Extrafine beclomethasone dipropionate breath-actuated inhaler (400 micrograms/day) versus budesonide dry powder inhaler (800 micrograms/day) in asthma.

Hydrofluoroalkane-134a beclomethasone dipropionate extrafine aerosol breath-actuated inhaler (Qvar Autohaler; BDP-AH) provides an alternative to chlorofluorocarbon metered dose inhalers or dry powder inhalers (DPIs). The aim of this six-week, open-label study was to determine whether BDP-AH demonstrates equivalent asthma control to twice the dose of budesonide (BUD)-DPI (Pulmicort Turbuhaler). Adults with symptomatic asthma inadequately controlled on BUD-DPI 400 micrograms/day and beta-agonist were enrolled. Patients (n = 193) were randomised to receive 400 micrograms/day BDP-AH (n = 98) (two puffs of 100 micrograms/actuation inhaler twice daily) or 800 micrograms/day BUD-DPI (n = 95) (two puffs of 200 micrograms/actuation inhaler twice daily). Both groups showed a statistically significant change from baseline in morning (a.m.) peak expiratory flow (PEF) at weeks 5-6 (p < 0.01), indicating study treatment improved a.m. PEF over prestudy 400 micrograms/day BUD. Changes from baseline in a.m. PEF at weeks 5-6 were 15.9 l/min for BDP-AH and 14.2 l/min for BUD-DPI; the groups were statistically equivalent (90% CI -7.02-10.44; p < -0.001 [equivalence = within +/- 25 l/min]). Other efficacy assessments (evening PEF, FEV1, asthma symptoms, beta-agonist use) confirmed the treatments were clinically equivalent. Thirty-nine (40%) patients on BDP-AH and 35 (37%) on BUD-DPI experienced at least one adverse event (p = 0.767). Four (4%) patients on BDP-AH and 3 (3%) on BUD-DPI reported increased asthma symptoms. BDP-AH at half the daily dose provided equivalent asthma control to BUD-DPI; both treatments were well tolerated.

Complement components C1q, C1r/C1s, and C1INH in rheumatoid arthritis. Correlation of in situ hybridization and northern blot results with function and protein concentration in synovium and primary cell cultures.

OBJECTIVE: To analyze the synovial site and the cell types expressing C1q, C1r/C1s, and C1-esterase inhibitor (C1INH) and to characterize newly synthesized C1q in patients with rheumatoid arthritis (RA). METHODS: Tissue and primary cell cultures of synovium from RA patients were analyzed for C1q, C1r/C1s, and C1INH by Northern blotting, in situ hybridization, and pulse-chase experiments for C1q. RESULTS: The de novo synthesis of C1q, C1r/C1s, and C1INH in synovium and primary cell cultures was proven by Northern blot and by antigenic and functional analysis. In in situ hybridization experiments, the synovial lining cell layer was identified as the site of C1q, C1r, and C1INH expression. In contrast, immunohistologic analysis showed that C1q, C1s, and C1INH proteins were present in a thin film covering the synovial lining cells. In situ hybridization performed on primary cell cultures provided evidence that only macrophages were able to express C1q, whereas fibroblasts and stellate cells synthesized C1r. CONCLUSION: The synovium is important for the synthesis and secretion of C1q and C1r/C1s, as well as the control protein C1INH, which supports the idea of a locally occurring inflammatory process in RA patients.

Malignant bile-duct obstruction: experience with self-expanding metal endoprostheses (Wallstents) in Austria.

Fifty-two patients in nine Austrian hospitals were treated with biliary self-expanding metal endoprostheses (Wallstents) for malignant biliary obstruction, and followed up retrospectively using questionnaires, answered by the endoscopists. Stent placement was successful in all patients. The technical failure rate at the first attempt was 7.7%, and stenting-associated mortality was 3.8% due to mispositioning of stents, leading in two cases to death. The 30-day mortality was 13.5%, and early complications occurred in 15.4%. The median survival was 216 days, and the median stent patency was 291 days. During follow-up, stent occlusion was observed in ten patients, acute cholangitis in 12 patients, acute pancreatitis in three patients, acute cholecystitis in one patient, and duodenal ulceration due to stent erosion in one patient. Routine use of biliary self-expanding metal endoprostheses by averagely experienced endoscopists can be recommended. Attention has to be paid to the correct placement of the guidewire and stent.

Prophylactic endoscopic sclerotherapy of esophageal varices in liver cirrhosis--long-term follow-up and final results of a multicenter prospective controlled randomized trial in Vienna.

This study reports the final results of a randomized multicenter trial on prophylactic endoscopic sclerotherapy of large esophageal varices in patients with liver cirrhosis. Forty-one patients received prophylactic treatment and 41 patients were in the control group. A first analysis 3 years after beginning the study revealed no significant difference in the distribution of the bleeding free intervals between both groups, but indicated a tendency towards longer survival of patients with prophylactic sclerotherapy. The follow-up of patients was continued for an additional 3 years. After this time, 53.7% of patients in the sclerotherapy group and 39.1% of patients in the control group were still alive. During the study period of 6 years, variceal bleeding was observed in 31.7% of patients in the sclerotherapy group and in 36.6% of patients in the control group. Neither survival nor incidence of bleeding were statistically different between the two groups. The etiology of cirrhosis did not influence the survival.

[Computer systems in gastroenterologic endoscopy. An analysis of current availability on the Austrian market]. / Computersysteme in der gastroenterologischen Endoskopie. Eine Analyse des derzeitigen Angebots auf dem österreichischen Markt.

Five systems for computerized documentation (ADAM-Fujinon, ENDOBASE-Olympus, MEDASYS-Pentax, MEPAS-Fritsch & Jirak, OPTAMED-Krötlinger) are compared in their different functions: configuration of system, software, communication, structure of program, user guidance, data-protection, data back-up, patient registration, preparation for examination, terminology setup, report generation, image filing, statistic, system adjustments, costs. This paper should be a help in buying a computer-aided system. All systems fulfil the three basic requirements for a computer-aided documentation in gastrointestinal endoscopy: database, image filing, report generation. Actually none of the programs can be favoured. Peculiarities, weakness and strength of the different programs are discussed. The principle of the scoring-method in choosing a system is explained.

Assessing nutritional status in elderly patients.

The physician can incorporate nutritional assessment of the elderly patient into office practice by considering two questions. First, is the patient at nutritional risk due to disease, disability or medication? Second, is the patient at risk of disease and disability because of poor nutritional status? The four primary components of the nutritional assessment are summarized by the mnemonic ABCD, with A standing for anthropometric measurements such as height and weight; B for biochemical parameters such as the serum albumin level and the hemoglobin count; C for clinical evaluation, including an assessment of functional, social and mental status, the medical history and the physical examination, and D for dietary history, such as the use supplements and the adequacy of the diet.

Dementing illness: the patient, caregiver and community.

Care of the elderly patient with dementing illness involves not only the patient but also the family and other caregivers, and the community. An evaluation and treatment plan must go beyond the patient's immediate medical problems to examine the caregiver's needs and the community services available.

Demonstration of endogenous lectins in synovial tissue.

We have recently shown that synoviocytes and extracellular matrices exhibit distinct patterns of carbohydrate expression. Their biological relevance is however not known. The purpose of the present study was to find out whether human synovial tissue would also show a specific receptor pattern for complex sugar molecules. Endogenous lectins were displayed by means of biotinylated neoglycoproteins and sulfated polysaccharides in paraffin-embedded material or cryosections. In addition to certain carbohydrate components that are known to be constituents of the carbohydrate part of cellular glycoconjugates, our panel included heparin and fucoidan, a sulfated fucose. Binding sites were shown using the avidin-peroxidase technique for light microscopy. The results were compared with immunohistochemical methods and enzyme histochemistry. Our study demonstrates that human synovial tissue contains a complex pattern of endogenous lectins depending on the different types of synovitis. The staining method we used in the investigation allows for precise localization of saccharide binding receptors and is therefore believed to be a reliable technique for further phenotypic characterization of synovial cells.

Euthanasia: a contemporary moral quandary.

KIE: Responding to an increased interest in establishing active, voluntary euthanasia as a viable medical and social policy, Reichel and Dyck consider the major arguments for and against the practice. Proponents of euthanasia support a patient's right of self determination and a compassion-motivated active ending of suffering. Opponents are concerned with the problems of determining intention and motivation, the danger of involuntary euthanasia of the aged, the handicapped, and the incompetent, and the impact on the physician patient relationship. Reichel and Dyck argue that, instead of euthanasia, physicians can offer terminally ill patients the "moral choice to die well" by alleviating pain, by respecting requests to forgo burdensome, invasive treatments, by providing comfort and support, and by communicating with patients and their families.^ieng

Biologic theories of aging.

Many theories have been proposed to explain aging. Currently, the most important theories include genetic control, deterioration of the immune system, somatic mutation, accumulated damage by free radicals, cross-linkage of macromolecules, and metabolic causes. While no single theory accounts for all of the observations about aging, recent research suggests that the primary process is under genetic control, with contributions from environmental factors.

Prophylactic endoscopic sclerotherapy of oesophageal varices in liver cirrhosis. A multicentre prospective controlled randomised trial in Vienna.

The effect of prophylactic treatment of oesophageal varices by endoscopic injection sclerotherapy before the first episode of variceal haemorrhage was studied in patients with cirrhosis in a prospective, randomised and controlled multicentre trial. From February 1984 to March 1987 patients with liver cirrhosis and large varices (stage III-IV according to Paquet) were treated and followed up. The sample comprised 87 patients: 45 in the prophylactic treatment and 42 in the control group. After excluding drop outs, 41 patients were treated in each group. Twenty nine per cent of patients in the sclerotherapy group and 34% in the control group had a variceal haemorrhage during the period of observation. There was no significant difference in the distributions of the bleeding free intervals between the sclerotherapy and the control groups. During the follow up period 24% of patients in the sclerotherapy group and 46% in the control group died. The distribution of survival times indicates a tendency towards longer survival of patients with prophylactic sclerotherapy, particularly in those with alcoholic cirrhosis.

Combined therapy with cisapride and cimetidine in severe reflux oesophagitis: a double blind controlled trial.

Combined treatment with cimetidine 1 g daily and cisapride 40 mg daily in patients with endoscopically diagnosed severe reflux oesophagitis was compared with single drug therapy (cimetidine and placebo). At the end of the six to 12 weeks treatment, 11 (46%) of the 24 patients under single drug therapy were endoscopically healed and three were improved. In contrast, 16 (70%) of the 23 patients under combined therapy were healed and all of the remainder were improved (p = 0.025). The severity of diurnal and nocturnal heartburn, decreased significantly more (p less than 0.05) on cimetidine + cisapride than on cimetidine + placebo. The combined treatment was well tolerated. These results suggest that combined therapy with cisapride and cimetidine may be useful in patients with severe reflux oesophagitis.

Improving the quality of life in nursing homes.

Physicians can help improve the quality of life for persons residing in long-term care facilities. Physician visits offer opportunities to share knowledge and skills with the staff, to influence nursing home policies and procedures, and to serve as advocates for residents and their families. The physician can ensure good medical care and can encourage practices that enable residents to use their remaining capacities and have maximum autonomy over their own lives.

[Treatment of duodenal ulcer with famotidine]. / Therapie des Ulcus duodeni mit Famotidin.

In a prospective double blind study the efficacy and safety of the new H2-receptor antagonist famotidine was compared with ranitidine. 48 patients with endoscopically proven duodenal ulcer were randomly allocated to receive famotidine 40 mg once at night, 20 mg bid, 40 mg bid or ranitidine 150 mg bid. After 4 weeks of treatment the ulcers of 7/12, 10/12, 9/12 and 6/12 patients were healed; the corresponding rates after 8 weeks were 9/12, 12/12, 11/12 and 10/12. Statistically there was no significant difference between the various groups. Adverse events of any clinical importance were not observed. These data indicate, that famotidine is as effective and as safe as ranitidine for the treatment of acute duodenal ulcer.

Effects of low and high dose oral cimetidine on hormone serum levels in patients with peptic ulcers.

Luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (hPRL) and testosterone (T) were assayed in a total of 131 patients with peptic ulcer. Initial oral treatment was performed with 1000 mg cimetidine per day for 6 to 12 weeks. After healing was confirmed endoscopically, the patients were switched to a maintenance dose of 400 mg per day cimetidine for 3 years. Serum hormone levels before and during the two regimens were estimated in 48 male, 22 postmenopausal and 5 premenopausal subjects. Comparison between the two cimetidine doses was possible in 76 male, 44 postmenopausal and 6 premenopausal patients. In all patients hormone parameters assayed before therapy were within the normal ranges. FSH was noted to increase significantly in all but the premenopausal group but remained within the normal range. In contrast, hPRL declined significantly in all groups of subjects except for premenopausal females during cimetidine treatment. LH and T did not change during treatment and no differences of hormone serum levels were noted between the two regimens. Present data combine to suggest that an initial treatment with 1000 mg of cimetidine per day did not provoke hyperprolactinemia, and a switch from an initial high dose to a maintenance dose of 400 mg per day did not cause further changes in hormone serum levels. Changes of LH, FSH, hPRL and T recorded in the present study are too small to be considered responsible for possible endocrine disorders observed during cimetidine therapy.