Schweizerische Rundschau fur Medizin Praxis = Revue suisse de medecine Praxis最新文献

Switzerland has adopted a prevention strategy including the promotion of non-sharing injection material and use of condoms. The access to sterile equipment has been made easier, but regional differences still exist. Studies conducted between 1989 and 1992 among drug users in different Swiss regions are reviewed in order to examine if progress in prevention occurred. Syringe sharing diminished everywhere, but rather high sharing rates persist where sterile material is less accessible. Condom use increased, but the situation is still unsatisfactory considering the high HIV prevalence among i.v. drug users. Where several surveys have been conducted consecutively, a stabilization of HIV prevalence was observed. This suggests a slowing down of the progression of the epidemic among drug users. These results, obtained in few years, are encouraging in the light of the pessimism which prevailed at the beginning of the epidemic about the ability of drug users to adopt preventive behaviour.

During the last few years, drug policies have been at the center of passionate debates and have been developed in different ways, according to the country or, in Switzerland, the canton. The concept of risk reduction strategy emerged. This article reviews the international literature on the development of this concept and of the prevention and treatment strategies derived from it. The implementation of such a concept is illustrated by the recent developments of drug policy in the canton of Geneva.

The 'cardiovascular hotline' in Heidelberg, established in April 1992, provides data concerning the self-measurement of blood pressure. For this purpose 277 hypertensives were asked from 15 April to 15 July 1993. 195 (70%) of those questioned (47% men, 53% women) practised home-recording, but only 17% on recommendation of their physician. Only 22% were introduced to the technique by experienced personnel; just 50% were adequately controlled. At least 35% of hypertensives used an oscillometric device and not more than 10% an auscultation device. 5 to 14% of the patients reported to have difficulties in handling their device. Approximately 60% of the patients practicing home-recording stated that this method enabled them to cope better with their disease. Compared with the 1987 pilot study in the Hamburg area, this percentage did not increase; however, it could be confirmed that only approximately 10% of the patients are unsuited for home-recording. 75% of the hypertensives measuring their own blood pressure documented their values, but in only 47% of all cases physicians drew conclusions from the data. 31% of the patients were unable to say whether their medication was adjusted on the basis of self-measured blood pressure values. In conclusion, many hypertensives practice self-measurement of blood pressure. Despite this fact, home-readings are not yet sufficiently accepted by physicians as a possible and desirable method to optimize high blood pressure treatment. This situation should be improved since compliance of physicians is the basis for a better education of hypertensive patients, thus optimizing patient compliance.

An increase of the intraosseous pressure is observed in the epiphyses of bones involved in degenerative joint disease. The increase of pressure may be caused by an accumulation of osmotically active substances in the interstitium, as it has been described in case of the compartment syndrome. Based on the postulated pathophysiological mechanism, a causative therapy of degenerative joint disease is proposed.

In the second part of this three-part review on patient compliance we attempt to outline the term of noncompliance in its various aspects. Noncompliance may arise on one hand by misunderstandings in the communication between physician and patient. Furthermore, compliance can be refused, or the patient may for various reasons be incapable of compliant behaviour. Patients who are aware of the mode of action of a drug usually take their medicine more reliably. The essential factors influencing compliance are explained and discussed. The interaction between patient and physician is, also by its multilayered complexity, an important component of patient compliance.

The clinical course of 37 patients (15 female, 22 male) treated endoscopically for benign biliary stenosis was analyzed retrospectively. Patients with chronic pancreatitis (n = 20) were compared to those (n = 17) with biliary stenosis due to other reasons, postoperative strictures in most cases. Each patient received at least one 10- or 11.5-French endoprosthesis. The liver enzyme and serum bilirubin levels returned to normal or slightly elevated levels. The average time until exchange or extraction of the prosthesis was 11.4 (range 2 to 33) months in patients with chronic pancreatitis and 5.1 (0.5 to 21) months in patients with postoperative strictures. The therapy was completed by extraction of prosthesis in six patients with chronic pancreatitis (30%) and in 14 patients with stenosis due other reasons (82.3%). None of the patients died of complications related to endoscopic therapy.

Acute cholecystitis as a rule requires operative treatment. When it occurs as a complication of gall stone disease, early cholecystectomy within two to three days has been accepted as a safe procedure. If possible, the laparoscopic approach should be preferred. In cases of technical difficulties conventional open cholecystectomy should be planned as a primary approach or be performed by conversion of the laparoscopic approach. Cholecystostomy performed as an interventional procedure is indicated in high-risk patients due to comorbidity only. For acalculous cholecystitis, however, this approach is regarded as the initial procedure of first choice.

Primary malignant neoplasms of the pancreas can occur as ductal adenocarcinoma in up to 80% and as a carcinoma of the exocrine or endocrine parenchyma in up to 20%. The treatment of pancreatic cancer is tumor resection. The surgical procedure depends on the tumor site: subtotal pancreatectomy, total or partial duodenopancreatectomy (Whipple's operation). The morbidity ranges from 5 to 15% and the mortality from 2 to 10%. Pancreatic carcinoma has an extremely poor prognosis, the median survival ranges from three to six months, the 5-year survival rate is 2 to 8%. These results are caused by mostly advanced tumors at the time of diagnosis. Early tumor stages with a 5-year survival rate up to 40% account for only 10% of the resected tumors; therefore, after tumor resection, recurrent disease occurs in up to 90%.