Before the late 1970s, interest in caffeine among both the general public and the scientific community was at a relatively low level for many years, even though it was recognized that caffeine was an al most universal component of the diet. The National Coffee Associa tion was supporting a continuing program of research, some re search was being conducted by a few of the largest companies selling coffee, and an occasional university researcher became inter ested in caffeine and conducted experiments, often on effects of caf feine in very high concentration in vitro on skeletal muscle fibres or on dividing cells. Since 1978, however, there has been a mighty up surge in both public and scientific interest in caffeine. It is interest ing to note that this was prompted not by discovery of hitherto un known effects or hazards of caffeine, but by the actions of a regulatory agency, the Food & Drug Administration (FDA) of the U. S. Public Health Service. The U. S. Congress passed new laws on foods and drugs in 1958. One of the provisions was for testing of food additives to assess risk to health. As it was clearly impracticable to require immediate test ing of all additives already in use, a list was drawn up of some hun dreds of additives that were generally recognized as safe (GRAS)."

The primary mission of the medical school is to create new doctors. Once the medical student has received his or her doctorate, the medical school's interest in, and acceptance of, responsibility for the continued professional development of the physician ceases almost entirely. Yet, with scientific advances in medicine increasing exponentially and the inevitable erosion of memory with time, teachings from our schools of medicine become increasingly irrelevant, forgotten, or both. To maintain competence, the physician must continuously re-educate him- or herself. CME-Continuing Medical Education-will probably never attain the status of the medical school's degree-granting undergraduate program, but medical schools and their faculties must recognize their responsibility, not creating competent physicians but also for maintaining that com only for petence. is the product of a Continuing Medical Education program This volume initiated by the Department of Anesthesiology at the Albert Einstein Col lege of Medicine/Montefiore Medical Center. Our Department of Anes thesiology has historically been, and continues to be, unusually active in post-doctoral education through regional and national conferences and symposia. We recognized, however, that programs that bring physicians together in one location for a limited menu of lectures, questions, and discussion reach only a fraction of the potential audience of anesthesiolo gists. Such programs, as valuable as they are, by their very structure exclude more anesthesiologists than they include."

Dr. G. M. Woerlee is well known in my department both as a clinician and teacher. Years ofexperience have taught him that the problems discussed here have as yet not been treated in this way in any single work. In my opinion there is a real need for such abook, not only for resident and specialist anaesthetists, but also among surgeons and internists, specialist and trainee. Management of a patient in the operating room is a matter of teamwork, and knowledge of the problems encountered is the basis of any mutual understanding The information which has been assembled and clearly presented in this book should prove to be of great assistance in guiding our patients though an important phase of their lives. Professor Dr. Joh. Spierdijk, Department of Anaesthesia, University Hospital of Leyden, The Netherlands. vii PREFACE Much of the literature being published in the field of anesthesiology today concerns a narrow, in-depth scrutiny of a specific area or anesthetic technique that does not provide the novice with an overview ofthe perioperativeperiod and the commoneveryday problems faced by the anesthetist. Dr G. M. Woerlee of the University of Leiden with his book, "Com mon Perioperative Problems and the Anaesthetist," has filled a void in the current anes thetic literature. Dr Woerlee reviews in a straightforward, no-frills manner problems routinely encountered during the perioperative period. Other anesthesia textbooks do not cover the material in quite the same logical, step-by-step fashion."

The peerless authority you trust...the portability you need! This practical handbook covers all of the most critical, clinically relevant topics from Stoelting's Anesthesia and Coexisting Disease, 5th Edition in a format suitable for a quick-reference guide you can carry in your coat pocket. The new edition presents the results of the latest clinical trials to help you make the most effective clinical decisions, while new illustrations aid in clarifying complex concepts. You'll have convenient access to dependable guidance on a full range of pre-existing conditions that may impact the perioperative management of surgical patients. Find the information you need easily with abundant tables throughout, a quick-reference outline format, and the same organization as Stoelting's Anesthesia and Co-Existing Disease. Confidently meet the needs of special patient populations such as pediatric and geriatric patients. Quickly access new guidelines on hot topics such as management of the morbidly obese patient. Make effective clinical decisions with access to current practice guidelines and results of the latest clinical trials.

Theodore H. Stanley, M. D. Anesthesiology and the Heart contains the Refresher Course manuscripts of the presentations of the 35th Annual Postgraduate Course in Anesthesiology which took place at The Cliff Conference Center in Snowbird, Utah, February 16-20, 1990. The chapters reflect new data and concepts within the general framework of "evaluating myocardial function," "pharmacology and the cardiac patient," "anesthesia for patients with cardiac disease," and "stress, cardiopulmonary bypass, coagulation problems and related issues. " The purposes of the textbook are to 1) act as a reference for the anesthesiologists attending the meeting, and 2) serve as a vehicle to bring many of the latest concepts in anesthesiology to others within a short time of the formal presentation. Each chapter is a brief but sharply focused glimpse of the interests in anesthesia expressed at the conference. This book and its chapters should not be considered complete treatises on the subjects addressed but rather attempts to summarize the most salient points. This textbook is the eighth in a continuing series documenting the proceedings of the Postgraduate Course in Salt Lake City. We hope that this and the past and future volumes reflect the rapid and continuing evolution of anesthesiology in the late twentieth century. vii LIST OF CoNTIUBUTDRS Bailey, P. L. Department of Anesthesiology, The University of Utah School of Medicine, Salt Lake City, UT 84132, U. S. A. Barash, P. Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, U. S. A. Covino, B. G.

Patients with pain disorders pose many clinical challenges for the attending physician. Even experienced clinicians occasionally arrive at the point where diagnostic, work-up, treatment, or prognostic thinking becomes blocked.
Pain teaches the reader to recognize and appropriately treat a variety of pain disorders using a case study format. Divided into three section, chronic pain conditions, chronic pain and related disorders, and treatment overview, and derived from consultation requests from providers in medical practice, the cases are written in a format that encourages the reader to formulate a differential diagnosis and treatment plan for a variety of pain problems. Succinct in its presentation and logical in its layout, Pain is the perfect resource for the busy practitioner on the go.

Despite the progress that has been made in intensive care medicine, sepsis and septic shock are still accompanied by a high mortality rate. In recent years, new therapeutic approaches have been developed on the basis of a better understanding of this complex condition. This monograph contains contributions by well-known scientists and clinicians in the fields of hygienics, microbiology, infectious diseases, physiology, surgery and intensive care medicine. It provides an up-to-date overview of the etiology, pathophysiology, prevention, and therapy of sepsis and its complications.

Concise, recent data are presented on obstetric problems arising in patients with cardiovascular diseases (not only congenital and acquired valvular heart diseases and hypertension, but also uncommon heart lesions) and on cardiological complications encountered in pregnant women. The goal of the book is to provide obstetricians with necessary cardiological information and cardiologists with essential obstetric information to enable both specialists to make optimal decisions regarding the permissibility of pregnancy, management of pregnancy and labour, or termination of pregnancy, and selection of an adequate form of contraception in women with heart and vascular diseases. Along with recent scientific findings, the book contains practical recommendations for examination diagnosis and treatment that is effective for the mother and safe for the fetus.

The number of studies on chronic and recurrent pain bears no relation to the frequency of these complaints in gynecologic practice, nor to the clinical and scientific problems that still need solving in this area. Several factors stand in the way of progress in this field, such as the strongly subjective nature of the complaints, the frequent lack of correlation between them and objective findings, and the complexity of the psychosomatic interac tions involved. Although progress in our knowledge has been much slower than we would have wished, and although we are well aware of these many gaps, it was considered useful to gather in a book what we think we have learned during 3 decades of active interest in pain patients and pain problems in gynecologic practice and 12 years of supervision of a pain clinic in the Department of Obstetrics and Gynecology of Leuven University. As there are many differences between acute pain - clinical as well as experi mental - on the one hand and chronic pain symptoms on the other, it was felt preferable to limit the scope of this book essentially to chronic and recurrent pain in gynecologic practice. When presented with a complaint of lower abdominal and/or low back pain, the gynecologist should constantly be on the lookout for nongynecologic causes, of which the most frequent will be either gastroenterologic or orthopedic and sometimes urologic. I have been fortunate in obtaining the collaboration of Dr."

This important book fills a need in the developing area of Pain Medicine. It provides physicians with an up-to-date resource that details the current understanding about the basic science underlying the mechanism of action of the various CAM therapies used for pain. It summarizes the clinical evidence both for efficacy and safety, and finishes with practical guidelines about how such treatments could be successfully and safely integrated into a Pain practice.

This book reflects the proceedings of the Boerhaave Course, "Developments in drugs used in Anaesthesia", held on r'lay 7th and 8th 1981 at Leiden University. The goal of the organizers of the course was to obtain a better under standing of the pharmacological and clinical applications of the drugs used in the field of Anaesthesiology. In my opinion, there is a constant need for post-graduate teaching not only on a clinical basis, but also in the so-called "basic sciences". This especially applies to anaesthetists. I would like to express my thanks to the speakers, who were all so kind as to send their manuscripts in time for publishing, and to thank the co-editors of this book, as well as rtr. B.P. Ccmnandeur, from r'lar tinus Nijhoff Publishers for their fruitful co-operation. Last but not least, I would like to thank the secretarial staff of my depar~ent for all the work they did arranging for manuscripts to be in the right places at the right times. Joh. Spierdijk THE USE OF H2 BLOCKERS T.H. STANLEY In the last decade a new important histamine receptor, H2 receptor, has been discovered which has major importance in gastric acid production. In addition, a new drug Cimetidine (Tagamet) which blocks the H2 receptor has been synthesized. The object of this presentation will be to discuss the possible role of this interesting drug (Cimetidine) before and during operation and possible postoperatively as well.

Georg Rodewald University of Hamburg Hamburg, Federal Republic of Germany Allen E. Willner Hillside Hospital Glen Oaks, NY In contrast to the initial years of cardiac surgery (37 years ago), there is now increasing interest in cerebral protection. Rodewald [1] in 1978 was among the first to point out the surgeon's concern with "psychopathological problems" and Taylor [2] in 1989 stressed that" *** the awareness of the cerebral consequences of open heart surgery has risen considerably in recent years * * * " This book reviews the evidence for neurological, psychological, and neuropsycho logical reactions to cardiac surgery. In previous studies one problem is that small samples of patients were studied with different measuring instruments so that it was difficult to ma~e sense of inconsistent findings. Considerable controversy resulted with little ability to sort out discrepant findings. It appeared that a large multi center study using uniform measures might help clarify the picture.

close circle of anaesthetic scientists but, with the help of computer technology, has greatly influenced the practice of the modern clinical anaesthesiologist. The efforts of anaesthesiologists, pharmaceutical companies, and the development of the internet has lead to a situation that now almost every anaesthesiologist can be in close contact to anaesthetic pharmacology computer simulation pro grams and target controlled infusion devices. These two tools allow us to in crease our understanding and improve the controllability of anaesthetic drug administration, on site, in the operating theatre. In Europe the growing enthusi asm regarding the study and practice of intravenous anaesthesia has lead to an increased output of manuscripts on this subject, the initiation of workshops on the pharmacology of anaesthetic agents and the formation of a society that embodies this spirit; the European Society for Intravenous Anaesthesia, the EuroSIVA. EuroSIVA The concept of EuroSIVA has been to provide a forum to co-ordinate, facilitate and promote high quality presentations in the area of intravenous drug admini stration. The first two meetings held in 1988 in Barcelona and 1999 in Amster dam achieved these aims. During the Barcelona and Amsterdam meetings pre senters of over 10 countries shared their knowledge with 250 and 400 partici pants, respectively. In addition to the EuroSIVA meetings the international board aims to promote education for those involved with intravenous anaes thesia."

Pain is a symptom of many clinical disorders, afflicts a large proportion of the population and is largely treated by pharmacological means. However, the two main classes of drugs used are the opioids and the non-steroidal anti inflammatory drugs, drugs that have a long history. The last decade has seen remarkable advances in our understanding of some of the pharmacological bases of pain and analgesia and this book aims to reflect these rapid changes in our understanding of pain mechanisms. One impetus to these scientific advances has been dialogue and interactions between scientists and clinicians; as a result we now has a number of animal models of clinical pain states, to mimic certain aspects of clinical pathophysiological pain states. Molecular aspects of receptors and the synthesis of tools for probing receptor function have also been rapid growth areas. A number of controlled clinical studies using novel licensed drugs have also resulted from recent research, offering hope to certain patients with severe intractable pain. However, we desperately need the pharmaceutical industry to develop new drugs based on these novel targets for analgesic therapy. This book attempts to provide an overview of the important areas of the pharmacology of pain. This book, although providing an account of the pharmacology of pain transmission and its control based on the underlying anatomical organization and physiological responses, does not attempt to cover these latter two areas."

Contrary to common belief, infectious diseases are not as well under control as we would like. We are now at a crossroads regarding the impact of the environment on infectious diseases. Renewed interest in biological weapons and the emergence of new pathogens, coupled with a better understanding of the impact of infectious agents on other conventional diseases, has led us to realise that we can no longer remain complacent about the impact of infectious agents on human, animal and crop health. The present book first discusses current and emerging military and civilian policies on the environment. In addition, the impact of environmental biology on the future of space exploration is discussed, especially in reference to the Mars mission. There follows a discussion of the state of bacteria in the environment, with a presentation of current and emerging techniques of microbial investigation. Finally, two case studies are presented on the impact of these techniques on both political and environmental problems.

The 1973 Boerhaave Course in Leiden on Measurement in Anaesthesia was composed of the lectures included in this book, supplemented by the series of 'lecture demonstrations' organised by Dr. P. Cliffe and given by the members of the Departments of Clinical Measurement and the Magill Department of Anaesthetics, Westminster Hospital, London. The aim of the 1973 Boerhaave Course on Measurement in Anaesthesia was designed to arouse interest in this subject where it has not already occurred. The subjects discussed in the lectures and presented in this book were those that were considered topical and appropriate. The lectures were meant to give an idea of some basic and advanced possibilities of measurement. It was not intended to be an exhaustive review of all the measurements relevant to anaesthetic practice and research. In this time of monitoring one has to keep in mind that good measurement is the basis of good monitoring. A certain amount of repetition is unavoidable as each lecture was intended to be complete in itsel. However, editing has reduced this to a minimum. Department of Anaesthesiology Johan Spierdijk University Hospital, Leiden Department of Anaesthetics Stanley Feldman Westminster Hospital, London Julian Leigh CONTENTS Preface ... V Contributors VIII PART ONE INTRODUCTION The difference between measurement and monitoring. What is worth measuring? . . . . . . . . . . . . . . . . . . . .. . . . 3 . JOH. SPIERDUK and A. NANDORFF Problems of interference and electrical safety associated with the - cording of biological signals . . . . . . . . . . . . . .. . . . 13 J. P. BLACKBURN 22 The scope of measurements using radioactive isotopes .

The 14th volume in the series will focus on cutting edge research at the interface of hypoxia and exercise. The work will cover the range from molecular mechanisms of muscle fatigue and muscle wasting to whole body exercise on the world 's highest mountains. State of the art papers on training at high altitude for low altitude athletic performance will also be featured.

The manuscripts in this book were generated from a conference occurring at the University of Heidelberg in September 1996. These manuscripts have been reviewed and updated by the designated authors in late 1997 for publication in early 1998. Conferences occur for a variety of reasons. These include the need to exchange information where complex activities are undergoing reassessment or change. For the emergency and critical care man agement of stroke this is certainly the situation. Today, both the pri mary care and the neurologic physician must provide medical care in an environment where daily change in the knowledge base of: brain function, disease mechanism(s), therapeutic efficacy, and cost control are all occurring. In addition, patient advocacy has become increasingly complex because government, employers, insurers, health care providers as well as families all desire a voice in the phy sician relationship with the patient. Our conference subject was the organization of rapid care delivery and the development of a ration al basis for treatment of a previously untreatable disorder acute stroke. Thus, the obvious need for multiple open and free discus sions about priority setting and modification of current treatment plans. Clearly, the face to face opportunities provided by this first conference on Emergency Management And Critical Care Of Stroke (EMACCOS) are required when patient care issues are as complex as these. Neuroscience is new to the experience of active therapeutic inter vention.

This book is based on the proceedings of a conference held in Tubingen, West Germany, in 1981, at which anesthesiologists, neuro surgeons, pathologists and neurophysiologists met to consider the place of controlled hypotension in neurosurgery. In the first part of the book alternative methods of inducing hypotension are considered, and it is important to emphasize that the techniques which are suitable for neurosurgery may not be so for other types of surgery, and vice versa. In neurosurgery, and par ticularly in aneurysm surgery, the emphasis is on lowering intra luminal pressure and not mainly on reducing blood flow or limiting tissue oozing. Another special consideration in neurosurgery is the influence of drugs used to induce hypotension on intracranial pressure, with nitroprusside (NTP), and especially nitroglycerine, increasing ICP in the closed skull and increasing brain "bulk" when the skull is open. These and other points are extensively covered. The use of a non-essential technique like controlled hypotension demands that the procedure should carry minimal risk to the patient. Contributions in part IV consider the neuropathology associated with too severe a lowering of oxygen supply through hypotension. In the clinical avoidance of such ischemic changes in individual patients, monitoring of the brain electrical function is much the most import ant and practical approach and is discussed in part III. The Editors hope that the publication of these contributions to the Tubingen Symposium will help in the effective and safe appli cation of the technique of controlled hypotension in neurosurgery."

Increased intra abdominal pressure as used in laparoscopic surgery produces various changes in the human organism. This book provides surgeons and anesthesiologists with a complete overview on these changes and the consequences for the patient in the perioperative and postoperative period. Special emphasis is laid on the management of pneumoperitoneum related complications.

This is the second part in a two-volume work on neuromodulation. It describes the techniques and procedures applied by direct contact with the central nervous system or cranial nerves (in order to modulate the function of neural networks) or in deeply located structures inside the nervous system (in order to alter the function on specific networks).

Monitoring of Cerebral and Spinal Haemodynamics During Neurosurgery is a comprehensive description of subdural monitoring of intracranial pressure (ICP) during neurosurgery. It offers thorough analysis of a comprehensive database consisting of measurements of ICP, cerebral perfusion pressure and other relevant physiological data from more than 1,800 patients subjected to intracranial surgery at Aarhus University Hospital. Features of anaesthesia, both inhalation and total intravenous, are discussed, and measures to reduce ICP are described. A majority of the patients had supratentorial tumours, but the database also includes patients with infratentorial tumours and patients with no intracranial space-occupying lesions. A chapter is reserved for discussion of the special features of children with cerebral tumours.

Pain is a common symptom, yet it is frequently underevaluated and undertreated. It is difficult to define, describe-and sometimes to prove. It's pain, and suspicions of exaggerations often add further insult to a patients' injuries. Biobehavioral Approaches to Pain translates this highly subjective experience-and its physical, psychological, social, and cultural dimensions-into practical insights key to transforming the field of pain management.

This pathbreaking volume synthesizes a rich knowledge base from across disciplines, including neurobiologic, genetic, biobehavioral, clinical, narrative, substance abuse, health services, ethical and policy perspectives, for a deeper understanding of the impact of pain on individual lives and the larger society. Its international panel of contributors highlights special issues and review best practice guidelines, from placebo effects to cancer, Whiplash Associated Disorders to pain imaging to complementary medicine, phantom limb pain to gene therapies to AIDS. Among the topics covered:

• The distinction between acute and chronic pain: is it clinically useful?
• Improving clinical assessment of patients with pain.
• Age and sex differences in pain.
• The what, how and why of the placebo and nocebo effect
• Psychosocial and partner-assisted biopsychosocial interventions for disease-related pain
• Substance abuse issues in pain treatment.
• The personal, social and economic costs of chronic pain.

Biobehavioral Approaches to Pain offers clinical and health professionals, psychologists, as well as specialists in pain management or palliative care, new directions in their ongoing dialogue with patients. Given the prevalence of pain in the general population, it should also interest researchers and students in the field of public health.

This book fills the void to provide a comprehensive review of the theoretical knowledge and scope of opioid pharmacotherapy in pain medicine. While the information provided is obtainable in other major texts already in print, the present format style plus the illustrations will make easy reading and fast accessibility of information on opioids available. Information provided is based on clinical practice rather than pure experimental for use in daily practice.

Advances of cardiovascular engineering prompt one to consider innovative device technology - that is, the development of new replacement heart valves or engineering of a totally implantable energy source for an artificial heart. However, these kinds of advances have often proved unable to achieve a long-lasting benefit as the cardiovascular field has matured so fast. Cardiovascular engineering has matured to the point where a major innovation must not only function, but must continuously function better than existing devices. This is difficult to accomplish in the complex cardiovasculature system, in which energy source, biocompatibility, compliance, and functionality all must be considered. The maturation of the field is evident from the fact that many engineered prosthetic systems perform well - for example, heart valves function for long periods of time, large-vessel vascular grafts are quite adequate, extracorporeal membrane oxygenation has significantly prolonged the feasible length of heart bypass and other surgical operations, and total artificial hearts can be used as a bridge to transplant without serious complications, yet none of these systems is as good as the natural ones it replaces. The reasons for this are many and incompletely understood. The next stage of progress must be better to alterations understandings of the various components of vasculature and their response by our devices, be they at the micro- or macro-circulatory levels, in the blood, or associated with the vascular wall.