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Palliative care serves to improve the quality of life in patients suffering from incurable diseases. Pharmacotherapy of distressing symptoms plays an important role. Off-label use refers to the use of drugs outside the marketing authorization. In addition to the indications off-label use may also be due to duration of treatment, route of administration and the admixture of substances. Off-label use is common in palliative and hospice care and is probably unavoidable in many cases. For treatment planning and realization of off-label therapy in clinical practice, patient-related aspects, information, therapy monitoring and documentation of therapy effects should be considered in addition to drug-related information. Only in this way it is possible to offer a scientifically adequate, appropriate and economic therapy that is linked to an appropriate risk-benefit ratio for the individual patient. Due to the lack of authorization studies, reporting is of particular importance.

During the last years an increasing number of patients suffering from therapy refractory chronic wounds which are frequently infected by multi-resistant bacteria - e.g. methicillin-resistant Staphylococcus aureus - have led to an increasing interest in the treatment using larvae or maggots of the blow fly species Lucilia sericata. Maggots are responsible for necrectomy and they have antimicrobial activity in particular against grampositive bacteria like a disinfectant of the wound. It is concluded that maggots debridement therapy (MDT) using larvae of the species Lucilia sericata in non-healing chronic ulcers of the lower legs successfully leads to cleaning, debridement, reduced bacterial load, and improved wound granulation. A review is given on the clinical use of maggots, their mechanism of action and clinical efficacy for wound healing.

Therapy of idiopathic pulmonary fibrosis (IPF) is directed at 1) inhibition of alveolitis and tissue damage, and 2) inhibition of matrix deposition. We and others have identified pentoxifylline (POF) as a promising drug in achieving these aims. For further clarification, we established a model of bleomycin-induced fibrosing alveolitis. Fisher 344 rats (n = 7 per group) were given bleomycin intratracheally once (0.7 U/100 g bw) and treated with POF (1.5 or 3 mg/kg bw per day i.p.), prednisolone (15 mg/kg bw i.m. per day), or sodium chloride solution (NaCL). The extent of inflammatory reactions was determined after 8 days by differentiation of cells of broncho-alveolar lavage (BAL) and by quantification of proliferating cells in lung interstitium subsequent to staining of the Ki-67 antigen. POF inhibited neutrophil alveolitis in BAL and reduced the amount of proliferating cells in the lungs significantly while prednisolone and NaCL did not. Both POF and prednisolone exerted a positive influence on postoperative weight loss as well as on lung weight increase subsequent to bleomycin instillation. The postoperative body weight loss and the lung weight increase after bleomycin instillation are most likely due to an inflammatory reaction subsequent to operation and bleomycin deposition. Tumor necrosis factor alpha (TNF-alpha) has been shown to be a key cytokine in bleomycin-induced fibrosing alveolitis as well as in IPF; it also exerts catabolizing effects. Since both POF and prednisolone are known to effectively inhibit proinflammatory cytokines and, among those, TNF-alpha, nonspecific antiinflammatory effects probably explain the benefits. Additionally, however, this study proved POF to be more effective in inhibition of BAL neutrophils and number of proliferating cells in lung interstitium. Further, it has been shown that POF, but not prednisolone, inhibits activation of neutrophil granulocytes and formation of reactive oxygen species. Thus we believe that the mechanism of action of xanthines might contribute to therapy of IPF. For further clarification, a prospective clinical study of POF in IPF therapy has been initiated.

We present the case of a 65-year-old woman with progressive systemic sclerosis. For 14 years, she had been occupationally exposed to scouring powder containing crystalline silica. In the skin of the finger of the patient, silica crystals were detected by polarizing microscopy. By means of a special dust measurement at the former working places where scouring powder was used, a silica exposition could be found exceeding the maximum allowable concentrations. Legal recognition of an occupational disease could be achieved in a special procedure by the top expert commission for occupational diseases.

From 1975 to 1989 37 patients with Lupus erythematodes exposed to quartz dust over many years were observed. Thirty of them suffered from silicosis. The coincidence of silicosis and Lupus erythematodes can be an expression of a common pathogenesis.

The main reason for premedication is the reduction of preoperative stress. Despite the proven fact that benzodiazepines best reduce preoperative stress, combinations of opioids and neuroleptic drugs are preferred for premedication by many on reviewing the journal Der Anaesthesist. This double-blind study was performed to investigate midazolam and meperidine/promethazine for intramuscular premedication. Method. 60 patients undergoing minor gynecological surgery were randomly assigned to receive either 5-7.5 mg midazolam or 50-75 mg meperidine and 25-50 mg promethazine intramuscularly 30-90 min before surgery. Anxiety, depression, and asthenia were assessed by the patient before and after premedication but before induction of anesthesia using visual analogue scales and a nominal scale. Sedation was assessed by an observer. Heart rate and blood pressure were the physiological stress parameters. Parameters of acceptance and side effects were registered perioperatively. Results. Midazolam had a significantly better anxiolytic and antidepressive effect. There were no differences in the other parameters except for adverse effects. Meperidine/promethazine produced significantly more side-effects than midazolam. The parameters of acceptance assessed the day after surgery were comparable. Conclusions. We conclude from these results that anesthesiologists still premedicate with meperidine/promethazine because the patients accept this premedication very well when asked the day after surgery. Nevertheless, premedication with midazolam provides significantly better anxiolytic and antidepressive effects with significantly less side-effects. Therefore, midazolam should be preferred to meperidine/promethazine for intramuscular premedication.

This publications shows new ways of prosthesis controlled by nerv action potentials. We introduce results of neurophysiological trials on animals which will be the basis for a neuroelectric prosthesis for human beings.

In a clinical study a group of pregnant women with suspected cervical incompetence was examined by vaginal sonography. Aim of the investigation was to compare results of performed vaginal palpation with results of sonography. 120 pregnant women with cervical insufficiency between 16th and 33rd week of gestation were examined by a 5-MHz vaginal sectorscanner probe. After focussing sagittal projection of uterine cervix and lower uterine segment the cervical length and opening of the internal os were assessed prior to cerclage. Postoperative vaginal sonography was performed to ascertain lengthening and stabilization of the incompetent cervix. Another group of 50 pregnant women with unsuspicious obstetrical findings were also examined to gain information about normal sonographical morphology and length of the competent uterine cervix. Comparing results of vaginal palpation and vaginal sonography showed, that the cervical length obtained by sonography was constantly higher in all patients than the results obtained by palpation. This difference became more distinct in the group of patients with extreme cervical incompetence. We are of the opinion that vaginal sonography is an objective method revealing the extent of cervical incompetence. Exact measurement of the cervical length and assessment of the internal os are efficient diagnostic criteria. They complete results of cervical palpation and offer precise information concerning an intended cerclage. In case of suspected cervical incompetence continuous sonographical examination can supervise the development of the uterine cervix during pregnancy. In future the number of prophylactic cerclage-operations perhaps decreases by using the technique of transvaginal sonography.

In order to determine the capacity for deposition of bone, 5 Beagles were each implanted extraorally with 6 aluminium oxide cylinders into the horizontal mandibular ramus. 4 months after the first implantation a second implantation was carried out in the opposite side with similar cylinders. After six months all were removed so that in altogether 60 implants the bone deposition could be observed 4 months and 2 months after implantation. A further 14 dogs received altogether 55 Tuebinger immediate implants. All animals were regularly observed post-operatively. After 6 months all cylinder full-implants had been accepted without reaction. All tooth implants which were either not put under strain or were immediately put under pressure healed without reaction. After three months 19 implants were lost and a further 5 were lost after 8 months. All cylinder implants were histologically examined 6 months after first implantation.

A 60-year-old man with progressive systemic sclerosis (PSS) had worked as underground miner in ore mining for 26 years with intensive exposure to crystalline silica. The PSS was acknowledged as an occupational disease. Parallel to the progress of the PSS there developed disturbances of the conduction system and cardiac rhythm with left heart failure. Despite treatment sudden death set in. A myocardial fibrosis was found histopathologically. This is a consequence of the PSS and therefore the occupational disease is the cause of death. Cardiac involvement means a poor prognosis and necessitates both evaluation of the damage in percent caused by the occupational disease and interdisciplinary teamwork in the dispensary care of patients.

In a clinical study a group of pregnant women with suspected cervical incompetence was examined by vaginal sonography. Aim of the investigation was to compare results of performed vaginal palpation with results of sonography. 53 pregnant women between 20th und 31st week of gestation were examined by a 5 MHz vaginal sector-scanner probe. After focussing sagittal projection of uterine cervix and lower uterine segment the cervical length and opening of the internal os were assessed prior to cerclage. Postoperative vaginal sonography was performed to ascertain lengthening and stabilization of the incompetent cervix. Comparing results of vaginal palpation and vaginal sonography showed, that the cervical length obtained by sonography was constantly higher in all patients than the results obtained by palpation. This difference became more distinct in the group of patients with extreme cervical incompetence. We are of the opinion that vaginal sonography is an objective method revealing the extent of cervical incompetence. Exact measurement of the cervical length and assessment of the internal os are efficient diagnostic criteria. They complete results of cervical palpation and offer precise information concerning an intended cerclage.