Cerebral hemodynamics in symptomatic and asymptomatic patients with severe unilateral carotid stenosis before and after carotid endarterectomy.

BACKGROUND: Data concerning hemodynamic status prior to and after carotid endarterectomy (CEA) in symptomatic and asymptomatic patients is insufficient. Transcranial Doppler (TCD) provides information regarding compensatory collateral flow as well as mechanisms of cerebral autoregulation in patients with carotid stenosis. PATIENTS AND METHODS: Forty eight symptomatic and 81 asymptomatic patients with unilateral severe carotid stenosis were examined by TCD before and in early postoperative period after CEA. RESULTS: Cigarette smoking was the only risk factor significantly more frequent in symptomatic patients. Preoperative anterior cerebral artery (ACA) and middle cerebral artery (MCA) asymmetry, basilar artery velocity and number of ophthalmic arteries with reversed flow, were not significantly different between the two groups. Pulsatility index, cerebrovascular reactivity and flow acceleration on the side of stenosis were significantly lower in symptomatic patients. After surgery there was a significant improvement of all TCD parameters in symptomatic as well as asymptomatic patients. CONCLUSIONS: The exhausted ability of cerebral autoregulation is an important factor differentiating between symptomatic and asymptomatic patients with severe carotid stenosis. Successful surgery provides good recovery of cerebral hemodynamics in both symptomatic and asymptomatic patients.

[Viscosupplementation in arthrosis]. / Viskosupplementation bei Arthrose.

Target of this paper is to focus on the current knowledge about viscosupplementation in the management of osteoarthritis. The molecular structure and the effects of hyaluronic acid derivates on mechanical, biochemical and cellular level are described. Since the exogenously introduced hyaluronic acid derivates stay on average only 10 to 20 hour in the synovial fluid and yet its effect continues over months, an additional effect is postulated: modulation of the activity of the different cells in the development and progression of the osteoarthritis (synoviocytes, chondrocytes, inflammatory cells), probably by direct effect on their specific receptors. These receptors play an important role in the migration, adhesion and activation of inflammatory cells, as well as maturation and differentiation of the chondrocytes for synthesizing the cartilage matrix. In experimental studies in vitro and in vivo an analgetic and anti-inflammatory effect of hyaluronic acid derivates was proven. These results were confirmed in clinical studies. An amelioration of symptoms was shown and a delay of disease progression seems possible. This therapy is well tolerated and complications are few. Further studies to determine the optimal dosage and product (low or high-molecular preparation), the possible combination with other therapies in ideal sequence and the effect in the different subtypes of population are needed.

Determination of future health status expectation in rheumatoid arthritis.

While examining the relationship between, neuroticism, somatic factors and future health status expectation in rheumatoid arthritis (RA) patients, the present study found a considerable level of pessimism in patients, which may be related to perceived limitation of the quality of life. However, psychosocial disposition (i.e., neuroticism) did not prove to be a crucial factor by which RA patients assessed their future health status expectation. These results may be important in future treatment procedures.

Relationship between self-rated functional status and psychosocial stress in patients suffering from rheumatoid arthritis.

BACKGROUND: To assess relationship between psychosocial factors and self-rated functioning in rheumatoid arthritis (RA). METHODS: In 66 RA patients (mean age +/- SD = 50.8 +/- 12.6 years, women 49 (74%), illness duration mean +/- SD = 13.4 +/- 10.5 years) aspects of developmental psychosocial stress thought to influence human behavior were assessed in an in depth interview using structured biographical history. Furthermore evaluation included Trait anxiety, global functional status according to the ACR criteria, radiological staging of illness and patients' self-ratings of functioning obtained by the Health Assessment Questionnaire (HAQ). Bivariate correlations were performed using psychosocial and somatic factors and self-rated functional status. RESULTS: Scores of developmental psychosocial stress significantly correlated with interviewers scoring of nurture (r = -0.722, p < 0.001) indicating good internal consistency of interview data. Significant correlations were found between patients' scoring of functional status (HAQ) and (i) ACR criteria (r = 0.490, p < 0.0001) and (ii) score of Trait anxiety (r = 0.367, p < 0.003). There was no significant correlation between developmental psychosocial stress and HAQ score. CONCLUSION: Developmental psychosocial stress does not significantly contribute as to how RA patients perceive their functional ability. In a proportion of RA patients self-rated functional status may depend on the patients disposition (e.g. neuroticism) probably promoting impaired illness behavior (e.g. regressive tendencies) which should be considered in assessing treatment procedures.

Experience of pain in rheumatoid arthritis--an empirical evaluation of the contribution of developmental psychosocial stress.

Using a structured biographical history we evaluated the relationship between aspects of development and reports of pain experience (i.e. intensity of pain, affective and affective-evaluative dimensions of pain according to the McGill pain questionnaire, and effectiveness of medication) in 66 patients with rheumatoid arthritis. It was postulated that higher loading with regard to developmental stress would have a negative influence on reports of pain experience. Multiple regression analysis showed that (i) the intensity of pain was significantly correlated with the functional stage of the illness, (ii) affective and affective-evaluative dimensions of pain experience correlated with the interviewer's scoring of nurture and the patient's relationship with his or her partner, and (iii) the effectiveness of medication was significantly associated with the partner's understanding of the patient's pain and duration of illness. However, independent variables could explain only part of the variance (i.e. 12% for pain intensity, 17% for affective and affective-evaluative dimensions of pain experience and 26% for the effectiveness of medication). These results suggest that the previously assumed importance of developmental psychosocial stress as a factor in chronic intractable pain may require careful reassessment.

Ibuprofen and diclofenac sodium in the treatment of osteoarthritis: a comparative trial of two once-daily sustained-release NSAID formulations.

An investigator-blind, parallel-group, multicentre study was undertaken to compare the efficacy and tolerability of once-daily, sustained-release (s-r) ibuprofen and diclofenac sodium in patients (mean age 59.8 years) suffering from painful osteoarthritis affecting chiefly the knee and/or hip. Patients attending eight Swiss centres received either two s-r tablets of ibuprofen (daily dose 1600 mg; n = 30) or a single s-r diclofenac 100 mg tablet (n = 31) each evening for 21 days. Clinical assessments were performed prior to initiating therapy and after 7 and 21 days of treatment. Both treatments were efficacious, but statistically significant differences in favour of s-r ibuprofen were observed for the principal measure of efficacy, the investigator's assessment of the overall change in clinical condition; by Day 21, 37% of ibuprofen-treated patients vs 10% of diclofenac-treated patients were 'much improved' (p = 0.04). Patients' assessments of the efficacy of their treatment also favoured s-r ibuprofen at Day 7 for the relief of night pain (p = 0.048), at Day 21 for alleviation of day pain (p = 0.006) and for the ability to carry out normal activities (p = 0.01), and at both Days 7 and 21 for quality of sleep (p = 0.04 and 0.03, respectively). The patients' overall opinion of treatment was also significantly in favour of s-r ibuprofen, which was rated 'good or excellent' by 80% (24/30), compared with only 38% of patients (11/29) receiving s-r diclofenac sodium (p = 0.002). Two patients (6%) receiving s-r diclofenac sodium ceased treatment owing to dizziness and severe diarrhoea, respectively; there were no withdrawals in the ibuprofen-treated group. Ten (32%) patients in the s-r diclofenac group reported a total of 12 adverse events (mostly gastrointestinal in nature), compared with three (10%) patients in the s-r ibuprofen group who reported only three events (abdominal pain, insomnia and constipation). In conclusion, although both NSAID treatments improved the clinical condition of patients with painful osteoarthritis, statistically significant differences in favour of once-daily s-r ibuprofen (1600 mg) were demonstrated in terms of efficacy, indicating a potential therapeutic advantage for this formulation. Ibuprofen was also better tolerated than diclofenac sodium (100 mg/day), the latter being associated with gastrointestinal side effects in a significant proportion of patients. Sustained-release ibuprofen (Brufen Retard) thus represents an important addition to the available therapeutic armamentarium of once-daily NSAID formulations.

[Arthritis in adolescence]. / Die Arthritis bei Adoleszenten.

Joint problems in adolescence are often monoarticular. In the acute form the differentiation between trauma and infection is of utmost importance, whereas in chronic joint diseases the differentiation will be mainly between mechanical disorders and true rheumatic diseases. In pauci- or polyarticular arthritis of short duration viral infections have to be considered, since true rheumatic diseases tend to run a more chronic course. In girls true sero-positive juvenile rheumatoid arthritis typically appears in this age group. In adolescent boys seronegative Spondylarthropathies involving the lower extremities and not uncommonly with enthesopathies may occur. The typical involvement of the sacro-iliac-joint usually starts after the age of 18 years. Bacterial arthritides are predominantly monoarticular and are caused in more than 50% by staphylococci.

[Double-blind randomized multicenter study with tenoxicam, piroxicam and diclofenac sodium retard in the treatment of ambulatory patients with arthroses and soft tissue rheumatism]. / Doppeltblinde randomisierte Multizenterstudie mit Tenoxicam, Piroxicam und Diclofenac-Natrium retard in der Behandlung von ambulanten Patienten mit Arthrosen und Weichteilrheumatismus.

In a randomized, double-blind comparative study involving a total of 1630 outpatients, tenoxicam, a new nonsteroidal anti-inflammatory drug belonging to the oxicam group, piroxicam and diclofenac retard were tested for their efficacy und tolerability in the treatment of osteoarthritis and extra-articular rheumatism. Single doses of 20 mg tenoxicam, 20 mg piroxicam or 100 mg diclofenac sodium retard were administered daily. Tenoxicam was found to be as effective as piroxicam and diclofenac-sodium retard in treating degenerative and extra-articular rheumatic disorders of the musculoskeletal system. When baseline values were compared with values obtained at all subsequent examinations, all evaluation parameters for all three substances showed improvement. In analyses of frequency, degree of severity and type of undesired effects tenoxicam proved to be superior to the reference drugs. This was particularly evident from an improved GI and CNS tolerance and a lower rate of withdrawal from treatment. Tenoxicam has a favourable risk-benefit ratio and can be recommended for the treatment of chronic pain due to inflammation resulting from degenerative and extra-articular rheumatic disorders of the musculoskeletal system.

A double-blind randomised multicentre study with tenoxicam, piroxicam and diclofenac sodium retard in the treatment of ambulant patients with osteoarthritis and extra-articular rheumatism.

In a randomised, double-blind comparative study involving a total of 1,630 out-patients, tenoxicam (a new non-steroidal anti-inflammatory drug belonging to the oxicam group), piroxicam and diclofenac retard were tested for their efficacy and tolerability in the treatment of osteoarthritis (OA) and extra-articular rheumatism (EAR). Single doses of 20 mg tenoxicam, 20 mg piroxicam or 100 mg diclofenac sodium retard were administered daily. Tenoxicam was found to be as effective as piroxicam and diclofenac sodium retard in the treatment of degenerative and extra-articular rheumatic disorders of the musculo-skeletal system. When baseline values were compared with values obtained at all subsequent examinations, all evaluation parameters for all three substances showed improvement. In analyses of the frequency, degree of severity and type of undesired effects, tenoxicam proved to be superior to the reference drugs. This was particularly evident from an improved gastrointestinal and central nervous system (CNS) tolerance and a lower rate of withdrawal from treatment. Tenoxicam has a favourable risk/benefit ratio and can be recommended for the treatment of chronic pain due to inflammation resulting from degenerative and extra-articular rheumatic disorders of the musculoskeletal system.

A lumbar hernia presenting as an obstructing lesion of the colon.

A patient with a lumbar hernia of Petit, presenting as an obstructing lesion of the ascending colon and concomitant acute cholecystitis is described. The anatomy, cause, and surgical treatment of lumbar hernia are reviewed.

Delayed pneumoperitoneum following traumatic haemopneumothorax. A case report.

An unusual case of delayed pneumoperitoneum following a penetrating wound of the chest is presented. The mechanism of pneumoperitoneum, the diagnostic dilemma of injury to the abdomen in penetrating wounds of the lower chest, and the alternative methods used in achieving early diagnosis of diaphragmatic penetration are discussed.

[C-reactive protein: should it be determined in inflammatory rheumatic diseases?]. / Das C-reaktive Protein. Soll man es bei entzündlichen rheumatischen Krankheiten bestimmen?

The structure, synthesis and possible functions of C-reactive protein (CRP) are discussed. CRP is a highly sensitive but non-specific indicator of tissue damage, but its diagnostic value in inflammatory rheumatic diseases is very limited. In SLE, a high level may suggest additional bacterial infection. While semiquantitative methods are of little help, the quantitative measurement of CRP can be used as both a clinical and a therapeutic parameter in patients in whom ESR does not parallel the inflammatory activity of the disease. Apart from these exceptions, CRP does not appear to offer major advantages over ESR in the day-to-day management of patients with inflammatory rheumatic diseases.

Muscle biopsy in polymyositis and dermatomyositis: a clinicopathological study.

The initial muscle biopsies of 30 patients with active polymyositis or dermatomyositis have been assessed histologically and morphometrically. Only 1 patient (3.3%) had a normal biopsy, while 3 had a normal electromyograph and 8 had a normal serum CPK level. No significant morphological differences were found between the various diagnostic subgroups. Sequential biopsies of 11 of these patients treated either with corticosteroids only or with intensive immunosuppression were studied. With response to treatment atrophy factors, variability coefficients, internal nuclei count, and the various histological changes improved in the whole group of patients. However, there was no consistent correlation between any of the morphological features or between these and clinical parameters in individual patients. The percentage of fibres with internal nuclei in the initial biopsy was lower (P < 0.001) in patients responding to up to 60 mg prednisolone per day than in those who eventually required cytotoxic drugs in addition.

[Increased renal prostaglandin E2 secretion in Bartter's syndrome]. / Erhöhte renale Prostaglandin-E2-Sekretion bei Bartter-Syndrom.

In a 52-year-old patient with Bartter's syndrome, peripheral venous prostaglandin E2 (PGE2) and plasma renin activity (PRA) levels were markedly elevated and plasma aldosterone concentration (pa) was at the upper limit of normal, though inappropriately high relative to the decreased plasma and whole body potassium levels. Blood pressure, plasma volume, exchangeable body sodium, plasma cortisol and urinary catecholamines were normal. Renal venous PGE2 was two to three times higher than peripheral PGE2. Indomethacin (300 mg/day) decreased peripheral PGE2 by 50%, PRA by 84% and PA by 72%, induced a positive potassium balance (greater than 350 mEq) with normal plasma potassium levels, and returned the previously marked resistance to the pressor effect of angiotensin II to normal. During the entire study, highly significant correlations (p less than 0.001) between peripheral PGE2 and PRA (r = 0.86) or PA (r = 0.90) were found. In this patient the hyperreninemia was not related to volume depletion. These data indicate that in Bartter's syndrome renal PGE2 secretion may be increased, systemic blood levels of PGE2 may be elevated and closely related to PRA, and indomethacin ameliorates these abnormalities and improves potassium balance. These results are consistent with the ascription of an important role to excessive renal PGE2 secretion in the pathogenesis of Bartter's syndrome.