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A 55-year-old woman presented with blistering on the back of her hands and shiny, thickened skin in her décolletage. Laboratory examination revealed increased urinary total and high carboxylated porphyrins and homozygosity for mutation C282Y in the HFE gene. Histopathology showed thickened collagen fibers in the presternal region. Based on these findings we made the diagnosis of porphyria cutanea tarda with pseudoscleroderma and hemochromatosis. Pseudoscleroderma is a rare complication of PCT but can also constitute the first cutaneous symptom of the disease, leading the way to diagnosis. Usually, adequate treatment of PCT with normalization of porphyrin values also results in improvement of pseudoscleroderma.

Background: Treatment for chronic low back pain in primary care has a poor-quality outcome. There is evidence that multimodal therapy is the most successful approach to its management. We tried to evaluate whether giving primary care physicians evidence-based recommendations on therapy of chronic back pain or directly implementing a multimodal program would improve the outcome of patients with low back pain treated in primary care., Methods: In the first phase, physicians were asked to document the course of patients suffering from low back pain of at least 4 weeks' duration with no decrease in intensity, noting pain intensity before and after 6 months of conventional, nonsurgical treatments. In the present, second, phase of the study, recommendations issued by the Medicines Committee of the German Medical Profession and the U.S. Agency for Health Care Policy and Research for the management of back pain were presented to doctors in printed form and at conferences. In parallel with this, a multimodal program for the treatment of chronic low back pain (4 h/day for 20 days: medical training therapy, cognitive-behavioral therapy, physiotherapy, and patient education) was organized in a private health-oriented sports center in cooperation with three private physiotherapy practices, and a psychologist and a pain specialist from the outpatient pain clinic at the University Hospital in Erlangen. We examined how physicians changed the therapy and how effective it was, the latter as reflected in the mean sum value of the percent pre- to posttreatment changes in pain intensity, how much pain interfered with daily living, depressivity, and quality of life. Data after interventions were compared with baseline data from the first phase., Results: Data relating to 36 patients following treatment by 14 primary care physicians who had been given information about therapy recommendations and to 51 patients who had participated in the multimodal therapy program were compared with baseline data recorded in 157 patients. Recommendations changed neither the therapy preferred by primary care physicians nor the quality of outcome of conventional treatment. In contrast, the multimodal program of therapy for chronic low back pain improved the outcome significantly more than conventional therapy (mean improvement in general outcome score 22 vs. 7%, respectively, compared with baseline data; P<0.001)., Conclusions: Giving primary care physicians information on the therapy recommended for treatment of low back pain does not lead to any change in physicians' preferred therapy. Multimodal programs for treatment of chronic low back pain should be organized locally, with existing health care providers joining forces to improve the quality of outcome in chronic low back pain managed in primary care.

Background: Intima-media thickness (IMT) of carotid arteries, measured by vascular ultrasound, has widely been used as a surrogate marker for coronary atherosclerosis. As recent studies showed significant but only weak correlation between IMT and coronary artery stenoses, this study evaluated calcified plaques in the extracranial carotid arteries as a reasonable marker for coronary artery disease., Patients and Method: 139 patients underwent cardiac catheterization with selective coronary angiography and ultrasound examination (B-mode, standard Doppler, color Doppler) of the carotid arteries. In case of calcified plaques number and distribution among the extracranial cerebral arteries were determined (Figure 1). Coronary angiograms were analyzed for disease severity and extent (number of main vessels with > 50% stenosis). Besides the traditional vascular risk factors hypertension, diabetes, smoking and hypercholesterolemia as well as body mass index, age and sex were analyzed., Results: Calcified plaques of carotid arteries were significantly correlated (r = 0.502, p < 0.001) with coronary artery stenoses as well as hypercholesterolemia (r = 0.410, p < 0.001), increasing age (r = 0.406, p < 0.001) and diabetes (r = 0.290, p < 0.001) in contrast to hypertension (r = 0.125, p = 0.075), smoking status (r = -0.043, p = 0.311), body mass index (r = -0.122, p = 0.083) and male sex (r = -0.103, p = 0.114) (Table 1). The number of calcified plaques was significantly correlated (r = 0.568, p < 0.001) with severity and extent of coronary artery disease, too (Figure 2). For two and more calcified plaques sensitivity concerning coronary artery stenoses was 80%, specificity 75%, positive predictive value 83%, negative predictive value 73% (Table 2). Multiple stepwise regression analysis was performed for all eight variables (calcified plaques, hypercholestrolemia, diabetes, hypertension, smoking status, age, sex, body mass index). Including calcified plaques the predictive value of all factors was higher (r = 0.644 to r = 0.607)., Conclusions: Determination of calcified carotid plaques by ultrasound is useful to improve the predictive value of risk factor-based multivariate models based on traditional risk factors.

Objective: The aim of this randomized cross-over study was the comparison between a sequential 28-day hormone replacement therapy (HRT) using micronized estradiol and a cyclic 21-day HRT using estradiol valerate with regard to the pharmacokinetics of estradiol. -, Material and Methods: Fifty postmenopausal women were randomly assigned to be treated either with Trisequens(R) for 28 days or with Sisare(R) for 21 days. After a wash-out cycle, the women were treated for one cycle with the other preparation in a cross-over fashion. The pharmacokinetic profile of the serum concentrations of estradiol was measured on day 1, 21 and 28 each immediately before and 1, 2, 4, 6, 8, and 10 hours after intake of a tablet, and the AUC (area under the curve) was calculated. -, Results: The serum concentrations of estradiol increased from a mean of 10 pg/ml up to 40 pg/ml (Trisequens(R)) and 30 pg/ml (Sisare(R)) on day 1, and to 80 pg/ml (Trisequens(R)) and 60 pg/ml (Sisare(R)) on day 21, and declined to 40 pg/ml (Trisequens(R)) and 10 pg/ml (Sisare(R)) on day 28. The AUC as calculated from both treatment cycles, was significantly higher on day 1, 21, and 28 during treatment with Trisequens(R) than with Sisare(R). This difference was, however, not signifcant on day 1 and 21 of the first treatment cycle. -, Conclusion: During treatment with 2 mg micronized estradiol the serum concentrations are significantly higher than with 2 mg estradiol valerate. On day 28 of treatment with Sisare(R), the estradiol levels decline to baseline values, while using Trisequens(R) they remain in the range of those measured on day 1.

Background: Treatment of patients suffering from migraine and/or tension-type headache in primary care needs to be improved. To this purpose we tested two strategies for implementation of evidence-based recommendations for treatment of headaches: first, communication of recommendations to the primary care physicians and, second, standardized communication and discussion of these recommendations with patients in combination with exercising of progressive muscle relaxation during patient seminars., Methods: Patients with at least 2 migraine attacks/month or 8 days of tension-type headache/month were included in the study. Evidence-based pharmacological and non-pharmacological recommendations of the Medicines Committee of the German Medical Profession for treatment of migraine and tension-type headache have been offered to primary care physicians by printed material and during conferences. Patient seminars at 10 days for 2 hours were organized by the outpatient pain facility of the neurological department of the university of Erlangen. During seminars the patients were informed about these recommendations and learned progressive muscle relaxation. Agreed therapy between physician and patient was documented by physicians and patients during a 6 months treatment interval and compared with the recommended therapy. Effectivity of treatment was assessed by pre-post changes of days of headache/month, attack frequency/month, headache intensity (visual analogue scale), pain related impairment (German version of the Brief Pain Inventory), and health related quality of life (German Version of the SF-36). 51 patients were documented by 24 primary care physicians after communication of recommendations and 46 patients completed the patient seminar. Data of both groups were compared with those of 80 patients from primary care physicians before interventions., Results: Communication of recommendations for headache therapy to primary care physicians did not improve conformity of the agreed therapy with the recommended. Contrary conformity of the agreed therapy for pharmacological treatment of migraine attacks and interval therapy of migraine by progressive muscle relaxation with the recommended therapy improved significantly. However, interventions did not significantly improve the outcome quality of outpatient treatment as compared to the therapy of primary care physicians before interventions., Conclusion: Effectivity of headache treatment in primary health care could not be improved by communication of evidence-based recommended therapy to primary care physicians nor by direct information of patients about these recommendations in combination with provided availability to learn progressive muscle relaxation.

Background: The basal cell carcinoma which is often occurring in the elderly can be well treated by surgery. For large and recurrent lesions and in cosmetically difficult locations external beam radiotherapy provides an equally effective treatment alternative., Patients and Methods: From 1986 to 1999, 60 females and 39 males received primary radiotherapy for a total of 127 histologically verified basal cell carcinoma lesions. Tumors were mostly localized in the face at the temple, nose and forehead. Radiotherapy was applied with orthovoltage equipment and energies of up to 100 kV. Single doses ranged from 2 to 5 Gy related to the 80%-isodose depth. Weekly doses ranged from 8 to 25 Gy and total doses from 25 to 60 Gy. The mean follow-up period was 36 +/- 21 months. The acute sequelae were scored according to CTC criteria. Radiogenic late effects as single events were related to the radiation portal., Results: 3 months after treatment all besides one patient (99%) experienced complete tumor remission (CR). In all cases, acute radiation reaction occurred within the radiation portal: CTC Grade 1 in 100%, CTC Grade 2 in 54% and CTC Grade 3 in 30% of the cases. All side effects regressed under simple local measures without further complications. Late sequelae were observed in three cases. Overall cosmetic outcome was good to excellent in almost all patients (98%). In two cases (2%) a local recurrence was observed 6 and 20 months after radiotherapy., Conclusion: External beam (orthovoltage) radiotherapy is very effective and yields high tumor control rates and good cosmetic results in long-term follow-up. Former dermatological treatment concepts should be replaced by an ICRU-based radiophysical dose prescription and should respect the newer radiobiological fractionation principles.

Background: Little is known about the outcome-quality of treatment for headache on primary care conditions in Germany., Methods: All physicians (2100) of middle franconia, a bavarian greater district with 1,6 Mio. inhabitants, involved in outpatient management were asked to include consecutively patients in the study which suffer from migraine (at least 2 attacks/month) and/or tension type headache (at least 8 days/month) of at least 4 weeks duration. Before and after a 6 months interval patients documented the following outcome data in a questionnaire: pain intensity during the last attack (numeric rating scale), pain dependent disability (Brief Pain Inventory, German version), health related quality of life (SF-36, German version) and depressivity (Allgemeine Depressionsskala). The pain chronification state (Mainz Pain Staging System) has been assessed by the physician. Therapy was not standardized and included the natural spectrum of medicamental and non-medicamental therapy of headache. Agreement of therapy with recommendations of the "Arzneimittelkommission der Deutschen Aerzteschaft" has been assessed., Results: 24 physicians participated in the study. Pre-post-data of 80 patients (46+/-14 y) could be analysed. Initially 67% were classified in pain chronification state I, 27% in state II and 6% in state III. Medicamental therapy agreed with recommendations in approximately 50% of patients, non-medicamental therapy has been used rarely. The pain intensity, pain dependent disability, depression and quality of life improved significantly. 45% and 55% of patients improved in at least 2 of 6 outcome-parameters by 30% of baseline value or by half standard deviation of the corresponding pre-post-differences, respectively. The latter outcome-measure reflects a medium effect size., Conclusions: On primary care conditions about 50% of patients suffering from migraine and/or tension type headache (predominantly low chronification stae) perceive a therapy effect that corresponds to a medium effect size.

Background: Evidence based standards for structure quality in out-patient management of chronic pain states do not exist. Therefore we tried to evaluate if german standards for outpatient management of chronic pain states which are based on opinions of experts for pain management influence the outcome quality of independent physicians for treatment of chronic low back pain., Methods: 35 independent physicians, selected on a voluntary basis from 2100 physicians of a bavarian greater district with 1,6 Mio. inhabitants, and one outpatient treatment facility for pain patients of the university of Erlangen-Nuremberg have been evaluated by questionnaires. Questions examined certain structural conditions of the treatment facility as compared to german guidelines for outpatient treatment of pain patients ("Schmerztherapievereinbarung"). 157 patients suffering from chronic low back pain documented before and after a treatment interval of 6 months their pain intensity during the last 24 hours (numeric rating scale), the interference of pain with daily living (german version of the Brief Pain Inventory) and their quality of life (SF-36). Pre-post changes have been used as parameters for outcome quality., Results: Neither baseline data nor pre-post differences of outcome parameter did correlate significantly with the scores of structure quality (17-71% of maximum) of the treatment facilities. However, multimodal therapy programs have not been used for pain management., Conclusions: Structural indicators of german guidelines for outpatient treatment of pain patients ("Schmerztherapievereinbarung") are not sufficient to improve outcome quality of patients with chronic back pain. Multimodal therapy programs have been shown to be effective in chronic back pain and should be implemented in the guidelines.

Background: Little is known about the outcome quality of treatment for chronic low back pain under primary care conditions in Germany., Methods: All physicians (2100) of middle Franconia, a region of Bavaria with 1.6 million inhabitants, involved in outpatient management were asked to include consecutively patients who suffered from low back pain of at least 4 weeks duration without decreasing intensity. Before and after a 6-month interval patients documented the following outcome data in a questionnaire: pain intensity during the last 24 hours (numerical rating scale), pain-dependent disability (Brief Pain Inventory, German version), health-related quality of life (SF-36, German version), depression (Allgemeine Depressionsskala), pain chronification state (Mainz Pain Staging System) and the days of inability to work within 3 months before start and end of the interval. Treatment of patients was not standardized and included the natural spectrum of non-surgical therapies for low back pain except multimodal pain therapy programs., Results: Thirty-five physicians participated in the study. "Before and after" data of 157 patients (43+/-12 years) could be analysed. Initially 20% were classified in pain chronification state I, 57% in state II and 23% in state III. The pain intensity, pain-dependent disability, depression and quality of life improved significantly but mean differences and effect sizes were small (p<0.41). Less than one third of patients improved by 30% or more from baseline or by one step in the chronification state of pain. Days off work did not change significantly. Predictors for positive therapy response could not be identified., Conclusions: Monodisciplinary treatment procedures are not sufficient to ameliorate problems of patients in advanced chronification states of back pain.

The replacement of finger joints, especially of the proximal interphalangeal joint (PIP), remains an unsolved problem. Long-term results of conventional reconstructive procedures as well as previously available artificial joint implants have been disappointing. In a controlled study, 12 PIP-joints were replaced by a new type of total endoprosthesis as an alternative to joint fusion. The cementless prosthesis is unhinged and consists of metal joint surfaces. After a follow-up of 18 months, implantation of this metal prosthesis resulted in almost complete pain relief and an active range of movement of 58 degrees. The absolute gain in mobility, however, was only 6 degrees. A swan-neck deformity was found in nine out of 12 cases but corrective surgery was not required. The proximal half of the implant had to be exchanged in two cases due to loosening. All patients were satisfied with the result. The disparity between subjective acceptance by the patients, who clearly prefer joint replacement to fusion, and objective results demonstrates the necessity for further development in this field. The type of prosthesis used in this study seems to be a useful baseline tool which could be turned into a ingenious PIP-joint replacement by further development aiming at reduced abrasion, increased initial stability, a more individual configuration, to name just a few goals.

Background: Outcome quality of medical treatment depends on structure quality of the treatment facility. In the present study we tried evaluate structural parameters of outpatient treatment facilities relating to management of headache, low back pain and cancer pain., Methods: 109 outpatient treatment facilities (104 offices, 3 outpatient departments of hospitals, 2 pain ambulances of hospitals) in middle franconia, one of the larger Bavarian administrative division (population: 1,6 Mio.), have been evaluated by questionnaires. Questions examined certain structural conditions of the treatment facility as compared to german guidelines for outpatient treatment of pain patients ("Schmerztherapievereinbarung")., Results: Only one treatment facility worked within an interdisciplinary setting. Less than 25% (median) of total patients of an outpatient treatment facility suffered from acute or chronic headache, low back pain or cancer pain. 38% of physicians participated regularly on pain conferences. Established methods for diagnosis and documentation of patients suffering from chronic headache, chronic back pain and cancer pain were regularly used by 16%, 12% and 10% of physicians, respectively. Regular interdisciplinary cooperation in the management of patients with chronic headache, chronic back pain and cancer pain was indicated by 28%, 24% and 41% of physicians, respectively. However, personal discussion of patient related problems took place in less than 5% of physicians. Although a considerable number of different therapies (included as standard therapy for outpatient management of chronic pain in the "Schmerztherapievereinbarung") can be applied in each outpatient treatment facility (median:5), psychological therapy for management of chronic headache, chronic back pain and cancer pain was used regularly by 5%, 2% and 7% of physicians, respectively. Scoring of all examined structural parameters provides a measure for the quality of the parameters of a certain outpatient treatment facility as compared to that of an optimal outpatient facility for pain treatment (quality score=100%). However, 75% of examined outpatient treatment facilities reached quality scores only up to 43%., Conclusions: There are considerable structural deficits in outpatient treatment facilities involved in management of patients suffering from chronic headache, chronic back pain and cancer pain. Realisation of standards according to the "Schmerztherapievereinbarung" needs organisation of an interdisciplinary network between the different specialties necessary for pain management. Interdisciplinary cooperation should be supported by the official organization of the medical self-government in Germany--the Kassenärztliche Vereinigung--which has to assure optimal conditions for outpatient treatments.

Because of age-related modifications of the heart, lung, and circulation, several cardiopulmonary parameters present altered normal and reference values with increasing age. Other parameters, for example, arterial blood pressure, change only insignificantly with age. In older age groups it is more difficult to establish reference ranges and values because of the lack of "healthy" subjects. To establish cardiopulmonary parameters, appropriate investigations for the age group, for example, treadmill-ergometer, should be preferred. In judging if a value resulting out of the reference range is to be considered really pathologic, other factors are to be taken into account, such as circadian variations, motivation, associated pathologies as well as the actual physical and psychological conditions, when we are dealing with older subjects or patients.

Unlabelled: In Middle Franconia, one of the larger Bavarian administrative division (population 1994: 1,657,101), the number of patients suffering from cancer pain, chronic headache and chronic back pain is not known. Furthermore, there are no data on interdisciplinary organization of outpatient pain management., Methods: All physicians and psychologists involved in outpatient pain management in Middle Franconia (n=2130) were asked (questionnaires) to estimate the number of patients suffering from cancer pain, chronic (>6 months) headache and chronic (>6 months) back pain treated the last 12 months., Results: 264 (12.4%) responses were analyzed; 107,346 patients had been treated in the last 12 months, 67% by a single specialist and 33% by two or more specialists. The participation of psychotherapists and anesthetists in outpatient management of pain patients was poor; 22,754 (21%) patients were thought to need multidisciplinary analgesia therapy in a pain clinic, which actually does not exist in Middle Franconia., Conclusion: The data presented suggest that patients suffering from chronic pain are not optimally managed in Middle Franconia. Regional institutions for multidisciplinary pain treatment have to be established close to where chronic pain patients live.

Between 1 January 1992 and 31 July 1995, 313 patients with acute and chronic infections were treated by vacuum sealing (VS). The average duration of VS treatment was 16.7 days, and there was an average of 3.1 changes in the VS system. In acute infections (n = 203) the wounds were closed by secondary suturing (65.5%), spontaneous epithelialization (17.2%), skin grafting (12.3%) and flap transfer (2%). Six patients died (3%). Infection recurred in 3.9% and was cured by another VS treatment. Unstable scar formations (1%) were treated by free flap transfers. When compared with standard open-wound treatment, the low-cost VS technique offers great advantages with regard to hospital hygiene, patient comfort and therapeutic results.

We examined 30 patients with an arthroscopic suture repair for anterior shoulder instability in a retrospective evaluation. The follow-up period ranged from 12 to 58 months with an average of 22 months. Arthroscopic suture repairs were done on 14 patients (acute group, average age 26.1 years) with acute detached glenoid labrum, confirmed on arthro-CT, within 10 days after the injury and on 16 patients (secondary group, average age 25 years) with chronic should dislocation. The evaluation according to the Rowe scale resulted in a mean score of 97.1 for the acute group compared with 92.7 for the secondary group. In each group we found one recurrent dislocation, which in the acute group was due to an adequate trauma. Two of the 14 acute group patients showed a reduction in external rotation of up to 20 degrees, compared with 6 patients in the secondary group. The external rotation of one patient in the secondary group was reduced to 40 degrees. The isokinetic muscle strength was decreased in both groups, both for 60 degrees/s and for 120 degrees/s, to 85% compared with the healthy side. The primary surgical therapy of young patients (below 25 years) with an acute shoulder dislocation and a detached glenoid labrum is recommended owing to the lower redislocation rate, an overall shortened course of treatment and a trend to better postsurgical range of motion.

Despite great effort concerning quality control in diagnostic radiology, there exist only a few studies giving reliable details about x-ray exposure during heart-catheterization. The mean radiation dose-area product of 100 patients (male 65%, middle-aged 60.7 +/- 10.4 years) investigated was irrespective the technique according to Sones or Judkins 45.2 +/- 14.7 Sv x cm2. In comparison to an optimated x-ray chest the local x-ray entrance-expositions in case of changing (90 mSv) and constant (300 mSv) projections were 300- and 1000-fold respectively. Concerning the dose-area product and the effective dose the multiplicative factor reached 160 and 100 respectively. Radiation entrance-exposure during cinematography was 15-fold as during x-ray-examination sequences. The cinematographic radiation dose was influenced significantly by location of the contrasted coronary artery (p < 0.001) and plane of projection (p < 0.001): intensive in entrance surface dose were projections x-raying spinal column and sternum (RCA in PA- and LCA in LAO-projection). Independent variables were body mass index (BMI, p < 0.001) and sex (p < 0.005), but not age. X-ray-dose of heart catheterization was lower in women than in men, this fact being only significant in the elderly (> 60 years), indicating an effect of postmenopausal osteoporosis. An effective minimization of x-ray exposition in heart catheterization can be realized by avoiding needless cine-sequences (25-35%), rotating out bone structures of the x-ray beam ( < or = 22%) and reduction of overweight (BMI 35 > 23 kg/m2: 25-35%).

Between 1 January 1992 and 15 March 1994 25 patients with compartment syndromes of the lower limb were treated by the vacuum-sealing technique (VS). Ten out of 25 patients had multiple injuries. Eight compartment syndromes were located in the thigh, 14 in the lower leg and 3 in the foot. The average time of VS was 12.7 (4-31) days with 2.1 (1-8) changes per patient. The wounds were either closed by secondary suturing (n = 20) or by skin grafts after partial closure of the wounds by suturing (n = 5). One patient developed a superficial wound necrosis, which healed spontaneously without invasive surgical treatment. In 52 intraoperative swabs of the wound surface there was bacterial growth in five bacteriologic specimens, but there were no clinical signs of infection.

Physiology of pain is a manifold and very complex phenomenon that is far from being understood. It cannot be explained without reference to psychosocial conditions. Pain has the function of a warning system, but the system is far from perfect, because a number of chronic diseases (e.g., arterial hypertension or malignant neoplasms) begin slowly and nearly painless. The role of pain in internal medicine will be exemplified by thoracic and abdominal pain. With regard to diagnoses both types of pain represent ambiguous symptoms. Their anatomic and physiologic substrates often cannot be ascertained completely by anamnestic means (according to localization, quality, trigger factors, time structure, and concomitant symptoms of pain). Visceral pain is regularly characterized by the phenomenon of the so-called "transferred pain": that means that the perception of pain is not restricted to the place of its origin but is also found in distant regions of the body, primarily in well defined dermatomes ("Head's areas"). This makes the differential diagnosis of internal diseases very difficult because of the parallel connection of nociceptive afferences from the skin and deeper-seated strata on identical spinal segments. Statements according to the pharmacotherapeutic aspects of pain primarily focus on the causal therapy of the prethoracic pain. In this regard differential-therapeutic aspects of angina pectoris, pericarditis, pleurisy, gastro-esophageal reflux, and vertebragenic, myogenic, and neurogenic disturbances are well to the fore.

Unlabelled: Though the predictive value of a diagonal earlobe crease (ELC) concerning coronary heart disease (CHD) is assessed controversially and seems to be influenced by age and ethnic origin, the ELC is mainly regarded as a reliable and valid sign of CHD. 670 patients, the greatest collective so far undergoing coronary angiography, were investigated prospectively with respect to the correlation between ELC and a hemodynamically relevant CHD (coronary diameter stenosis > 70%). In presence of ELC, CHD was observed in 55.0%, in its absence in 55.9% (One-vessel-disease (1-VD) 25.8% vs 26.7%, 2-VD 14.5% vs 14.4%, > 2-VD 14.8% vs 14.8%; n.s.). ELC itself was dependent on age (p < 0.000009), overweight (body mass index (BMI) > 25 kg/m2, p < 0.034) and hyperuricemia (> 7.0 mg%; p < 0.05), but not influenced by sex and other coronary risk factors such as smoking, diabetes, hypercholesterinemia and hyperlipoidemia, physical in-activity and family history of CHD. Actual just as former smoking and male sex are associated positively to CHD, whereas diabetes, hypercholesterinemia and hyperlipoidemia seem to predict a two-or multivessel disease: this emphasizes the validity of our data., Conclusion: The ear-lobe crease is associated with age and overweight, but does not predict a hemodynamically relevant coronary heart disease.

The results of studies concerning the mortality rates of both sexes are of great similarity in all industrial countries. For underdeveloped countries, little information is available, but analogue proportions can be supposed. In the nations of the industrialized world males have a significantly higher mortality rate, which shortens their life expectancy in comparison with that of woman. Since about 1970 a deceleration of this development has been observed. The diseases responsible for this fact are ischemic heart disease, lung cancer, accidents, and other traumatic incidences, but also infectious diseases. Concerning the origins of ischemic heart disease, the influence of sex hormones especially on the lipid profile are being discussed; nevertheless, for the enhanced coronary risk of males environmental and behavioral factors seem to be more important than biological reasons. As for carcinosis being a reason for the mortality of males, lung cancer is in the foremost position. Cigarette consumption, as well as the higher exposure to cancerogenic substances related to typically male professions, are held responsible for this. As for other types of cancer, environmental factors depending on gender are strongly considered as a reason for different rates of mortality. Furthermore, sociological explanations for these differing frequencies are being discussed. Occupational differences and the different positions held in working life by each gender are believed to be responsible for the higher rate of mortality among males. Also, risktaking behavior seems to be found more often among males, than among females. A variety of hypotheses based on genetics have been given to explain the different gender-specific rates of mortality, but none of them has yet been proven correct.(ABSTRACT TRUNCATED AT 250 WORDS)

The physiologic changes of the different organs in the elderly result in a diminishing efficiency of the organism and its capability of adapting to new and unusual conditions. Accordingly, physical exercise has to be seen and assessed as prevention of illness in old age. In terms of prevention exercise training is taking the first place within the five different types of physical activities. The other types (coordination, flexibility, strength, rapidity) have to be handled with special conditions, whose importance must be assessed individually. The importance of exercise, physical activities, and sports is increasing especially in preventing coronary artery disease. Metabolic diseases, hypertension, impairment of cerebral functions and also diseases of the musculoskeletal system are improving under suitable physical training. General training exercise training slows down the loss of cardiopulmonal efficiency due to progredient aging. Risks and benefits of physical training have to be deliberated very carefully in considering the state of health of the elderly.

Report about a rare case of pulmonary embolism caused by a clinically unsuspected aneurysm of the popliteal vein. The aneurysm was suitable for local venous reconstruction. The diagnosis and the treatment are discussed.

301 patients, operated for Crohn's disease in a ten-year period (1980-1989) were analyzed retrospectively, regarding perioperative risk of bowel resection (n = 336). The overall mortality rate was 0.6% (elective 0, emergency 6%). The reasons of this low mortality rate are of different nature. Very important is a meticulous perioperative treatment and a standardized operative approach.

For the acquisition of subjective variables in outpatients and inpatients, a new device--the Rating Box--has been designed. The Rating Box provides a standardized, date- and time-logged documentation of symptoms by the patient and rapid transfer of data to a personal computer. The simultaneous acquisition of several symptoms using different types of scales is possible. The acoustic alarm of the Rating Box reminds the patient to enter data at preselected times. The device is easy to handle, even by older patients, and has been successfully tested in the acquisition of pain variables in patients with a variety of painful conditions.

Cardiac insufficiency, coronary heart disease, and arrhythmia are not only more frequent in elderly patients, they are very often combined. By reason of cardiac morbidity and general morbidity as well as changed physiological and pathophysiological conditions, diagnosis of cardiac disease in elderly patients is more difficult. These conditions also apply to modifications in the therapy of cardiac diseases in advanced age. Especially pharmacodynamic and pharmacokinetic effects in advanced age combined with multimorbidity also account for the risk of interactions because of the simultaneous application of different pharmacological groups.

Tachycardiac and bradycardiac arrhythmias increase with age. Because cardiac arrhythmias at an advanced age are almost always caused by organic disease, one must face more frequently electrical complications (e.g. ventricular fibrillation). Owing to the decrease of arterial flow volume as well as mean arterial pressure, bradycardiac and tachycardiac arrhythmias result in cerebral symptoms more often in elderly than younger persons. The causes of this observation are the disturbed cerebral autoregulation of blood pressure, but also the insufficient capacity of adaptation of the ageing circulation. In this situation it is more frequently necessary in old people than in younger ones to treat cardiac arrhythmias by antiarrhythmic drugs. The cardiodepressant effect of most antiarrhythmic drugs must be taken into account in this context.

The documentation of illness-related data, e.g. repetitive recordings of pain parameters, medication or mood, is commonly accomplished by the use of questionnaires. Several disadvantages for both the patient and experimentor related to this method can be avoided by the application of specially designed data-loggers. The use of commercially available portable pocket computers is usually complicated because of the miniature full-range keybords. This paper describes a completely new design, which relies on the use of only four keys. All operations are imaged on an LCD display (4 lines with 16 signs). The Rating Box allows the presentation of visual analogue scales (VAS) of different step widths, movement of cursors, forced choice and multiple choice decisions, as well as the input of decimal numbers. Up to 11 scale types can be deliberately combined in a series of up to 27 items. The combination can be individually designed and edited by the experimentor. The results are stored together with the input time and date. Actual inputs are not influenced by comparison to earlier input, since data recall can only be accessed by the experimentor. The use of the Rating Box by a patient is called up by signal tones at individually given times of day. Additional inputs are possible when required. Warnings are presented for general malfunctions. The results can be transmitted to a personal computer and processed statistically or to daily or weekly profiles of mood, pain or disability scores, for example. A pilot study in elderly patients (42-76 years) with pain due to cancer gave promising results. The Rating Box was well accepted as opposed to a questionnaire. Nine out of 12 patients preferred the Rating Box both methods were judged to be equivalent by two patients and only one regarded the use as difficult and thus preferred the questionnaire. In addition, 5 out of 12 patients confessed by inquiry to have filled in the questionnaire forms retrospectively. This possibility is in principle excluded by the Rating Box.

The manifestation of Crohn's disease with perforation in pregnancy has been described in one case only. In our case, a 25-year-old woman in the 28th week of pregnancy was admitted to our hospital with signs of an acute abdomen. Due to deterioration of the maternal and foetal situation, the child was delivered by a Caesarean section. Subsequently, exploration of the abdomen showed an ileum perforation with diffuse fibrinous peritonitis. In this case, the definitive diagnosis could not be made prior to laparotomy. The aim of surgical therapy in such cases should be the limited resection with end to end anastomosis. In diffuse peritonitis, discontinuous resection and secondary reconstruction after three to six months is preferred.

59 patients with rectal cancer were treated by local excision. In 17 of these patients a radical resection was performed afterwards. In one of 21 local excised "low risk" T1-carcinomas a recurrence was observed. Five of 11 local treated patients with "high risk" tumours developed a recurrence. In the group of the radically treated patients two recurrences were seen. Regarding our results the local excision of "low risk" T1-carcinomas seems to be justified, if final histological workup reveals an adequate margin of healthy tissue.

Scleromyxedema is an uncommon fibromucinous connective tissue disease characterized by accumulation of mucinous material in the dermis. A monoclonal paraprotein is regularly identified. A review of the literature (57 cases) shows the exceptional association of scleromyxedema with multiple myeloma (8.7%) and macroglobulinemia Waldenström (3.5%). A man with scleromyxedema, IgG lambda paraproteinemia, and sclerodactylia--as a special sign of scleromyxedema--is reported. Melphalan is the drug of choice in serious cases, but not effective in sclerodactylia.

Today, the steadily growing selection of industrially produced infusion and nutritive solutions can hardly be overlooked by the clinician. It is therefore most important for him to limit himself to a number of modern, clinically approved solutions whose composition, maximal infusion rate, indications, contra-indications and side-effects are well known to him. Moreover, a successful infusion therapy and parenteral nutrition postulate the mastery of modern infusion techniques.

Largely confirmed Caird's figures. Using Schellong's test we recorded systolic pressure falls of 20 mm Hg and more in 25% of 160 residents in an old people's home in the age range 59-88 years. These cases of circulatory dysregulation were all manifestations of the hypodynamic form of the orthostatic syndrome. This means that only systolic blood pressure fell, diastolic pressure as well as heart rate being largely unaffected. The phenomenon appears to be due to age-related deterioration in circulatory regulation; at least no evidence has been found to suggest that it has a specific aetiology. In a double-blind cross-over study the effect of dihydroergotamine (DHE) was compared to placebo in 40 patients. Half the patients were given 2 mg DHE three times daily for 14 days and the other half placebo tablets; following one week's wash-out, the treatments were then reversed for a further 2-week period. Schellong's test (measurement of blood pressure and pulse after 10 minutes in the supine position and then after 1, 2, 5 and 10 minutes standing) was performed at the beginning and end of each treatment period. The average falls in upright systolic pressure for all 40 patients were as follows: before treatment 20 mm Hg, end of placebo periods 19 mm Hg, end of DHE periods 7 mm Hg. The differences between the values recorded after treatment with DHE and the other 2 values are statistically significant.

Between 1980 and 1986 16 male patients of between 30 and 65 years of age were treated operatively because of distal biceps tendon ruptures. The operative procedures are reported and the results of a follow-up examination two years later are communicated. The good results of the applied operative treatment allow to recommend the operative procedure. A special method of measurement of muscle power is presented.

An autosomal dominant inherited ASD with conduction defects in one family is described. 6 members of 4 generations were fallen ill. In 4 patients the diagnosis was made clinically, in 2 sisters the diagnosis was confirmed by operation. Moreover, the last 2 patients had a mitral insufficiency--probably congenital. The ecg-findings of 4 patients additionally showed conduction defects in form of AV-and bundle branch blocks.

This paper reports on four different types of dextrocardia in situs solitus and situs inversus. The topography of the atrial and ventricular cavities, of the great vessels and of the coronary arteries is described in detail. The value of the selective coronary arteriography in differentiation between the types of dextrocardia is discussed.