Conservative Drug Treatment Research Articles

Ist der allgemein akzeptierte therapeutische Nutzen des Gehtrainings bei Patienten mit arterieller Verschlusskrankheit evidenzbasiert?

When assessing the quality of clinical trials in intermittent claudication, on principle the same strict biometric and medical standards need to be applied for studies on the effect of walking exercise as for conservative drug treatment studies. However, as demonstrated by a recent review of the Cochrane Collaboration, this is apparently not always the case. The review included ten randomized controlled studies published between 1966 and 1997 with a total of 258 patients. The exercise regimes varied considerably between studies with regard to mode, intensity, frequency, duration and supervision, just as the treadmill tests employed to measure walking distance and walking time, respectively (primary endpoint). None of these studies used a confirmatory approach, and they all have a number of further methodological flaws when taking current biometric and medical guidelines into account. Also unmentioned in the abstract remains the important fact that, owing to missing data, finally only 53 patients from three studies could be pooled for the actual meta-analysis. All in all, the Cochrane review under discussion here is hardly suitable to scientifically prove the generally accepted efficacy of walking exercise in intermittent claudication. At the same time, it becomes clear that even publications of well-reputed institutions such as the Cochrane Collaboration should always be critically scrutinized. On the other hand, applying modern guidance for investigation under the aspect of evidence based medicine must not lead to a retrospective discrimination of accepted historical scientific data and thereby call into question proven therapeutic strategies.

Effect of early pregnancy on a previous lower segment cesarean section scar

Objective: To summarize the manifestation, diagnosis, and early management of early pregnancy on a previous cesarean section scar. Method: Fifteen cases of early pregnancies implanted on previous cesarean section scars were diagnosed and treated in two obstetrical centers. Results: The 15 patients had light, painless vaginal bleeding and their serum β-subunit human chorionic gonadotropin (β-HCG) was elevated. The interval between cesarean section and admission ranged from 6 months to 12 years (7.1±3.6 years). Doppler and real-time ultrasonic examinations demonstrated an enlargement of the previous cesarean section scar in the lower segment, a gestational sac or a mixed mass attached to the cicatrix, and a very thin myometrium between the gestational sac and the bladder wall. Serum β-HCG dropped to normal in 12 of the 15 patients following treatment with crystalline trichosanthin injected into the cervix followed by oral mifepristone, intramuscular injections of methotrexate, or other appropriate treatment. Two patients underwent total hysterectomy due to massive vaginal bleeding. The remaining patient was misdiagnosed with choriocarcinoma and also had total hysterectomy. Conclusion: Pregnancy on a previous lower segment cesarean section scar is rare but very dangerous. Early diagnosis and effective conservative drug treatment may be instrumental in decreasing the occurrence of uterine rupture.

Do Interventions Provide Additional Benefit to Drug Treatment of Acute Coronary Syndromes? A Call for a Reserved, Watchful Approach

IntroductionBalloon angioplasty has revolutionized clinical cardiology since its first use in coronary patients by Andreas Grünzig in 1977.1 Initially limited to single, concentric, and proximal lesions, its clinical applicability rapidly expanded to more complex stenoses and total occlusions. With equipment improvement and growing investigator experience, even the most vulnerable lesions found in patients with unstable angina or acute myocardial infarction, were soon recognized as potential targets for percutaneous interventions.2-6 The overwhelming and unquestioned success of coronary angioplasty is most prominently demonstrated by the estimated more than 1,000,000 procedures that will be performed worldwide during 1999.There is little doubt that, in patients with severe coronary lesions and exercise-induced angina, coronary angioplasty with minimal invasiveness can widen the vessel lumen and initiate coronary remodeling. This will lead, in many cases, to a durable relief from angina symptoms, as reviewed elsewhere.7 However, though vigorously advocated by interventional cardiologists, the benefit of percutaneous revascularization procedures in patients with acute coronary syndromes is less clear. This is even reflected in the AHCPR Clinical Practice Guidelines, 8 in which both conservative medical management and early invasive therapies are regarded as suitable alternatives in most patients. This chapter will address the question of whether and when coronary angioplasty will add to the benefits of conservative drug treatment.

Endoscopic approach to the anterior skull base

Today, endoscopic endonasal operations have become daily routine in ENT-surgery, particularly endonasal surgery in cases of chronic polyposis of the paranasal sinuses. Younger ENT surgeons become familiarized with these endonasal techniques during their training. On the other hand, the number of operative procedures on the paranasal sinuses via the possible external approaches is decreasing because a growing number of diseases can be treated by modern endonasal techniques. Modern suction-irrigation endoscopes, combined with a high performance endocamera (chip camera) provide a clear vision in the operative field. This allows the surgeon to work quite safely inside the nose and the paranasal sinuses, as well as near to the posterior part of the orbit and the frontal skull base. Working under videoendoscopic control is especially safer for the less experienced surgeon because supervision of every step of the operation is easy to achieve. Many patients with chronic polyosis of the sinuses are resistant to conservative drug treatment and depending on the amount of polyposis, are typically treated by endonasal operations, such as partial ethmoidectomy or complete sphenoethmoidectomy. However, during the last few years more conditions involving the frontal skull base or the paranasal sinuses are treated by endoscopic approaches. 1-4 We have developed a new concept for the treatment of conditions such as cerebrospinal fluid (CSF) leakage, fractures of the skull base and the orbit, etc., primarily using endoscopic minimally invasive operative techniques.

In vivo “calculus analysis”, based on radiographic and laboratory investigations

Authors have developed a method for the determination of the composition of calculi “in vivo”. The method consists of the comparison of the characteristics of roentgenographs and the results of laboratory investigations of the single calculi. In the knowledge of these, the composition of the calculus in the cavity system can be determined in most of the cases and as a practical results, the eventual conservative drug treatment established. The method is naturally only recommended if the precise analysis of the removed or spontaneously voided calculus cannot be carried out.