[Medical education and communication in primary pain treatment: clinical relevance and pedagogic challenge]. / Ärztliche Edukation und Kommunikation in der primären Schmerzbehandlung: Klinische Relevanz und pädagogische Herausforderung.

The term education can be understood here as informing the patient about the symptoms of the disease and the treatment. Patients with chronic pain require comprehensible information from the physician and beyond that esteem, encouragement and participation in decision-making processes. A successful patient-physician interaction is a quality ensuring element of the first degree. Imparting information in this context is of special importance which is not only derived from legal and ethical obligations but also from the scientifically proven therapeutic efficacy. A successful communication and relaying of information promotes motivation (compliance) and therapeutic effectiveness from both parties. Comprehensible explanations on biopsychosocial pain, interdisciplinary diagnostics and multimodal pain therapy reduce misunderstandings, false expectations and premature termination of therapy. The explanation of the biopsychosocial pain model opens for the patient a holistic view of the phenomenon of chronic pain and promotes self-help strategies. The question as to how and what should be imparted is not only a question of temporal resources but also represents a pedagogic challenge. The contents and experience imparted in the education are only substantially effective if they lead to a feeling of being personally affected due to being close to real life and plausibility and if the resulting multimodal treatment options can be implemented in the daily routine. The communicative duties of a physician are demanding and require practical training as can be reflected and practiced in the form of train-the-trainer seminars, workshops and Balint groups. It has been proven that competence in counselling techniques also has a positive effect on the experience of the physician in his profession. Pain patients can profit from information flyers, internet and interactive computer-based consulting systems if they fulfil basic standards, including topicality, neutrality, biopsychosocial understanding of disease and preventive information.

Counterrotation of the globe in macular translocation.

BACKGROUND: Macular translocation is a new treatment option in age-related maculopathy. The aim of this study was to report experience with the handling of the sensory problems concerning subjective cyclorotation and binocularity that arise with this technique. METHODS: The data of 33 patients who had undergone macular translocation and counterrotation of the globe by muscle surgery in a first operation, followed by silicone oil removal and sometimes revision of the eye muscles in a second operation, were evaluated. The counterrotation consisted of a partial transposition of the rectus muscles and extensive surgery on the anterior margins of the oblique eye muscles. Subjective monocular cyclorotation, motility and binocularity were tested. RESULTS: In 5 patients after the two operations binocular single vision was proved; in one of these cases there was even stereoscopic function. Seventeen patients excluded one eye: 13 excluded the operated eye, 4 the fellow eye. Eleven patients experienced double vision or tilted images under binocular viewing conditions and thus required further surgery or occlusion of one eye. CONCLUSION: The majority of patients were not hindered by subjective cyclorotation. Nevertheless, in a large proportion of patients binocularity could not be reestablished because of still reduced visual acuity or cyclotropia. The data show that the aim of restoring binocularity can be achieved but in practice is often not attained.

[Course and blood coagulation findings following systemic short-term fibrinolysis in acute myocardial infarct]. / Verlauf der Gerinnungsbefunde nach systemischer Kurzfibrinolyse beim akuten Myokardinfarkt.

UNLABELLED: A series of 16 consecutive patients with acute myocardial infarction was investigated with respect to changes in coagulatory parameters after intravenous short-term treatment with 1,500 000 IU streptokinase (SK) over a period of 90 minutes. Samples for coagulation assays (fibrinogen, thrombin, time activated partial thromboplastin time (aPTT), normotest, thrombin-coagulase time, platelets, antithrombin III, plasminogen and antiplasmin activity, alpha 2-macroglobulin, alpha 1-antitrypsin, factor X a were collected before and immediately after iv SK, and after 4, 8, 12, 24, 36, 48 and 72 hours. Platelets, antithrombin III, factor X a, alpha 1-antitrypsin and alpha 2-macroglobulin showed no changes over the observed period. The concentrations of fibrinogen and the activities of plasminogen and antiplasmin decreased clearly during the first 24 hours, reaching a minimum immediately after SK administration. Thrombin time and aPTT were prolonged for 36 hours, with a maximum in the first hours after lysis. CONCLUSIONS: Invasive diagnostic and/or therapeutic procedures during the first 24 hours after SK lysis should be carried out only for a definite, strict indication and under repeated control of the coagulatory status. After 24-36 hours there is a trend to normalisation of haemostasis. After 36 hours, surgery may be performed without fear of complications due to abnormal coagulability.

[Peripartum cardiomyopathy--a case report]. / Peripartale Kardiomyopathie--ein Fallbericht.

Peripartum cardiomyopathy (PPCM), a disorder of heart muscle, presents with the onset of cardiac failure in the last month of pregnancy or in the first 5 postpartum months. A patient with foudroyant clinical course is presented. Despite detailed clinical investigations and postmortem examination no aetiological factor was found. Diagnostic and therapeutic possibilities are discussed.

[Possibilities of systemic fibrinolysis in acute myocardial infarct]. / Möglichkeiten der systemischen Fibrinolyse bei akutem Myokardinfarkt.

Recanalisation of the infarct-related coronary artery could be achieved in 60 to 80% of patients with acute myocardial infarction by means of systemic fibrinolysis, if the interval between the onset of symptoms and the admission to therapy was less than 3 (maximal 6) hours. Fibrinolytic therapy should be combined with an exact conventional treatment in form of sedation, analgesia, oxygen delivery and optimisation of hemodynamics and metabolism with nitroglycerin, calcium antagonists and beta-blockers. Coronary angiography should be performed as soon as possible to decide about further therapy like percutaneous transluminal coronary angioplasty, coronary bypass surgery or medical treatment.

[Serum digitoxin levels in pacemaker patients]. / Untersuchungen zum Serumdigitoxinspiegel bei Schrittmacherpatienten.

In most cases pacemaker patients represent a diverse geriatric group in which ECG and clinical signs are of minor usefulness in diagnosing digitalis toxicity. We therefore determined serum glycoside concentrations in 200 consecutive patients attending our pacemaker clinic (with a mean maintenance dose of 0.093 mg digitoxin per day) and tried to correlate these to clinical, ECG and chemical findings. Multivariate analyses were also carried out to assess whether serum digitoxin concentrations lay in a subtherapeutic (0 to 8.99 ng/ml), therapeutic (9 to 27 ng/ml) or toxic (above 27 ng/ml) range on the basis of a combination of variables. The mean digitoxin concentration was 24.0 +/- 10.3 ng/ml (0 to 45 ng/ml) and correlated poorly with patient compliance (r = 0.36), serum potassium (r = 0.24), weight (r = 0.17) and digitoxin dose (r = 0.13), but not with ECG and subjective or clinical findings. A prediction of the three ranges of the serum digitoxin concentration was possible by means of variable compliance, body weight and digitoxin dose with a probability of up to 79%. In view of the above-mentioned problems indications for digitalis therapy in pacemaker patients must be constantly reviewed and control determination of serum digitoxin concentration should be frequently undertaken.

[Acute myocardial infarct and nitrogen balance]. / Akuter Myokardinfarkt und Stickstoffbilanz.

Nitrogen balance studies were performed over 6 days in 20 consecutive patients with acute myocardial infarction and results compared with the haemodynamic parameters. 10 patients with unstable angina, but without acute myocardial infarction, formed a control group. All patients had a nitrogen input of 11.6 g/d. Nitrogen excretion was 13.9 g/d in patients with acute myocardial infarction and 8.9 g/d in the control group (p less than 0.001). 12 patients with complicated acute myocardial infarction had a mean nitrogen excretion of 15.6 g/d. There was no difference in nitrogen excretion between patients with or without diabetes mellitus. Mean nitrogen excretion in patients with acute myocardial infarction correlated significantly with severity of haemodynamic changes and blood glucose level on day of admission. The importance of parenteral nutrition in patients with complicated acute myocardial infarction and increased catabolism is emphasized.

[Moducrin--a new combined preparation in the treatment of hypertension (author's transl)]. / Moducrin--ein neues Kombinationspräparat zur Behandlung der Hypertonie.

A product combining 25 mg hydrochlorothiazide, 2.5 mg amiloride hydrochloride and 10.0 mg timolol maleate (Moducrin) was tested in 20 previously untreated hypertensive persons. The systolic blood pressure before treatment was 199.1 +/- 24.8 mmg Hg and after treatment 149.1 +/- 19.1 mm Hg. Diastolic blood pressure showed a drop from 120.9 +/- 11.9 mm Hg to 92.2 +/- 13.3 mm Hg. Both decreases were highly significant (p less than 0.01). The heart rate, moreover, was reduced during treatment from 81.5 +/- 11.1 beats per minute to 66.8 +/- 9.25 beats (p less than 0.01). Haemoglobin, haematocrit and serum uric acid showed significant changes, but did not reach pathological ranges. Treatment had to be stopped in only one case in this study because of incipient asthmatic bronchitis. We conclude that this combination drug has a very good antihypertensive effect and is well tolerated.

[Importance of risk factors in myocardial infarction (author's transl)]. / Die Bedeutung der Risikofaktoren für den Verlauf des Myokardinfarktes.

Importance of risk factors as hypertension, hyperlipidaemia, diabetes mellitus and cigarette smoking because of hemodynamic and complication during acute myocardial infarction and influence of live quality during the first year after myocardial infarct was pointed out in this study. No risk factor was found in 12.1% out of 248 patients. 25.8% had one, 33.5% two, 12.9% three and 3.2% four risk factors. If only one risk factor for coronary heart disease was documented, 35.9% showed cigarette smoking. If there were two risk factors, most of the people had diabetes mellitus and hypertension, and the combination diabetes mellitus, hyperlipidaemia and cigarette smoking was favourite if there were three risk factors present. The mean age of all patients was 65.9 +/- 10.8 years. Patients who smoked or had hyperlipidaemia were statistically significantly younger (p < 0.001). There was no correlation between number of risk factors or kind of it and pulse frequence, cardiac index, pulmonary artery pressure and third heart sound during phase of acute myocardial infarction. Also no correlation was found between the risk factors hypertension, diabetes mellitus and cigarette smoking and rhythm disturbance of reinfarction. Patients with normal lipids had significant more bradycard or tachycard rhythm disturbances as patients with hyperlipidaemia (p < 0.05). Patients without diabetes mellitus or hypertension had better bicycle tests than patients with this risk factors (p < 0.01). 92% of hypertensive patients had regular drug medication; 14.1% of smoking patients continued smoking cigarettes after acute myocardial infarction. Only 62.1% of diabetic patients, 54.1% of hyperlipidaemic patients and 40% of overweight patients kept diet. Because of this bad quality of patient compliance there was no exact information possible in predicting value of secondary preventive measurements after acute myocardial infarction.

[Influence of isosorbiddinitrate on hemodynamics at rest and during exercise (author's transl)]. / Beeinflussung der Ruhe- und Belastungshämodynamik durch Isosorbiddinitrat (ISDN). Untersuchungen an Patienten 3 Wochen nach akutem transmuralem Myokardinfarkt.

23 patients with acute transmural myocardial infarction were exercised (4 min. 30 Watt) at the end of the hospital period (14-26 days after administration) (probatory exercise). This test was repeated identically after 5 mg of ISDN; again hemodynamic measurements were done (heart rate, arterial pressure, pulmonary artery pressure, cardiac output). 60% of the investigated patients had elevated (above 20 mm Hg) wedge pressures (pulmonary diastolic pressure) during exercise. The elevated PA-pressure was lowered significantly by administration of ISDN. In Group II (with exercise PADP above 20 mm Hg) this reduction of preload improved ventricular performance significantly. In Group I (PADP ex below 20 mm Hg) reduction of the preload worsened ventricular performance (not significant). Heart rate rose at rest and was reduced during exercise after ISDN. Arterial pressure was lower after ISDN as well as during exercise. ISDN proved to be a valuable drug in the postinfarction period even in patients free of angina pectoris since it may help to normalize disturbed hemodynamics (which can only be detected by exercise testing in many cases).

[The efficacy of the intra-aortic balloon pump for patients with heart failure complicating acute myocardial infarction (author's transl)]. / Die Effektivität der intraaortalen Ballonpumpe bei Patienten mit Herzinsuffizienz durch akuten Myokardinfarkt.

Assisted circulation was carried out with the help of an intra-aortic balloon pump in 22 patients with acute transmural myocardial infarction and heart failure (despite medication). Two patients died in hospital. The combination of the balloon pump and nitrates proved to be particularly effective. The follow-up examination of the survivors showed a distinct pulmonary arterial pressure during ergometry. All of the examined patients revealed extensive akinetic and diskinetic areas, significant stenosis being detectable either in the proximal area of the Ramus descendens anterior or in two or three blood vessels.

[The value of different investigation procedures in arterial hypertension (author's transl)]. / Zur Wertigkeit verschiedener Untersuchungen bei arterieller Hypertonie.

221 patients with arterial hypertension were investigated as outpatients. 198 patients were found to have primary and 23 patients to have secondary hypertension. The results of urinary analysis were pathological in 25% of patients and renal function tests were abnormal in 20% of cases. Significant bacteriuria was recorded in 19% of urinary cultures. Intravenous pyelography showed true pathological findings in 12% of cases, false positive findings in 7% and false negative findings in 5%. Isotopic nephrograms showed true positive findings in 52%, false negative in 3% and 45% showed normal results. In 53% of patients angiography of the kidneys showed normal results, whilst this investigation proved pathological in 44% of cases and gave false negative results in 3% of patients. An additional search for coronary heart disease risk factors revealed that 73% of these hypertensive patients were overweight, 47% had hyperlipidaemia, 33% suffered from diabetes mellitus and nicotine abuse was present in 21% of cases. A relevant yet inexpensive screening programme for the investigation of hypertension is formulated on the basis of the results of this investigation.

[Ventricular rupture during acute myocardial infarction (author's transl)]. / Herzruptur bei akutem Myokardinfarkt.

In a series of 523 consecutive patients with acute myocardial infarction (AMI) 112 died; among these were 18 with rupture of the free wall of the left ventricle (HR) (group RU); two other cohorts were formed: one sample of all patients with acute (transmural) myocardial infarction (group KO) and another cohort of death of AMI in 1976 (EX). 1. patients with HR are significantly older than the KO group; there is no difference in age compared to the patients who died of AMI other than HR (group EX). 2. Women with AMI have a higher chance to die of HR than men. 3. The RU group has significantly more often clinical signs of congestive heart failure than the control group. 4. Cardiogenic shock is significantly more frequent in the RU-group than in the control group. 5. All deaths (EX + RU) have worse hemodynamic data than the control group (KO). 6. Elevated blood pressure (before and after AMI) could not be identified as a risk factor for HR in our patients. 7. In the course of AMI, death in pump failure occurs significantly later than heart rupture.

Bacterial contamination of pulmonary artery catheters.

The catheter tips of 152 patients, who were haemodynamically supervised by pulmonary artery monitoring or continuous cardiac output determination, were bacteriologically examined. 106 cultures remained sterile, 21 cultures revealed a growth of non pathogenic organisms. Staphylococcus aureus was cultured 15 times, pseudomonas aeruginosa 4 times, Citrobacter as well as Escherichia coli twice, and Klebsiella and Enterobacter once each. There was no statistically significant connection between dwelling period and contamination. Also diabetes mellitus or corticoid medication in high dosage had no significant influence on contamination rate.

[Arrhythmias during catheterization of patients with acute myocardial infarction (author's transl)]. / Rhythmusstörungen beim Einschwemmkatheterismus akut Infarktkranker.

Arrhythmias in forty consecutive patients with acute myocardial infarction during ventricle passage of floating catheters were compared with those in forty patients with chronic heart disease. Lidocaine (1 mg/kg body weight i. v.) as a bolus proved to be effective in reducing the incidence of these arrhythmias, because the number of single ventricular premature beats (VPBs), and the number of VPBs in salves was significantly reduced. Haemodynamic changes due to this bolus are small and short-lasting, so that they are acceptable, especially when continuous monitoring of the patients is attempted. Furthermore dangerous arrhythmias are reported in 1600 cases treated with floating catheters.

[Continuous monitoring of the pulmonary artery pressure in acute myocardial infarction (author's transl)]. / Kontinuierliche Uberwachung des Pulmonalarteriendruckes beim akuten myokardinfarkt.

The method of continuous pulmonary artery pressure (PAP) monitoring and its use in 66 patients with acute myocardial infarction is described. Measurement of PAP should be the first diagnostic step in hemodynamic monitoring and early recognition of left ventricular failure. In cases of elevated PAP and critical general state of the patient, monitoring should be extended by measuring pulmonary wedge pressure and cardiac output. Hemodynamic monitoring should be continued for 3 to 5 days, since some cases of acute myocardial infarction with increasing PAP up to the 4th day after the onset were recorded. With the safety precautions mentioned, neither threatening, arrhythmia, nor thromboembolic or septic complications were observed.

[Behavior of pulmonary artery pressure in the egometric exercise test in chronic coronary disease]. / Zum Pulmonalisdruckverhalten im ergometrischen Arbeitsversuch bei chronisch koronarer Herzkrankheit

Bicycle exercise stress tests of 39 patients with coronary heart disease are compared to those of 33 healthy persons. The difference in enddiastolic pulmonary artery pressure (PAEDP) of the patients compared to the healthy is low at rest (PAEDPhec healthy = 8.49 +/- 2.80, PAEDPCHD = 10.51 +/- 5.09, p = 0.05). Stress testing (50 Watts) brings significant differences of the average enddiastolic pressures (PAEDP healthy = 12.76 +/- 3.61, PAEDPCHD = 19.38 +/- 7.96, p = 0.001). More important than this (already well known difference) is the wide divergence of results within the group of patients with CHD. For this reason this type of investigation seems to be a good "screening method" regarding selection for coronary arteriography. The reason for the pathological rise of PAEDP can be found in a decrease of compliance due to ischaemia ("coronary factor"), or in exercise induced temporary heart failure ("myocardial factor"), or both.

[Pulmonary artery end-diastolic pressure recordings after myocardial infarction (author's transl)]. / Pulmonalarteriendruckverhalten nach Myokardinfarkt

29 patients with acute myocardial infarction were subdivided into 3 groups using the information gained by continuous measurement of the pulmonary artery end-diastolic pressure (PAEDP) during a stay of 3 to 5 days in the coronary care unit of this hospital. Group I comprised patients with a PAEDP of below 12 mm Hg (without treatment), group II those with a PAEDP of between 12 and 20 mm Hg and group III those patients with a PAEDP of above 20 mm Hg. 3 to 6 months after rehabilitation and ambulant ""coronary training'' a follow-up control PAEDP measurement was performed at rest and during ergometric stress with the bicycle exercise test. 2 out of the 15 patients in group I had a pathological PAEDP at rest, whilst exercise of 50 watts raised the PAEDP to pathological values in 40% of this group of patients. Group II: 58% of the patients with an initially-raised PAEDP showed a normal value at follow-up examination 3 months subsequently. Exercise of 50 watts raised the PAEDP to pathological values in 66% of the patients in this group. Group III. The pathologically high PAEDP recordings at rest made it impossible to subject these patients to stress with the bicycle ergometer. The prognostic value of the classification of patients with myocardial infarction into pressure groups and the importance of PAEDP follow-up measurements on patients after myocardial infarction at rest and after ergometric stress are discussed.