[Clinical pharmacology--imaginations and realities].
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Drug Therapy↗
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Determinants of functional outcome after revascularization for critical limb ischemia: an analysis of 1000 consecutive vascular interventions.
BACKGROUND: When reporting standards for successful lower extremity revascularization were established, it was assumed that arterial reconstruction, patency, and limb salvage would correlate with the ultimate goal of therapy: improved functional performance. In reality, factors determining improvement of ambulation and maintenance of independent living status after revascularization have been poorly studied. The purpose of this study was to assess the important determinants of functional outcome for patients after intervention for critical limb ischemia. METHODS: The results of 1000 revascularized limbs from 841 patients were studied. Indications were rest pain, 41.1%; ischemic ulceration, 35.6%; gangrene, 23.3%; infrainguinal, 70.9%; aortoiliac, 24.2%; and both, 4.9%. Treatment was by endovascular intervention, 35.5%; open surgery, 61.7%; and both, 2.8%. Patient were mean age of 68 +/- 12 years, and 56.6% were men, 74.7% were white, 54.2% had diabetes mellitus, 67% were smokers, 13.4% had end-stage renal disease and were on dialysis, and 36% had prior vascular surgery. Patients were treated with conventional therapy by fellowship-trained vascular specialists at a single center and were analyzed according to the type of intervention, the arterial level treated, age, race, gender, presentation, the presence of diabetes, smoking history, end-stage renal disease, coronary disease, hypertension, hyperlipidemia, obesity, chronic obstructive pulmonary disease, previous stroke, dementia, prior vascular surgery, preoperative ambulatory status, limb loss <or=1 year of treatment, and independent living status. The technical outcomes of reconstruction patency and limb salvage as well as the functional outcomes of survival, maintenance of ambulation, and independent living status were measured for each variable using Kaplan-Meier life-table analysis, and differences were assessed using the log-rank test. A Cox proportional hazards model was used to assess independent predictors of outcome and obtain adjusted hazard ratios and 95% confidence intervals. RESULTS: At 5 years, 72.4% of the entire cohort had a patent reconstruction and 72.1% had an intact limb. Overall 5-year functional outcomes were 41.9% for survival, 70.6% for maintenance of ambulation, and 81.3% for independent living status. Outcome was not significantly affected by the type of treatment (endovascular or open surgery) or by the level of disease treated (aortoiliac, infrainguinal, or both). The most important independent, statistically significant predictors of particularly poor functional outcome were impaired ambulatory ability at the time of presentation (70% 5-year mortality, hazard ratio, 3.34; 39.5% failure to eventually ambulate, hazard ratio, 2.83; 30% loss of independent living status, hazard ratio, 7.97), and the presence of dementia (73% late mortality, hazard ratio, 1.57; 41.2% failure to eventually ambulate, hazard ratio, 2.20; 46.4% loss of independent living status, hazard ratio, 5.44). These factors were even more predictive than limb amputation alone. CONCLUSION: Functional outcome for patients undergoing intervention for critical limb ischemia is not solely determined by the traditional measures of reconstruction patency and limb salvage, but also by certain intrinsic patient comorbidities at the time of presentation. These findings question the benefit of our current approach to critical limb ischemia in functionally impaired, chronically ill patients--patients who undoubtedly will be more prevalent as our population ages.
Adult↗
[Therapy of heart failure with ACE inhibitors--"evidence-based medicine" and clinical reality].
Treatment of patients with chronic heart failure improves symptoms and NYHA functional class in about 50-80% of all patients treated. A 15% reduction can be observed in the need for hospitalisation and a 16-31% reduction in 1-year mortality. 37% risk reduction for progression to symptomatic heart failure can be achieved with ACE-inhibition in asymptomatic patients with systolic left ventricular dysfunction (55). Thus, ACE-inhibition should be part of standard treatment in symptomatic and asymptomatic patients with left ventricular dysfunction. In symptomatic patients with chronic heart failure, combination therapy of an ACE-inhibitor with digitalis and diuretics is state of the art and improves symptoms significantly. The addition of a vasodilatator can be considered in selected cases. Based on recently published data on beta-adrenoreceptor-blockade in the treatment of chronic heart failure, beta-blockers seem to get part of standard therapy of heart failure in the present and near future (2, 44, 50, 60). In spite of innovations of modern heart failure therapy prognosis is still bad. Survival after diagnosis of severe heart failure (functional class NYHA III and IV) is limited to a mean of 14 month.
Angiotensin-Converting Enzyme Inhibitors↗
[The dimension of the body and its significance in the catathymic picture perception. Suggestions for its therapeutic use with hypochondriasis as an example].
After a short presentation of the waking dream therapy of the guided affective imagery (GAI) and various theoretical comments, it is postulated according to both of Freud's reality conceptions, that also the dimensions of the bodily experience, as it expresses itself in the course of a therapy with GAI, must be split into two conceptions from psychic body reality and material body reality. Based on the therapy minutes of a serious hypochondriac an illustration of both body reality conceptions is given. In conclusion, based on eight finished therapies of hypochondriacs, it was described how hypochondriac patients describe and experience their bodies in GAI. From this it is then evident that hypochondriacs can be helped with the aid of GAI thus going against the general opinion.
Adult↗
The "holding function" of the therapist in the treatment of borderline patients.
In this paper, I have attempted to show that during crises in the therapy of borderlines it is crucial not to respond, needless to say in reality, but neither by confrontation nor with interpretation to the apparently impulse-ridden transference. To interpret to the patient, during such periods, the vicissitudes of the object hunger in the transference often intensifies the turmoil, confuses the issue, and precipitates further regression. It is of primal importance to recognize that during these crises the patient needs a holding environment to restore and enhance the observing, anxiety-containing, and integrative capacity of the ego. This holding environment rests not only on the stability of the therapeutic setting, including the reliability and acceptance of the therapist, but on helping the patient acknowledge and process the precipitants of the emotional crises.
Borderline Personality Disorder↗
[Systemic viewpoint and psychotherapeutic ethics--four imperatives].
Systems (e.g. families) tend to reduce the behavioral options of their members (a process that is usually called "trivialization"). The task of systemic therapy is to help in constructing "realities" that widen the range of possible options in a system. This demand is a value-decision as base of an ethics of systemic therapy. It is concretized in four ethical "imperatives": (1) Think and act ecologically valid! (2) Be aware of the definitions and evaluations that you make! (3) Be aware of your personal responsibility! (4) Try to create meaningful differences in a respectful way! Following these prescriptions the systemic therapist can choose interventions out of a wide range of possible behaviors, and thus has him-/herself an optimum of choices.
Adolescent↗
Is spiritual healing a valid and effective therapy?
This paper briefly reviews the evidence supporting the reality of healing as a scientifically-attested phenomenon, the techniques and mechanisms of healing and the potential value of this therapy if it were developed and integrated into the medical services. The need for further extensive research is indicated and strategies for such research are suggested.
Humans↗
[Vectors of gene transfer. Applications in pneumology].
Human gene therapy in 1996 is a reality with almost 100 trials world-wide involving nearly 450 patients. The stakes are enormous. To assure the efficacy and safety of such a regime is mainly a problem of vector to carry the chosen nucleotide sequences. The ideal vector should have as a unique function that of the transport of the gene of therapeutic interest to the desired area at the proper quantity. The ideal vector does not currently exist and each system, viral or non-viral has both advantages and inconveniences.
Base Sequence↗
What can rehabilitation interventions achieve in patients with primary fibromyalgia?
Symptoms of primary fibromyalgia (FM) persist for years, independent of applied therapy. That is the sad reality we have to deal with. But is that really true? The following review is a scan of literature from September 1, 2001 to August 31, 2002, concerning rehabilitation interventions for patients with FM, to find progress in this field and to ascertain state-of-the-art treatment strategies for the disease. The main problem when treating patients with FM successfully is the heterogeneity of the patients' group. Several investigators determined subgroups within FM patients diagnosed by the 1990 American College of Rheumatology classification criteria of FM. Therefore, uniform recommendations for treatment cannot be given. Current treatment recommendations for FM include reassurance and explanation of the nature of the illness, evaluation and eradication of mechanical stressors as far as possible, symptomatic analgesic drug treatment, moderate individually adapted physical exercises, and adjuvant psychotherapeutic support in an interdisciplinary setting. Individually adapted measures are highly emphasized to differentially treat FM subgroups, as far as identified. This review will focus on these points on the one hand, and provide an overview about the current symptomatically-oriented therapy on the other hand. This all occurs against the background of an unknown etiology of the disease so far. Experimental approaches will be noted as well. The demonstration of a long-term effective intervention for managing the symptoms associated with FM is needed.
Analgesics↗
Transference neurosis in group psychotherapy: the concept and the reality.
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Adult↗
Periodontal regeneration: myth or reality?
One of the goals of periodontal therapy is regeneration. During the past 20 years, several materials and techniques have been developed and tested for enhancing periodontal regeneration. This paper evaluates flap debridement, allogenic and alloplastic grafting, and the use of nonresorbable and resorbable barrier membranes as regenerative techniques. One of the most predictable regenerative therapies is treatment of the three-walled intrabony defect. This defect can be repaired with 2 to 2.5 mm of bone fill and results in significant gains in clinical probing attachment and decreases in probing depths. There is a slightly greater improvement in periodontal measures with barrier membranes. Commercial preparations of allogenic bone and alloplastic fillers have a long, safe history of use and are primarily osteoconductive. They decrease probing depths and provide short-term gains in clinical attachment levels. Barrier membranes provide short-term evidence of improving Class II furcation invasions, however there is insufficient evidence that these improvements are sustained long-term. Class III furcations are not predictably treated by regenerative therapies. To date, there is an absence of clinical evidence that regenerative therapy increases the long-term life span of teeth.
Alveolar Bone Loss↗
[Prescription of antiretroviral and prophylactic drugs in HIV diseases: reality of medical practices].
Antiretroviral and prophylactic therapy given to HIV-infected patients attending hospital (DMI 2 data base) was analyzed according to TCD4+ cell count; 19,020 patients were included in the study. Under 200 TCD4+/mm3, more than 80% of the patients received antiviral therapy, most often AZT (45.3%) or ddI (27.2%). Combined treatment was quite low, less than 8%. Although above 500 TCD4+/mm3, 11.6% of patients received AZT, this study showed that antiretroviral therapy followed French recommendations. This was not the case for prophylaxis: a large proportion of patients under 200 TCD4+/mm3 did not received pentamidine aerosol, or cotrimoxazole, or dapsone.
Anti-Infective Agents↗
The uses and abuses of meta-analysis.
Meta-analysis is a quantitative process of summary and interpretation which involves pooling information from independent studies concerning a single theme in order to draw conclusions. Greatly increased employment of meta-analysis is currently being advocated for clinical and policy decision making. However, the prestige of meta-analysis is based upon a false model of scientific practice. Interpreting empirical research is an extremely complex activity requiring clinical and scientific knowledge of the field in question; and teams of professional 'meta-analysts' with a primary skill base in information technology and biostatistics cannot take over this role. Meta-analysis is not a hypothesis-testing activity, and cannot legitimately be used to establish the reality of a putative hazard or therapy. The proper use of meta-analysis is to increase the precision of quantitative estimates of health states in populations. If used to estimate an effect, the reality of that effect should have been established by previous scientific studies. But the summary estimate from a meta-analysis can only be directly applied to a target population when the 'meta-protocol' and 'meta-population' match the target situation in all relevant particulars. These constraints can rarely be satisfied in practice, so the results of meta-analysis typically require adjustment--which is a complex, assumption-laden process that negates many of the statistical power advantages of a meta-analysis. Lacking any understanding or acknowledgement of the need for adjustment, most meta-analyses must be regarded as abuses of the technique.
Clinical Trials as Topic↗
[The development of our therapeutic concept in the treatment of ulnar epicondyle fractures].
50 patients with epicondylus ulnaris fractures are analysed. 4 types of fracture are recognised. The results of therapy are often described in literature much more optimistically than in reality. The first critical examination and the selection of therapy, mostly a surgical intervention, had a great influence on mobility of the elbow joint, on strength and subjective perception. The results could only be assessed after three years. Complications of concomitant injuries - nerve lesion and ligament/capsule structures - were discussed with regard to surgical approach.
Arthrography↗
Gene therapy in vascular surgery comes of age.
In the last decade, gene therapy for cardiovascular diseases has been becoming a reality. However, although numerous successful experimental studies have suggested possible strategies of gene therapy for cardiovascular disorders, the clinical outcome remains limited. Because cardiovascular diseases are the result of complex causes, there is no exact answer to the following question: Which is the best gene to treat vascular diseases? In addition, current limitations include less clinically relevant vectors regarding both gene-transfer efficiency and safety, and at present, most efforts are focused on identifying more effective therapeutic genes, as well as developing more effective vectors. Furthermore, greater pathophysiologic understanding of these diseases, including vein-graft remodeling and ischemic limbs, is required. Regarding the relevant vector, we recently developed a novel mononegavirus-based gene-transfer vector, namely recombinant Sendai virus, which has shown dramatically superior gene-transfer efficiency to other vectors, including adenovirus, in several organs (eg, the vessel wall and skeletal muscles). These efforts now offer new possibilities to get more fruits in the field of gene therapy for vascular surgery.
Combined Modality Therapy↗
Current perspectives in immunotherapy.
Since the declaration of the war on cancer in 1971, our ability to effectively treat cancer has been less successful than anticipated. Surgery and radiation therapy remain our most effective treatment modalities, with chemotherapy proving beneficial in only a limited number of tumor types. The reality of this poor response to conventional therapy has prompted a search for other potentially beneficial therapies. The idea of using the immune system to eradicate tumor is not new. Over 100 years ago, William Coley (in 1893) first reported on the ability to induce tumor regressions by nonspecific activation of the immune system in response to bacterial toxins. Despite this early beginning, efforts to reliably manipulate the immune system to promote tumor regression has been universally disappointing. With recent advances in our understanding of the immune system, and the identification and availability of numerous growth promoting and growth-suppression cytokines, the concept of immunotherapy being a useful therapeutic intervention for the treatment of cancer is becoming a reality. Immunology in general, and tumor immunology specifically, are fields foreign to the practicing tumor surgeon. As progress in these fields are made, it will become important for the surgical oncologist to have a better understanding of tumor immunology as it relates to therapy. This paper reviews our current understanding of the immune system as it relates to cancer immunotherapy (using primary intracranial glioma as the tumor model), and then relates this knowledge to recent work in the development of tumor-specific vaccines.
Cytokines↗
Percutaneous approaches to valvular heart disease.
Percutaneous endovascular therapy has now become a reality. From early balloon valvotomy for valvular stenosis, technologies have been developed that allow percutaneous replacement of pulmonic and aortic valves and repair of regurgitant mitral valves in selected patients. Following extensive investigations in animals, early clinical reports have shown successes in selected patients. As criteria for patient selection and clinical safety and efficacy trials progress, the role of these new technologies in patient care strategy will become better understood.
Adolescent↗