Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors: Part D Basic conditions supporting drug treatment.

Physiological changes in old age: loss of muscle mass; reduction in bone mass; percentage of fat increased; lower amount of body water; lack of thirst; diminishing kidney function (caution: sufficient intake of fluids: 1.5-2 l and moderate intake of protein 8 g/kg body weight); reduced secretion of digestive enzymes, delayed emptying of stomach (which means premature feeling of repletion). Lack of fluids and nutrition is therefore likely. Daily intake of 1,500 kcal and 1.5-2 l fluids is necessary. An indicator for malnutrition is low body weight (defined for persons older than 65 years of age as BMI < 20) and a protein serum concentration < 35 g/l. Malnutrition carries an increased risk of infections, falling and fractures, bed sores, anemia, decompensation of chronic diseases. 10-20% of subjects over 80 years of age show signs of malnutrition, 40-60% of subjects in care institutions or hospitals. There are regressive changes in the locomotor and the nervous system of the elderly which have an effect on physical fitness. These changes reduce strength, endurance, proprioceptive capacity (e.g. coordination, balance) and mobility. Exercise in the old and very old should increase skeletal muscle strength in particular and improve coordination and balance. Regular physical exercise and moderate training has a positive effect on mobility and thereby improves independence and reduces falls. Moreover, it has a positive effect on cardiac output, maximum heart rate, stroke volume and the risk of a cardiovascular event and mortality can be reduced. Moreover, moderate physical exercise is often more effective in treating chronic disease than drug therapy e.g. heart failure, coronary heart disease, asthma/COPD, stroke, diabetes mellitus Type 2, degenerative diseases of the joints, depression and others. Examine cardiovascular risks in persons over the age of 50 before beginning physical exercise. Avoid maximum stress levels.

Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors - Part C Special Pharmacology.

This article contains the 4th part of the Pharmacotherapy Guidelines for the Aged by Family Doctors for Family Doctors. Part 4 is dedicated to fecal incontinence and chronic constipation. The diagnostic categories are divided according to severity and dysfuntion of bowel and pelvic floor, sphincter and neural control. Therapy is also outlined. Importance is given to patient history, in particular the use and abuse of drugs that stimulate peristalsis and promote constipation. Therapy in the elderly is guided by the maxim: use the most conservative therapy possible, where stool training has considerable importance. Drug therapy based on symptoms can only be recommended when non-drug measures continue to fail. In patients with fecal incontinence: 1) opiates (which reduce colonic motility), 2) loperamide (which has the capacity to dilate the rectum) and 3) anion exchangers which have the capacity to prevent cholonic diarrhea. In patients with chronic obstipation: 1) trial: stool-forming laxatives (ensure intake of sufficient amount of fluids) 2) trial: laxatives with an osmotic effect and 3) trial: stimulating laxatives (beware abuse, do not use in cases of acute abdomen).

Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors: part C--Special pharmacology.

The part "Special pharmacology of the aged" of this guideline contains recommendations for typical conditions in the family doctors practice: in the January issue 2009 dementia and Morbus Parkinson, in this issue osteoporosis and urinary incontinence and in the next issue rectal incontinence and obstipation. This issue of the IJCPT contains the third part of the Pharmacotherapy guidelines for the aged by family doctors for family doctors. Part 3: Osteoporosis and urinary incontinence. Osteoporosis is a systematic disease characterized by low bone mass and declining bone structure. Exercise, adequate diet, nicotine abstinence as well as reduction of alcohol consumption may counteract the progression of the disease. Osteoporosis manifests in bone fractures with minimal trauma. Attention must be given to the risk of falling, e.g., by avoiding drugs that increase the risk of falling: e.g., psychotropic agents, analgesic drugs and antiarrhythmic agents. Specific osteoporosis medication e.g. calcium, vitamin D, biphosphonates and SERM (selective estrogen receptor modulators) is evaluated by family doctors according to indication, dosage, contraindications, long-term therapy and nature of any fracture. Duration of therapy is at least 3 - max. 5 years followed by reassessment of indication. There are 3 types of urine incontinence (urge-, stress-, and overflow-incontinence). Another standardization of urinary incontinence follows dysfunctions of the pelvic floor: detrusor muscle-dependent, due to sphincter spasm, prostate gland dependent. Urge incontinence with a dysfunction of the detrusor muscle is the most common type. Mixed types are frequent. Non-drug measures (e.g. pelvic muscle training, bladder training, toilet training are first choice treatments. Drug therapy (estrogen, imipramine) are without proven effect.

Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors.

Part C of the guideline is preceded by Part B General Pharmacology IJCPT. 2008; 46: 600 - 617. Included in Part C are practical guidelines for improving the therapy of some age-specific diseases and problems commonly encountered in general practice. The article in this issue is dedicated to the therapy of Dementia and M. Parkinson. Further guidelines for the other age specific diseases and problems named above will be published in the following issues of IJCPT. An important feature of these guidelines are the inclusion of Levels of Evidence and of the Strength of Recommendations for the therapy which are shown when reliable studies are available. (For both see levels of evidence at the end of this article.).

[Assessment of the efficacy and safety of the phytopharmacon STW 5 versus metoclopramide in functional dyspepsia--a retrolective cohort study]. / Wirksamkeit und Unbedenklichkeit des Phytopharmakons STW 5 versus Metoclopramid bei funktioneller Dyspepsie unter Praxisbedingungen--eine retrolektive Kohortenstudie.

AIM: The objective of this study was to assess the efficacy and safety of the phytopharmacon STW 5 versus metoclopramide in functional dyspepsia. METHODS: A retrolective, epidemiological cohort study with parallel groups in 23 randomised centres where both drugs were used routinely was performed. The main outcome variable was improvement of 10 dyspepsia-specific symptoms of a valid gastrointestinal symptom score (GIS) during therapy. For inclusion, patients had to suffer from at least three of these symptoms before therapy. Secondary outcome variables were change of single symptoms, time till complete symptom relief, investigators' judgement of efficacy and tolerability, duration of inability to work and occurrence of adverse events. RESULTS: The per protocol collective comprised 490 STW 5 and 471 MCP patients. Anamnestic data were comparable. 439 of patients had taken MCP as drops. There was no relevant difference in median treatment duration. Significantly more patients were symptom-free after STW 5 treatment (71.6 vs. 62.8% p = 0,012). Additionally, the extent of symptom improvement (excluding nausea and vomiting) and median duration of inability to work (1 vs. 3 days) were significantly different in favour of STW 5. More physicians assessed STW 5 as effective (71.6 vs. 63.1% p<0.01) and very well tolerated (90 vs. 70.6% p<0.001). Adverse drug reactions were documented only under MCP. CONCLUSION: The present study illustrates a comparable to higher efficacy of STW 5 vs. MCP with better tolerability in treating functional dyspepsia under practice conditions, especially regarding complete symptom improvement, symptom duration and quality of life. The study confirms the results of prospective trials for STW 5 as being an appropriate alternative to the frequently administered antacids and prokinetics.

Phytotherapy for functional dyspepsia: a review of the clinical evidence for the herbal preparation STW 5.

Functional gastrointestinal disorders such as functional (or non-ulcer) dyspepsia are characterized by a broad spectrum of symptoms referred to the upper abdomen without a detectable cause utilizing routine diagnostic measures. It is now believed that disordered gut function (including abnormalities like disturbances of motility such as postprandial fundic relaxation, gastric emptying and disturbed visceral sensory function) play a key role for the manifestation of these disorders. The underlying pathophysiology is not yet fully understood. However, the available data suggest that a number of factors may contribute to the manifestation of symptoms. These factors include environmental factors such as acute infections as trigger event, psychological stressors that may precede acute exacerbations and a genetic predisposition. Considering the large number of mechanisms, a treatment targeting a single mechanism is unlikely to be effective in all patients. Indeed, chemically defined treatments usually gain a 10-15% superiority over placebo. In recent years placebo-controlled studies have demonstrated superiority of a commercial multicomponent herbal preparation, STW 5, with the trade name Iberogast, for the treatment of patients with functional dyspepsia and irritable bowel syndrome. This phytopharmacon is a combination of nine plant extracts each with a number of different active constituents. Pharmacological studies have shown different effects of the single plant extracts on the (molecular) mechanisms which are discussed as underlying the manifestation of symptoms. Various well-controlled clinical trials have independently confirmed clinical efficacy and safety. The clinically efficacy of this multicomponent herbal preparation questions the current trend of highly targeted drug molecules that usually target one single receptor population while it has not been shown that a single receptor group plays a pivotal role for the control of symptoms. Herbal medicines are obtained from various plants and contain complex extracts with a large number of different active substances. While there are only limited head-to-head comparisons with conventional chemically defined medications, the combination of extracts with various gastrointestinal active ingredients appears to be advantageous for a heterogeneous condition such as functional dyspepsia.

[The efficacy of a combination herbal medicine in the treatment of functional dyspepsia. Meta-analysis of randomized double-blind studies on the basis of a valid gastrointestinal symptom profile]. / Wirksamkeit eines pflanzlichen Kombinationspräparats bei funktioneller Dyspepsie. Metaanalyse randomisierter Doppelblindstudien auf Basis eines validen gastrointestinalen Symptomprofils.

BACKGROUND AND AIM: Functional dyspepsia is a heterogeneous clinical entity of incompletely known etiology. Overall, four randomized double-blind studies from the nineteen-nineties investigating acute treatment of this condition with the combination herbal medicine Iberogast, are available. A meta-analysis of the studieswas carried out to evaluate the overall therapeutic effect. PATIENTS AND METHODS: In all four, triple-arm, controlled multicentre studies, the efficacy of 4 weeks of treatment with 3 x 20 drops daily, applied after a washout phase, was investigated, the primary efficacy parameter being a specific gastrointestinal symptom score. Of the 592 participants in the studies, 196 were treated with Iberogast, 131 with placebo, and 61 with cisapride as positive control. The remaining 204 patients, who were treated with an experimental herbal preparation of similar composition, were not admitted to the final analysis. RESULTS: While overall appreciable improvement of the clinically relevant symptoms of moderate severity was seen under treatment with the combination herbal preparation, the individual studies differed in terms of the statistical significance of the results obtained. The meta-analysis of studies revealed a clear therapeutic effect for the herbal medicine (p < 0.0001). CONCLUSION: The clinical experience with the combination preparation for the treatment of functional dyspepsia was confirmed by the meta-analysis of the modern double-blind studies.

Hygienic monitoring of environmental surroundings in office-based ambulatory surgery units--an instrument for infection control.

Out-patient operations cause lower costs and they are a method the patients are less burdened with than it is the case with usual operating methods. Avoiding nosocomial infections is regarded as another advantage. The rate of infection can be given by a carefully kept nosocomial infection surveillance. Ambulatory surgery units have difficulties in keeping these statistics because they often do not take over the after-treatment of this patients. Out-patient operations in surgeries must guarantee the same standard of hygiene which can usually be found in hospitals. Hospital epidemiologists, health authorities and professional associations have published corresponding guidelines with organizational/functional and structural requirements. These requirements, however, are only met by few ambulatory practices. Surgery holders justify the non-observance of the guidelines by supposing that the spectrum of germs in their office differs from that in a hospital and that there aren't any pathogens. The standard of hygiene in ambulatory surgery units is not controlled regularly. Therefore the hygienic conditions and the microbial burden of five surgeries that carry out out-patient operations under general anaesthesia were determined within the scope of microbial monitoring of the surroundings. Only two surgeries achieved a standard of hygiene which is comparable with that of a hospital. Up to 42% of the taken samples were sterile. The other three surgeries did not meet the requirements. The microbial burden in these surgeries was distinctly higher. The spectrum of detected microorganisms was very wide and there were pathogens too. Hygienic controls and monitoring of the surroundings should be carried out regularly as a measure to guarantee the production and maintenance of quality. Thus the actually achieved hygienic standard in the surgeries can be controlled and improved if necessary. Ambulatory surgeries should be liable to similar hygienic controls as hospitals.

Effect of salt concentration and temperature on survival of Legionella pneumophila.

The effects of various concentrations of sodium chloride solutions (0.1%-3%) and different temperatures (4, 10, 20, 30 and 37 degrees C) on survival of Legionella pneumophila were investigated. It was found that at temperatures between 4 degrees C and 20 degrees C, Legionella organisms survived in salt solutions up to 3% NaCl. Only the combination of high temperatures, i.e. 30 degrees C and 37 degrees C, with NaCl concentrations over 1.5%, reduced cell numbers significantly. It was interesting to note that the addition of small amounts of NaCl (0.1%-0.5%) enhanced survival of Leg. pneumophila, suggesting a protective effect of NaCl. In order to obtain information about conditions encountered in the environment, the survival experiments were repeated in sterile sea water from the Baltic Sea and the North Sea. The marked bacterial die-off, especially at higher temperatures, was not observed in natural sea water. All these results indicate that Leg. pneumophila can survive in the marine environment.

Effect of polyunsaturated phosphatidyl-choline on lipid transport system in alcoholic liver injury.

The aim of this study was to determine whether serum lipid composition and lipolytic activities in alcoholinduced liver dystrophy were modified by the co-administration of polyunsaturated phosphatidylcholine (PPC). Chronic alcohol intoxication was induced in rats by intragastric ethanol administration of 3.5 g/kg body weight per day over 56 days. Aqueous PPC suspension was given intragastrally in doses of 100 and 300 mg/kg body weight. Chronic alcohol intoxication led to the development of protein and lipid dystrophy of hepatocytes. PPC partially prevented alcoholic injury of the liver cells and had a normalizing effect on cholesterol esterification, lipolysis of lipoproteins and on the fatty acid composition of the main lipoprotein classes.

Hepatic and pancreatic effects of polyenoylphosphatidylcholine in rats with alloxan-induced diabetes.

Polyenoylphosphatidylcholine (PPC: 100 or 300 mg kg-1 b.w., by gastric intubation for 30 days) produced a clearcut protection of the liver of rats treated with alloxan (150 mg kg-1 b.w., i.p.). The liver of rats treated with alloxan was characterized by hydropic dystrophy and lymphocytic infiltrations. Treatment with alloxan increased serum gamma-GT and ALAT activities. The liver structure of rats treated with PPC did not differ from the liver of control animals. PPC normalized the biochemical abnormalities caused by the diabetes. The number of pancreatic islets and beta/alpha cell ratio decreased in the diabetic rats. A number of beta-cells in this group did not contain granules. PPC prevented the decrease in the number of islets and the beta/alpha cell ratio in the pancreas of the diabetic rats. The intensity of staining of beta-cell granules in the pancreas of PPC-treated rats had a position intermediate between the control and diabetic groups. Alloxan increased the blood glucose content where treatment with PPC decreased this. The results suggest that PPC acts as a cytoprotector in the liver and pancreas of rats with experimental diabetes induced by alloxan.

"Essential" phospholipids versus nicotinic acid in the treatment of patients with type IIb hyperlipoproteinemia and ischemic heart disease.

In patients with moderate, dietary noncorrigible hyperlipoproteinemia type IIb and ischemic heart disease, treatment with nicotinic acid is limited by the side effects of the drug. In 100 patients, 6-month treatment with nicotinic acid (n = 50) or "essential" phospholipids (EPL); Lipostabil, manufacturer: Rhône-Poulenc Rorer) (n = 50) indicated comparable efficacy for both substances: Significant (p < .001) reductions of serum total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglyceride values were similar in both groups, while nicotinic acid increased high-density lipoprotein (HDL) cholesterol significantly (p < .01) better than Lipostabil. A detailed analysis of ultracentrifugal lipoprotein profiles, hydroperoxide concentrations in LDL, and cholesterol-accepting properties of HDL in a small number of Lipostabil- and nicotinic acid-treated patients revealed favorable shifts in the lipoprotein profile, significant (p < .05) reductions of LDL hydroperoxides, and favorable increases of the most antiatherogenic HDL2b subfraction only in the Lipostabil-treated group. Clinically, both medications reduced the intensity and number of angina pectoris attacks per week (p < .05), but only Lipostabil-treated patients significantly (p < .05) increased their working capacity in the veloergometric test. Since in the nicotinic acid-treated group dropouts (nine patients, eight related to the drug) and side effects [14] exceeded those in the Lipostabil-treated group (two dropouts not related to the drug, no side effects), it is suggested that Lipostabil is a preferable alternative in the treatment of patients with moderate, dietary noncorrigible hyperlipoproteinemia IIb and ischemic heart disease.

Comparison of BGB-MUG and LSTB-MUG in microbiological surveillance of recreational waters.

Recreational water surveillance is an important tool to prevent health hazards for the population. Therefore distinct guide and imperative values for fecal indicators are listed in the EC directive about water quality control. The detection methods, however, give laboratories some room to choose their own method, which has led to difficulties in the comparability of results. In 1989 an ad-hoc working group of the coastal countries of Germany established detection methods, which by now are obligatory for these countries. Fecal and total coliforms (FC and TC) are detected by a triplicate mpn-procedure using brilliant green-bile-lactose broth supplemented with tryptophane and 4-methylumbelliferyl-beta-D-glucuronide (BGB-MUG) as selective medium. Gas-, fluorescence- and indole-positive cultures are considered fecal coliform-positive. In the last years rises in TC but not in FC counts were observed in fresh waters. A study was carried out to evaluate the official method in another bathing season, to determine bacterial species leading to false-positive TC cultures and to compare BGB-MUG with laurylsulphate-tryptophane-MUG (LSTB-MUG). Water samples of different salinities and nutrient input were collected in weekly intervals from April to October. FC and TC concentrations were determined and all TC-positive cultures were differentiated further. The FC counts obtained by enrichment in BGB-MUG or LSTB-MUG were nearly identical, the rate of fluorescence-positive, indole-negative tubes being approximately 0.6%. Differentiation of FC-negative cultures showed a false-negative rate of 2.87% for BGB-MUG and of 8% for LSTB-MUG. During the summer months TC counts in BGB-MUG exceeded FC counts by far at most of the sampling sites. This effect was much less pronounced in LSTB-MUG; the difference between both enrichment media being significant. Differentiation of presumptive TC from BGB-MUG resulted in a high percentage of Aeromonas spp. in fresh waters. LSTB-MUG was clearly more selective for TC than BGB-MUG, but still with an average of 10% of the test tubes being false TC-positive (BGB-MUG 46%). The sensitivity of BGB-MUG was below 60% (LSTB-MUG 89%). LSTB-MUG should be preferred as enrichment medium in mpn-examination of recreational water, if no further differentiation is carried out. The selectivity for TC is better than in BGB-MUG and the only slight inhibitory effects can be tolerated.

Evaluation of MUG-supplemented media for the detection of E. coli in recreational water surveillance.

Four media containing 4-methylumbelliferyl-beta-D-glucuronide were evaluated as a non-confirmatory procedure for E. coli detection in recreational water surveillance. The media included ECD-Agar for membrane filtration and laurylsulphate-tryptose, brilliant-green-bile and lactose as broth media in a three tube most probable number procedure. From six representative water sites, samples were collected weekly over a typical summer season (17.05-27.09.1994) and processed as parallels, using each media at two different incubation temperatures (36 degrees/44 degrees C). Results showed that incubation temperature had no impact on E. coli counts. Each media at a given temperature could be regarded as individual enrichment procedure. None of these enrichment procedures showed a constant and predictable higher sensitivity during the sampling period at all sites compared to the others tested. For parallel results, the rate of agreement, based upon EC-guideline (76/160/EWG) staging of recreational water quality, was 85% for membrane filtration and 75% for the MPN-procedure results. Marked differences could be observed in false-positive specificity showing correlation to the selective characteristics of the media. Subsequently lactose-broth at 44 degrees C performed worst with 30% non verifiable results, while ECD-agar and laurysulphate-tryptose-broth, both at 44 degrees C, had a nearly 100% confirmation rate. Thus, combining high specificity with no lack in sensitivity these two MUG-supplemented media seem to be best suited for E. coli detection in routine recreational water surveillance.

[Absorption of di-linoleoylphosphatidylcholine after oral administration]. / Resorption von Dilinoleoyl-phosphatidylcholin nach oraler Gabe.

Essentiale and Lipostabil contain "essential" phospholipids from the soybean, mainly 1,2-dilinoleoyl-phosphatidylcholine (CAS 998-06-1, DLPC) which is considered as the main active ingredient. A single oral dose of d15-DLPC loaded with deuterium 9 times in the choline and 6 times in the linoleic acid of the 1-position was given to volunteers. Sera from 11 blood samples taken within 48 h after application were examined by means of mass spectrometry with regard to d9-choline and d6-linoleic acid in the 1- and 2-position of serum phosphatidylcholines (PC) as well as in the serum triglycerides. d9-choline, i.e. the total of d15-PC and d9-PC, showed maximum values of 5.6% of the total serum PC concentration. Normally, about 1.3% of PC in the human serum is DLPC. Serum 1-linoleoyl-PC was increased by 32-40% after oral application of d15-DLPC. A minor uptake of d6-linoleic acid into the 2-position of serum PC, which is rich in linoleic acid, and into the serum triglycerides was observed with peak values of 2.3% and 6.1%, resp. The uptake of polyunsaturated PC species like DLPC and 1-linoleoyl-PC into the liver after oral application of drugs containing such species in high amounts like "essential" phospholipids with about 50% of DLPC let expect therapeutic effects on membranes into which this special species is incorporated.