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BACKGROUND: Chronic pain is a widespread social problem. This paper reports on the care situation for patients with chronic pain in out-patient community settings in Austria. MATERIALS AND METHODS: The study took the form of a telephone survey together with internet research. Every second out-patient pain service (from a total of 83) was contacted and 21 out of 42 agreed to participate. RESULTS: The number of community-based physicians with a certificate in pain therapy as well as the number of out-patient pain services showed considerable regional variation. Partial or full interdisciplinary teams are a feature of approximately 50% of out-patient pain units and 76% of such services use guidelines according to their own estimation. Pain perception tends to be measured using pain rating scales rather than pain questionnaires. A wide range of treatments is offered either directly or via referral. CONCLUSIONS: Quality criteria relating to the structure of care established by the Austrian Society for Pain have only been partially implemented. Potential for improvement exists particularly with regards to the prevalence of pain-specific training, interdisciplinary teamwork and the measurement of outcomes.

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BACKGROUND: Pulmonary wedge pressure (PWP) is an established index of cardiac function and an essential component in the management of patients with congestive heart failure and in critically ill patients. AIM: To evaluate feasibility and accuracy of non-invasive prediction of PWP by Doppler echocardiography in daily clinical practice. METHODS: Agreement was assessed between values predicted by Doppler vs. invasively measured PWP. Forty-five consecutive patients [mean (S.D.) age 62 (10) years] with CAD (44%), DCMP (40%) and without structural heart disease (16%) were studied (EF< or =40% in 58% of the patients). Doppler transmitral and pulmonary venous flow velocity profiles were recorded. For binary and quantitative prediction of PWP, four different methods and five different linear equations, suggested previously in the literature, were evaluated. RESULTS: Predictive values to identify elevated PWP were highest for pulmonary venous flow reversal exceeding the duration of forward mitral flow during atrial systole (PPV 1 and NPV 0.96). Likewise, agreement with measured PWP was highest for equations comprising both transmitral and pulmonary venous flow variables (relative mean difference 0.11, S.D.+/-4.01 mmHg for the most accurate equation). Feasibility was slightly, but not statistically, lower when pulmonary venous flow was considered vs. transmitral flow parameters alone for binary prediction (87 vs. 93%) as well as for quantitative assessment (82 vs. 93%). CONCLUSION: Semiquantitative prediction of elevated PWP by Doppler echocardiography is feasible as well as accurate in daily clinical practice. However, accuracy of numeric estimates is limited. Hence, invasive measurement of PWP is still necessary in certain clinical settings.

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This study sought to compare the efficacy and safety of intravenous flecainide and sotalol for immediate cardioversion of atrial fibrillation. We performed a prospective, randomized, single-blind, multicenter trial, including 106 hemodynamically stable patients with atrial fibrillation, stratified according to duration of the arrhythmia. Exclusion criteria included severely reduced left ventricular systolic function, recent antiarrhythmic therapy, and hypokalemia. Patients were randomly assigned to receive either intravenous flecainide or intravenous sotalol. Trial medication was given at a dose of 1.5 mg/kg body weight (maximum 150 mg). Overall, 28 of 54 patients (52%) given flecainide and 12 of 52 patients (23%) given sotalol converted to sinus rhythm during the first 2 hours after start of the infusion (p = 0.003). Multivariate analysis confirmed that treatment allocation to flecainide, an arrhythmia duration of < or = 24 hours, higher plasma magnesium level at baseline, higher age for men, and lower age for women independently increases the probability of conversion. The frequency of adverse effects was not significantly different in the 2 treatment groups.

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We report our experience with primary angioplasty (PPTCA) in acute myocardial infarction performed without prior thrombolytic therapy. Between January 1991 and April 1993, 44 patients underwent PPTCA. Duration of symptoms was 163 +/ 106 min; age range of patients was 30 to 89 years (mean 60.6 +/- 13.5 years). Twelve patients presented with cardiogenic shock (27%), 17 patients (39%) had at least one relative contraindication for thrombolysis. Primary success rate was 98%. No stroke or major bleeding was observed. Reocclusion occurred in two patients, whereby this complication was silent in one of the cases. Significant residual stenosis remained in two additional patients. Three patients (7%) underwent elective bypass surgery (ACBG). Overall two-week mortality was 9%, and only 3% in the subgroup of patients without cardiogenic shock. Complete follow-up (FU) exceeding four months is now available in 36 patients (mean FU 13.7 +/- 7.3 months). During the FU period three patients had ACBG and five patients had PTCA. Thus, seven of 36 patients (19%) needed an additional procedure. Three patients had died, all of them were older than 70 years and initially presented with cardiogenic shock. Overall survival (in hospital and FU) was 84% (97% when patients with cardiogenic shock were excluded). Long-term survival (in hospital and FU) of the twelve patients initially presenting with cardiogenic shock was 50%. In conclusion, PPTCA is a promising therapeutic option in patients with acute myocardial infarction, especially when thrombolysis is contraindicated or when cardiogenic shock is present. It appears to be feasible even in centers with only one available catheterization unit.

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Pre-test probability for coronary artery disease can readily be determined using the patient's history, risk profile and resting ECG. The present study shows that this can be reliably done for both sexes. With pre-test probability of greater than 70% relevant coronary stenoses were found in both sexes in approximately 90%. With pre-test probability values of less than 60% this was only true in 20%. There seems to exist, however, a subgroup of female patients with rather atypical complaints but causing severe discomfort, showing normal coronary arteries it angiography. In these, subsequent myocardial metabolic studies and/or myocardial biopsy may reveal certain anomalies. Normal coronary arteries in women with chest pain therefore do not exclude any cardiac disorder. However the diagnoses to be expected from these sophisticated methods bear no consequences in terms of therapy. From a pragmatic point of view, therefore, it is suggested (for both sexes) to use pre-test probability in the selection for coronary angiography in order to detect organic coronary stenoses that can be managed by adequate treatment.

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In 35 patients with aortic stenosis the Doppler-derived values of the aortic valve area (continuity equation) were compared with those determined at cardiac catheterization (Gorlin's formula). The comparison of three modifications of the continuity equation showed that the procedure generally proposed (calculating the area of the left ventricular outflow tract from its diameter) significantly underestimated the valve area (modification 1). Modification 2, which used direct planimetry of the left ventricular outflow tract, yielded results quite consistent with invasive measurements. The employment of peak velocities instead of velocity-time integrals (modification 3) did not significantly alter the results. However, the scatter was considerable in all three modifications. When critical aortic stenosis was defined with a valve area less than or equal to 0.70 cm2, modifications 1, 2, and 3 accurately predicted the severity of stenosis in 80, 86, and 80%, respectively.

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In 60 patients with aortic regurgitation, angiography and cross-sectional Doppler echocardiography have been compared in order to examine the reliability of the noninvasive method in quantitating aortic regurgitation. In a parasternal short-axis view just below the aortic valve, the ratio of the cross-sectional area of the jet divided by the cross-sectional area of the left ventricular outflow tract was determined. This measurement was possible in 50 patients (83%). Grossman's classification was used as the criterion for assessing the severity of aortic regurgitation by angiography. Values for the ratio of grade I ranged from 0.03 to 0.18, II 0.06 to 0.29, III 0.30 to 0.55, and IV 0.40 to 0.65. Assuming four Doppler grades (less than 0.15, 0.15-0.29, 0.30-0.44, greater than or equal to 0.45), we found complete agreement between the two methods in 42 patients (84%). In six cases there was underestimation, in two cases overestimation, by one grade only. Considering all cases, X2 analysis gave 96.6, P less than 0.00001, the contingency coefficient was 0.81. We conclude that, using this measurement, cross-sectional Doppler is a reliable method for the quantitative evaluation of aortic regurgitation.

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Results of CW-Doppler measurements in 34 patients with aortic stenosis have been compared with catheter-derived data. The relevance of this noninvasive method for clinical decision making was examined. There was a good correlation between Doppler peak gradients and corresponding catheter values (r = 0.96). This gradient, however, was of limited clinical significance because, especially with simultaneous aortic insufficiency, it was not possible to characterize the severity of the stenosis over a wide range. The correlation for the mean gradient of both methods was also excellent (r = 0.94). Hence it was possible to derive, in a noninvasive way, a clinically proven parameter of the severity of aortic stenosis. 90% of Doppler mean gradients were found within +/- 15 mm Hg of the corresponding catheter data. The ratio of modified time to peak to modified ejection time was calculated to characterize spectral shapes. This value was also well correlated with the mean gradient (r = 0.91). A ratio of 0.3 separated patients with mean gradients above or below 50 mm Hg. The simultaneous consideration of Doppler derived mean gradient and spectral shape proved to be a valuable method for quantifying aortic stenosis for clinical purposes.

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In a randomized trial the effect was studied of celiprolol, a cardioselective beta receptor blocker with strong intrinsic activity (ISA) on the incidence of ventricular arrhythmias in patients with acute myocardial infarction (AMI). All patients received the first (oral) dose of 100 mg celiprolol or placebo exactly 6 hours after the onset of symptoms. Arrhythmia analysis was carried out from Holter recordings using a Pathfinder system. The results in 10 patients receiving celiprolol and 11 patients receiving placebo show that there was no difference in the distribution of the Lown classes between the two groups. The hourly VPC rate was somewhat higher in the celiprolol group from the very onset of the study, but the trend toward a decrease in VPC with time was identical in both groups. There was not a single incidence of ventricular fibrillation in the study population. It is concluded that celiprolol - under the circumstances of this study - did not show a beneficial influence on ventricular arrhythmias in AMI. This may, in part, be due to the strong ISA of this substance, but possibly also to the fact that celiprolol levels in the blood (measured by HPLC) were significantly lower in patients with AMI than in healthy volunteers.

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109 patients with advanced stage non-Hodgkin lymphomas were treated with cytostatic chemotherapy. 91 of these patients were classified according to the Kiel classification as having lymphomas of low-grade malignancy, whilst the remaining 18 had lymphomas of high-grade malignancy. The primary treatment in low-grade malignant lymphomas was a combination of chlorambucil and prednisone: in case of progression or therapeutic failure more aggressive schedules (COP, C-MOPP, HOP, CHOP, BACOP) were used. Patients with high-grade malignant lymphomas were treated in the first instance according to these aggressive schedules. Although no complete remissions were achieved, 25 out of the 47 patients with CLL responded with a partial remission to chlorambucil/prednisone, whilst 12 out of 19 non-responders to this schedule reacted favourably to COP. The results in 10 patients with immunocytic lymphomas were of a similar order. Better results were achieved in patients with germinal centre tumours: 9 out of the 11 patients with centrocytic lymphomas and all 20 patients with centrocytic-centroblastic tumours responded with a complete or partial remission. Of 18 patients with high-grade malignant lymphomas, 5 responded with a complete remission, 8 with a partial remission.

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During a period of 3 years 25 patients with small cell bronchogenic carcinoma were treated with combination chemotherapy and radiotherapy. The regimen was composed of adriamycin, cyclophosphamide and vincristine (ACO). After the first three cycles of combination chemotherapy-radiotherapy treatment was given to the primary tumor, the regional lymph nodes, the mediastinum and clinically involved cervical nodes. All patients showed a complete or partial regression of tumor. The median duration of response of patients with limited disease was 12 months, for those with extended or disseminated disease 8,6 months. Median survival from start of therapy was 14 months for those with limited disease at presentation and 10,9 months for those presenting with disseminated disease. The data were compared with those of other studies and discussed.

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58 women with metastatic breast cancer, non-responsive to hormone therapy, were treated with a modified CMF regimen. After progression the combination of adriamycin and vincristine was used. With CMF the response rate was 41% (10% complete remissions, 31% partial remissions), 38% showed no change, whilst progression of the disease was observed in only 21% of patients. The median duration of remission was about 8 months. Progression of the disease was treated by a combination of adriamycin and vincristine and remissions were obtained in 24% of cases. The median survival time of our patients from the time of tumour metastasis was 18.6 months and was dependent on the results of treatment.

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The role of cytostatic drugs in the treatment of patients with advanced, metastasizing tumours and certain-therapeutic regimes are discussed in respect to the following tumours: breast cancer, gynaecological tumours, urinary tract cancers, tumours of the head and neck, lung cancer and bone and soft tissue sarcomas. Recent progress in the management of these patients is outlined, whilst the limitations of cytotoxic treatment, with the inherent possibility of potentially fatal complications, are emphasized.

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