids. After relapse, in March 2002, high-dose chemotherapy with cyclophosphamide and reinfusion of T-cell-depleted autologous peripheral CD34+ blood stem cells were performed. This led to a complete clinical, endoscopical and histological remission for 9 months without any treatment. Thereafter, endoscopy showed initial aphthous lesions with minimal histological signs of inflammation. The patient is asymptomatic, but low-dose prednisolone and methotrexate are prophylactically given. Immunoablative chemotherapy followed by autologous peripheral blood stem cell transplantation may be a beneficial therapeutic option in complicated refractory CD.

Rationale and design of a trial improving outcome of type 2 diabetics on hemodialysis. Die Deutsche Diabetes Dialyse Studie Investigators.

BACKGROUND: Non-insulin-dependent diabetes mellitus dialysis patients have the highest cardiovascular mortality known in any group of patients. Mixed dyslipidemia with moderately elevated low-density lipoprotein (LDL) cholesterol and high levels of triglyceride-rich lipoproteins is common in this condition. It is not known, however, whether patients with type 2 diabetes on dialysis with this form of dyslipidemia derive benefit from lipid-lowering therapy. Recently, drugs have become available that potently lower triglyceride-rich, apoB-containing lipoproteins and thus permit testing of this issue. This is the first trial to address specifically the issue of whether the excessive cardiovascular mortality of patients with type 2 diabetes on dialysis can be lowered by statins. METHODS: The Die Deutsche Diabetes Dialyse Studie is a prospective randomized placebo-controlled trial that tests the hypothesis that atorvastatin, a hydroxymethyl-glutaryl coenzyme A reductase inhibitor, decreases the rate of cardiovascular mortality and of nonfatal myocardial infarction in patients with type 2 diabetes who have been on hemodialysis treatment for no more than two years. The primary endpoint, cardiovascular mortality, includes fatal myocardial infarction, sudden death, death during coronary intervention, death from heart failure, and other coronary causes. Secondary endpoints comprise overall mortality, nonfatal cardiovascular events, fatal and nonfatal cerebrovascular disease, and the mean percentage change in lipid profile from baseline. The trial enrolls 1200 men and women on hemodialysis for less than two years and with type 2 diabetes at 150 centers throughout Germany. Inclusion criteria are age of 18 to 80 years, low-density cholesterol of 80 to 190 mg/dl (2.1 to 4.9 mmol/liter), and triglyceride levels of less than 1000 mg/dl (11.4 mmol/liter). Patients are randomized to cither inactive (placebo) or active (atorvastatin, 20 mg/day) drug therapy. The average duration of follow-up is more than 2.5 years. To protect against a lower than expected rate of events, the trial will be continued until a predetermined fixed number of endpoints occurs in the entire cohort so that the predefined power of the trial will be guaranteed. CONCLUSIONS: This trial was designed to demonstrate that lipid lowering with atorvastatin will improve life expectancy and quality of life in type 2 diabetics on hemodialysis. The resolution of this question is important because the genesis of vascular lesions in this condition is multifactorial and the precise role of dyslipidemia has not been defined.

Diabetes and cardiovascular risk evaluation and management in primary care: progress and unresolved issues - rationale for a nationwide primary care project in Germany.

This review highlights established and more recently recognized risk factors for coronary heart disease (CHD) relevant for patients seen in primary care, emphasizing the key role of diabetes mellitus type 2. Recent trends in risk factor research as well as current methods of risk stratification, and new systemic markers are discussed. Beyond the need for more forceful public health strategies to improve early recognition and intervention, the necessity of an integrated comprehensive investigation of the overall characteristics of cardiovascular disease, especially in primary care patients as a prerequisite for future concerted actions is pointed out. Based on this, a large-scale epidemiological investigation focusing on CHD and diabetes in the primary care sector is suggested.

Monitoring of the inflammatory response in early peritonitis.

The inflammatory response which is similar in all forms of peritonitis was recorded by determining the levels of parameters shown to represent the activation state of plasmatic and cellular systems as well as the inhibitory capacity of the plasma. In a selected series of patients with different underlying diseases, blood sampling was started at the time of admission when the clinical finding of an acute abdomen led to emergency laparotomy. Depending upon the duration of the illness and the severity of the peritonitis, a significant increase in fibrinopeptide A and of C3a could be detected within a few hours, which was followed by an increase in the elastase alpha-1-proteinase inhibitor complex. Differences due to variable cause could not be found. There was a striking correlation between the preoperative values of these three parameters and the postoperative course of the patients. Additionally, there was a significant enhancement of an endothelial proliferation-inhibiting capacity in the serums of the lethal group, whereas endotoxin could only be detected in trace amounts in four patients with intraabdominal infection in the preoperative period.

Determination of the anti-ischemic activity of nebivolol in comparison with atenolol.

The anti-ischemic effect of 5 mg nebivolol o.i.d., a newly developed beta 1-selective adrenoceptor blocking drug with vasodilating properties, was compared with that of atenolol (100 mg o.i.d.) following a treatment period of 6 days. The study was performed in 24 patients with documented coronary artery disease and stable angina pectoris according to a double-blind randomized study, designed using conventional symptom-limited exercise testing. Exercise testing 3 h after the first dose showed a more marked ST-segment reduction by atenolol than by nebivolol (59% vs. 18%). ST-segment depression measured 24 h after administration of the penultimate dose was statistically significantly reduced by nebivolol (from 0.19 +/- 0.07 to 0.13 +/- 0.07 mV; P = 0.0059) but not by atenolol (from 0.17 +/- 0.06 to 0.14 +/- 0.10 mV; P = 0.0703). Approximately 3 h after the last dose, the reduction was comparable (45% and 38% by nebivolol and atenolol, respectively). Exercise duration, exercise time necessary to produce ST-segment depression by 0.1 mV and exercise time to the onset of angina were also prolonged following administration of both drugs. Thus, at steady-state single daily doses of 100 mg atenolol and 5 mg nebivolol were about equieffective when measured at time of maximal effect (i.e. 3 h after drug administration). However, duration of action with respect to the ST-segment depression seems to be slightly longer for nebivolol.

Effect of dipyridoimidazole pretreatment on mutagen activation in rats.

Rats were pretreated with a single oral dose of different mutagenic fractions obtained from glutamic acid pyrolysate: Glu-P-2 (2-amino-dipyrido[1,2-a:3',2'-d]imidazole), Glu-P-3 (3-amino-4,6-dimethyldipyrido[1,2-a:3',2'-d]imidazole), the tar residue and a basic extract (B2). The liver S9 fractions of these animals were used to investigate the mutagenic activation of 3 promutagens (2-aminoanthracene, Glu-P-2 and Glu-P-3) in Salmonella typhimurium strain TA1538. Different factors were analyzed; influence of the structure of the compounds administered, doses, time interval between pretreatment and sacrifice and sex of the rats. Interpretation of the hepatic induction effects was complicated, however, by the fact that simple oral pretreatment with the solvents (DMSO or ethanol) enhances the activation of the substrates tested for mutagenicity. A dose-effect relationship was found between 2-AA mutagenic activation and Glu-P-2 pretreatment. Glu-P-3 induced the activation of 2-AA more than did Glu-P-2, in the male as in the female. The mutagenicity of 2-AA activated with S9 from male rats was found to be optimal after 24 h pretreatment with 20 mg Glu-P-2/kg b.w. The mutagenicity of Glu-P-2 was poorly influenced by the different pretreatments applied to either the males or the females, whereas some dose effect was found in the autoinduction of Glu-P-2 mutagenicity. Compared to Glu-P-2, the mutagenicity of Glu-P-3 was increased at higher levels when tested with S9 from males pretreated with the same compound, but no differences were observed between males and females.

Mutagenicity of some derivatives of dipyrido[1,2-a:3',2'-d]imidazoles in Salmonella typhimurium with metabolic activation by rat liver and small intestine subcellular fractions.

The mutagenic effect of 2-amino-dipyrido[1,2-a:3',2'-d]imidazole (Glu-P-2) was compared with that of the 3-amino, 3-nitro, or 3-N-hydroxylated derivatives of the same base ring with methyl groups at positions 4 and 6 of the molecule. The compounds were tested in Salmonella typhimurium strain TA98 without metabolic activation and in the presence of different concentrations of subcellular fractions from livers or small intestines of rats pretreated with different P448/P450 inducers. The 4,6-dimethyl compounds are always more mutagenic than Glu-P-2. Pretreatment with Aroclor 1254 (ARO) is the most effective inducer in the activation of the 2- and 3-amino compounds by liver S9, whereas the same fraction decreases the mutagenicity of the 3-nitro derivative. S9 from small intestine increased the mutagenic effect of the 3-nitro and 3-N-hydroxylated compounds, but it was unable to activate the amino compounds.

Mutagenicity of several derivatives of dipyrido[1,2-a:2',3'-d]imidazoles.

Different derivatives of dipyrido[1,2-a:2',3'-d]imidazoles have been investigated, as mutagens for Salmonella typhimurium. The nature of different substitution groups and their positions on the base ring influenced markedly the mutagenicity of these compounds. From this structure/effect relationship study, it was demonstrated that the 2 and 3 positions were of special interest. The 3-N-hydroxylated compound was the most active mutagen tested. We also observed that the frequently found frameshift mutagens were responsible for base-pair substitution. Metabolic activation by liver S9 mix increased the reversion rates of the strains tested. The SCE assays correlated poorly with the Salmonella/microsome mutagenicity test.

The use of atorvastatin treatment in usual care environments: pooled analysis of six prospective, observational studies in 90,535 patients.

OBJECTIVE: We investigated the pattern of use as well as the efficacy and safety of atorvastatin in unselected inpatients and outpatients in routine clinical practice in Germany. DESIGN: Six prospective, observational studies with a similar design were pooled. The studies lasted for up to 12 weeks and data from 90,535 patients (7,287 inpatients, 83,248 outpatients) were collected. The studies were performed in Germany in 2000 and 2001. Hospital or office-based physicians selected hyperlipemic patients with or without coronary heart disease (CHD) for once daily treatment with atorvastatin. Information on demographics, atorvastatin dosage, concomitant medication, concomitant diseases, cardiovascular risk factors, lipid profile as well as adverse events (AEs) and serious adverse events (SAEs) were obtained at 2-3 visits and descriptively analyzed. MAIN OUTCOME MEASURES: Absolute and relative changes in lipid parameters, percentage of patients with low-density lipoprotein cholesterol (LDL-C) values within target ranges according to the National Cholesterol Education Program (NCEP) criteria, and frequencies of AEs. RESULTS: On average, patients were treated for 22.4 days (inpatients) and 106.0 days (outpatients), respectively. The overall mean atorvastatin dose of 14.4 mg/day was well tolerated by a heterogeneous patient population with a variety of concomitant diseases and medications. Overall, 0.8% of patients suffered from one or more AEs, 0.6% were considered as treatment-related. The corresponding figures for SAEs and treatment-related SAEs were 0.1% (131 patients) and 0.01% (13 patients), respectively. Subgroup analyses did not reveal a particular safety concern in any subgroup. In total, 99% of patients judged the tolerability of atorvastatin as very good or good. The mean percentages of reduction in LDL-C at the final visit ranged between 24.8% and 28.5%. Overall, 26.3% of patients reached the NCEP LDL-C goal compared to 4.9% at baseline. Inpatients achieved the target range for LDL-C more frequently than outpatients (35.3% vs 25.6%). An underuse of atorvastatin titration in clinical practice in Germany was apparent, particularly in outpatients. CONCLUSIONS: The use of atorvastatin in usual care environments is effective and safe. There is a gap between treatment guidelines and clinical practice in Germany as reflected by the number of patients outside the target range for LDL-C. A major opportunity exists to increase the number of patients who achieve LDL-C target ranges by appropriate dose titration and/or giving patients a higher initial dose. Available guidelines need to be implemented more stringently.

[Diagnostic value of computed tomography in stomach cancer]. / Diagnostischer Wert der Computertomographie beim Magenkarzinom.

60 patients with gastric cancer were checked by computed tomography; 57 underwent surgery. Small tumors could not be demonstrated reliably. Double contrast studies and gastroscopy remain the leading diagnostic procedures. In advanced cases computed tomography informs the surgeon about extragastric tumor expansion and the existence and location of metastatic disease. Nearly all carcinomas with a diameter of more than 2 cm in computed tomography proved to be stage T4 (UICC). In selected cases diagnostic laparotomy could be avoided. Because of the lack of therapeutic alternatives the influence of computed tomography on the regimen is limited. Therefore CT-studies are not absolutely necessary in gastric cancer, but can be very helpful in selected cases.