Zeitschrift für ärztliche Fortbildung und Qualitätssicherung
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Z Arztl Fortbild Qualitatssich · Apr 1998
Review[Early detection and diagnosis of invasive mycoses].
An invasive mycosis may cause death in high-risk patients. An early systemic antimycotic therapy can save life. Therefore, a continuous mycological monitoring in one week intervals is necessary in high-risk patients beginning with the day of admission. ⋯ Only by interpreting the time course of the mycological findings and the patient's clinical status, an invasive mycosis may be diagnosed with some certainty. In any case, additional procedures like radiological techniques (i.e. CT-scan), histology etc. should be used.
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Clinical practice guidelines can be used to achieve optimal utilization of scarce resources for the medical management of defined patient groups. However, this does not mean that the total amount of resources allocated to these patient groups will be reduced automatically. Examples of different health economic consequences for guideline implementation will be discussed, especially with regards to the cost-effectiveness to therapy and to the total health care budget. ⋯ Quality criteria of sound evidence-based guidelines are introduced. Evidence-based guidelines that are developed in cooperation with recognized clinical experts attain wide acceptance among physicians. Sound evidence-based guidelines comprising cost-benefit relations of therapy can be the core of an internal health care reform.
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The regional application of opioids close to the spinal cord by using pumps induces a pain reduction comparable to the systemic medication of the WHO analgesic ladder. However, this method does not reduce the side effects of these drugs, e.g. nausea, vomiting, dysfunctional bladder emptying, and obstipation. ⋯ Catheters and port systems have to be revised in 15% of all cases. Therefore, the indication for this method has to be considered carefully and includes the following criteria: pain of somatic origin, exclusion of mental diseases and psychogenic causes of pain, causal therapy is exhausted, insufficient effects of peripheral analgesics and co-analgesics, oral or transdermal opioids are insufficient despite dosages resulting in side-effects, pain is sensible to opioids, regional application of opioids has been tested effective before implantation.
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Back pain is a common disease causing tremendous costs for treatment, rehabilitation, pension payments and work-loss. The reasons of back pain vary considerably and often remain doubtful. The effectiveness of current treatment concepts has not yet been proven significantly. In accordance with the literature, in chronic pain only multimodal concepts of treatment seem to be successful as far as they take care about somatic, psycho-social, and sport physiological aspects.
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Z Arztl Fortbild Qualitatssich · Jan 1998
Review[Sympathetic reflex dystrophy and phantom pain. Diagnosis, therapy and prognosis].
The incidence of phantom limb pain has been significantly underestimated for many years. However, studies published during the recent decade indicate that the real incidence of phantom limb pain may be between 60% and 90%. Reflex sympathetic dystrophy (RSD) occurs with an incidence of about 15.000 new cases every year in Germany. ⋯ None of the patients treated with a combination of local anaesthetics and low dose morphine developed phantom limb pain. Therapy of choice for RSD is the sympathetic blockade. The most suitable method is intravenous regional sympathetic blockade (IVRSB) with guanethidine (2).