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The vast majority of minor burns requiring treatment are best managed by clear rational concepts of therapy. If these burns are either treated less than optimal or overtreated, complications like infections or delayed wound healing may ensue. In order to draw conclusions from data obtained in studies on patients with minor burns, we need cohort studies making use of clearly defined therapeutic concepts.
There is a small but growing body of research supporting the effectiveness of computer-generated environments in exposure therapy for driving phobia. However, research also suggests that difficulties can readily arise whereby patients do not immerse in simulated driving scenes. The simulated driving environments are not "real enough" to undertake exposure therapy. This sets a limitation to the use of virtual reality (VR) exposure therapy as a treatment modality for driving phobia. The aim of this study was to investigate if a clinically acceptable immersion/presence rate of >80% could be achieved for driving phobia subjects in computer generated environments by modifying external factors in the driving environment. Eleven patients referred from the Accident and Emergency Department of a general hospital or from their General Practitioner following a motor vehicle accident, who met DSM-IV criteria for Specific Phobia-driving were exposed to a computer-generated driving environment using computer driving games (London Racer/Midtown Madness). In an attempt to make the driving environments "real enough," external factors were modified by (a) projection of images onto a large screen, (b) viewing the scene through a windscreen, (c) using car seats for both driver and passenger, and (d) increasing vibration sense through use of more powerful subwoofers. Patients undertook a trial session involving driving through computer environments with graded risk of an accident. "Immersion/presence" was operationally defined as a subjective rating by the subject that the environment "feels real," together with an increase in subjective units of distress (SUD) ratings of >3 and/or an increase of heart rate of >15 beats per minute (BPM). Ten of 11 (91%) of the driving phobic subjects met the criteria for immersion/presence in the driving environment enabling progression to VR exposure therapy. These provisional findings suggest that the paradigm adopted in this study might be an effective and relatively inexpensive means of developing driving environments "real enough," to make VR exposure therapy a viable treatment modality for driving phobia following a motor vehicle accident (MVA).
The cumulative evidence acquired over 20 years suggests that beta-blockers improve functional capacity, ventricular function, and decrease mortality in patients with heart failure either due to dilated cardiomyopathy or ischaemic heart disease. This effect is independent of the beneficial effects of digoxin, diuretics and particularly ACE inhibitors and has resulted in re-evaluation of requirements for transplantation in patients with advanced cardiac failure. Ninety percent of patients appear to respond to beta-blockers but no clinical or biochemical parameters can identify a favourable response. The beneficial effects occur slowly but last for years. Further ongoing trials will provide more information but beta-blockade therapy should be considered in addition to other therapy in the management of heart failure.
Antibiotics inspite of certain contradictions remain an important part of the treatment of mucoviscidosis (MCV). Despite this the current practice of their extensive use does not always rest on firmly placed criteria. Before colonisation with pseudomonas (PA), the systemic prophylaxis of infection by Staphylococcus (SA), or Hemophilus (HI) is debatable. At the time of exacerbations, even if this may be caused by a virus, the prescription of antibiotics (ATB) active against SA and HI should often be continued for 2 or 3 weeks to maintain a durable clinical benefit. While awaiting the results of complimentary multi-centre trials at present underway it remains uncertain whether eradication of the germ at all costs remains indispensable. Systemic anti-PA antibiotic therapy given quarterly from the time of the implantation of the germ has not yet proved to have definitive advantages when compared to the treatment of exacerbations. An appreciation of the benefit of therapy should take count not only of survival curves but also of the quality of life. The indications for treatment should not neglect the possibility of therapeutic progress, sometimes unexpected. Intensive therapy may be justifiable in certain cases awaiting a lung transplant. ATB is only one part of treatment aimed strictly at the broncho-pulmonary system. Drainage and account of infectious agents other than classical bacterial infections or pathogenic mechanisms other than infections (nutritional problems, bronchial hyper-reactivity, immunological phenomenon, or primary or secondary inflammatory changes) should not be ignored.
The use of a variety of diagnostic and therapeutic procedures made available by modern technology for critical patients have given rise to forms of death which are incompatible with a person's dignity in cases in which the inevitable occurrence of death is inexplicably delayed. The search for the multiple factors influencing this phenomenon, related to the development and progress of medicine, leads to the investigation of four aspects deemed essential in their determination: imperative technology, sanctity of life, omnipotence of medicine and the lack of a unique medical decision. Apart from the availability of high technology, there is an increasing requirement of the patient's full autonomy with respect to the decisions involving the end of his life, which include the debated right to die. In the struggle towards death with dignity in a context where practical decisions are required, the following are taken into account: refusal of treatment, irreversibility of clinical diagnosis and palliative support, and withholding and withdrawal of life-sustaining therapy.
OBJECTIVES: To determine the concordance between referring physician behavior and published criteria for performance of imaging studies and institution of prophylactic therapy, respectively, in children referred to an academic children's hospital headache clinic. Study design A retrospective review of the records of 106 consecutive patients referred to an academic children's hospital headache clinic. RESULTS: Approximately half of patients referred to the clinic had already had head computed tomography or magnetic resonance imaging ordered by the referring doctor and performed before their clinic appointment. However, using published criteria, only 10% of patients seen in the clinic would have required an imaging procedure before institution of therapy. The referring physician had initiated treatment with daily prophylactic medications for headache in more than 30% of patients before their clinic appointments, of whom 89% were on appropriate medications at age-appropriate and weight-appropriate doses. Half of these children exhibited a positive response to this medication before being seen by the consulting neurologist. However, more than 60% of the children actually met the criteria for recommending prophylactic therapy. CONCLUSIONS: Imaging is more frequently obtained and prophylactic therapy less frequently implemented by the referring physician than would be indicated by published recommendations.
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Malignant gastrointestinal tumors are still worldwide a very common cause of death from cancer. Even though the surgical techniques and the neoadjuvant/adjuvant therapies have improved over the last years and multimodal concepts in cancer treatment have been established, these types of tumors remain a challenge. Therefore predictive/prognostic markers need to be established, to be able to tailor chemotherapies and therefore improve efficacy of neoadjuvant/adjuvant treatment. Over the last years potential predictive/prognostic factors have been characterized by molecular-biological technologies: the tumor suppressor gene p53, the cell-cycle regulatory proteins p21 and p27, the marker of proliferation Ki-67, the epidermal growth factor receptor, HER2/neu, angiogenetic factors (the vascular endothelial growth factor, cyclooxygenase 2, thymidine phosphorylase), enzymes involved in the DNA-repair-system (ERCC1), enzymes involved in the 5-fluorouracil-metabolism (thymidylate synthase, dihydropyrimidine dehydrogenase) or other genetic alterations, like the loss of heterozygosity or the microsatellite instability. The results of the mainly retrospective studies are promising but prospective studies are needed to validate those markers in the therapy of gastrointestinal tumors. The goal is that we will be able to predict when and with what to treat.
Although remarkably successful in prolonging useful life, there is minimal probability that the majority of the world's population will benefit from contemporary therapy for irreversible renal failure because of its inordinately high cost in light of available resources. While affluent nations establish priorities for allocation of slots for maintenance dialysis of recipients of organ transplants, poor and developing countries must await the development of inexpensive, low technology treatments to substitute for absent kidney function. One attractive potential alternative to contemporary uremia therapy is the use of the intestine as a giant substitute and somewhat displaced nephron. Possible means of extracting wastes via the gut include ingestion of a mixed oral sorbent, instillation of bacterial crystallized enzymes to transform nitrogenous wastes to essential amino acids, or administration of high osmolality laxatives to promote diarrhea containing nitrogenous wastes. Any of these approaches may extract sufficient solute and water to sustain anephric life. An optimistic view of evolving uremia therapy is that within the next decade pills and purges for the poor may supplant more effective though expensive high technology approaches now encompassed in so-called modern nephrology.
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Treating cancer by targeting its vasculature is a recent conceptual revolution. The use of newly discovered potent antiangiogenic factors has confirmed the anti-growth and anti-metastatic efficiency of anti-angiogenic therapy in a variety of experimental solid tumour models. Using gene transfer technique to deliver anti-angiogenic molecules in vivo is becoming a widely accepted new approach. This review summarizes the biological basis, current situation and development trends of this new therapy, as well as its promising perspectives in cancer treatment.
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