Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

[Controversies of partial nephrectomy for renal cell carcinoma : survey in the German-speaking countries]

BACKGROUND

The goal of this study was to evaluate how partial nephrectomy is technically performed in Germany, Austria, and Switzerland.

METHODS

A one-page anonymous questionnaire was designed to evaluate the indication, the technical procedure, and the follow-up of R1 situation after partial nephrectomy. Furthermore, the size of the hospitals and their catchment areas were recorded. The questionnaire was sent to 341 clinics and a statistical analysis was performed.

RESULTS

The response rate was 69 %. Up to 99 % of the clinics also perform partial resection in T1b tumors. Of those responding, 58 % perform this surgery laparoscopically, and 83 % of the surgeries are performed in warm ischemia. For the follow-up, 29 % suggest imaging within the first 6 weeks. According to this survey, maximum care clinics perform laparoscopic nephrectomy more frequently (p = 0.003).

CONCLUSION

The survey of 236 hospitals performing partial nephrectomy shows great variability in the indication, technique, and aftercare of organ-preserving renal tumor surgery. It also shows that a large proportion of tumors >4 cm undergo organ-preserving surgery, many of them minimally invasive. The diverse handling with positive instantaneous section and R1 results suggest the need for further studies concerning long-term follow-up after minimally invasive surgery with R1 situation and renal tumors > T1a.

Seltene Komplikation nach Bleier-Secu-Clip-Anwendung

A case of bilateral torsion of the fallopian tubes, the right with a hydro-salpinx is reported. This occurred 8 months following tubal sterilization following by the Bleier Secu-clips in a case of acute abdominal pain following tubal sterilization the differential diagnosis of a torsion of the fallopian tube with swelling of the infracted tube must be considered in addition to a torsion of an ovarian cyst.

[Multiple intracerebral lesions. Identification of the causative agent by 16S rDNA-PCR]

Molecular biological methods such as polymerase chain reaction (PCR) enable microbiologists to detect bacteria even if antibiotic treatment has already been started. Based on this case report of a 39-year-old man with multiple intracerebral lesions, we describe a PCR method called 16S rDNA-PCR which can be used to identify panbacterial DNA by focussing on the universal gene sequences for the bacterial 16S part of the ribosome.

[Aneurysm of the internal carotid artery--a differential diagnosis of paralysis of the caudal cranial nerves]

Paralysis of the caudal cranial nerves, e. g. the nervus glossopharyngeus, vagus and accessorius, may cause disorders in swallowing and speaking leading to a reduction in the patient's quality of life. Glomus tumors or malignant lesions of the skull base are a frequent cause of such lesions. We report on the case of a 48 year old patient who presented an acute lesion of these cranial nerves in combination with paresis of the nervus hypoglossus as a result of an aneurysm of the internal carotid artery directly underneath the base of the skull. The aneurysm was treated by parent vessel occlusion. The results of this procedure were a shrinkage of the aneurysm and an improvement in the neurological symptoms.

[Neuritis of the optic nerve after vaccinations against hepatitis A, hepatitis B and yellow fever]

BACKGROUND

Vaccinations are preventive measures against serious infections. In relation to the number of vaccinations per year, the incidence of severe complications is extremely low.

PATIENT

Two weeks after vaccinations against hepatitis A, hepatitis B and yellow fever in preparation for a trip to Africa a 21-year-old woman experienced an acute and irreversible loss of vision to 0,05 and nasal visual field defect in the left eye. Whereas vision acuity did not recover the scotoma disappeared within 6 weeks. Cerebrospinal fluid showed a lymphocytic pleocytosis. Oligoglonale bands were absent. Pathological parameters were not presented in the serum. The MRI showed a hyperintense thickening of optic nerve,as well as a hyperintense focus in right temporal side using the T(2)W-Sequence.

CONCLUSION

Only few cases have been reported with neurological complications, such as encephalitis, following vaccinations each of the above mentioned. As no other causes for the inflammation were found, the optic nerve involvement must have been caused by the vaccination. Which of the three vaccinations caused encephalitis can not be classified.

[Similarity of monozygotic twins regarding vocal performance and acoustic markers and possible clinical significance]

Auditory similarities in voices of monozygotic twins have already been described in the literature. However, is there a clinical relevance? Thus, the present study was designed to identify parameters of vocal performance and acoustic features which are significantly more similar in monozygotic twins than in non-related persons. In our hypothesis, comparable prerequisites for an increased vocal load in a profession or in an artistic education of the voice could be due to these similarities. We compared intra-pair differences with data from a control group. Moreover, we examined the correlation of intra-pair differences with the age of the monozygotic twins. A greater difference in older twin pairs than in younger pairs could show the effect of an exogene influence. In addition to the few phoniatric studies in twins in the literature, we used current methods for acoustic analysis. We examined seven parameters of vocal performance and three acoustic features in 31 monozygotic twin pairs (median age 36 years, range 18-75 years) and compared them with 30 control group pairs, which consisted of non-related persons of the same age and sex, newly combined from the group of monozygotic twins ("statistical twins"). We found significant differences in seven of ten parameters (vocal range, highest and lowest vocal fundamental frequency, fundamental speaking frequency, maximum voice intensity, number of partials, vibrato of intensity; U-test by Mann-Whitney). No correlation of the differences of the identical twins with age was found in the examined parameters. The voices of identical twins are significantly more similar than those of non-related persons regarding the above mentioned features. Thus, the suitability of the voices of monozygotic twins for professions with a high demand on voice is comparable. Results of the group comparison correlate largely with the literature. The missing correlation with age could be due to the fact that the environmental effects were not measurable, and/or the development of the voice is more influenced by genetic effects.

[Prediction of the onset of voice mutation in singers of professional Boys' choirs: investigation of members of the Thomaner choir, Leipzig]

Die phoniatrische Betreuung der kindlichen Singstimme während des Stimmwechsels erscheint gerade bei Sängern in Knabenchören mit hoher stimmlicher Belastung wichtig. Die vorliegende Studie sucht nach Methoden, den Eintrittszeitpunkt der Mutation vorherzusagen und das Vorliegen einer Mutation differentialdiagnostisch von hyperfunktionellen Stimmstörungen oder entzündlichen Erkrankungen des Stimmorganes zu trennen. Dazu wurden 36 Knaben des Leipziger Thomanerchores im Sinne einer Longitudinalstudie alle 3 Monate über 3,5 Jahre bis zum hörbaren Einsetzen der Mutation untersucht. Es erfolgte die Bestimmung von zehn stimmlichen und acht stimmunabhängigen Parametern, die erstmals in solch umfassender Form auf ihre prädiktive Aussagekraft geprüft wurden. Die statistische Auswertung wies besonders den Serumtestosteronspiegel und die Wachstumsrate als Grössen aus, die mit dem Prämutationsverlauf korrelieren und eine konkrete Vorhersage ermöglichen. Das Vorliegen einer Mutation kann ausserdem durch den Verlauf der mittleren ungespannten Sprechstimmlage und unter Hinzuziehung des Genitalstatus bestätigt werden. Durch die exakte und prädiktive Bestimmung des Mutationsbeginnes können Erkrankungen des Stimmapparates vermieden werden, die aus dem intensiven Singen in der Mutation resultieren. Weiterhin geben die Ergebnisse dem Chorleiter wertvolle Informationen für die Planung der Besetzung seiner Knabenstimmen.

Combination of inhaled nitric oxide and intravenous prostacyclin for successful treatment of severe pulmonary hypertension in a patient with acute respiratory distress syndrome

OBJECTIVE

To investigate the combination of inhaled nitric oxide (iNO) and intravenously administered prostacyclin (i.v. PGI2) in a patient with severe pulmonary hypertension and acute respiratory distress syndrome (ARDS).

DESIGN

Single case study.

SETTING

Intensive care unit of a university hospital.

METHODS

In an ARDS patient with severe pulmonary hypertension, gas exchange and hemodynamics were measured during combined treatment with iNO and i.v. PGI2. On two subsequent days, a protocol consisting of four 20-min periods was performed: baseline, 10 ppm iNO, 10 ppm iNO plus 4 ng kg-1 min-1, and 4 ng kg-1 min-1 PGI2 alone. At the end of each period hemodynamic and gas exchange data were obtained.

RESULTS

The combination of iNO and i.v. PGI2 resulted in a marked decrease in pulmonary artery pressure and a concomitant increase in cardiac output which was more pronounced than the effect of either drug alone. During iNO, as well as during the combination of iNO and i.v. PGI2, oxygenation was improved, whereas during i.v. PGI2 alone oxygenation was worse than baseline.

CONCLUSION

We conclude that the combination of iNO and i.v. PGI2 might be more useful than either drug alone when severe pulmonary hypertension leading to impaired right ventricular function is present in ARDS. A systematic study of this observation is warranted.

Long-term measurements of energy expenditure in severe burn injury

The objective of this study was to evaluate resting energy expenditure (REE) in spontaneously breathing and artificially ventilated burn patients during the entire intensive care period. In 27 patients with 51 +/- 20% body surface area burned (BSAB) the REE was determined via indirect calorimetry. Three groups were formed according to the mortality prognosis index of Zawacki et al. In groups A, B, and C the predicted mortality rates were <20%, 20% to 80%, and >80%, respectively. The frequency of acute respiratory distress syndrome (ARDS), sepsis, renal failure, and mortality increased from group A toward group C. The REE test revealed wide individual variation and was usually overestimated by all tested formulas. The mean REE was comparable in groups A, B, and C during the first 20 days (49 +/- 16% vs. 59 +/- 21% vs. 57 +/- 18% above the REE calculated by the Harris-Benedict equation, or HBEE). The REE of patients in groups A and B declined after this period, whereas the long-term ventilated patients in the prognostically unfavorable group C showed a high REE up to the 45th day, usually accompanied by severe organ dysfunction and major metabolic disorders. During this time a nutritional regimen meeting the actual REE could not be achieved. In the clinical situation when indirect calorimetry is not available, REE can be stated to be 50% to 60% above HBEE in patients with >20% BSAB for at least 20 days. Expecting a stable clinical course in patients with a predicted mortality of <20% (group A), oral nutrition usually seems sufficient after a short period of artificial nutritional support (1 week). Patients with a predicted mortality of more than 20% have a complication-burdened clinical course and a prolonged period of ventilation (groups B and C). These patients need parenteral and enteral nutrition for at least 20 days after trauma to prevent severe malnutrition.

[MORBUS: the Sentinel Practice Network. Report on a study in South Oldenbury]

There has been considerable public concern that emissions from intensive livestock farming may have hazardous effects on human health, particularly on the respiratory system. From October 1991 to September 1992, data on consultations of asthmatic children (up to 8 years) were obtained by a network of 25 GP and paediatric practices in South Oldenburg, a region with one of the highest livestock densities in Germany. Comparable data from a similar network of 75 practices in 3 adjacent regions (Brunswick, Hanover, Verden) with average livestock density served as a reference. In South Oldenberg, 2084 consultations of 542 asthmatic children were observed, with asthma being the reason for visit in 734 of the contacts (36%). The boy-girl ratio was 2.1:1 among index patients and 1.9:1 among consultations. Consultation rate was 25.2 contacts by asthmatic children per 1,000 total consultations of children up to 8 years in South Oldenburg, compared to 17.8 per 1,000 in Hanover, 15.7 per 1,000 in Brunswick and 13.6 per 1,000 in Verden. Consultations due to asthma scored 11.2/1,000 in South Oldenburg, 10.8/1,000 in Hanover, 7.2/1,000 in Brunswick and 6.5/1,000 in Verden. Asthmatic patients in South Oldenburg were younger (mean age 38 vs. 42 months) than those observed in the reference regions. There were no regional patterns in sex ratio, severity of asthma, respiratory allergies or atopic dermatitis. As this is an ecological study design, inferences concerning the cause of the observed regional differences can only be weak. We therefore propose a case-control study in order to obtain exposure and health data on an individual level.

Short-term immunotherapy: a prospective, randomized, double-blind, placebo-controlled multicenter study of molecular standardized grass and rye allergens in patients with grass pollen-induced allergic rhinitis

BACKGROUND

Short-term immunotherapy (STI) can be beneficial for patients who are noncompliant with long-term specific immunotherapy.

OBJECTIVE

The efficacy and tolerance of STI with seven preseasonal injections of molecular standardized allergens from grass and rye pollen has been investigated in a double-blind, placebo-controlled multicenter study with 87 patients at 12 German University hospitals.

METHODS

Symptoms of the eyes, nose, and bronchi and use of symptomatic drugs were documented daily in diaries by patients with allergic rhinitis to grass and/or rye pollen and without bronchial asthma. Patients were monitored by skin prick test titration and measurement of levels of specific IgE and IgG4.

RESULTS

The median nasal score for the 10 weeks with the strongest symptoms during the grass pollen season was significantly lower (p = 0.014) with 35.0 for STI (n = 41) versus 69.0 for placebo (n = 40); the overall symptom score was 54.0 for STI versus 97.5 for placebo (p = 0.020). Only STI-treated patients exposed to less than 40 pollen grains per cubic meter per week showed a significantly lower nasal symptom score of 39.0 versus 75.0 for placebo (p = 0.006); these patients also had fewer nasal symptoms and less use of topical nasal drugs (p < 0.001). The threshold dose in skin prick tests was significantly higher, being 9.06 histamine equivalent for skin prick test (HEP) for STI-treated patients who received the maximum dose (n = 22) versus 4.33 HEP for placebo (p = 0.005). Specific IgE levels were significantly higher, being 55.9 SU/ml for STI versus 39.2 SU/ml for placebo after seven injections (p = 0.006) and level of specific IgG4 was 5.36% for STI versus 1.28% for placebo (p < 0.001). No severe systemic reactions were observed.

CONCLUSION

STI with seven preseasonal injections with molecular standardized allergens is effective and well tolerated.

[Brush cytology and HPV detection in chronic laryngitis and papillomatosis]

BACKGROUND

We investigated the utility of cytologic studies (including follow-up studies) in our specialty in determining the prevalence of human papillomavirus, specifically in the larynx. We utilized Papanicolaou's method of exfoliative cytology and in situ hybridization of the culture (biotin-marked DNA probes).

PATIENTS

486 patients with chronic hyperplastic laryngitis and 74 patients with papilloma were enrolled in the study.

RESULTS

In 198 typings in 132 patients (59 patients with papilloma, 41 with chronic hyperplastic laryngitis, 17 with cancer, and 15 healthy), we found distributions of the individual types that were independent of the diagnosis. Particularly often, we encountered human papillomavirus types 18 and 31 in the presence of dysplasia, human papillomavirus type 16 in the presence of cancer, and type 11 in general.

CONCLUSIONS

Cytologic examination and human papillomavirus typing of the culture permit us to define a third risk category in addition to the known risk groups smokers and dysplasia patients. Besides this, cytologic follow-up studies can provide further insight into the behavior of preneoplastic epithelial changes.

[Metastasis of adenocarcinoma of the ovary to the subglottis. A laryngologic rarity]

Malignant tumors of the larynx are an important disease entity in otorhinolaryngology and mainly involve squamous cell carcinomas. Different epithelial or mesenchymal malignant tumors are reported only sporadically and metastases localized in the larynx are even rarer. In this report we present a patient who was found to have a laryngeal metastasis from an adenocarcinoma. An ovarian carcinoma treated 7 years previously was the primary tumor and first metastasized into the left lung and then into the subglottig area of the larynx. Because the surgical procedures and chemotherapy used for each lesion were successful and no local recurrences were found, the same therapeutic rules for the treatment of metastases to the larynx should be applied as in cases of primary malignancies.

[Lethal, non-menstrual toxic shock syndrome associated with Staphylococcus aureus sepsis]

We report a rare case of non-menstrual toxic shock syndrome (TSS) in the course of Staphylococcus aureus sepsis in a 31-year-old primigravida who developed high fever and severe pulmonary and cardiovascular failure within a few hours at the end of the 29th week of a twin pregnancy. Mechanical ventilation was necessary due to signs of adult respiratory distress syndrome (ARDS) and catecholamines were needed to maintain a somewhat adequate blood pressure. A forceps delivery was performed immediately. Postoperatively, the patient was brought to the intensive care unit (ICU) due to the suspicion of severe septic shock. In addition to the extreme cardiovascular instability and massive disturbance of pulmonary gas exchange, the clinical picture was characterised by a disseminated intravascular coagulopathy (DIC) with marked petechial bleeding and ecchymoses on all extremities. Moreover, a confluent, spotty exanthem of the trunk and extremities could be seen. Despite all therapeutic efforts, the patient died within a few hours after admission to the ICU with signs of multiorgan failure. Post-mortem, multiple staphylococcal abscesses were found in the kidneys, liver, and uterus. Moreover, acute ulcerous endocarditis of the mitral valve and septic myocardial foci with myocarditis were seen. The Staph. aureus strain isolated from the blood cultures was shown to produce TSS toxin 1 (TSST-1) and enterotoxin B. In summary, the clinical picture can be interpreted as severe staphylococcal sepsis complicated by TSS. TSS is a specific type of infectious disease, occurring mainly in young women during the menstrual period (80%-90%), but it has also been reported in non-menstrual cases (10%-20%). It is characterised by sudden-onset high fever, hypotension, rash, mucosal hyperaemia, and various additional symptoms such as myalgia, vomiting, and diarrhoea. The clinical course depends on the extent of the organ failure due to decreased tissue perfusion during hypotension. Severe cases are accompanied by multiple organ-system failure including impaired renal function, which is reversible in nearly all cases. Respiratory failure ranges from interstitial and alveolar aedema to ARDS in 10% of cases; severe DIC is seen in 10%-15%. Another severe clinical complication is cardiac insufficiency. The etiology of TSS is based on a localized or, rarely, systemic infection with certain Staph. aureus strains that are capable of producing toxins, the most important one being TSST-1. Staph. aureus strains can also produce various other enterotoxins that may be involved in the pathogenesis of TSS. The pathogenetic importance of the toxins is supported by the antibody titers in TSS patients: more than 80% of healthy adults show high levels of antibody titers, whereas 90% of TSS patients exhibit low levels in the acute phase followed by a significant increase during convalescence. It is not clear whether the toxins cause TSS by a direct effect or by release of mediators due to their function as superantigens. The clinical characteristics of non-menstrual TSS are identical to those of menstrual TSS, but it can occur in many clinical settings in both sexes at any age. Severe clinical courses are more frequent in non-menstrual TSS: the mortality is about 8%-11% in non-menstrual TSS compared to 2%-5% in menstrual TSS. The diagnosis is based mainly on clinical signs and the isolation of toxin-producing Staph. aureus strains. Besides antibiotic therapy, treatment is primarily directed to the correction of hypotension and additional organ-system failure. Other therapeutic measures such as the elimination of toxins by plasma separation or the administration of antibodies or gamma-globulins are subjects of investigation with no general recommendations at this time.

Organochlorine residues in human breast milk: analysis through a sentinel practice network

STUDY OBJECTIVE

The study aimed to assess through a sentinel practice network the validity of data on levels of organochlorine residues in human milk along with personal, lifestyle, and exposure variables of breastfeeding women; to compare the results of this new approach with those of the Lower Saxony breast milk surveillance programme; and to test hypotheses on potential determinants of contamination levels.

DESIGN

Eligible women were enrolled into this cross sectional study by a network of 51 paediatric practices when bringing their babies for a U3 infant screening examination (4th to 6th week after delivery). Lifestyle and exposure factors were obtained by questionnaire. All milk samples were analysed for hexachlorocyclohexane, hexachlorbenzole, DDT, dieldrin, polychlorinated biphenyls (PCB) and heptachlor; half the samples were also analysed for dioxin. Analytic statistics were computed using polychotomous logistic regression (PLR).

SETTING

The study was conducted in Lower Saxony, Germany, from summer 1992 to summer 1993.

PARTICIPANTS

Altogether 156 primiparous, breast feeding German women, aged 25-35 years, who had been born and had grown up in West Germany, were studied.

MAIN RESULTS

Compared with the regular programme, participants in this study had their milk analysed sooner after delivery and were more likely to have grown up in rural areas, less likely to have been exposed to hazardous substances, less likely to have a diet of health food, and slightly less likely to be a smoker at the time of the study. Breast milk contamination levels were comparable in both studies, and in all but two cases well below the tolerable concentrations established by the Deutsche Forschungsgemeinschaft (German Research Fellowship). After adjustment for potential confounders using polychotomous logistic regression, there were statistically significant positive associations between breast milk contamination and age (PCB, test for trend: p = 0.006), average dietary fat intake per week (dioxin, p = 0.01), and proximity of residence to hazardous sites (dioxin, p < 0.05), and negative associations between residue levels and relative body weight at the time of the study (PCB; p < 0.0001) and difference in body weight (weight minus weight before the pregnancy; PCB, p = 0.0002), respectively.

CONCLUSIONS

Sentinel practice networks are a feasible and low-biased approach to population based breast milk studies. The contamination levels and associations found are biologically plausible and comparable with the results of other studies. To reduce organochlorine residue levels in human milk in the short term, breast-feeding women should be advised not to try to reduce their weight until after lactation. Public promotion of a lower dietary fat intake may reduce the lifetime accumulation of organochlorine compounds in the human body fat tissue in the long term, resulting in lower concentrations in breast milk as well.

[Data quality in the MORBUS Sentinel Project--expiratory wheezing in infants]

Since 1991 the MORBUS project is being conducted to establish and run a sentinel network of 100 general and paediatric practices in three regions of Germany. A number of health conditions have been and will be monitored consecutively with special emphasis on environmentally determined health problems. From March to June, 1991, 1054 contacts of 1- and 2-year-old children with expiratory wheezing were reported. Quality of these event data was assessed by means of internal completeness. Important clinical information was missing in about 10% of all cases without evidence for regional differentiations. Data quality by this criterion was better in first contact than in re-contact cases (9.7% vs 18.1% missing). Questions concerning the parents (allergies, smoking, education) were less frequently answered (up to 24% missing) than questions of obvious medical relevance to the child. Completeness of parental information varied considerably between regions. There was no association between the medical specialty of the doctors and the quality of their data. In a longitudinal view, there was a slightly positive trend over time in the proportion of clinically incomplete case reports at borderline statistical significance (p = 0.057). Apart from these minor findings then, there was an overall good consistency of completeness in the MORBUS data on expiratory wheezing. By optimizing questionnaires and data transmission, it should be possible to increase the data quality even further.

[Spontaneous liver rupture as a rare complication of the HELLP syndrome]

The HELLP syndrome (haemolysis, elevated liver enzymes, low platelet count) was first referred to by Weinstein in 1982 as an extremely progressive form of gestosis. In addition to the more common gestotic symptoms, such as oedema, proteinuria and hypertension, the clinical picture is characterized by microangiopathic haemolysis, thrombocytopenia and, especially, impaired hepatic function. Within this clinical picture severe complications can occur, such as eclamptic attacks, renal dysfunction, intracranial haemorrhage, intrahepatic haemorrhage and coagulopathy. An imbalance in prostanoid metabolism has been implicated in the pathogenesis. A decrease in synthesis of the vasodilator and thrombocyte aggregation inhibitor prostacyclin leads to a preponderance of the vasoconstrictor thromboxane A2, which promotes thrombocyte aggregation. This results in local vascular spasms and endothelial lesions, which in the case of hypercoagulopathy are accompanied by the formation of fibrin deposits with resultant vascular constriction. Intravascular fibrin deposits indicate that the coagulation system has been compromised and can lead to consumption coagulopathy in approximately 10% of cases. In the majority of cases, however, one finds low-grade disseminated intravascular coagulation (DIC), i.e. mild hypercoagulopathy with thrombocytopenia, a tendency to thrombocyte aggregation and fibrinogen deficiency in the presence of usually normal plasmatic coagulation. These vascular changes occur particularly in organs that have high blood flow, such as liver, kidneys and placenta. In the liver, sinusoidal obstruction causes vascular congestion, leading to an increase in intrahepatic pressure, dilatation of Glisson's capsule, development of subcapsular hepatic haematomas and hepatic rupture. Hepatic haematoma virtually always requires surgical treatment, and otherwise the patient has hardly any chance of survival. Nevertheless, mortality is around 35%.(ABSTRACT TRUNCATED AT 250 WORDS)

Posttraumatic hypocaloric parenteral nutrition--development and clinical application

The use of hypocaloric parenteral nutrition (HPN) is very common in surgical medicine because it allows for a standardized peripheral venous supply of nutrients. HPN causes very little stress to the posttraumatically labile carbohydrate metabolism-this applies to the use of glucose as well as to sugar substitutes: For example, mean glucose concentrations in serum on glucose administration of 2-3 g/kg/day are between 5.5 and 8.4 mmol/l. The mean dose of amino acids of 1.0-1.2 g/kg/day commonly used in HPN leads to a 50-67% improvement in the N-balance compared to an exclusive water/electrolyte supply or the administration of 2 g of carbohydrates per kg and day. Even a high caloric nutritional therapy leads to no significantly improved N-balances on the first posttraumatic days. HPN is recommended after major surgery and severe trauma in order to better estimate the individual metabolic reaction to nutritional supply prior to any consumption-orientated parenteral nutrition. HPN is also important as an adjunct to early-phase enteral nutrition. Its value after moderate surgical interventions is questionable because studies have yet to confirm HPN's clinical efficacy. HPN should not be used after minor surgery or brief periods of fasting. A possible, but as yet uncertified indication for HPN is the longer-term nutrition of very obese patients.

How reliable are short-term measurements of oxygen uptake in polytraumatized and long-term ventilated patients?

O2-uptake was measured continuously in 18 polytraumatized and 21 long-term ventilated patients. All patients were on assisted ventilation with sufficient sedation and analgesia. O2-uptake was measured every minute, the values were recorded over 24 h and the mean O2-uptake/min was calculated. At the same time, the O2-uptake of the last 15 min of every hour was measured separately (e.g. 7.45-8.00, 8.45-9.00, etc.). The mean O2-uptake/min measured continuously was compared and correlated with the mean O2-uptake per day, calculated on the basis of each of the short-term measurements. There were only slight differences between the mean values of the two procedures: In the group of long-term ventilated patients the mean O2-uptake was found to be 364 ml/min in continuous measurements and 363 ml/min in short-term measurements. This O2-uptake corresponded to an energy expenditure of 2360 kcal/day. The mean correlation coefficient was 0.89 (range: 0.79-0.96). If O2-uptake was measured over 2 periods of 15 min each, e.g. in the late morning and in the afternoon, the mean correlation coefficient improved to 0.94 and the standard deviation was reduced. Comparable results were obtained in the group of polytraumatized patients. This study shows that under certain preconditions short-term measurements of O2-uptake of 2 x 15 min allow sufficiently reliable predictions of the daily O2-uptake and energy expenditure in severely traumatized or critically ill patients.

[The significance of digoxin-like immunoreactive factor (DLIF) for intensive care medicine]

The estimation of serum digoxin is a usual method in intensive care. In a case report the detection of digoxin-like-immunoreactive-factor (DLIF) is shown, which gives false high levels. DLIF is observed in renal damage, high cardiac activity, pregnancy and newborn.

The influence of posttraumatic parenteral calorie and nitrogen supply upon the cumulative nitrogen balance

The aim of the study was to describe the influence of posttraumatic calorie and nitrogen (N) supply upon the cumulative N-balance by analyzing the literature of the past 18 years. Three groups of patients were formed, in which nutritional therapy was performed following trauma of differing severity: (1) patients following moderate trauma-N-losses 10-15 g/day; (2) patients following severe trauma--N-losses 15-20 g/day; and (3) polytraumatised patients--N-losses more than 20 g/day. The data gained for the calorie and N-supplies as well as for the N-balances in each group of patients served as a basis for the calculation of regression analyses of higher order; in these the cumulative N-balance was regarded as a function of the calorie and the N-supply: NBcum = f (C, N) Whilst for the group of polytraumatized patients only statements for a nutrient supply of about 20-30 kcal/kg BW/day and 0.2-0.3 g N/kg BW/day are possible, due to the limited data available, general statements about the different influence of calorie and N-supply can be made for nutritional therapy after moderate and major trauma; the calculated functions reveal that the N-supply influences the N-balance decisively, whereas the calorie supply exerts only a slight N-sparing effect. The mathematically calculated optimum of the N-supply after severe trauma is 0.2 g/kg BW/day, corresponding to an amino acid supply of 1.25 g/kg BW/day.

Glucose, fructose, and xylitol in postoperative hypocaloric parenteral nutrition

The aim of the study was to use glucose, fructose and xylitol as alternative carbohydrates in hypocaloric parenteral nutrition (HPN) and to investigate their different nutritional effects. Twenty-four patients who had undergone elective gastrointestinal resection were examined in a prospective randomized study. Only metabolically normal patients between 30 and 65 years of age were admitted to the study. No patient with a body weight more than 20% above or below the normal weight of the patients was admitted. The study period extended from the operation day to the fifth postoperative day. The patients were given approximately 1.1 g amino acids and approximately 2.9 g carbohydrates per kg/B.W. and day using either glucose, fructose or xylitol as carbohydrates. The mean plasma glucose concentrations ranged between 6 and 8 mmol/l without insulin being supplied. There were no significant differences between the groups. However, the administration of glucose led to a somewhat larger dispersion range of the values. The labile plasma proteins (transferrin, prealbumin, retinol-binding protein) in the 3 groups revealed almost identical concentration courses. With N-losses between 51 and 57 g/4 days, only slightly negative cumulative N-balances were calculated (-4 to -13 g/4 days). No significant differences were observed between the 3 groups in the level of the urea-N production rates. Advantages which favor a general administration of fructose/sorbitol or xylitol in HPN could not be found in our investigation.

Continuous measurement of oxygen uptake. Evaluation of the Engström metabolic computer and clinical experiences

A new system for continuous measurement of oxygen uptake was tested. The tidal volumes delivered by the system, the accuracy of the oxygen sensor cell, measurement of the oxygen uptake at different inspired oxygen concentrations, and comparative tests of oxygen uptake using the Fick principle were studied. Judging from our results, even thorough maintenance could not entirely prevent leakages. Due to a construction error, there was a large increase in measured oxygen uptake if inspired oxygen concentration was increased. While carbon-dioxide output was constant, this led to respiratory quotients of less than 0.5. By modifying the system with a mixing chamber for the inspiratory gas, new tubing to the oxygen sensor cell and changes in the computer software, these errors have been corrected in the meantime. In comparative tests of oxygen uptake using the Fick principle (cardiac output and arteriovenous oxygen content difference), we found a mean difference between EMC and the Fick principle of about 6.6% (P less than or equal to 0.001, r = 0.91) with nearly identical standard deviations for both values. Our experience indicates that the EMC is suitable for continuous measurements of oxygen uptake. Additional technical improvements seem to be possible.

[Continuous measurement of oxygen uptake using the Engström Metabolic Computer]

A new system for continuous measurement of oxygen uptake was tested (EMC). Delivered tidal volumes of the system, the accuracy of the oxygen sensor cell, measurement of the oxygen uptake related to different inspiratory oxygen concentrations as well as comparative tests of oxygen uptake according to Fick's principle were studied. Furthermore, we looked for possible leakages in the system. Following to our results even thorough maintenance could not entirely prevent leakages. There was a remarkable increase in measured oxygen uptake if inspiratory oxygen concentration was increased. While carbon-dioxide output was measured at constant levels this led to low respiratory quotients, some of these were less than 0.5. This was caused by a construction error of the system which could be corrected in the meantime. In 70 comparative tests of oxygen uptake between EMC and Fick's principle (measurement of cardiac output and arteriovenous oxygen content difference) we found a mean difference of about 10% (p less than or equal to 0.001) with nearly identical standard deviations. The EMC measured the higher oxygen uptake. Based on our experience the EMC is suitable for continuous measurement of oxygen uptake but it needs good knowledge of the system and the underlying measuring procedures. Additional technical improvements seem to be possible.

[Parenteral feeding following heart surgery operations]

After aorto-coronary bypass operations 40 patients were treated in a prospective-randomized study with 3 types of hypocaloric parenteral nutrition consisting of the same content of amino acids (75 g/day) but different amounts of carbohydrates: 120 g dextrose, 120 g or 200 g dextrose/fructose/xylitol (1:2:1) per day. 18 patients received only 75 g/day of dextrose (controls). The fluid volume for parenteral nutrition did not exceed 1500 ml/day. Changes in carbohydrate and protein metabolism were investigated. Because of restricted carbohydrate dosage, we needed no insulin to keep blood glucose within values of about 7-10 mmol/l. Postoperative serum insulin levels were significantly raised to 4-5 fold of preoperative values in all groups. Serum potassium concentrations remained normal under a supply of 80-100 mmol/day. Cumulative nitrogen balances were improved by about 48-58% in groups receiving parenteral nutrition despite a calorie/nitrogen ratio of 40:1 or 66:1 respectively. The expected beneficial effects on the concentrations of visceral serum proteins (transferrin, prealbumin, retinolbinding protein, cholinesterases) could not be found.

[Cytodiagnostic studies of the laryngeal mucosa in chronic laryngitis]

Cytological diagnostic aids in chronic inflammation of the larynx have been rarely employed so far. A study was conducted to prove whether there is any possibility of larnygeal cytological diagnosis and whether there are any premalignant changes. In view of the results obtained by gynaecological exfoliative cytology, attention was focussed on the metaplastic cells. The frequent incidence of metaplasias was highly significant, whereas dysplasias occurred only in chronic laryngitis besides in tumours. One trend occupying higher cytological diagnostic groups in the Papanicolaou pattern was seen in chronic laryngitis. In our opinion, cytological diagnosis in laryngeal investigation is an aid in the followup control in chronic laryngitis, which is a repeatable procedure without unduly stressing the tissue. Recording of cellular changes in chronic laryngitis can enable a prospective appreciation of morphological changes, which can be useful as diagnostic tool for examining suspicious findings.

[Reduced parenteral calorie administration after severe multiple injuries]

15 polytraumatized patients were treated within 5 posttraumatic days with reduced calorie and normal amino-acid supply (17 kcal/kg BW as carbohydrates and 1.0 g AA/kg BW). Changes in carbohydrate and protein metabolism were investigated. The fluid volume for parenteral nutrition did not exceed 2,000 ml/day. In spite of restricted carbohydrate dosage, we still needed 28IU of insulin daily to keep the blood glucose within a range of 8-10 mmol/l. Nitrogen balance ranged between -7 and -12 g per day. The unstable serum proteins transferrin, prealbumin, retinol-binding protein and the cholinesterases remained within normal values. Plasma AA showed the familiar pattern of the posttraumatic state with elevated levels of nearly all AA including BCAA although we were using a solution with a reduced BCAA content. The free fatty acids in serum reached values 40% above normal, the triglycerides remained within normal values. Infusion therapy can be considerably simplified by reducing carbohydrate dosage. The risk of intensifying existing metabolic disturbances declines. After five posttraumatic days a combined parenteral/enteral nutrition offering more calories was possible in 70% of our patients.

[Mr 1268--a new furylmethyl-substituted benzomorphan. Comparison of its effects with pentazocine and placebo in a double-blind study]

Mr 1268 (alpha-5,9-dimethyl-2(3-methyl-3-methylfuryl)-2-hydroxy-6, 7-benzomorphan) was tested in two dosages (15 mg and 30 mg) at random on a total of 200 patients with severe postoperative pain in a double blind study against pentazocine and placebo. The analgesic effect of 30 mg Mr 1268 and 30 mg pentazocine compared with placebo was statistically significant 15 min after intramuscular injection. At the dosage applied no major respiratory or circulatory effects were observed in the patients. The minimal changes in the systolic blood pressure were of no statistical significance. Side-effects observed in many patients in the verum group were miosis and transpiration. For all other side-effects there was no statistically significant difference between placebo and the verum group or among the various verum groups.

[Catamnestic studies in sub- and infertile couples]

310 infertile couples have been studied retrospectively over a 15-year period from the andrological and gynaecological view. Teratozoospermia in men and tubal disturbances in women respectively turned out to be the most common causes. Isolated male infertility was found in 33%, that of the female partner in 19%. Both partners were involved in 40%. 93 women (30%) finally gave birth to a child after successful treatment.

[Postoperative changes of plasma amino acids following abdominal and vaginal hysterectomy]

This study on the metabolism of amino-acids following gynaecological operations confirms, that abdominal and vaginal hysterectomies cause a so-called post-aggression metabolism. The majority of the aminograms showed changes in the metabolism of nitrogen. The aminograms were carried out by the Stein-Moore chromatography. The administration of a 3% complete solution of aminoacids changed the metabolism of the short time enzyme proteins into an anabolic phase and therefore diminished complications such-as paralytic ileus impaired wound healing, infections, and edema.

[Urea and potassium losses and changes in amino acid concentration after aortocoronary bypass operations]

Changes in urea nitrogen excretion, renal potassium losses, and changes of amino acid concentrations in plasma following aortocoronary bypass operations were observed in 10 patients. The observation time included the preoperative day, the day of operation, and 4 postoperative days. The patients were treated with a 5% glucose solution (800-1000 ml/m2). The additional spontaneous oral intake was estimated and reached approximately 600-800 kcal and 25-30 g protein on the 3rd and 4th postoperative day. The calculated urea nitrogen loss was between -8.2 g (operation day) and -11.2 g (4th postoperative day). The concentrations of serum amino acids in plasma were below normal preoperatively. It seems possible that this is due to longer preoperative fasting because only patients with normal body weight were admitted to operation. The amino acid concentrations fell significantly to lower than normal values during the postoperative period. There were massive renal losses of potassium of about 140 mEq/day on the day of operation and on the 1st postoperative day. High parenteral substitution was necessary to avoid severe falls in serum potassium levels and possible cardiac arrythmias.

[Plasma amino acids in gynecologic operations]

Complete solutions with amino-acids, carbohydrates and electrolytes are able to reduce the metabolic changes of so-called postaggression-metabolism (adaptation-disease). The infusions can be used routinely for basic-partial parenteral nutrition from the end of operation treatment to beginning of oral nutrition. It is not necessary to control many parameters. Realising this practice postaggression-metabolism in gynecologic patients will be normalised soon.