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Chronic pain in the hip, groin or thigh can be caused by a wide spectrum of diseases posing extended diagnostic problems. We describe the case of a 10-years old child with chronic pain in the groin with gait restriction for more than six months without successful classification and treatment.

The girl suffered from heavy pain in the groin after a sporting contest which forced her to walk with walking sticks and to avoid climbing stairs. Within six months she was examined by pediatric, orthopedic, pediatric surgery, pediatric orthopedic, radiology, pediatric rheumatology specialists. Working diagnoses were transient synovitis (coxitis fugax), arthritis, streptococcal arthritis, Morbus Perthes, rheumatic fever, rheumatoid arthritis. She was treated with antibiotics and ibuprofen in high dosage. Repeated laboratory tests and imaging studies (ultrasound, x-rays, magnetic resonance imaging) of the hip and pelvis did not support any of these diagnoses.

Six months after beginning of the complaints the girl was presented by her mother to our institution. The physical examination showed a sharp localized pain in the groin, just in the region of the inguinal ligament with otherwise free hip movement. There was no visible inguinal hernia. The family history for hernia was positive. After infiltration of the ilioinguinal nerve the girl had a complete long-lasting disappearance of pain and gait disturbance. This led to the diagnosis of inguinal hernia with nerve entrapment. After hernia repair and neurolysis/neurectomy there was a continuous state of disappearance of pain and gait disturbances.

Conclusion: To avoid such a diagnostic dilemma one should always discuss all possible causes. Non-visible inguinal hernia may be more common in females than previously thought. Nerve entrapment as a cause of groin pain has been well described. The relationship of the start of complaints with sporting activity, a positive family history for inguinal hernia, a lack of signs of inflammation and bone involvement in the laboratory and imaging studies together with a localized pain in the groin, almost immediate long-lasting disappearance of pain after infiltration of the ilioinguinal nerve allowing free motion leads to the diagnosis of inguinal hernia with nerve entrapment. Hernia repair and neurolysis are the adequate treatment avoiding unnecessary radiation.

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Candesartan cilexetil is the prodrug of candesartan, an angiotensin II receptor antagonist. Candesartan binds selectively and non-competitively to the angiotensin II receptor type 1, thus preventing the actions of angiotensin II. Clinical trials have demonstrated its efficacy at a dose range of 2 to 32 mg once daily in hypertension of all grades, heart failure, in reducing urinary albumin excretion in diabetes mellitus and in coexisting hypertension and renal failure. Pharmacokinetic properties of candesartan cilexetil in elderly patients are not significantly different from those in younger individuals. Hepatic impairment does not change pharmacokinetics of candsartan cilexetil at doses up to 12 mg/day. No dose adjustment is necessary in patients with mild or moderate renal impairment. Tolerability of candesartan cilexetil is not much different from that of placebo. All adverse events are usually of mild to moderate severity and not dose-related. The most common adverse events were headache, upper respiratory tract infection, back pain, and dizziness. The incidence of these adverse effects, as well as of cough, was similar in patients treated with candesartan cilexetil or placebo. The incidence of adverse events in long-term trials was not different from that in short-term trials. Tolerability of candesartan cilexetil does not differ with either age or gender.

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Aim: of this study was to compare the clinical benefit - reduction of heart attacks, strokes or deaths - of the different statins applying the results of randomized controlled endpoint studies.

Method: We analyzed 11 published randomized controlled endpoint studies statin-to-placebo looking for the cardiovasculoprotective benefit of the 5 statins (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin) tested: AFCAPS/TexCAPS, ASCOT, CARE, FLORIDA, HPS, PROSPER, LIPID, LIPS, MIRACL, 4S, WOSCOPS.

Results:

1. Statins produced substantial benefit for the patients, reducing the rate of cardiovascular morbidity and mortality.

2. This benefit was independent of the patient´s initial cholesterol or LDL-cholesterol concentrations and could also be demonstrated in patients who had average or low cholesterol levels.

3. Men and women showed a comparable benefit from statin treatment, elderly patients a little more than younger patients.

4. The statins did not have like effects. There were clear differences in potency as well as in the interval between initiation of treatment and the onset of clinical benefit.

5. Estimating 5 years of treatment, cardiac morbidity decreased with atorvastatin up to 44 %, with pravastatin up to 36 %, with fluva- or simvastatin up to 32 % and with lovastatin up to 24 %, approximately.

6. Estimating 5 years of treatment, morbidity of suffering from stroke decreased with atorvastatin up to 41 %, with simvastatin up to 34 % and with pravastatin up to 31 %, approximately. For fluva- and lovastatin there are no comparable data. Within the first 16 weeks of treatment following an acute coronary syndrome relative risk for suffering a non-lethal stroke was reduced with atorvastatin 80 mg/day up to 59 % compared to placebo, the relative risk for stroke up to 50 %.

7. The fastest onset of clinical benefit - reduction of fatal and non-fatal cardiovascular events, hospitalization and necessity of invasive interventions - was demonstrated by treatment with atorvastatin (rapid, within some weeks), followed by lovastatin (after one year), fluva-, prava- and simvastatin (after 1½ - 2 years).

8. These results were achieved with atorvastatin 10 mg/day (80 mg/day used in MIRACL), lovastatin 20 to 40 mg/day (caused by dosage titration), pravastatin 40 mg/day, simvastatin 20 to 80 mg/day (caused by dosage titration) or fluvastatin 80 mg/day.

9. The advantage of atorvastatin may be due to its ability to reduce cardiovascular disease by stopping the growth of plaques in artery walls.

10. Atorvastatin was the most powerful compound in the group of statins, improving patients´ health and expectation of life.

Conclusions: The authors of the studies agree, that patients at risk for cardiovascular diseases should be treated with a statin irrespective of initial cholesterol concentrations, sex or age. If an acute cardiovascular event has happened, statin treatment should be initiated early to improve the prognosis of these patients at high risk, independent from initial LDL cholesterol values.

Summing-up of these 11 trials, the best results and the greatest benefit for the patients were achieved with atorvastatin, which might be considered to be the gold standard for prophylaxis of cardiac ischemia and stroke.

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Introduction:

10.5% of the German population believes in the effects of lunar phase on disease. The topic is hot in German TV program. It is believed that at new moon the rate of bleeding complications is increased and operations during the waning phase of the moon would be best to avoid complications, pain and scaring. To our knowledge the effect of lunar phase has not been studied in ambulatory surgery.

Patients and methods:

782 patients were evaluated for complications and perception of the personal health after herniotomy, haemorrhoidectomy and crossectomy with partial vein stripping with or without phlebectomy as part of a quality control study. A questionnaire has been sent out to the patients asking the patient to rate postoperative pain, pain medication, restriction of daily activity, mental health and emotion, status of complaints after the operation.

Results:

In 782 patients (mean age 50 years) 866 operations were performed. There were no major complications and only in 3.71% minor complications (local bleeding, haematoma, inflammation, abscess, seroma, lymphatic fistula, dehiscence) were observed. The operations were equally distributed to the lunar phases. Complications and patient’s subjective perception of pain, restriction of daily activity, mental health and emotion, status of complaints after the operation were not associated with a lunar phase.

Conclusion:

The hypothesis that lunar phase influences the outcome of ambulatory operations is not valid. With regard to the organization of operations in the hospital and the patient’s uncertainty to decide the right time the lunar phase philosophy may have an socio-economic impact not yet understood.

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Etwa 30 Prozent der Männer und 3 Prozent der Frauen haben erhöhte Harnsäurewerte, und jeder zehnte Patient mit Hyperurikämie entwickelt eine Gicht. Bei der Therapie des akuten Gichtanfalles sind Steroide oder nichtsteroidale Antiphlogistika Mittel der Wahl. Für die Vermeidung einer chronischen Gicht ist eine Harnsäure senkende Dauertherapie notwendig. Je nach Patient sind hierfür Allopurinol (urikostatisch) oder Benzbromaron (urikosurisch) geeignet. Die beste Compliance erreicht man mit dem Allopurinol-Benzbromaron-Kombinationspräparat. Bei sachgerechter Therapie der Gicht unterscheiden sich Lebensqualität, Arbeitsfähigkeit und Lebenslänge dieser Patienten nicht von der von Gesunden.

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Teaching medical students the particular and the general of clinical medicine has been considered for more than hundred years of medical education in Germany the most rewarding aspect of a clinical professor. The actual amendment of medical education in Germany has banned the lecture from the curriculum of medical education.

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Since introduction of the PDE-5 inhibitor sildenafil 4 years ago, there has been a fundamental change in the treatment of erectile dysfunction (ED). Intracavernosal or intraurethral injections of vasoactive substances or penile implants as mechanical aids now play hardly any part in it. The development of the PDE-5 inhibitors vardenafil and tadalafil prompts the question of whether and how these three substances differ in terms of their efficacy and adverse effects. Sildenafil has proven to be a very effective medicinal product. Studies with a follow-up period of up to 6 years have been conducted. The success rate of sildenafil varies in the group of ED patients with an organic underlying disease from 43% in patients who have undergone radical prostatectomy to 85% in patients with a neurological underlying disease, and amounts to an average 82% (range 43-85%, 100mg). In an evaluation of spontaneous reports of deaths associated with sildenafil, the FDA concluded that there was no deducible evidence of an increase in the mortality rate among sildenafil users compared to the general population. In fact, fewer deaths associated in time with the ingestion of sildenafil were reported than might have been expected purely statistically on the basis of the normal mortality rate for men in this age group. According to the initial studies conducted, vardenafil and tadalafil demonstrate efficacy data approximately comparable to those of sildenafil. As yet, insufficient data are available to evaluate the adverse effects of vardenafil and tadalafil, particularly their long-term use and use in high-risk groups. Sildenafil has already been used by over 20 million men in over 110 countries and is one of the beststudied pharmacological substances available. This adventage in terms of knowledge and safety data makes sildenafil a safe and reliable treatment for patients with erectile dysfunction.

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Berichte über Lebererkrankungen in Zusammenhang mit Amoxicillin-Clavulansäure (A-C) belegen, dass A-C neben leichten Befindlichkeitsstörungen auch ernste Nebenwirkungen verursachen kann. Bei 153 Fällen lag nach Konsensuskriterien ein Zusammenhang zwischen A-C und einer Lebererkrankung vor. Die mittlere Behandlungsdauer betrug 13,9 Tage, die Zeit bis zum Auftreten hepatischer Symptome 3,6 Wochen, bis zur Normalisierung der erhöhten Leberenzyme 11,5 Wochen nach Therapiebeginn; drei der 153 Patienten überlebten die Erkrankung nicht. A-C kann, wenn auch selten, schwere bis tödliche Nebenwirkungen verursachen, unabhängig von Alter oder Geschlecht des Patienten. Vermehrt gefährdet sind Patienten mit umfangreicher Begleitmedikation. Bei lokalisierten oder unkomplizierten Infektionen ist abzuwägen, ob A-C erforderlich ist. Bei Therapie mit A-C sollten innerhalb der ersten beiden sowie vier Wochen nach Therapiebeginn die Leberparameter untersucht werden, um eine mögliche arzneimittelbedingte Lebererkrankung frühzeitig zu erkennen.

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Die Kombination Amoxicillin und Clavulansäure wird seit etwa 20 Jahren zur Therapie von bakteriellen Infektionen erfolgreich eingesetzt. Sie ist in 123 Ländern zugelassen und ist mit bisher etwa 1 Milliarde Verordnungen eines der am häufigsten eingesetzten Antibiotika überhaupt. Die klinische Wirksamkeit und Verträglichkeit sind für die Behandlung verschiedener infektiologischer Indikationen gut belegt.

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Die von Professor Lode/Berlin unterzeichnete Stellungnahme der Professoren Adam, Lode und Stahlmann zeigt, wie wichtig es ist, auch bei schon lange zugelassenen Medikamenten das Auftreten von Nebenwirkungen im Auge zu behalten.

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Introduction: There is a growing body of evidence that amoxicillin-clavulanic acid may induce severe adverse effects in patients.

Methods: A medline search of case reports and reviews on amoxicillin-clavulanic acid induced adverse effects was performed. The criteria of a consensus conference on the reporting of drug-induced liver disease were applied.

Results: Amoxicillin-clavulanic acid has been associated with drug-induced cholestatic hepatitis in 208 reported patients. In 153 evaluable patients there were 106 males and 47 females with a mean age of 60 years (1-90). Liver associated co-morbidity and co-medication does not play a major part in the development of disease. In most instances respiratory tract infection and sinusitis were treated by amoxicillin-clavulanic acid with a mean treatment duration of 13.9 days and a reaction time until first onset of jaundice of 25.2 days average. Infection and cholestasis from other reason were ruled out in most patients. Liver injury was classified according to laboratory parameters to be hepatocellular in 35 patients, cholestatic in 24 patients and mixed in 83 patients. Normalization of liver enzymes was observed 11.5 weeks after onset of drug administration (average); three of 153 patients did not survive the adverse event.

Conclusion: Amoxicillin-clavulanic acid which is marketed for treatment of respiratory infections and sinusitis/ otitis may in some cases induce severe adverse effects and death in patients of different age, especially if they are on multidrug regimens. In consideration of this fact many authors recommend to reflect carefully, whether amoxicillin-clavulanic acid is necessary in treatment of patients with localized or uncomplicated infections. If amoxicillin-clavulanic acid is prescribed, transaminase, alkaline phosphatase and bilirubin tests should be obtained within the first two weeks and after four to five weeks after beginning of treatment to recognize early enough undesired hepatic side effects.

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Unter den stoffwechselbedingten Arthritiden ist die Gicht die häufigste, die Pseudogicht/Chondrokalzinose die zweithäufigste. Andere stoffwechselbedingte Arthritiden spielen eine geringe Rolle.

Etwa 3% der Männer und 0,3% der Frauen erleiden im Laufe ihres Lebens eine Gicht, und es gibt in praktisch jeder Arztpraxis Patienten mit Gicht. Typisch für die Gicht ist die hochakute, extrem schmerzhafte Monarthritis im Wechsel mit beschwerdefreien Intervallen.

Ursache ist eine Hyperurikämie, die meist durch eine familiär gehäuft auftretende renale Ausscheidungsschwäche für Harnsäure oder - in wenigen Fällen - durch einen Enzymdefekt (v.a. der HPRTase) bedingt ist. Patienten mit Hyperurikämie aufgrund einer Erkrankung außerhalb des Purinstoffwechsels (z.B. Niereninsuffizienz) oder einer Therapie (z.B. mit Zytostatika) entwickeln nur selten eine Gicht.
Diagnostik und Therapie der Gicht sind einfach und kostengünstig. Die Dauertherapie mit Allopurinol oder Benzbromaron ist unkompliziert, wirksam und gut verträglich.
Bei sachgerechter Therapie der Gicht unterscheiden sich Lebensqualität, Arbeitsfähigkeit und Lebenslänge von Gichtpatienten nicht von Gesunden. Unbehandelt führt die Gicht zu schweren Schäden an den Gelenken und zum Verlust von Lebensqualität und Arbeitsfähigkeit bis zur krankheitsbedingten Berentung.

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