[Stress-related alteration of urine compositions: idiopathic CaOx stone formers, patients with chronic inflammatory bowel disease (CIBD) and healthy controls]. / Stressbedingte Alteration der Harnzusammensetzungen : Untersuchung von idiopathischen CaOx-Steinbildnern, Patienten mit chronisch entzündlicher Darmerkrankung und gesunden Probanden.

BACKGROUND: Increased emotional stress in everyday life influences the way of living and metabolism of people living in developed countries. Contemporaneously, the incidence and prevalence of urolithiasis rises. Does a pathogenetically relevant relationship exist between chronic stress burden and permanently altered urinary composition? PATIENTS AND METHODS: The influence of chronic stress burden on urine composition and risk of urinary calcium oxalate (CaOx) stone formation was, for the first time, comprehensively investigated in 29 healthy controls (CG), 29 idiopathic CaOx stone formers (SF) and 28 patients suffering from chronic inflammatory bowel disease (CIBD). After 4 days with standardized nutrition, 24-h urine was collected. Extensive urinalysis was performed and APCaOx index calculated. Evaluation of subjective stress level was carried out by using the standardized and well-established questionnaire Trierer Inventar zur Beurteilung von chronischem Stress (TICS). The concentration values of the urinary parameters as well as the APCaOx values were linearly correlated with the stress scores obtained from the different items of the TICS. A significance level p≤0.05 was considered to indicate statistical significance. RESULTS: The mean APCaOx indices amounted to 0.8±0.3 in CG, 1.2±0.7 in SF and 1.9±1.2 in CIBD. The increased APCaOx in SF mainly results from relatively increased Ca and oxalate excretions, whereas in CIBD this also results from reduced urinary excretions of citrate and Mg as well as reduced 24-h urinary volumes. The calculation of linear correlation coefficients between a TICS stress dimension and a concentration value of a urinary parameter or APCaOx results in r values not exceeding 0.600. However, some of these correlations are statistically highly significant. In SF only one combination with Ca was observed, while in CIBD in contrast a number of combinations, in particular including Na, was obtained. In CG direct statistical relationships between stress burden and citrate as well as Mg exist. In this group, increased stress burden is associated with increased inhibitory potential to prevent CaOx stone formation. CONCLUSION: In the investigated study groups, differently complex relationships between amount of stress burden and risk of CaOx stone formation were observed, however, without obvious physicochemical principle(s). In some individuals, stress can be associated with a significantly stress-related alteration of urinary composition towards increased CaOx stone formation risk. The results obtained from the CIBD group allow for the first time a conclusive link between emotional stress and inflammatory activity on the one hand and inflammatory activity and metabolic risk constellation of CaOx stone formation on the other hand.

[Influence of acupuncture on postoperative pain, nausea and vomiting after visceral surgery : a prospective, randomized comparative study of metamizole and standard treatment]. / Einfluss von Akupunktur auf postoperative Schmerzen, Ubelkeit und Erbrechen nach viszeralen Eingriffen : Eine prospektive, randomisierte Vergleichsstudie mit Metamizol und Standardbehandlung.

BACKGROUND: The objective of this study was to assess repeated needle acupuncture in the treatment of postoperative pain and nausea after visceral surgery. MATERIAL AND METHODS: Sixty-six patients undergoing visceral surgery (hysterectomy, cholecystectomy) were randomly assigned to group A (three sessions of needle acupuncture, n=21), group M (3x1000 mg metamizole, n=20), or group K (control, n=25). All patients received patient-controlled analgesia (PCA) using piritramide. To adjust for nonspecific effects due to physician-patient interaction during acupuncture sessions in group A, patients in groups M and K also received three standardized visits. Primary outcome parameters were defined as pain intensity, analgesic consumption, and frequency of nausea and vomiting in a period up to the morning of the second postoperative day. RESULTS: Patients in group A reported significant less pain, nausea, and vomiting compared to patients in group K. Mean cumulative piritramide consumption was significantly lower in group A (25.0 mg) than in group M (34.5 mg) and group K (55.2 mg). CONCLUSION: Repeated needle acupuncture may be effective in postoperative pain relief and the treatment of nausea and vomiting in the postoperative period. These effects seem not to be due solely to interaction between the acupuncturist and the patient.

[Physiotherapeutic and rehabilitation therapy for ankylosing spondylitis. Status quo and are they still necessary in the age of anti-cytokine therapy?]. / Physikalisch-therapeutische und rehabilitative Massnahmen bei der ankylosierenden Spondylitis. Status quo und was spricht im Zeitalter der Anti-Zytokin-Therapie noch dafür?

Ankylosing spondylitis (AS) is one of the most common chronic inflammatory rheumatic diseases characterized by erosions and bone proliferation with consecutive morphologic and functional deficits. Physiotherapeutic and rehabilitation measures are often necessary for AS patients for their whole life. In recent years, biologicals have substantially improved the outcome in AS patients, but their positive influence on vertebral and joint functions still requires differential indicative physiotherapeutic strategies and rehabilitation, in most cases in combination with effective analgesic and anti-inflammatory medication. Although physical therapy and rehabilitation have not been investigated in large controlled trials, they are essential for the multimodal therapeutic concept of AS.

[Physiotherapy strategies in osteoporosis--recommendations for daily practice]. / Differenzialindikative physikalische Therapiestrategien der Osteoporose--Empfehlungen für den Praxisalltag.

Physiotherapy in osteoporosis essentially takes the form of stimulatory therapy tailored to the findings and the pathomechanism. The choice of therapy and its dosage depend on the desired result (prevention, cure, rehabilitation). Physical therapy applied in osteoporosis includes electrical, thermic (hydrothermic, high frequency thermic, light thermic) and mechanical (massage, physiotherapy) stimuli, which can be applied regionally, locally or hoistically. To be efficient, a pain therapy requires that the various painful states be differentiated between: whereas, for example, in the case of acute pain physiotherapy fulfils the function of immediate therapy (normally rest and "mild" cold applications), in chronic pain it has to fulfil the function of an adaptive performance therapy of neuronal structures (formative-adaptive physiotherapy, thermic therapy improving trophism, direct current, transcutaneous electric nerve stimulation/TENS). It is necessary and extremely important forday-to-day clinical practice that physiotherapy strategies that are tailored to each patient's needs and also economically justifiable be implemented. The article isintended to contribute to this.

Exercises and physiotherapeutic strategies for preventing and treating osteoporosis.

For the treatment of osteoporosis, appropiate physiotherapy needs to use the given or remaining abilities of a patient to modulate and optimize the biological functions and structures (bone, muscle) in an adaptive, stimulating and regenerating sense. In addition physiotherapy can set serial physical stimuli to minimize pain perception by bio-psychosocial effects. Physiotherapy for osteoporosis has to be seen equivalent to pharmacotherapy with respect to prevention, cure and rehabilitation. In general, 2 different aims for effective treatment can be defined: 1. Aims that can be achieved solely with physical therapy, such as structural improvement of the existing and pharmacologically increased bone mass, slowdown of round-back formation and fall prophylaxis. 2. Aims that can be mainly achieved with physiotherapy and pharmacotherapy, such as increase of bone density and differentiated amelioration of pain. This article summarises the current knowledge on exercise and physiotherapy in preventing and treating osteoporosis, and focuses specifically on the diagnostic-orientated stimulating preventative, curative and/or rehabilitative effects, in which the choice of the individual regimen and the dosage need to be optimized for every patient individually.

Current knowledge about physiotherapeutic strategies in osteoporosis prevention and treatment.

In treating patients with osteoporosis, one option in physiotherapy is to comply with given physical norms by using physical stimuli to influence biological functions and structures (bone, muscle) for adaptation, stimulation, and regeneration. Serial physical stimuli can also be used for interventions and actions to minimise pain perception by means of biopsychosocial influence. In osteoporosis, physiotherapy has to be rated on a par with pharmacotherapy with respect to prevention, cure, and rehabilitation. Generally, two different aims can be defined: (1) those which can be achieved with physical therapy alone, such as structural improvement of the existing and pharmacologically increased bone tissue, slowing down of round-back formation, and fall prophylaxis and (2) those which can be achieved with physiotherapy and pharmacotherapy, such as effective pain relief and increased bone density. Regulation and normalisation of physical capacities with an aim towards maintenance and economisation of functions and improvement in abilities call for a skillful and case-specific use of physiotherapy.

Acquired nevoid telangiectasia.

BACKGROUND: Acquired nevoid telangiectasia (ANT) is a segmental dilatation of papillary plexus vessels. OBJECTIVE: In the present study, the frequency of ANT and its associations with collagen vascular and spinal disease have been investigated. METHODS: 188 unselected patients, seen at an interdisciplinary dermatorheumatologic outpatient clinic, were clinically examined for the presence of ANT and possible associations to preexisting disease. RESULTS: ANT was seen in 17% of patients, all females. The mean age of ANT patients was 57.5 +/- 8.2 years. Most common diseases were lupus erythematosus and scleroderma. Twenty-four of them suffered from generalized fibromyalgia, 8 had spondylitis deformans, 1 suffered from thoracal syringomyelia and 1 had a spine trauma. Two types of ANT have been seen: the cervicothoracal transition type and the lumbosacral transition type. CONCLUSIONS: ANT is not uncommon among patients attending a dermatorheumatologic outpatient clinic. ANT indicates spinal or neuromuscular complaints, but is not related to collagen vascular disease itself.

[Effects of Kneippism, a standardized complex therapy, on pain, quality of life and use of medicines: cohort study with a one-year follow-up]. / Auswirkungen der Kneipp-Kur, einer standardisierten Komplextherapie, auf schmerz, Lebensqualität und medikamentenverbrauch: kohortenstudie mit 1-jahres-follow-up.

BACKGROUND: Inpatient as well as outpatient cure in a spa environment with commonly 3- to 4-week duration features a combination of different treatments customized according to the needs of the individual patient. The physiological rationale and the mode of action are widely accepted. However, firm quantitative evidence of the clinical effectiveness is incomplete. OBJECTIVE: To document the effects of a well standardized complex therapeutic regimen (Kneippism) on pain, quality of life, and drug consumption during therapy and with 1-year follow up. STUDY DESIGN: Prospective cohort study with assessments at the beginning, during, and at the end of treatment and with follow-up investigations 3, 6, and 12 months thereafter. SETTING: Four spa clinics in Bad Wörishofen, Southern Bavaria. PATIENTS: 363 patients (248 outpatients, mean duration of therapy 23.3 days, and 115 inpatients, mean duration of therapy 27.4 days), one half between 40 and 60 years old above 60 years of age, predominantly suffering from musculoskeletal and/or cardiovascular diseases. INTERVENTION: Custom-tailored combination of therapies comprising of hydro-, kinesi-, and phytotherapy, dietetics, 'ordnungstherapie', and continued disease-specific standard treatment, if necessary. MAIN OUTCOME MEASURE: Pain, patients' self-rating, (IRES questionnaire), medication. RESULTS: The monitored dimensions of pain improved significantly during treatment and remained at that level essentially for the complete follow up interval. The same was true for various dimensions of reported subjective complaints as well as for drug consumption. CONCLUSION: When estimating the clinical relevance of a complex therapeutic regimen such as a cure of 3- to 4-week duration, the question of the impact of the specific effect of single components is secondary to the question of the overall relevance of that therapeutic concept. The findings of this study point at potential long-term effects of at least 1-year duration.

[Progressive systemic sclerosis - treatment results of extracorporeal photopheresis]. / Progressive systemische Sklerodermie. Behandlungsergebnisse unter extrakorporale Photopherese.

The treatment of progressive systemic sclerosis (PSS) is still unsatisfactory. We report on clinical, laboratory and immunological findings in 26 patients with PSS (6 males, 20 women) treated with extracorporeal photopheresis (ECP) for 8 cycles in a nonrandomized, uncontrolled study. ECP was performed on two consecutive days once a month. 8-methoxypsoralen concentrations in plasma and buffy coat were monitored by HPLC. We performed a standardized examination programme and determined parameters of inflammation and immune function. Global assessment revealed a partial remission in 18 patients, a stable disease in 8 patients and a slight progression in one patient. In the peripheral blood count a significant increase of CD3-positive NK cells was noted (p=0.03) although the leukocyte count decreased from 2,255 to 1,156 cells/microl. There was a non-significant decrease of elastase (102. 9 vs. 90.4 ng/ml), sulfidoleukotriens (2,255.4 vs. 1,688.9 pg/ml), ICAM-1 (301.9 vs. 276.6 ng/ml), soluble IL-2 receptor (609.0 vs. 422. 3 U/ml), and IL-10 (164.7 vs. 138.7 pg/ml). IL-6 and IL-8 did not show significant changes. The ECP treatment of patients with PSS shows immunomodulatory effects changing levels of pro-inflammatory and cytokine substances. Even after 8 cycles partial remission or stable disease is seen in patients as shown by global assessment and certain clinical symptoms. On the other hand, sufficient data on the long-term outcome are still missing.

[Nail changes in rheumatic disease]. / Nagelveränderungen bei rheumatischen Erkrankungen.

Clinically the nail organ ist easy to investigate. When estimating dermato-rheumatological diseases, knowledge of important associated nail symptoms is extremely helpful. In some diseases like osteoarthropathia psoriatica and special variants, Reiter's syndrome and connective tissue disease, typical or even characteristic symptoms can be found. In other disorders like rheumatoid arthritis, goal and systemic vasculitis, associated nail disorders are not uncommon, but of less diagnostic specificity. We review data from the literature and from our dermato-rheumatological outpatient clinic.

Lupus erythematosus-associated red lunula.

BACKGROUND: Red lunulae have only rarely been described in patients with lupus erythematosus. OBJECTIVE: We assessed the frequency and classified the type of red lunulae in patients with definite lupus erythematosus seen in an interdisciplinary dermatorheumatologic outpatient clinic. METHODS: We studied 56 patients with either systemic or cutaneous lupus erythematosus for the presence of red lunulae. RESULTS: Eleven of 56 patients (19.6%) with lupus erythematosus had red lunulae. All of them showed a complete type of red lunulae, which was seen on all finger nails in 10 patients and on a single finger nail in 1 patient. Seven patients suffered from systemic lupus, the other from subacute cutaneous (n = 2) or chronic discoid cutaneous lupus (n = 2). There was no statistically significant difference in autoantibody expression or treatment regimen between patients with or without red lunulae. However, symptomatic patients had a shorter disease interval, and all but 1 showed either periungual erythema or chilblain lupus. Periungual erythema was not observed in any patient without red lunulae. CONCLUSION: Red lunulae, although rarely described in the literature, are not an uncommon symptom of patients with lupus erythematosus. They seem to be associated with periungual erythema or chilblain lupus. Red lunulae should be considered in the clinical spectrum of lupus disease.

Fibromyalgia in lupus erythematosus.

Fibromyalgia has been reported to occur with high prevalence in systemic lupus erythematosus. Data on fibromyalgia in other subsets of lupus erythematosus are not available. Risk factors for fibromyalgia have not been defined. We investigated 60 patients with different subsets of lupus erythematosus for the presence of fibromyalgia, association with clinical and laboratory parameters and disease activity. Our data were compared with the multicentre lupus erythematosus registry at the Free University of Berlin. Ten out of 60 patients with more than 11 tender points and widespread pain for more than 3 months were classified as positive for fibromyalgia. All of them were female. Fibromyalgia-positive patients suffered significantly more often from headache, morning stiffness, diffuse alopecia, muscle pain, arthralgia, renal involvement, and disclosed peripheral blood cell cytopenia, rheumatoid factor, hypergammaglobulinaemia and intake of corticosteroids and azathioprine. Fibromyalgia was more frequent in systemic lupus than in other lupus subsets. Evaluation of fibromyalgia symptoms and lupus disease activity was performed in 30 patients in a 1-year (range 9-13 months) follow-up. These 30 patients consisted of 9 fibromyalgia-positive and 21 fibromyalgia-negative patients. Both groups were characterized by stable clinical features such as number of tender points and ECLAM index. Fibromyalgia did not show a correlation with lupus activity. We suggest that fibromyalgia and lupus erythematosus are distinct complaints. Patients with lupus are at risk of developing secondary fibromyalgia. The clinical features of fibromyalgia-positive patients may contribute to misinterpretation of lupus activity.

In vitro investigations of drug release and penetration--enhancing effect of ultrasound on transmembrane transport of flufenamic acid.

Percutaneous absorption studies are performed in various in vitro models to determine the rate of drug absorption via the skin. We designed an phonophoretic drug delivery system to investigate the influence of ultrasound on transmembrane transport of different drugs. Phonophoresis is defined as the migration of drug molecules, contained in a contact agent, through the skin under the influence of ultrasound. We investigated the absorption of flufenamic acid in a buffer medium in dependence of ultrasound energy and application time. For evaluating membrane penetration of flufenamic acid, the concentration range of buffer solution was measured. Flufenamic acid was determined by using a fluorimetric method. Ultrasound energy was supplied for between 5 and 30 min at a range of intensities (0; 0.3; 0.6; 0.9; 1.2; 1.5 W/cm2). energy levels commonly used for therapeutic purpose. The pronounced effect of ultrasound on the transmembrane absorption of the drug was observed at all ultrasound energy level studied. The time of application was found to play an important role in delivery and transport of drug. Dependent on time, we observed an arise of temperature up to 4.5 degrees. It appears that there was no difference between an intensity of 0.3 and 1.5 W/cm2 and the measured drug concentrations in solution. The highest penetration was observed at an intensity of 1.0 W/cm2 after 30 min. These results were not significantly different from concentration in measurements after 30 min and 0.5 and 1.5 W/cm2. It seems that the arise of drug concentration is caused by effects of temperature and by variation of membrane delivery in dependence of temperature.

[Therapy of hyperhidrosis with tap water iontophoresis. Positive effect on healing time and lack of recurrence in hand-foot eczema]. / Therapie der Hyperhidrosis mittels Leitungswasseriontophorese. Positive Effekte auf Abheilungszeit und Rezidivfreiheit bei Hand-Fuss-Ekzemen.

Hyperhidrosis is due to an overfunction of eccrine glands (triggered by the autonomous nervous system) and may be a cofactor for palmoplantar eczema (dermatitis). Tapwater iontophoresis was used in 54 patients with hyperhidrosis manuum et pedum. After 10 applications directed by the dermatologist, 89% of patients noted an improvement in their hyperhidrosis. 20 patients suffering from palmoplantar eczema (dermatitis) who continued the treatment at home for at least 6 months were compared with a historical sex- and age-matched group of 20 eczema-patients without iontophoresis: The factors evaluated were the time needed for clearing and the relapse-free interval. Though iontophoresis-treated patients had a slightly faster clearing, this was statistically not significant (20 vs. 22.3 days; p > 0.05). However, the difference for relapse-free interval between the two groups was statistically highly significant (24.8 weeks vs. 8.35 weeks; p < 0.0001). Tapwater iontophoresis seems to be effective not only to control sweating. According to recently published data, galvanization seems to have a capsaicin-like effect as well. Our hypothesis is therefore, that galvanization with tapwater iontophoresis interrupts the neurogenic inflammation and prolongs the relapse-free interval in hyperhidrotic palmoplantar eczema (dermatitis).

In vitro investigations of drug release and penetration--enhancing effect of ultrasound on transmembrane transport of flufenamic acid.

Although topical drugs are usually applied at a convenient site, the target for the drug interaction may be systemic. Phonophoresis is the use of ultrasound to enhance the delivery of topical applied drugs. The purposes of our study were to investigate the in vitro penetration and the in vivo transport of flufenamic acid in dependence of ultrasound. Percutaneous absorption studies are performed in various in vitro models to determine the rate of drug absorption via the skin. We designed a phonophoretic drug delivery system to investigate the influence of ultrasound on transmembrane transport of different drugs. We investigated the absorption of flufenamic acid in a buffer medium in dependence of ultrasound energy and application time. For evaluating membrane penetration of flufenamic acid, the concentration range of buffer solution was measured. Ultrasound energy was supplied for between 5 and 30 min at a range of intensities up to 1.5 W/cm2, energy levels commonly used for therapeutic purpose. The pronounced effect of ultrasound on the transmembrane absorption of the drug was observed at all ultrasound energy levels studied. The time of application was found to play an important role in delivery and transport of drug. Dependent on time, we observed a rise of temperature up to 4.5 degrees C. It appears that there was no difference between an intensity of 0.3 and 1.5 W/cm2 and the measured drug concentrations in solution. The highest penetration was observed at an intensity of 1.0 W/cm2 after 30 min. These results were not significantly different from concentration measurements after 30 min and 0.5 and 1.5 W/cm2. It seems that the arise of drug concentration is caused by effects of temperature and by variation of membrane delivery in dependence of temperature. Using this in vitro model we note it is possible to compare the transdermal penetration and absorption of commercial flufenamic ointment in volunteers.

[Enthesopathies--diagnosis and therapy]. / Enthesiopathien--Diagnostick und Therapie.

Problems are frequently encountered regarding the terminology, diagnosis, differential diagnosis, and therapy of diseases of thes tendons insertion point (enthesis): Terms such as tendinosis, tenopathy, tendinitis, tendovaginitis, tendoperiostitis, insertions tenopathy, tendomyosis, etc. often are used interchangeably even through they describe anatomically and pathophysiologically different conditions. The term enthesiopathy is used as a generic term in this overview article irrespective of the causality.

Comparative assessment of pelvic floor function using vaginal cones, vaginal digital palpation and vaginal pressure measurements.

A group-comparative study to assess pelvic floor muscle function using vaginal cones, vaginal digital palpation, and vaginal pressure measurements in 30 women suffering from genuine stress urinary incontinence and in an age-matched group of continent women was undertaken. Vaginal digital palpation score and vaginal pressure during active contraction were greater (p < 0.001) in continent women (1.9 +/- 0.1 and 8.6 +/- 0.7 cm H2O, respectively) as compared with incontinent women (1.0 +/- 0.1 and 4.1 +/- 0.4 cm H2O, respectively). Continent women were able to retain a vaginal cone of greater weight (6.3 +/- 0.4; n = 9, weight ranging from 10 to 90 g) than women suffering from stress incontinence (4.7 +/- 0.5; p < 0.001). There was a better correlation between all three techniques of assessing pelvic floor function in continent as compared with incontinent women, especially in the comparisons involving vaginal cones. (Vaginal pressure measurement-vaginal digital palpation, r = 0.86/0.75; vaginal pressure measurement-vaginal cones. r = 0.57/0.10; vaginal digital palpation-vaginal cones, r = 0.60/0.18.) In some women, especially those with incontinence, heavy cones were retained in spite of a weak pelvic floor due to the transverse position of the cone in the vagina which was verified radiographically.