Direct Irritation Research Articles

The role of intradiscal steroids in the treatment of discogenic low back pain

LBP is one of the most common reasons for visiting a doctor and is the most common cause of disability under age 45.Amongst a variety of etiologies, internal disc disruption (IDD) has been postulated as an important cause of low back pain. Treating discogenic low back pain continues to be a challenge to physicians. Inflammation, either from direct chemical irritation or secondary to an autoimmune response to the nucleus pulposus has been implicated as the primary pain source. Both steroids and non-steroidal anti-inflammatory drugs have partial effectiveness in treating pain associated with inflammation. Therefore, the rationale for using intradiscal steroids is to suppress the inflammation within the disc, thereby alleviating the patient’s symptoms. The goal of this article is to review the literature regarding the efficacy of intradiscal steroids to treat low back pain of discogenic origin.

Updated guidelines on cough launched

Updated guidelines on cough launched

Chronic Upper Airway Cough Syndrome Secondary to Rhinosinus Diseases (Previously Referred to as Postnasal Drip Syndrome): ACCP Evidence-Based Clinical Practice Guidelines

To review the literature on postnasal drip syndrome (PNDS)-induced cough and the various causes of PNDS. Hereafter, PNDS will be referred to as upper airway cough syndrome (UACS). MEDLINE search (through May 2004) for studies published in the English language since 1980 on human subjects using the medical subject heading terms "cough," "causes of cough," "etiology of cough," "postnasal drip," "allergic rhinitis," "vasomotor rhinitis," and "chronic sinusitis." Case series and prospective descriptive clinical trials were selected for review. Also, any references from these studies that were pertinent to the topic were obtained. In multiple prospective, descriptive studies of adults, PNDS due to a variety of upper respiratory conditions has been shown either singly or in combination with other conditions, to be the most common cause of chronic cough. The symptoms and signs of PNDS are nonspecific, and a definitive diagnosis of PND-induced cough cannot be made from the medical history and physical examination findings alone. Furthermore, the absence of any of the usual clinical findings does not rule out a response to treatment that is usually effective for PND-induced cough. The differential diagnosis of PNDS-induced cough includes allergic rhinitis, perennial nonallergic rhinitis, postinfectious rhinitis, bacterial sinusitis, allergic fungal sinusitis, rhinitis due to anatomic abnormalities, rhinitis due to physical or chemical irritants, occupational rhinitis, rhinitis medicamentosa, and rhinitis of pregnancy. Because of a high prevalence of upper respiratory symptoms associated with gastroesophageal reflux disease (GERD), GERD may occasionally mimic PNDS. A crucial unanswered question is whether the conditions listed above actually produce cough through a final common pathway of PND or whether, in fact, in some circumstances they cause irritation or inflammation of upper airway structures that directly stimulate cough receptors and produce cough independently of or in addition to any associated PND. PNDS (ie, UACS) secondary to a variety of rhinosinus conditions is the most common cause of chronic cough. Because it is unclear whether the mechanisms of cough are the PND itself or the direct irritation or inflammation of the cough receptors located in the upper airway, the guideline committee has decided that, pending further data that address this difficult question, the committee unanimously recommends that the term upper airway cough syndrome be used in preference to postnasal drip syndrome when discussing cough associated with upper airway conditions.

Diagnosis and Management of Cough Executive Summary: ACCP Evidence-Based Clinical Practice Guidelines

Recognition of the importance of cough in clinical medicine was the impetus for the original evidence-based consensus panel report on “Managing Cough as a Defense Mechanism and as a Symptom,” published in 1998,1 and this updated revision. Compared to the original cough consensus statement, this revision (1) more narrowly focuses the guidelines on the diagnosis and treatment of cough, the symptom, in adult and pediatric populations, and minimizes the discussion of cough as a defense mechanism; (2) improves on the rigor of the evidence-based review and describes the methodology in a separate section; (3) updates and expands, when appropriate, all previous sections; and (4) adds new sections with topics that were not previously covered. These new sections include nonasthmatic eosinophilic bronchitis (NAEB); acute bronchitis; nonbronchiectatic suppurative airway diseases; cough due to aspiration secondary to oral/pharyngeal dysphagia; environmental/occupational causes of cough; tuberculosis (TB) and other infections; cough in the dialysis patient; uncommon causes of cough; unexplained cough, previously referred to as idiopathic cough; an empiric integrative approach to the management of cough; assessing cough severity and efficacy of therapy in clinical research; potential future therapies; and future directions for research. To mitigate future diagnostic confusion, two new diagnostic terms have been introduced to replace two older terms that may represent misnomers. The committee unanimously recommends that the term upper airway cough syndrome (UACS) be used in preference to postnasal drip syndrome (PNDS) when discussing cough that is associated with upper airway conditions because it is unclear whether the mechanism of cough is postnasal drip, direct irritation, or inflammation of the cough receptors in the upper airway. The committee also recommends using the term unexplained cough rather than idiopathic cough because it is likely that more than one unknown cause of chronic cough will be discovered. The term idiopathic implies that one is dealing with only one disease. For managing adult patients with cough, the committee recommends an empiric, integrative diagnostic approach, which is presented in the section entitled “An Empiric Integrative Approach to the Management of Cough”.3 Guidelines for managing acute, subacute, and chronic cough are presented in algorithmic form (Fig 1–3). Guidelines with algorithms for evaluating chronic cough in pediatric patients < 15 years of age are presented in the section entitled “Guidelines for Evaluating Chronic Cough in Pediatrics”2,4 [Fig 4, ​,5].5]. For a full discussion on how to use the algorithms, please refer to these sections. Figure 1 Acute cough algorithm for the management of patients ≥ 15 years of age with cough lasting < 3 weeks. For diagnosis and treatment recommendations refer to the section indicated in the algorithm. PE = pulmonary embolism; Dx = diagnosis; ... Figure 3 Chronic cough algorithm for the management of patients ≥ 15 years of age with cough lasting > 8 weeks. ACE-I = ACE inhibitor; BD = bronchodilator; LTRA = leukotriene receptor antagonist; PPI = proton pump inhibitor. See the legend of ... Figure 4 Approach to a child 6 years of age and in some children ... Figure 5 Approach to a child ≤ 14 years of age with chronic specific cough (ie, cough associated with other features suggestive of an underlying pulmonary and/or systemic abnormality). Children > 14 years of age should be managed as outlined in ...

Cough and the Common Cold: ACCP Evidence-Based Clinical Practice Guidelines

Objective:To review the literature on cough and the common cold.Methods:MEDLINE was searched through May 2004 for studies published in the English language since 1980 on human subjects using the medical subject heading terms “cough” and “common cold.” Selected case series and prospective descriptive clinical trials were reviewed. Additional references from these studies that were pertinent to the topic were also reviewed.Results:Based on extrapolation from epidemiologic data, the common cold is believed to be the single most common cause of acute cough. The most likely mechanism is the direct irritation of upper airway structures. It is also clear that viral infections of the upper respiratory tract that produce the common cold syndrome frequently produce a rhinosinusitis. In the setting of a cold, the presence of abnormalities seen on sinus roentgenograms or sinus CT scans are frequently due to the viral infection and are not diagnostic of bacterial sinus infection.Conclusion:Cough due to the common cold is probably the most common cause of acute cough. In a significant subset of patients with “postinfectious” cough, the etiology is probably an inflammatory response triggered by a viral upper respiratory infection (ie, the common cold). The resultant subacute or chronic cough can be considered to be due to an upper airway cough syndrome, previously referred to as postnasal drip syndrome. This process can be self-perpetuating unless interrupted with active treatment.

Epidural catheter-induced paresthesia accompanied by changes in skin color and temperature in an obstetric patient

Placement of epidural catheters for labor analgesia is a common procedure that has become more popular in recent years. However, this procedure can often cause paresthesia, which is typically characterized as a transient and intense burning pain radiating to the hip or leg. In this case report, we describe a patient who had persistent paresthesia in her right foot caused by an indwelling epidural catheter, which was successfully relieved following a partial withdrawal of the epidural catheter. More interestingly, we also observed dramatic changes in skin color and temperature (cold and pale) on her right foot that was well correlated both in time and location with the epidural-induced paresthesia. This cold and pale skin on the right foot represents a localized sympathetic discharge associated with the epidural-induced paresthesia, a phenomenon that has not previously been described. Based on the location of the paresthesia and the pathway of the sympathetic nerve fibers, it is unlikely that this localized sympathetic discharge was due to a direct irritation of the preganglionic sympathetic fibers in the spinal nerve roots by the epidural catheter and thus, a spinal reflex was probably involved. This phenomenon provided us with additional clinical evidence of nerve root irritation, which prompted us to act quickly, and resulted in a favorable outcome.

Biceps Tendinitis Caused by an Osteochondroma in the Bicipital Groove

Tendinitis of the long head of the biceps brachii muscle is commonly seen in athletes who do repetitive overhead motions. Common causes of biceps tendinitis include impingement syndrome, subluxation of the biceps tendon, and attrition tendinitis, whereas biceps tendinitis secondary to a bone neoplasm is rare. A case of biceps tendinitis caused by an osteochondroma arising in the left humeral bicipital groove in a 25-year-old male baseball player is reported. The tumor was hook-shaped, originated from the inferomedial portion of the humeral lesser tubercle, and surrounded the biceps tendon. Symptoms of increasing pain and inability to throw resulted from direct irritation of the biceps tendon by the tumor. Total excision of the tumor relieved the symptoms within 3 weeks. To our knowledge, there have been no reported cases in the English-language literature of biceps tendinitis caused by an osteochondroma.

Contact dermatitis

The term ‘dermatitis’ is synonymous with the term ‘eczema’. Contact dermatitis refers to an eczematous rash caused by contact with a substance. It is classified as exogenous eczema (caused by external factors), as opposed to endogenous eczema (e.g. atopic eczema). Contact dermatitis is divided into two distinct types — irritant and allergic. Irritant contact dermatitis is caused by direct irritation of the skin by various factors including mechanical trauma, heat, humidity and chemicals. Allergic contact dermatitis occurs where an individual is sensitized to a specific allergen and is a type IV hypersensitivity reaction. In the clinical setting, there is often overlap between the different types of eczema, with several factors having a role in the development of an individual’s dermatitis. Atopic eczema predisposes to the development of irritant dermatitis. Irritant dermatitis often occurs before the development of allergic contact dermatitis, as disturbance of the skin barrier function allows penetration of allergens.

Nonhabitual Seizures in Patients with Implanted Subdural Electrodes

The implantation of subdural electrodes has been widely employed in the invasive monitoring of patients with medically refractory epilepsy. The use of subdural electrodes, though, has been associated with rare but occasionally troublesome complications. We report the occurrence of nonhabitual seizures after implanting subdural grid electrodes. Among 57 patients diagnosed with medically refractory epilepsy who were evaluated in our department over a 12-month period, 21 patients underwent craniotomy for subdural grid/strip electrode implantation. Subdural grids and strips (AdTech, Racine, Wisc., USA) were used for continuous video EEG monitoring. In 3 patients, during subdural monitoring, consistent nonhabitual seizure activity was recorded. This was both clinically and electrographically different than the patients’ habitual seizures. The patients’ nonhabitual seizures disappeared postoperatively after removing the implanted electrodes. The occurrence of nonhabitual seizures, though quite rare, could lead to mislocalization of an epileptogenic focus. This complication might be the result of direct mechanical cortical irritation or chemical irritation caused by blood breakdown products. The occurrence of nonhabitual seizures comes to add itself to the existing list of complications associated with employment of subdural electrodes for invasive monitoring.

The effects of the shallow and the deep endotracheal suctioning on oxygen saturation and heart rate in high-risk infants

An experimental study involving repeated-measures within subjects was conducted to examine the effects of shallow and deep endotracheal suctioning (ETS) on the SpO 2 and HR in 27 ventilated high-risks infants. The order in which subjects received the ETS protocol was randomly assigned. The results showed no significant changes in both the SpO 2 and HR responses before, during and after ETS between the two ETS protocols. It is concluded that when there is no beneficial effect of performing deep ETS, it should not be carried out due to the potential hazard of direct irritation with more negative pressure on the airways in high-risk infants.

Laparoscopic Findings, Management, Histopathology, and Outcomes in 25 Women with Cyclic Leg Pain

Study ObjectiveTo determine pelvic findings, histopathology, and clinical outcome in women with chronic pelvic pain and cyclic sciatica-like pain after laparoscopic surgery. DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingUniversity-affiliated teaching hospital. PatientsOf 2115 women with chronic pelvic pain, 25 also complained of cyclic pain radiating to the leg (right 15, left 9, both 1), pain over buttocks, and paresthesia of the thighs and/or knees, exacerbated during menses. InterventionLaparoscopy. Measurements and Main ResultsLaparoscopic findings were endometriosis nodules (5 patients), peritoneal pockets and/or peritoneal endometriosis (19), and inflammatory peritoneum (1). Associated pelvic endometriosis was identified and confirmed in 17 women (68%). No additional lesions other than peritoneal pockets were found in eight (32%). All nodules, peritoneal pockets, and abnormal peritoneum were excised with a combination of hydrodissection and carbon dioxide laser. Peritoneum over resultant deep defects was sutured with one to three 2-0 nonabsorbable sutures in accordance with the surgeon's practice and experience. Endometriosis was confirmed in all five nodules, and histology of excised pockets showed endometriosis in nine (60.0%), endosalpingiosis in two (13.3%), chronic inflammation in one (6.7%), and normal tissue in three (20.0%). After laparoscopic excision sciatic symptoms were eliminated in 19, markedly improved in 4, remained the same in 2, and recurred in 3 patients after 2 years. ConclusionCyclic leg signs and symptoms were associated with pelvic peritoneal pockets, endometriosis nodules, or surface endometriosis of the posterolateral pelvic peritoneum. We hypothesize that the pain associated with these lesions is more likely referred pain originating from pelvic peritoneum than direct irritation of the lumbosacral plexus of the sciatic nerve.

Rheumatoid nodule as a cause of Morton's metatarsalgia

A 46-year-old-lady with seropositive rheumatoid arthritis presented with a typical history of Morton's metatarsalgia. Examination revealed a palpable tender mass between the third and fourth toes of her right foot. She underwent excision of the lesion. Histology revealed a Morton's neuroma embedded within the substance of a rheumatoid nodule. This has rarely been described previously and supports the concept of direct neural irritation as a factor in the pathogenesis of Morton's metatarsalgia.

Immunophenotypic analysis of the inflammatory infiltrates in herniated intervertebral discs.

The herniated portion of the lumbar disc was analyzed immunohistochemically for inflammatory infiltrates to determine their immunophenotype. To investigate the pathomechanism behind spontaneous regression of herniated discs. Spontaneous regression of herniated intervertebral discs has been increasingly reported. The inflammatory response of the host has been suggested as a factor in this phenomenon. However, whether the inflammation is induced from direct chemical irritation of the nucleus pulposus material or whether it is secondary to an autoimmune response to the nucleus pulposus remains controversial. The herniated portion of the disc was collected from 38 patients who underwent surgery for lumbar disc herniation. Thin cryostat sections were made, and the extent to which inflammatory cells had infiltrated the disc specimen was defined. Then the immunophenotype of cellular infiltrates in the herniated disc specimens was assessed by immunostaining using a series of antibodies for lymphocyte, monocyte, macrophage, and dendritic cell markers. The inflammatory infiltrates in 14 of the 38 herniated discs were subjected to immunohistochemical analysis. None of them expressed the immunophenotypic markers of the lymphocyte (CD20, CD45RO, CD4, CD8, TCRgammadelta), mature monocyte (CD33), or dendritic cell (CD1a, CD80, CD86, S100). Abundant infiltration of CD68-positive cells that lacked CD33 but had a variable amount of CD11b, CD11c, and CD40 likely represents a process of differentiation from monocytes to macrophages. These findings are consistent with an immunophenotype of inflammatory responses to tissue injury or chemical irritation rather than antigen-specific immune responses. Therefore, understanding the mechanism of tissue repair is fundamentally important in the management of patients with disc herniations.

THE RATIONALE OF USING NON-STEROIDAL ANTI-INFLAMMATORY DRUGS IN DENTISTRY

Pain control is of great importance in dental practice. It is pain that brings the patient to the dental office. The use of non-steroidal anti-inflammatory drugs is one important component in dentistry. But the adverse reaction of these drugs cause serious problems. The adverse reaction effects are most frequently related to the gastrointestinal tract, such as simple dyspepsia or nausea, vomiting, or gastric bleeding. These adverse reactio effects result from direct gastric irritation or prostaglandin inhibition. Since prostaglandins are responsible for inhibtion of gastric acid secretion and stimulation of the cytoprotective mucous in the stomach, most non-steroidal anti-inflammatory drugs can counteract these effects. Sinc 1971, the mechanism of action of non-steroidal anti-inflammatory drugs was known through their inhibtion effect on the cyclooxygenase enzyme (COX). The unwanted side-effects of these drugs are due to their inhibtion of COX-1 whereas their anti-inflammatory effects are due to inhibition of COX-2. Several points need to be considered to use this drug safely and effectively in dentistry. Knowing the action of non-steroidal anti-inflammatory drugs can recognize the possibility of drug interactions is an important step toward preventing problems in dental clinics.

Drug-induced aseptic meningitis: diagnosis and management.

Drug-induced aseptic meningitis (DIAM) has been reported as an uncommon adverse reaction with numerous agents. It is a diagnosis of exclusion, and clinical signs and CSF findings vary greatly. The body of evidence regarding DIAM is largely in the form of anecdotal case reports and must be interpreted carefully bearing this in mind. The major categories of causative agents are nonsteroidal anti-inflammatory drugs, antimicrobials, intravenous immunoglobulin, intrathecal agents, vaccines and a number of other less frequently reported agents. There appears to be an association between DIAM and connective tissue disease, particularly systemic lupus erythematosus, and ibuprofen. There are 2 major proposed mechanisms for DIAM. The first involves direct irritation of the meninges by intrathecal administration of the drug, and the second involves immunological hypersensitivity to the drug, most likely type III and type IV hypersensitivity. Recognition and diagnosis of DIAM is important, as it is treatable by withdrawal of the drug and recurrence is prevented. The outcome of DIAM is generally good, usually without long term sequelae. This article describes the case reports of DIAM in the current literature and discusses the diagnosis and management of this rare complication.

Stachybotrys chartarum (atra) contamination of the indoor environment: Health implications

In 1998, widespread contamination of water-damaged school portables with the toxigenic mold Stachybotrys chartarum was detected in the province of Ontario. This mold may cause human disease through direct irritation, type 1 hypersensitivity or the production of toxins. A variety of respiratory, dermatological, eye and constitutional symptoms have been associated with heavy and prolonged exposure to S chartarum. S chartarum has also been potentially implicated as a rare cause of idiopathic pulmonary hemorrhage in infants. Ingestion of food heavily contaminated with toxin-producing molds, including S chartarum, can cause bone marrow suppression and immunotoxicity. However, the level of toxin exposure that occurs following inhalation of S chartarum is very low; consequently, serious adverse health effects from such an exposure are extremely unlikely. In a child with symptoms felt to be temporally related to the school environment, an assessment of the child's school should be carried out by the public health authorities so that potential irritants and allergens can be identified. Avoidance of exposure is the most effective mode of therapy. Buildings found to be heavily contaminated with molds, particularly S chartarum, should undergo thorough cleaning and repair to remove the offending agent(s), and prevent further water damage and mold overgrowth.

Prevention of occupational allergy caused by exposure to acid anhydrides.

This paper focuses on the prevention of IgE-mediated symptoms of the eyes and airways caused by exposure to acid anhydrides in the workplace. Acid anhydrides are widely used in the production of alkyd resins and as curing agents for epoxy resins. Heavy exposure to acid anhydrides causes severe irritation. However, reports of direct irritation of mucous membranes or skin are rare in recent years, since a package of multiple engineering controls has been introduced to reduce exposure. On the other hand, acid anhydrides are well-known industrial inhalant sensitizers and can cause occupational allergy even at very low exposure intensities. Therefore, safe use in industry demands both control of the level of exposure causing allergic diseases in the workshop and programmes for prevention of occupational allergy.

Expression and localization of ornithine decarboxylase in reversible papillomatosis induced by uracil in rat bladder.

Direct mechanical irritation by uracil calculi formed following feeding of 3% uracil in the diet to male rats produces severe papillary hyperplasia (papillomatosis, which is reversible) of bladder epithelium. To evaluate the mechanism of the appearance of uracil‐induced papillomatosis, we examined the changes of the enzyme activity and the localization of ornithine decarboxylase (ODC), as well as polyamine biosynthesis, and epithelial proliferation, that accompany the sequential bladder epithelial changes following administration and withdrawal of uracil. Moreover, expression of ODC mRNA was investigated using northern blotting and localization of ODC mRNA was demonstrated using in situ hybridization. ODC activity during uracil administration was maintained at a high level compared to that in normal epithelium, but sharply decreased after cessation of uracil treatment. The accumulation of ODC protein was observed in the proliferating bladder epithelium by immunohistochemical examination and western blotting analysis, and even after cessation of treatment, the protein binding to anti‐ODC antibody remained mildly elevated. Sequential changes of proliferating cell nuclear antigen (PCNA)‐positive cells in the epithelium during the development and disappearance of papillomatosis correlated with ODC activity. ODC mRNA was expressed strongly in the proliferating epithelium in rats treated with uracil and weakly in normal epithelium, in accordance with the location of ODC protein. Consequently, our data demonstrate that cell proliferation in the development of papillomatosis is closely associated with polyamine metabolism, and moreover suggest that ODC activity is up‐regulated at a post‐translational step.

Alcoholic Gastritis

Gastritis is inflammation of the gastric mucosa. Alcohol ingestion may lead to an acute hemorrhagic or erosive gastritis through direct irritation of the gastric mucosa. Alcohol also leads to increased gastrin production and decreased pepsin secretion,which can cause gastric irritation. Endoscopy performed on healthy adults after direct ingestion of alcohol shows gastric hyperemia and erosions. Although alcohol-related gastritis most often is asymptomatic, it also may present with epigastric or upper abdominal pain, nausea, vomiting, and massive or occult gastrointestinal bleeding. In adults, alcohol use is a common cause of erosive gastritis, but nonsteroidal anti-inflammatory drug use is the most common cause. The incidence of alcoholic gastritis has not been identified in children and adolescents.Chronic antral inflammation frequently is observed in adult alcoholics. However, it is not clear whether this condition is a result of alcohol use, Helicobacter pylori, or their interaction. One study examined alcoholic patients who had gastritis after abstinence and then compared treatment for H pylori with antacid therapy. Neither abstinence from alcohol alone nor antacids was successful in improving gastritis. However, eradication of the H pylori cleared the gastritis. Ongoing animal studies also seem to confirm the presence of damaging interactions between H pylori and alcohol.Gastritis is neither common nor extensively studied in adolescents. As in adults, H pylori has been shown to be a causative agent, when present, in ulcer disease and gastritis in children and adolescents. Similarly, agents shown to be toxic in adults (such as alcohol) are at least as toxic in adolescents and children. Identification and treatment of alcoholic gastritis is important for several reasons: 1) chronic gastritis and ulcer disease increase future cancer risk; 2) gastritis can lead to life-threatening gastrointestinal bleeding; and, perhaps most important for adolescents, 3) identification of alcohol use should lead to interventions to decrease the morbidity and mortality associated with alcohol use and abuse.Alcohol use is a major problem among youth. Average age for first time use is 11.9 years for males and 12.7 years for females. Recent heavy drinking (defined as five or more drinks in a row in the past 2 weeks) has been reported by 15% of eighth graders, 24% of tenth graders, and 40% of college students. Parents often underestimate whether their children drink alcohol. Additionally,the physical indicators of alcohol or drug abuse seen in adults often are not seen in children; behavioral changes are more common indicators in youth.With the high prevalence of alcohol use among adolescents, it is important to question all adolescent patients about it. Current preventive services guidelines for adolescents recommend annual screening for alcohol use and counseling on its dangers, with a special emphasis on drinking and driving. Systematic screening about alcohol use at health super-vision visits provides an important opportunity to educate about and help prevent adolescent substance abuse. Special care should be taken to ask about alcohol use when adolescents present with abdominal symptoms, whether acute or chronic. Although not the most frequent cause of abdominal symptoms or of gastritis in adults or children, alcohol-related gastritis will not resolve until the offending agent is removed.Asking adolescents who have symptoms of gastritis about alcohol use is critical. Understanding the cause of the gastritis provides an opportunity to address the root of the problem—alcohol. Among adolescents, identification of alcohol use and alcohol-related morbidity and counseling on healthy behavior may influence lifelong health practices. This diagnosis can provide a window of opportunity.

,,Alternative" Verfahren in der Rheumatologie und in der Orthopädie

Patients suffering from chronic painful diseases often inquire about so-called "alternative" or unconventional therapies where science-oriented "conservatively traditional" methods have frequently helped to alleviate symptoms without effecting a genuine cure. Although such ,,alternative" methods may surely often produce a marked placebo effect, it must be pointed out that so fare there has not been any proof of any specific effectivity. The only exception may be methods producing a direct irritation of skin or tissue provoking some kind of counter-irritation that may be effective. However, even with these methods, such as cupping or acupuncture, it would be advisable to examine whether the same treatment effect may be achieved by methods involving less interference with the patient's body, for example physiotherapy or electrotherapy. It is a truism that every patient and in particular also the chronic patient should have the benefit of best possible treatment. Hence, as a matter of principle only such methods should be employed that have definitely proved effective and where the efficacy definitely outranks the risks involved in side effects. For example, it should be ruled out that whereas a patient in an early stage of rheumatoid arthritis is not subjected to a basic treatment method that would most probably be effective, he is treated according to a method of highly doubtful merit. Even under the new all-pervading aspect of cost reduction only such methods can be OK'd whose effectiveness has been confirmed in accordance with generally recognised examination criteria. Physicians should therefore be wary of uncritical reports on claims of success achieved via seemingly highly technological newfangled methods. Before purchasing any (costly) equipment of this sort the physician must make sure that effectivity has been really established beyond doubt for the claimed indications. Finally, it is pointed out that the Federal German Board of Physicians and Statutory Health Insurance Bodies has issued guidelines regarding the non-eligibility for sickness insurance cover of electro-acupuncture, Mora/bioresonance therapy and soft/mid-laser therapy, since these are counted among those procedures that are not considered essential for adequate, meaningful and economic patient care and can therefore not be applied within the framework of statutory health insurance.