[Symptomatic therapies in palliative medicine]. / Symptomatische Therapien in der Palliativmedizin.

Palliative Care is an approach that improves quality of life of patients in complex situations with life-threatening illness. The relief of suffering is important. In this meaning palliative care has a lot to do with symptomatic therapy, because we can't treat the underlying illness. In spite all of that the knowledge of the illness, its possibilities of treatment and its prognosis are important to know, if we want do take good and wise decisions. With three examples I would like to show, how different decisions about therapies can be of the illness. The neuropathic pain can derive from different aetologies. There are multiple options of therapy, but we don't have a good test to predict which therapy will fit for which patient in pain. We have only one evidence-based pharmacological treatment of dyspnoea, that's morphine. The decision whether to give or not nutrition to a patient with advanced cancer or advanced dementia seems to be a difficult one. But if we have a look into the literature it's much easier to decied, because there is almost no advantage for the patient if we nourish him.

Comparison of three bone ultrasounds for the discrimination of subjects with and without osteoporotic fractures among 7562 elderly women.

UNLABELLED: Bone ultrasound measures (QUSs) can assess fracture risk in the elderly. We compared three QUSs and their association with nonvertebral fracture history in 7562 Swiss women 70-80 years of age. The association between nonvertebral fracture was higher for heel than phalangeal QUS. INTRODUCTION: Because of the high morbidity and mortality associated with osteoporotic fractures, it is essential to detect subjects at risk for such fractures with screening methods. Because quantitative bone ultrasound (QUS) discriminated subjects with osteoporotic fractures from controls in several cross-sectional studies and predicted fractures in prospective studies, QUS could be more practical than DXA for screening. MATERIAL AND METHODS: This cross-sectional and retrospective multicenter (10 centers) study was performed to compare three QUSs (two heel ultrasounds: Achilles+ [GE-Lunar] and Sahara [Hologic]; the phalanges: ultrasound DBM sonic 1200 [IGEA]) for determining by logistic regression nonvertebral fracture odds ratio (OR) in a sample of 7562 Swiss women, 75.3 +/- 3.1 years of age. The two heel QUSs measured the broadband ultrasound attenuation (BUA) and the speed of sound (SOS). In addition, Achilles+ calculated the stiffness index (SI) and the Sahara calculated the quantitative ultrasound index (QUI) from BUA and SOS. The DBM sonic 1200 measured the amplitude-dependent SOS (AD-SOS). RESULTS: Eighty-six women had a history of a traumatic hip fracture after the age of 50, 1594 had a history of forearm fracture, and 2016 had other nonvertebral fractures. No fracture history was reported by 3866 women. Discrimination for hip fracture was higher than for the other nonvertebral fractures. The two heel QUSs had a significantly higher discrimination power than the QUSs of the phalanges, with standardized ORs, adjusted for age and body mass index, ranging from 2.1 to 2.7 (95% CI = 1.6, 3.5) compared with 1.4 (95% CI = 1.1, 1.7) for the AD-SOS of DBM sonic 1200. CONCLUSION: This study showed a high association between heel QUS and hip fracture history in elderly Swiss women. This could justify integration of QUS among screening strategies for identifying elderly women at risk for osteoporotic fractures.

Quality controls for two heel bone ultrasounds used in the Swiss Evaluation of the Methods of Measurement of Osteoporotic Fracture Risk Study.

Because of the important morbidity and mortality associated with osteoporosis, it is essential to detect subjects at risk by screening methods, such as bone quantitative ultrasounds (QUSs). Several studies showed that QUS could predict fractures. None, however, compared prospectively different QUS devices, and few data of quality controls (QCs) have been published. The Swiss Evaluation of the Methods of Measurement of Osteoporotic Fracture Risk is a prospective multicenter study that compared three QUSs for the assessment of hip fracture risk in a population of 7609 women age >/=70 yr. Because the inclusion phase lasted 20 mo, and because 10 centers participated in this study, QC became a major issue. We therefore developed a QC procedure to assess the stability and precision of the devices, and for their cross-calibration. Our study focuses on the two heel QUSs. The water bath system (Achilles+) had a higher precision than the dry system (Sahara). The QC results were highly dependent on temperature. QUS stability was acceptable, but Sahara must be calibrated regularly. A sufficient homogeneity among all the Sahara devices could be demonstrated, whereas significant differences were found among the Achilles+ devices. For speed of sound, 52% of the differences among the Achilles+ was explained by the water s temperature. However, for broadband ultrasound attenuation, a maximal difference of 23% persisted after adjustment for temperature. Because such differences could influence measurements in vivo, it is crucial to develop standardized phantoms to be used in prospective multicenter studies.

[Pyogenic liver abscess]. / Der pyogene Leberabszess.

27 patients who presented with pyogenic liver abscess from 1957 to 1984 are analyzed retrospectively and compared with the literature. Diagnosis and start of therapy were frequently delayed because of the unspecificity of symptoms. Symptoms included fever, abdominal pain, weakness, and loss of weight. In 50% of all patients, the abscess was found by chance at laparotomy or autopsy. The most frequent causes of abscess formation were cholestasis due to extrahepatic obstruction and intraabdominal infections. Frequently a predisposing condition such as carcinoma, diabetes mellitus or alcohol abuse was found. The overall mortality was 25%, and was higher in patients with multiple abscesses of the liver (36%) than in patients with solitary abscesses (10%). With the introduction of new imaging procedures (ultrasound, computer tomography), the abscesses can be punctured under view and the antibiotic therapy can be based on bacterial analysis. The causative bacterial organism could be identified by cultures of the abscess fluid and blood in up to 90%. The bacteria identified usually were identical to the intestinal flora. Using specific antibiotic therapy, surgical treatment is often unnecessary and can be reserved for abscesses resistant to conservative treatment and for those due to correction of the original source of abscess formation.