Cudalb A, Gresser U (2020)
Creative Education, 11, 2424-2442

Aim: The growing shortage of doctors in Germany is a subject that is currently well documented in the mass media. The fields with the biggest deficits are internal medicine, general medicine, and anesthesia. One of the measures to correct this problem is employing doctors who have studied abroad. Theobjective of this study is to assess the extent to which the deficit of trained medics in Germany can be amended with doctors trained in Romania and Poland. Subject and methods: A very good overview of this phenomenon was acquired by putting together a  compilation of the educational process which leads to graduating as a medical doctor in Romania, Poland and Germany, the available literature regarding doctors migration and the annual statistical data provided by the German Medical Association. The study included processing the data obtained through two self-made questionnaires addressed to Romanian doctors. The first, with 129 respondents, was addressed to physicians who studied in Romania and were already working in Germany. The second, with 59 respondents, was addressed to Romanian students who wish to come and work in Germany. Results: The results of the Romanian survey were compared with similar studies carried out in Poland, revealing great similarities between the selected groups in training, motivation, way of thinking and perceptions of working conditions. The resulting graphics and figures provide a visual representation of the phenomenon, strengthening the conclusion. Discussion and conclusion: Taking into account the aging population in Germany, the increasing numbers of females in the medical profession, the growing trend of part-time work, the difficult medicine admission process and the unabated emigration of German doctors to the US, UK, Austria, and Switzerland, it is safe to conclude that Germany needs foreign-trained doctors. It became evident that not all the information regarding the training process in the three studied countries completely overlaps. There were also discrepancies between what is documented and the actual numbers of completed procedures that are required in order to complete the training. When taking all of this into account, the question this paper set to answer was positively answered, proof of which is the growing percentage of Polish and Romanian trained doctors working in Germany.

Braun J, Gresser U (2017)
Creative Education (CE) 8: 1729-1741. DOI 10.4236/ce.2017.811118

Specialists for internal medicine are very important group of the medical profession. Although they make up the largest group of specialized physicians, there is a shortage of physicians, and in particular of internists in Germany, Austria and under some aspects in Switzerland. Germany, Austria and Switzerland show also an intensive transfer of physicians. It is therefore of interest to investigate if the term “internist” in the three countries under consideration is based on the same or equivalent education, in particular regarding the quality standards. Exchange date between the three countries, the organisation of the medical profession, the access requirements to the specialist medical training, the structure of the specialist’s training as well as the requirements for keeping the specialist’s name have been compared. The main differences are the access requirements and the linkage of the qualification to the independent exercise of the medical profession. Also regarding the performance catalogues, the Swiss education follows a different approach as in Germany and Austria.

Weinreich T, Filz HP, Gresser U, Richartz BM (2017)
Journal of Clinical and Diagnostic Research JCDR 11: LC20-LC24. DOI 10.7860/JCDR/2017/24112.9553

Introduction: Obesity is accompanied by restriction in the quality of life and an increased risk of morbidity and mortality. Cardiovascular, orthopedic, and metabolic disorders are among the possible consequences. In the management of obesity, a combination therapy that includes dietary, exercise, and behaviour modules has proven its worth. Aim: To evaluate the effect of weight-associated parameters, circulation associated parameters, glucose metabolism, body composition and life quality changes within a four-week inpatient rehabilitation program. Materials and Methods: Fifty-two patients underwent a 4-week inpatient rehabilitation program consisting of nutrition therapy, behavioural therapy and exercise therapy modules at the Eleonoren Clinic of Winterkasten, Germany. Results: The mean weight reduction of 52 obese patients - 40 (76.9%) males, 12 (23.1%) females; mean age 46 years; mean Body Mass Index (BMI) 43,79 kg/m² - achieved was 7.1 kg (from 1.20 kg to 17.50 kg), and the BMI reduction was 2.3 kg/m² (from 0.40 kg/m² to 5.40 kg/m²). The excessive weight loss was highly significant (p<0.001). Weight reduction was accompanied by an improvement in the diabetic metabolic state (lowering of fasting blood-glucose 20 mg/dl, postprandial blood glucose 26 mg/dl, HbA1c 0.27%). In all 73% of the patients suffered from arterial hypertonia. The significant mean decline of systolic and diastolic blood pressure was 12.8 mmHg and 6.8 mmHg, respectively. The resting pulse was reduced by an average of 11 beats per minute. The Bioelectric Impedance Analysis (BIA) revealed a significant reduction of body fat content (p<0.001). The subjective impression of impaired life quality (SF-36 questionnaire) improved significantly. Conclusion: The study clearly shows that the inpatient rehabilitation program at the Eleonoren Clinic was suitable to enhance the physical and mental state of people with obesity. In a two-year follow-up program the patients should take care of a permanent lifestyle change toward an improved dietary, movement, and health behaviour.

Gresser U (2016)
Klinikarzt 45 (11): 538-545

Aktuelle wissenschaftliche Daten zeigen auf, dass Hyperurikämie möglicherweise nicht nur mit dem Risiko von Gichtanfällen und/oder Tophi verbunden ist, sondern das Symptom einer genetisch bedingten Fehlfunktion des Enzyms Xanthinoxidase sein könnte. Das Enzym Xanthinoxidase katalysiert den Abbau von Hypoxanthin zu Xanthin und Xanthin zu Harnsäure. Die dabei entstehenden Hyperoxidanionen bewirken oxidativen Stress mit Zellschädigungen. Hohe Aktivitäten von Xanthinoxidase in der Gefässwand führten zu der Hypothese, dass eine Überaktivität der Xanthinoxidase eine kausale Rolle bei der Entstehung von Atherosklerose spielen könnte. Dies könnte erklären, weshalb Patienten mit Hyperurikämie vermehrt kardiovaskuläre Erkrankungen, Erektile Dysfunktion und Niereninsuffizienz bekommen. Von den harnsäuresenkenden Medikamenten hemmen nur die Xanthinoxidasehemmer auch das Enzym Xanthinoxidase und damit dessen wohl atherogene Wirkung, und hier wohl Febuxostat deutlich stärker als Allopurinol. Der Artikel berichtet über die wichtigsten Aspekte von Gicht und Xanthinoxidase-Überaktivität und gibt Hinweise zur Therapie.

Recent scientific data show that hyperuricemia may be associated not only with the risk of gout attacks and/or tophi, but could be the symptom of a genetic malfunction of the enzyme xanthine oxidase. The enzyme xanthine oxidase catalyzes the degradation of hypoxanthine to xanthine and to uric acid. The resulting superoxide anions cause oxidative stress cell damage. High activity of xanthine oxidase in the vascular wall led to the hypothesis that overactivity of xanthine oxidase may play a causal role in the development of atherosclerosis. This could explain why patients with hyperuricemia increasingly develop cardiovascular disease, erectile dysfunction, and renal insufficiency. Of the urate lowering drugs only xanthine oxidase inhibitors also inhibit the enzyme xanthine oxidase, and thus its  atherogenic effect, and here probably Febuxostat is significantly stronger than allopurinol. The article reports on the main aspects of gout and xanthine overactivity and treatment.

Kolodziej M, Gresser U, Richartz BM (2016)
Creative Education 7: 2021-2034. DOI 10.4236/ce.2016.715203

With the continuing shortage of physicians in Germany, healthcare is increasingly being sustained by foreign physicians. The paper addresses the comparability of medical education curricula in Germany and Poland and the qualification of physicians having Polish exams and specialist medical training for clinics and practices in Germany. Methods: The Medical Licensing Act and the Model Specialty Training Regulation of the German Medical Association were compared to the respective Polish regulations for medical education. In orienting surveys, physicians with Polish exams were questioned and they provided information regarding their current situation in German healthcare. Results: Based on educational criteria, physicians with Polish exams and specialist training are well suited to work in medicine in Germany. They receive theoretical education comparable to that of German physicians; practical education during specialist medical training is more extensive in Germany. The survey could yield that Germany, as a job market, is very appealing for physicians with Polish exams. The primary reasons for this are better opportunities for training as well as better compensation. Conclusions: The solicitation of physicians equates to an economic loss for Poland. Nevertheless, the solicited physicians benefit from working in Germany. The European Union lacks common, detailed European standards for medical education.

Siebler S, Gresser U, Richartz BM (2016)
eCAM Volume 2016, Article ID 2636542

Objective: This study aims to evaluate the effect of daily dietary nutritional supplement on somatic, psychological and urogenital symptoms in postmenopausal women. Material and Methods: In this study 28 healthy, symptomatic, peri- and postmenopausal women of 47-67 years of age were allocated to use the nutritional supplement JuicePLUS+®. Primary research parameters: Menopause Rating Scale (MRS) was used to assess menopausal symptoms at baseline and after 8 and 16 weeks of treatment. Secondary parameters: Proliferation behaviour of vaginal smear was scored at baseline and after treatment. Results: Treatment with the supplement resulted in a reduction of somatic, psychological and urogenital symptoms. The overall MRS score showed an average improvement of 44.01%. Most benefits were observed for the psychological symptoms irritability (60.55%) and physical and mental exhaustion (49.08%), modest effects were observed for hot flashes (44.86%) and sleeping problems (35.56%). There was a minor improvement in sexual problems, 6 women reported an increased libido. No statistically significant effect was found in vaginal dryness and proliferation behaviour of vaginal mucosa. No adverse effects were observed. Conclusion: Dietary nutritional supplement may constitute an effective alternative therapy to conventional alternative medicine for somatic, psychological and sexual symptoms.

Gille TG, Gresser U (2015)
Endo heute 28: 182-186

Einleitung: Im EBM werden neben den Vergütungsziffern auch sog. Prüfzeiten angegeben. Diese nutzen die kassenärztlichen Vereinigungen für Plausibilitätsprüfungen. Wird eine bestimmte Zeitsumme überschritten, ist die Abrechnung auffällig und wird einer weiteren Prüfung unterzogen. Diese Untersuchung kann weitreichende Konsequenzen haben von Regressverfahren bis zur Anklage wegen Betruges. Wir haben deshalb untersucht, ob diese Prüfzeiten eine hinreichende wissenschaftliche Basis haben und am Beispiel der Koloskopie durch Analyse von Studien sowie eigenen Untersuchungsdaten überprüft, inwieweit die Koloskopieprüfzeit valide ist.
Ergebnisse: 1. Die Prüfzeiten wurden normativ und ohne wissenschaftliche Basis festgelegt. 2. In der wissenschaftlichen Literatur zur Koloskopie fanden sich überwiegend Untersuchungszeiten unter der Prüfzeit des EBM. 3. Bei den 1262 Koloskopien der eigenen Patienten ergab sich bei 74 % eine Prozedurzeit unter der vorgegebenen Prüfzeit, bei 26 % oberhalb.
Zusammenfassung: Es wird deshalb empfohlen, bis zur Validierung der Prüfzeiten des EBM durch wissenschaftliche Studien, diese im Rahmen der Plausibilitätsprüfung nicht mehr zu verwenden.

Prinz A, Gresser U (2015)
NZFam 21/2015 vom 06.11.2015, 2: 989-995

Jeden Tag werden weltweit Kinder von ihren Eltern getrennt, sei es durch Flucht, Krieg, Tod, Trennung der Eltern, gerichtliche oder behördliche Maßnahmen. Die Erfassung von Folgen solcher Traumata und ihre Bedeutung für die medizinische Versorgung der Betroffenen werden immer wichtiger.
Ziel der vorliegenden Literaturanalyse war es, zu klären, ob Kinder, die in ihrer Kindheit und Jugend Kontaktverlust zu ihren lebenden Eltern erleiden, über das aktuelle Trauma hinaus länger anhaltende gesundheitliche Folgen zeigen.
Ergebnisse: Es gibt nur wenige Studien, die sich mit der Frage gesundheitlicher Folgen von Kontaktabbruch zwischen Kindern und ihren lebenden leiblichen Eltern befassen. Die Studien ergeben:
Kontaktverlust zu leiblichen Eltern führt unabhängig vom Lebensalter des Kindes bei Beginn und der Dauer des Kontaktverlustes zu einem erhöhten Risiko für die Entwicklung von schweren Depressionen, Angststörungen, Panikstörungen, Alkoholabhängigkeit, Drogenmissbrauch, Drogenabhängigkeit und Phobien. Kontaktverlust zu Mutter bzw. Vater bewirken beide erhöhte Erkrankungsrisiken mit unterschiedlichen Risikokonstellationen.
Die Folgen können lebenslang anhalten. So führte z.B. Kontaktverlust zu einem Elternteil durch Trennung – nicht aber durch Tod - zu einem erhöhten Risiko, an einer Alkoholabhängigkeit zu erkranken. Am ausgeprägtesten war dies bei Kontaktverlust zur lebenden Mutter, hier war das Erkrankungsrisiko für Alkoholabhängigkeit signifikant erhöht (iHR = 4,70 mit p < 0,0001) mit einer errechneten Erholungszeit von 115,5 Jahren. Kontaktverlust zu lebenden Eltern wirkt sich nachweislich der wissenschaftlichen Studien deutlich stärker aus als Kontaktverlust aufgrund von Tod. Durch Kontaktverlust zu lebenden Eltern werden die betroffenen Kinder etwa doppelt so stark und dreimal so lang belastet, wie bei Kontaktverlust durch Tod.

Autorengespräche dazu bei ZDF und 3SAT siehe unter Links

Wiesinger F, Gresser U (2015)
J J Dent Res. 2: 029

Aim. Investigation of the effect of dietary supplementation with plant substances on the course of refractory chronic periodontitis in various risk groups.
Materials and Methods. 30 subjects with refractory periodontitis were given the plant extract JuicePLUS+® whilst otherwise continuing with unchanged oral hygiene and diet. The primary research parameters were plaque accretion (API), bleeding index (BOP) and probe depth. Secondary soft parameters were the effects of the dietary supplementation on oral and general well-being.
Results. We observed a 19.3% reduction in the BOP. In 90% of subjects the bleeding index showed improvement. 63% achieved a marked improvement in their inflammatory state within two months; no notable improvements were seen later in the trial. The periodontal pocket depths reduced by on average 0.164mm (upper jaw) and 0.292mm (lower jaw). The soft endpoints improved markedly. No differences in the efficacy of the supplement between individual risk groups were seen. No side effects of the supplement were reported. 10 months after the study, 70% of the subjects reported a positive effect during the study.
Conclusion. Dietary supplementation with JuicePLUS+® can favorably influence the extent and clinical course of refractory periodontitis and can positively stimulate the psyche.

Gresser U, Gathof B, Zöllner N (1990)
Klin Wochenschr 68:1222-1228

Immer noch aktuell:

Since 1962 our group has performed four studies on uric acid values in blood donors in Southern Germany (Bavaria). Uric acid levels in men have increased over the years, from 4.86 mg/dl in 1962 to 6.00 mg/dl in 1971, 5.60 mg/dl in 1984, and 5.90 mg/dl in 1989. Women aged 51 to 60 years had significantly higher uric acid levels than those in the fourth decade. In women treated with oral contraceptives uric acid levels were significantly lower than in other women of the same age. 
Hypouricemia (uric acid levels ≤ 2,0 mg/dl) was observed in three women, none of whom had a history of medication.
Hyperuricemia exists when uric acid levels are ≥ 6.5 mg/dl. In 1989 2.6 % of the female blood donors and 28.6 % of the males were hyperuricemic, with an increased risk of gout, nephrolithiasis, and nephropathy.

Jordan B, Gresser U (2014)
Der Sachverständige 4/2014 vom 08.04.2014; 41: 71-83
Verlag C.H. Beck München

Die Zahl der in den letzten Jahren öffentlich gewordenen Justizfehler, für jedermann nachzulesen, wie z.B. im DER SPIEGEL 33/2011 vom 15.08.2011 über den Fall von Horst Arnold, die sich zum Teil zu Justizskandalen auswuchsen, hat das Vertrauen der Bürger in den Rechtsstaat erschüttert. Oft wurde weder den Opfern angemessen Gerechtigkeit zuteil, noch wurden die Ursachen der Justizfehler den deutschen Gesetzbüchern entsprechend rechtsstaatlich gewürdigt. In solchem Kontext öffentlich gewordene Fälle sind zum Beispiel die von Gustl Ferdinand Mollath, Ulvi Kulac, Horst Arnold, Jörg Kachelmann oder der des Vaters aus Memmingen, wobei jeder Fall eine ganz eigene Geschichte ist. Es wäre für die Wirksamkeit des Rechtsstaates wichtig, Fehler zuzugeben und Falschbeschuldigungen gemäß § 164 StGB bzw. § 239 StGB  zur Rechenschaft zu ziehen. So wurde beispielsweise im Falle von Horst Arnold die gerichtlich festgestellte Falschbeschuldigerin Heidi K. wegen der „Freiheitsberaubung in mittelbarer Täterschaft“ verurteilt, nicht aber wegen der Falschbeschuldigung – diese war bei Beginn der Ermittlungen verjährt. Auch im Fall des sieben Jahre lang unschuldig inhaftierten Vaters aus Memmingen wurde die Falschbeschuldigung wegen Verjährung nicht geahndet.

Verjährung ohne Klärung bahnt sich im Fall von Jörg Kachelmann an. Hier wurde wohl noch nicht einmal mit den Ermittlungen wegen des Verdachtes auf Falschbeschuldigung begonnen – die im Raum stehende Falschbeschuldigung wird wohl im Mai 2014 verjähren, die mittelbare Freiheitsberaubung wohl im Juli 2015. Und dies, obwohl das LG Mannheim mit Entscheidung vom 17.10.2013 festgestellt hat, dass die Herrn Kachelmann beschuldigende Frau Claudia D. keinen Unterlassungsanspruch hat, wenn Herr Kachelmann sie öffentlich als „Falschbeschuldigerin“ bezeichnet, da bereits die Strafkammer des LG Mannheim festgestellt habe, dass Frau D. „nachweislich [...] falsche Angaben gemacht“ habe.

Es geschehen Fehler, aber es fehlt offensichtlich an der Analyse und Beseitigung der Fehlerursachen. Man vermisst eine angemessene Fehlerkultur.

Eine zentrale und nicht selten auch mitursächliche Rolle bei den bekannt gewordenen Fehlurteilen des Rechtssystems spielen medizinische und psychologische Gutachten.

„Der Gutachter muß ein unabhängiges Beweismittel sein und bleiben [und] [...] darf von keiner der am Strafprozeß beteiligten Personen abhängig sein oder werden“. Doch gerade bei diesem von Rasch als „das heißeste Problem in der ganzen Gutachtenerstattung“ bezeichneten Prozess der Sachverständigenbeauftragung spielen in der öffentlichen Diskussion immer wieder Hinweise auf mögliche Einflussnahme der Gerichte auf die von ihnen bestellten Gerichtsgutachter eine Rolle.

Um einen Anhaltspunkt dafür zu erhalten, ob es Einflussnahmen auf Gutachter bei von einem Gericht in Auftrag gegebenen Gutachten gibt, und was die Gutachter selbst dazu sagen, wurde eine Befragung unter Gutachtern durchgeführt.

Hier geht es zum Artikel:
http://beck-online.beck.de/default.aspx?sec=ICAgIGJlY2szNGFjOGI0ODYwZDQ0MTlhfh20ZRgEGjZwmeL1nIp1eqhbIbkuvsxV%2bU1dkCzw0itJ%2byka38wPbvegTavjdZ56IcBXDDigurpz26qP%2bEQs8g7RHchvo8ZGQWKqa9SKZwBRw%2fNy9yIKXEpaISKl4bFf
Wir bedanken uns hierfür beim C.H. Beck Verlag.

Jordan B, Gresser U (2014)
Dtsch Arztebl 2014; 111(6): A-210-212 / B-180 / C-176

Der Fall „Mollath“ hat deutschlandweit eine vielfältige Diskussion aus-gelöst. Gustl Mollath wurde in Folge eines psychiatrischen Gutachtens als „für die Allgemeinheit ... gefährlich“ eingestuft und sieben Jahre in einer psychiatrischen Klinik untergebracht. Im August 2013 wurde die Wiederaufnahme des Verfahrens durch Beschluss des Oberlandes-gerichts Nürnberg veranlasst.

Dieser und weitere Fälle lassen die Öffentlichkeit über das Begut-achtungswesen nachdenken. Ein besonders sensibler Punkt dieser Diskussion ist die Frage, inwieweit Gutachten objektiv, unabhängig und neutral sind.

Um dieser Diskussion eine wissenschaftliche Grundlage zu geben, wurde im November 2013 eine Studie zum Thema Begutachtungsmedizin in Deutschland am Beispiel Bayern im Rahmen einer Dissertation an der LMU München durchgeführt. Diese wurde im Deutschen Ärzteblatt vom 07.02.2014 in Auszügen erstmals als Originalarbeit veröffentlicht. Im Zuge der Studie wurden an 583 über das Internet ermittelte medizinische und psychologische Gutachter in Bayern Fragebogen versandt. 35 Briefe kamen als unzustellbar zurück, 548 waren zustellbar. 252 Befragte beteiligten sich an der Umfrage. Hiervon fünf gaben an, nicht gutachterlich tätig zu sein, vier teilten mit, nicht an der Umfrage teilnehmen zu wollen. Dies entspricht einer Rücklaufquote von 46,0 %.

http://www.aerzteblatt.de/archiv/154014/Gerichtsgutachten-Oft-wird-die-Tendenz-vorgegeben?src=search

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.

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.

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

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.

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.

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

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.

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.

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.