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--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.

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.).

Measurement of the exclusive 3He(e,e'p) reaction below the quasielastic peak.

New, high-precision measurements of the 3He(e,e(')p) reaction using the A1 Collaboration spectrometers at the Mainz microtron MAMI are presented. These were performed in antiparallel kinematics at energy transfers below the quasielastic peak, and at a central momentum transfer of 685 MeV/c. Cross sections and distorted momentum distributions were extracted and compared to theoretical predictions and existing data. The longitudinal and transverse behavior of the cross section was also studied. Sizable differences in the cross-section behavior from theoretical predictions based on the plane wave impulse approximation were observed in both the two- and three-body breakup channels. Full Faddeev-type calculations account for some of the observed excess cross-section, but significant differences remain.

Measurement of the beam-helicity asymmetry in the p((-->)e,e'p)pi(0) reaction at the energy of the Delta(1232) resonance.

In a p((-->)e,e'p)pi(0) out-of-plane coincidence experiment at the three-spectrometer setup of the Mainz Microtron MAMI, the beam-helicity asymmetry has been precisely measured around the energy of the Delta(1232) resonance and Q(2) = 0.2(GeV/c)(2). The results are in disagreement with three up-to-date model calculations. This is interpreted as a lack of understanding of the nonresonant background, which in dynamical models is related to the pion cloud.

Neutral pion threshold production at Q(2) = 0.05 GeV(2)/c(2) and chiral perturbation theory.

New data are presented on the p(e,e'p)pi(0) reaction at threshold at a four-momentum transfer of Q(2) = 0.05 GeV(2)/c(2). The data were taken with the three-spectrometer setup of the A1 Collaboration at the Mainz Microtron MAMI. The complete center of mass solid angle was covered up to a center of mass energy of 4 MeV above threshold. Combined with measurements at three different values of the virtual photon polarization epsilon, the structure functions sigma(T), sigma(L), sigma(TT), and sigma(TL) are determined. The results are compared with calculations in heavy baryon chiral perturbation theory and with a phenomenological model. The measured cross section is significantly smaller than both predictions.

Measurement of the recoil polarization in the p(e-->, e'p-->)pi(0) reaction at the Delta(1232) resonance.

The recoil proton polarization has been measured in the p(e-->,e'p-->)pi(0) reaction in parallel kinematics around W = 1232 MeV, Q2 = 0.121 (GeV/c)2, and epsilon = 0.718 using the polarized cw electron beam of the Mainz Microtron. All three proton polarization components, Px/P(e) = (-11.4+/-1.3+/-1.4)%, P(y) = (-43.1+/-1.3+/-2.2)%, and P(z)/P(e) = (56.2+/-1.5+/-2.6)%, could be measured simultaneously. The Coulomb quadrupole to magnetic dipole ratio, CMR = (-6.4+/-0.7(stat)+/-0.8(syst))%, was determined from Px in the framework of the Mainz Unitary Isobar Model. The consistency among the reduced polarizations and the extraction of the ratio of longitudinal-to-transverse response is discussed.

Participation and interactions of neutrophil elastase in haemostatic disorders of patients with severe infections.

The prognosis of septicaemia depends on the occurrence of complications such as shock and coagulation defects. The damage to haemostasis is usually explained by the action of the main coagulation and fibrinolysis enzymes, thrombin and plasmin. This paper presents data concerning the role of a third protease, granulocytic elastase. 82 patients who had been admitted to our hospital with suspected septicaemia were examined. Septicaemia was proven in 22 patients by the growth of microorganisms in blood cultures, and was clinically diagnosed in 9 patients. The plasma levels of neutrophil elastase-like protease complexed to a1antitrypsin (a1AT-ELP) were measured by zone immunoelectrophoresis assay (ZIA). The a1AT-ELP values were significantly increased in the 31 septic as compared to the 51 non-septic patients. In patients with complicated septicaemia, negative correlations of a1AT-ELP with factor XIII and the coagulation inhibitor antithrombin III were demonstrable. Among the patients with septic complications, the 3 who survived exhibited a dramatic decrease of a1AT-ELP, whereas in the other 16 patients who died the levels remained elevated. It might be of therapeutic significance that in 9 patients receiving fresh plasma and AT III-concentrate substitution for DIC the a1AT-ELP levels dropped, whereas they remained high in the other septicaemia patients. There were no correlations between a1AT-ELP and the a2antiplasmin-plasmin complexes (a2AP-P1), but strong correlations with signs of coagulation. The data suggest an interaction of coagulation and elastase release, probably involving the Hageman factor.

Lipoprotein fractions, lipoprotein lipase and hepatic triglyceride lipase during short-term and long-term uptake of ethanol in healthy subjects.

In short-term experiments, healthy fasting persons were given a basic dose of 0.5 g of ethanol/kg body weight, followed by hourly maintenance doses of 0.15 g of ethanol/kg body weight. After 10 h there was a significant increase of triglycerides in the VLDL, LDL, and HDL, the main rise (from 42 to 92 mg/dl) being found in the VLDL triglycerides. Other subjects, who received nourishment isocaloric with ethanol, likewise showed a significant rise of triglycerides in all lipoprotein fractions. Chylomicron triglycerides increased from 9.3 to 35.5 mg/dl. There was no significant change in postheparin HTGL, but postheparin LPL activity decreased after 10 h from 17.9 to 12.2 mmol FFA/ml/h in the fasting subjects, and from 28.5 to 10.2 mmol/FFA/ml/h in the persons receiving food. In long-term experiments after 4 weeks of 70 - 80 g of ethanol and isocaloric food daily, triglycerides increased, especially in the VLDL (from 50 to 82 mg/dl). The increase in the HDL, however, was also significant. After 4 weeks of ethanol, the chylomicron triglycerides in the plasma of the fasting subjects reached a value of 29.3 mg/100 ml, LDL cholesterol decreased, and HDL cholesterol increased. After 4 weeks of ethanol there was an increase in the lipoprotein lipase of the adipose tissue.

[3 multicenter phase II studies of the treatment of small cell bronchogenic carcinoma (incl. AIO studies BI + BII)]. / Drei multizentrische Phase-II-Studien in der Behandlung des kleinzelligen Bronchialkarzinoms (incl. AIO-Studien BI + BII).

Between March 1979 und January 1983 122 patients with small-cell carcinoma of the lung were treated with different polychemotherapy regimen. 33 patients received VP-16-213 (etoposid), ifosfamide and vindesine (VPIV). 37 patients were treated with adriamycin, cisplatin and vincristine (APO). A third 3-drug combination, cyclophosphamide, methotrexate and CCNU (CMCC), was given to the remaining 52 patients alternating with the two other regimen. Response rates varied between 61% for the APO regimen and 85% for the VPIV regimen. The median survival was 10 months for patients treated with VPIV or APO and 12 months for patients treated with alternating drug combinations. This difference was not statistically significant. The rate of long-term survivors (longer than 2 years after diagnosis) was 9.9%. Side effects were seen more frequently in the group treated with APO.