Zeitschrift fur arztliche Fortbildung最新文献

As for generally accepted therapeutic methods, the "special methods" may appear to be effective due to spontaneous recovery provided by nature. A great number of sceptical physicians are aware of this fact. The pharmacologist works continuously to differentiate effects directly caused by medical treatments - mainly drugs - from effects resulting from spontaneous recovery. This is one of the most difficult problems in medical treatment. As a representative example of all "special methods", we concentrate here on the history of homeopathy. As is generally known, there is no conformity in homeopathy, for example monotherapy versus therapy with complex homeopathic products; refusing the simile-rule; treatment with high potencies versus treatment with low potencies; classic versus scholastic homeopathy. The number of homeopathies really equals the number of homeopathic physicians. For this reason, instruction in homeopathy on the academic level is impossible. In addition, we have to forget all natural laws only to prove that "potentiation" may be true. Therapeutic success due purely to chance may be explained rationally and is occasionally seen in all other "special methods". The theories of homeopaths for the action with homeopathic products are neither in accordance with our natural laws nor comply with a rational philosophy.

Quality assurance for acupuncture therapy requires a good basic and on-going training in both conventional western medicine as well as in the theory and practice of acupuncture, the ability to synthesize the patient's objective findings and subjective feelings, and honesty with the patient and towards oneself. Thus, based on the continuous critical evaluation of the objective and subjective parameters, the question of acupunture as the optimal form of therapy for this specific case is honestly answered and one has the courage to admit failures. With regard to the theory, surveys of the acupuncture literature show that a considerable improvement in quality and honesty is necessary. There is a lack of standardised experimental methods (e.g. 28 different placebos in 28 different studies!). Especially German acupuncture journals have a disturbed relation to failures. To hide or deny failures is of no benefit neither to acupuncture, science to the relationship between the physician and the patient since the practitioner must be able to rely on the information in the literature. Furthermore, one should be open minded to alternative methods even if this means to refer a patient to a colleague.

Impairment of the autonomic nervous system is frequently detectable in diabetic patients. Symptoms and signs are less often observed but if present may be very important with regard to quality of life, metabolic control, and prognosis. Currently used methods to detect disturbances of the autonomic innervation of the cardiovascular system are easily performed, noninvasive, reliable and reproducible. They are not very time consuming and require only standard technical equipment allowing the quick identification of patients at risk. Damage of the cardiovascular autonomic nerve function may explain apparently disparate complaints and signs, i.e. orthostatic hypotension, painless myocardial ischemia, complications during anesthesia, postprandial hypotension and development of the diabetic food syndrome. The diagnosis of asymptomatic cardiovascular neuropathy should always induce attempts to intensify diabetes treatment because better metabolic control may improve or at least stop deterioration of nerve function.

Sleep disorders in central or peripheral nervous system diseases frequently occur, but they often are neglected in diagnosis and therapy. During the last 20 years, sleep medicine has obtained more and more importance. It is possible to draw conclusions about the topical organization of sleep-wake-regulation by investigating of certain diseases. In the following survey the most important clinical pictures in neurology are described in consideration of an affected sleep. Typical symptoms and polysomnographic findings as well as recommendations for therapy are demonstrated.

A comparison of general medicine in a de jure (Germany) and de facto (Netherlands, Great Britain) existing structured primary care model describes the present state as well as the pro and contra of the strengthening of the general practitioner (GP) within the primary health care system. For the patient, the better continuity and comprehensiveness of care has to be emphasized. For the patients, who choose to inscribe on a list of a GP, a reduction of health insurance fees is proposed for the German out-patient care system. Another option would be to reimburse a specialist's service with 80% when he has been consulted directly but with 100% after referral from a GP. The patient care must be strengthened by a modification of the fee system and the task description of a GP has to be defined and delineated from specialist medicine.

The homeopathy is a therapeutic line developed about 170 years ago which is based on the sciences of the late 18th century. The homeopathy is founded (1) on the vitalism of Aristoteles, (2) on the examination of remedy reactions in healthy subjects as basis of the therapy of patients, (3) on the "simile" rule, that means the treatment of symptoms with remedies which produce similar symptoms of a mild intoxication in healthy subjects, (4) on the principle of potentiation with the opinion that low doses provoke stronger therapeutic effects, (5) on the individual finding of a remedy due to an extensive anamnesis and (6) on the principle of nosodes, that means the use of diluted body secretion due to infectious diseases for therapy. The therapeutic principles of homeopathy are based on insecure hypotheses and on the patient's information of improved behaviour. Thus, homeopathy does not agree with the present natural science.

The phytotherapy should be understood as being integrated into the rational pharmacotherapy. The modern phytotherapy tries hard to proof effects with pharmacological and clinical studies. The task force E of the federal bureau of health of Germany has made a statement regarding this problem. This article reviews only controlled clinical trials about the application of extracts of echinacea purpura or echinacea pallida.

The treatment of chronic pain consists of four basic concepts: Drugs (analgetic drugs, TAD, etc.), treatment by physicians (chiropraxis, massage, TENS, etc.), injection with local anesthetics and autosuggestion. Necessary for diagnosis and treatment of chronical pain is the knowledge of pathophysiology and anatomy of nerves, ligaments, muscles and the sympathetic nervous system. Diagnosis of chronical pain rarely includes roentgenograms or other technical procedures, mainly to exclude tumors, fractures or specific infections. The knowledge of pathophysiology means the knowledge of sympathetic and motoric efferences on one side and the functional examination of the anatomic structures on the other side.