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

Gastrointestinal side effects are common to all nonsteroidal anti-inflammatory drugs (NSAID). Relevant to the patient are NSAID-induced dyspepsia and ulcer complications such as hemorrhage and perforation. The most important prophylactic means is repeated verification that the NSAID cannot be replaced by other measures, e.g. physical therapy or simple analgesics. If a NSAID is needed, it should be administered at the lowest effective dose. The present drugs used in preventing NSAID-induced ulcers and their complications are far from perfect. Major problems are adverse effects, high costs and insufficient efficacy in the prevention of ulcer complications. Thus, prophylactic antiulcer treatment is recommended in high-risk patients (as a primary prophylaxis) and in patients with previous ulcers (as a secondary prophylaxis). Similar arguments apply for prevention of ulcers in intensive-care patients. Patients at risk are critically ill, those with previous ulcers and in particular those with clotting disorders. Acid-reducing drugs are recommended for nonintubated patients, whereas sucralfate is preferred in patients on artificial ventilation because it is associated with a lower risk for nosocomial pneumonias.

Endoscopic hemostasis in cases of acute upper gastrointestinal bleeding may be achieved by various methods with comparable initial results, nevertheless the frequency of re-bleeding is different in regard to the techniques. The frequency of re-bleeding may be reduced by the application of fibrin tissue sealant, the eradication of Helicobacter pylori and by daily endoscopic controls. The use of big channel endoscopes makes intragastral survey easier, and beyond that endoscopic doppler-ultrasound may reveal visible and not visible arterial vessels on the bottom of the ulceration, so indicating the greater risk of re-bleeding. The progress of endoscopic hemostasis combined with specific pharmaco-therapy is on the way to relieve laparotomy in favour of intraluminal minimal invasive techniques in a larger scale.

Heartburn and epigastric pain are the leading symptoms of reflux disease. Next to other symptoms like pharyngeal burning, regurgitation and retrosternal pain, chronic hoarseness and coughing as well as angina pectoris symptoms may point towards a pathological reflux. In endoscopically verified reflux esophagitis proton pump inhibitors are the treatment of first choice. Aim of therapy is loss of symptoms, healing of epithelial defects and prevention of Barrett's esophagus. If a columnar epithelium-lined esophagus is seen, surveillance is recommended in one- or two-year intervals.

Manometry and pH-metry are essential in the examination of functional disturbances of the esophagus. Before they are used, morphological lesions have to be excluded. Proven indications for functional methods are symptoms which cannot be clarified otherwise. Indications for manometry are: dysphagia of unknown origin, noncardiac chest pain and necessary preoperative studies. Indications for long-term pH-metry are: atypical reflux symptoms, (in particular chronic respiratory disease), noncardiac chest pain, atypical esophagitis and preoperative examination prior to antireflux surgery. Used critically, manometry and pH-metry can be very helpful as cost-effective diagnostic tools.

Antibiotic prophylaxis is recommended for patients at risk for developing bacterial endocarditis as a sequel of bacteremia during endoscopy. In addition antibiotics are necessary for endoscopic procedures with a high risk of infection such as endoscopic retrograde cholangio-pancreatography in patients with stenosis of the bile or pancreatic duct and percutaneous endoscopic gastrostomy.

There is a growing interest in the function of antioxidants and free radicals and their roles in the development of arteriosclerosis. Oxidised LDL-cholesterol and polyunsaturated fatty acids may be involved in the development of arteriosclerotic lesions. The potential of antioxidant vitamins to prevent cardiovascular disease has been the subject of many studies. Up to now the results of different in vitro and in vivo studies remain controversial. For the first time, measurements of the concentrations of lipophilic antioxidants alpha-tocopherol (vitamin E) and beta-carotene (provitamin A) in fat-tissue have been used as an approach. This method is believed to provide an average of the antioxidant intake over a longer period of time and probably reflects steady-state levels rather than intake. A case-control study was conducted using first occurrence of myocardial infarction in men as disease endpoint. In the swiss part of EURAMIC, cases were recruited in collaboration with the hospitals of Zurich. Controls were chosen randomly from the population register of Zurich. Fifty-seven male cases and 74 male controls were enrolled in the protocol. The classical risk factors showed the expected pattern. Levels for beta-carotene were significantly lower in the patient group (0.36 microgram/g biopsy versus 0.52 microgram/g biopsy in controls, p < or = 0.02). In contrast, levels for alpha-tocopherol were similar in both groups (237.5 micrograms/g biopsy in patients and 233.4 micrograms/g biopsy in controls). The Swiss alpha-tocopherol levels were the highest of all participating centres. Analyses of the questionnaires showed significantly higher consumption of vitamin C supplements in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Three different dialysis procedures have been investigated and compared with respect to the efficacy of aluminium elimination in intoxicated dialysis patients. For this purpose ten patients with increased serum aluminium have been treated for two months with the chelator DFO. The effect of DFO on the aluminium clearance has been investigated. In spite of difficult conditions during studies due to an unexpected cumulation of severe adverse effects of DFO, some statements given here may be of value for the care of hemodialysis patients: 1. Both, the commonly used cuprophan filters as well as the newer highly permeable dialysis membranes like the polysulfone membrane used in our study, permit a steady but low elimination of aluminium during a dialysis session without significant difference in efficacy. A prerequisite, however, is a very low level of aluminium in the dialysate. 2. DFO induces a dose-dependent mobilization of aluminium accumulated in the tissue. The level of plasma aluminium increases distinctly, dialysable aluminium-DFO complexes are produced, and marked amounts of aluminium can thus be eliminated by the use of DFO. 3. IF DFO is used, even the economical cuprophan membrane CF1511 may lead to a satisfactory elimination rate of aluminium. Equal increase of elimination rate is achieved whether the Cuprophan membrane CF1511 is combined with the hemoperfusion filter Alukart or the highly permeable polysulfone membrane F60 is used alone. This is of importance particularly in cases of severe intoxication with aluminium. The polysulfon dialysator may be preferred to conventional membranes combined with hemoperfusion because of the simpler handling. 4. In order to prevent accumulation of aluminium in dialysis patients, besides the use of dialysates poor in aluminium, phosphate binders containing aluminium should be avoided completely if possible. They may be replaced by the two phosphate binders calcium carbonate and calcium acetate and a diet poor in phosphates. The use of aluminium-containing phosphate-binders should be restricted to exceptional cases such as patients with hypercalcemia, severe intolerance of calcium-containing phosphate-binders or patients with hyperphosphatemia that cannot be treated otherwise. 5. Finally, regular controls of plasma aluminium levels are mandatory in dialysed patients. In cases with an increase over 50 micrograms/l and positive DFO test, DFO treatment should be initiated. Low doses of 10 mg/kg body weight DFO per week are actually in use for those cases.(ABSTRACT TRUNCATED AT 400 WORDS)

A 35-year-old Swiss woman with AIDS experienced fever, jaundice and cough. Laboratory evaluation revealed signs of an infection and cholestasis. The examination by ultrasound showed thickening of the intra- and extrahepatic bile ducts and gallbladder wall, without dilatation or stones. Endoscopic retrograde cholangiography demonstrated diffuse sclerosing cholangitis like lesions in the biliary tract and confirmed the diagnosis of a HIV related cholangiopathy. The cause was a cytomegalovirus infection as shown by liver biopsy with detection of cytomegalovirus early antigen. The treatment with ganciclovir was of some efficacy with improvement of jaundice.