The period that followed World War II has witnessed a dramatic change in neurology. From being a discipline in which its partici- pants were castigated for being interested solely in diagnosis, usually of disorders of unknown causation without effective therapy, neurology has evolved into a highly active treatment- orientated subject. This transition is clearly reflected in the ap- proach to diseases of the peripheral nervous system, and to the Guillain-Barre syndrome (GBS) in particular. In a state-of-the- art review made in 1952, Elkington (1952) observed that no less than 56% of neuropathies remained undiagnosed, and amongst those of unknown causation he listed GBS. With intensive in- vestigation and follow-up, the proportion of neuropathies seen at tertiary referral centres which elude diagnosis is now as little as 13% (McLeod et al. 1984). Overall, of course, the proportion is even less. This change is partly because of the introduction of new diagnostic techniques and partly because of the application of the great expansion in knowledge evident throughout medicine. In this book, Professor Richard Hughes has assembled current information on GBS and related disorders, including chronic in- flammatory demyelinating polyneuropathy (CIDP), the existence of which was not appreciated until Austin's perspicacious study published in 1958. In the Introduction, Professor Hughes gives an account of the way in which recognition of the GBS emerged and matured, and shows that it followed, pari passu, with the realisation that paral- ysis and sensory loss may result from peripheral nerve disorders.

Die Infektion ist nach wie vor ein gravierendes Problem bei der Behandlung brandverletzter Patienten. Erkenntnisse uber die Pathophysiologie des Verbrennungstraumas und der Sepsis zeigen neue Therapieansatze auf und stellen konventionelle Behandlungsschemata teilweise in Frage. Die neuen Erkenntnisse uber Pathologie und Pathophysiologie septischer Komplikationen, die Aetiologie der Infektion, Infektionswege und Infektionskontrolle stellt dieses Buch dar. Es bietet allen, die Verbrennungen medizinisch behandeln, Hilfestellung bei der taglichen Arbeit.

In recent years much enthusiasm and energy has been directed toward the development of human gene therapies, especially for inherited conditions and cancers. However, current gene transfer technology is limited in its transduction efficiency and ability to permanently and safely correct genomic defects. Thus the promise of gene therapy for these conditions is as yet unrealized. The progression of gene transfer technology will eventually surmount these limitations. Gene Therapy for Acute and Acquired Diseases includes selected examples of ongoing studies in molecular genetics that have the potential to evolve into human therapies for acute illnesses. These chapters are intended to highlight lesser known applications of gene therapy for acquired disorders. It is expected that human gene therapy trials for these conditions will be forthcoming in the near future, leading to previously unimaginable therapies. Thus, this first-ever book about gene therapy for acute and acquired diseases is intended to serve as a glimpse into the future.

This book concentrates on problems generated by acute care in severely traumatized patients during the first 24 hours after injury. During this hectic period, highly complicated problems have to be solved at the site of the accident, during transport to hospital, and in hospital. Multiple medical and paramedical disciplines are involved in providing care to the severely injured. This book endeavors to present a problem-oriented approach to the diagnostic, therapeutic, and organizational aspects that may be encountered.

Nitric Oxide (NO) is a free radical, a gas, and a pluripotent product of mammalian cells. Only a few years ago, scientific discussions of NO were largely held in the context of the chemistry of air pollution. Now, however, the great significance of NO as a signalling and cytotoxic molecule has captured the attention of the biomedical community. This book provides a very up-to-date review of the role of NO in sepsis and ARDS. Consideration is given to NO both as a pathophysiologic mediator as well as a therapeutic agent. An internationally recognized group of scientists and clinicians have contributed chapters dealing with cutting-edge science and practical clinical strategies. Numerous tables and charts have been included to aid the reader in understanding this fascinating and important subject.

Individualized dosing regimens specific to the patient, infection, bacteria, and antibiotic can optimize outcome. Integration of pharmacokinetic and pharmacodynamic data, called dual individualization, can be accomplished through the use of AUIe. AUIC dosing has been shown to predict bacteriological outcomes, hasten clinical outcomes, reduce the emergence of resistance, and be cost-effective. MPC dosing has been shown to predict the emergence of resistant submutants. AUIC and MPC information can provide guidance as to when low doses can be used, and when higher concentrations are required. This strategy can ensure efficacy, minimize toxicity, reduce the opportunity for resistance to occur, and save money. REFERENCES I. Paladino JA. Streamlining antibiotic therapy: clinical application of pharmacokinetic and pharmacodynamic principles. J Osteopath Med 1991; 5: 16-25. 2. Liss RH, Batchelor FR. Economic evaluations of antibiotic use and resistance - a perspective: report of task force 6. Rev Infect Dis 1987; 9 (suppI3): S297-312. 3. Holmberg SO, Solomon SL, Blake PA. Health and economic impacts of antimicrobial resistance. Rev Infect Dis 1987; 9: 1065-78. 4. Sanders cc. Mechanisms responsible for cross-resistance and dichotomous resistance among the quinolones. Clin Infect Dis 2001; 32(Suppl I ):S 1-8. 5. Ballow CH, Schentag 11. Trends in antibiotic utilization and bacterial resistance: report of the NNRSG. Diagn Microbiol Infect Dis. 1992; 15(suppl):37S-42S. 6. Rice LB, Eckstein EC, DeVente J, Shlaes OM. Ceftazidime-resistant Klebsiella pneumoniae isolates recovered at the Cleveland Department of Veterans Affairs Medical Center. Clin Infect Dis 1996; 23: 118-24.

The book is based on papers presented at the recently held international meeting on central-nervous-system monitoring in Hamburg, Germany. Experts inthe fields of neurophysiology, experimental and clincial anesthesia and intensive care discussed the state of the art in noninvasive central-nervous-system monitoring. Starting with the principles of CNS monitoring in humans, the topics covered include pharmacokinetic pharmacodynamic interactions, the usefulness of spontaneous and evoked brain electrical activity as an overall-control for afferent systems andfor the assessment of analgesic drug treatment, perioperative anesthesiological monitoring, and intraoperative awareness. Recently developed specific EEG and EP indices such as spectral edge frequency, median frequency, auditory and somatosensory evoked responses for the assessment of depth of anesthesia are evaluated for intraoperative monitoring. The surgical and anesthesiological perspective in intraoperativemonitoring during vascular surgery are presented, as is the state of theart in the monitoring of afferent central-nervous-system pathways by monitoring transcranial motor evoked potentials. Bispectral EEG analysis forthe assessment of anesthetic adequacy represents the future trend in intraoperative monitoring. In addition to neurophysiological methods, assessment of jugular bulb venous oxygen saturation and transcranial Doppler sonography may give additional information for the interpretation of brain fuction. In the field of intensive care, topics in multimodal long-term monitoring of brain function are presented. The application of an expert system supporting the diagnosis of brain death is also included.

I am very happy and honoured to have so many famous contrib utors from around the world presenting their knowledge and experience in this book, including Dr. Rufer who, as early as 1967, attempted to improve the pressure-volume curve of a child dying from RDS using dried surfactant from dogs; Drs. Enhorn ing and Robertson who were the first to treat rabbit fetuses with surfactant replacement and impressively demonstrated that sur factant improved lung mechanics; and Dr. Fujiwara who at the end of the 1970's had already successfully treated the first babies with surfactant replacement and published this work al ready in 1980. Thus, the idea of surfactant replacement therapy is now more or less 20 years old and almost 10 years have passed since the first publication by Dr. Fujiwara of his impressive clinical results. Up to now (September, 1988) about 2,200 babies have been treated worldwide with tracheal instillation of surfactant, with most promising results. The type of surfactant used varies from pure natural extracts from bovine or pig lungs, to surfactant extracted from human amniotic fluid, to pure phospholipids. To date, however, there is still no surfactant commercially available (except in Japan), in spite of the fact that it is urgently awaited by neonatologists and intensive care doctors throughout the world. This volume is based on the contributions presented at the international congress on Surfactant Replacement Therapy which was held in Rotterdam, The Netherlands, in November 1987."

Perinatal medicine, which is concerned with the problems of the fetus and newborn, has rapidly developed in the last two decades as an important and challenging specialty. Rapid advances in the field, coupled with tech nological advances, now are making survival of infants with weights as low as 500 grams possible. Ventilator care for severe respiratory problems is on the verge of being replaced by surfactant replacement therapy; on the other hand, development of such technologies as extracorporeal mem brane oxygenation and jet ventilation has revolutionized the care of these sick infants. The advances taking place today in the field of perinatal medicine make periodic updates, like the one provided by this volume, a virtual necessity for clinicians and paramedical personnel alike. A distinguished group of specialists in various aspects of perinatal medicine has contributed to this book. Their wide-ranging experience and points of view should make this book a valuable reference for all physicians and allied health personnel involved in the care of the high-risk fetus and newborn. MANOHAR RATHI, M.D. Acknowledgements. I am grateful to the contributors for their cooperation in preparing the manuscripts, to my associates for their help and support, and to the publishers for their continued interest in this work. Above all, I thank Ms. Rose Aiello-Lech and Ms. MaryAnn Cichowski for their hard work in making this publication possible."

This monograph focuses on splanchnic function in health and disease. It represents a distillate of the communication that took place at the First International Symposium of Applied Physiol ogy of the Peripheral Circulation, "Splanchnic Circulation: No Longer a Silent Partner." The individual chapters roughly follow the individual presentations and display in durable form the con cepts and importance that this symposium achieved. The concept for this annual symposium was the child of An tonio Artigas, who not only recruited sponsorship but also Jean Francois Dhainaut and me to help with the organization and work. We chose the splanchnic circulation as the peripheral cir culatory system to be presented first for many important reasons. Much new information has become available which demon strates, as the title of the symposium implies, that splanchnic function has major influence on the overall expression of health and disease in humans. All aspects of splanchnic physiology, it seems, have been rediscovered to be dynamic, important, and complex in their interactions within individual tissues and among remote tissues and organs. It is hoped that after having reviewed this monograph the reader will agree that the splanchnic circula tion and its organ systems are emerging as important aspects of critical illness and host-defense homeostasis."

Intensive care in childhood is a relatively new field of medicine. Due to major differences in physiology, many disciplines are involved in the care of the critically ill child. Apart from specific disease patterns, morbidity in direct relation to the stay in the ICU or the underlying disease mainly determine long term morbidity. Today we understand that the treatment of the critically ill child can have a great impact on the quality of life in adulthood. This book covers the whole spectrum of intensive care in childhood. It is based on the experience of leading specialists from the various fields involved in the treatment of these children.

Nephrology, initially born as a small branch of medicine, has, in the last few decades, become an extraordinary large field of medicine. The recent development of renal medicine is mirrored by the numerous nephrological journals published, a natural consequence of the increasing number of basic and clinical research studies performed continuously all over the world. Undoubtedly the progress which has occurred in the different, specific fields of renal medicine has given rise to subspecialities which range from renal physiology and pathology to hemo- and peritoneal dialysis and renal transplantation. Even the diagnostic methodology in nephrology, very useful in the clinical practice, has become a speciality within the speciality. Thus, the problem for clinical nephrologists, as well as for internists, is to remain continuously up-dated in all fields of nephrology. Nephrology textbooks are published continuously and in great number. However, the time required for having authors appointed, chapters completed, manuscript edited, galley proofs corrected and the whole book printed makes many textbooks already out of date when they go on sale and their half lives are very short. On the other hand, nephrological journals are so many and the articles so numerous and detailed, that it is often impossible to rely on them for up-dating practicing clinicians.

Assisted Circulation 4 is an authoritative review of the progress which has been achieved in the last 5 years since the publication of "Assisted Circulation 3" in 1989. The present book highlights the work of well-known experts on indications for assisted circulation, cardiac support devices such as bridges, devices for transplantation, devices for chronic mechanical support, biological energy sources, cardiomyoplasty, extracorporeal membraneoxygenation and an overview of cardiac devices support with a specific emphasis on xenotransplantation. Assisted Circulation 4 is the latest product of an ongoing effort by the editors to keep readers regularly informed of recent developments in the field. Assisted Circulation is a standard technology in cardiac surgery and especially in cardiac transplantation.

Echocardiography has been one of the most significant advances in cardiology in the past two decades. It can provide anatomic, functional hemodynamic, and blood flow information. Conventional transtho- racic echocardiography has limitations, particularly in certain patients such as those with obesity, chronic lung disease, or chest wall defor- mity, or in those where a transthoracic approach is difficult for reasons including trauma, life support apparat uses, and surgical dressings. There are also certain disease states or conditions in which transtho- racic echocardiography expectedly gives incomplete or inadequate in- formation. Transesophageal echo cardiography has opened a unique "new window to the heart." The immediate proximity of the esophagus and the posterior heart permits exceptionally high resolution images, par- ticularly of the left atrium, mitral valve, and intraatrial septum. Addi- tionally, from the stomach (trans gastric views), the ventricles can be dependably imaged. Transesophageal echo cardiography presently is utilized in two environments: intraoperatively and for outpatient examinations. Intraoperatively, TEE is utilized to monitor cardiac function and de- tect intracardiac air or debris, to diagnose or quantitate cardiac path- ology, and to access operative results.

During the last decade a multitude of studies concerning the dynamic changes in cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), and intracranial pressure (ICP) in the acute phase after head injury have been published. These studies have been supplemented with studies of cerebral autoregulation, CO2 reactivity and barbiturate reactivity. Other investigations include studies of cerebrospinal fluid pH, bicarbonate, lactate and pyruvate. In this book experimental and clinical studies of the dynamic changes in CBF, CMRO2, CO2 reactivity and barbiturate reactivity are reviewed. The author's own clinical studies of the dynamic changes in CBF and cerebral metabolism are summarized and discussed, and the therapeutical implication as regards the use of artificial hyperventilation, sedation with barbiturate and mannitol treatment are discussed.

This supplement of Acta Neurochirurgica contains the proceedings of the Ninth Convention of the Academia Eurasiana Neurochirurgica held in Chateau St. Gerlach, Houthem, The Netherlands, 29 July - 1 August 1998. During this convention a three-day symposium on Neurosurgery and Medical Ethics was held. In this time of tremendous technical advancement in medicine in general and neurosurgery in particular, we are liable to lose sight of the sick patient as a human being, and the odds are that he will be the object rather than the subject of our action in the near future. It is a purpose and a task of the Academia Eurasiana Neurochirurgica to recognize this thread and to pay attention to tradition, morality and ethics in neurological surgery. The theme of this convention and the subject of the symposium met this purpose as no other. In the scientific sessions during the first day, the moral backgrounds of medical ethics in the most important cultures and religions in east and west were elucidated by invited experts in this field. A mutual respectful understanding of each other's conception of and belief in ethical principles is a growing necessity in our multicultural societies in both continents. On the second day, the ethical aspects of different fields of neurological surgery were discussed by members of the Academia. In this context, also the internationally much-discussed and much-criticized regulations on euthanasia in The Netherlands were explained.

C. Manni The focusing of general interest and of many disciplines on disaster medicine is an interesting and recent phenomenon in our society. Disasters have by now left the his torical and philosophical sphere and finally entered the operational arena. Modern man, in other words, no longer accepts disasters in a passive and fatalistic manner, but claims to be able to control them like so many other forces of nature. The new approach is aimed at preventing, containing, and remedying the invariably tragic consequences of these events. The role of medicine in this context is of fundamental importance and is charac terized by two main aspects: application of techniques of intervention appropriately and effectively, and collaboration with the general organization, assuming responsi bility for the protection of health and the treatment of injuries. Following a period of more or less chaotic growth, during which sectionalism and empirical interests prevailed, and localized aspects of this new discipline underwent considerable development, a need is now felt to propose and realize a more com prehensive scientific approach. It has become necessary to identify and to rationally analyze the individual components of this branch of medicine. As in any analysis, the recognition of the "object" of the research is of fundamental importance: hence the title of this first round table: "Types and Events of Disaster."

The 1992 International Yearbook of Nephrology is the 4th in a successful series of yearly books updating practising nephrologists and nephrologists-in-training on rapidly changing areas of nephrology. We were encouraged to proceed in our editorial venture by reviews of the previous issues which have appeared in various Nephrology Journals. These reviews have pointed to the successful use of the International Editorial Board, the broad range of topics of current interest which have been covered and the comprehensive and practical nature of the reviews. The principal aim of the Yearbook remains to provide reviews which are more current than those which appear in Nephrology textbooks and which can be in the hands of the readers a few months after the authors have completed the manuscripts. The appointed authors are always experts in the field, who are asked to give an objective review of the topic, up-dating the readers on the world-wide literature and providing them with a complete, accurate and up-ta-date list of important recent references. We have decided to maintain the successful format of the first three issues. Thus, the volume will continue to be divided into sections; each section will continue to have a different primary focus every year, depending upon what is of greatest interest at the time.

Sepsis and Innovative Treatment: The Odyssey R. C. Bone The Odyssey by Homer, dates back to the 8th century, B. C. [1]. It is a great epic adventure of Odysseus's dramatic journey from Troy back home to Ithaca. Odysseus survives the ordeals of this journey and returns with new powers and insights. The study of the pathogenesis and treatment of sepsis has also been an odys- sey. I feel we will return from this odyssey with new insights and treatments. However, as with Odysseus, this will occur only after considerable struggle. In the 1980s we had a rather simplistic view of sepsis. It was a highly lethal complication caused by infection and often charac- terized by shock and multi-organ failure. Our knowledge of the inflammatory responses associated with sepsis was embryonic compared to today. The inflammatory response was often treat- ment with mega-dose corticosteroids along with fluid resuscita- tion, vasopressors and antibiotics. Because of the paucity of mul- ti-center controlled trials documenting the risk/benefit ratio of the treatment of sepsis with corticosteroids, two large multi-cen- ter controlled trials were organized to evaluate the role of corti- costeroids in sepsis [2, 3]. Because animal models showed bene- fits of corticosteroids only with pre-treatment or early treatment, a definition of sepsis was used that did not require positive cul- ture documentation or septic shock to be included in the studied population.

The acute abdomen is one of the most frequent, most dangerous and most difficult problems that the diagnostic radiologist has to deal with. This comprehensive manual presents a clinico-radiologic approach to the use of diagnostic imaging techniques for acute abdominal conditions. Imaging techniques, radiologic symptoms and clinical conditions are treated separately. This lucid format, together with a detailed subject index, offer the reader a quick and reliable reference aid in daily practice. The text is clearly structured and concise in style, and provides helpful practical hints, including discussion of diagnostic pitfalls. It is supported by a wealth of illustrations covering native diagnosis, ultrasonography, computer tomography and angiography.

Sepsis and infection are the major enemies of the intensive care patient in whom immunological defenses are severely impaired. This major problem is thefocus of attention in this book, based on the presentation of the First International Congress on the Immune Consequences of Trauma, Shock, and Sepsis, which is one of the first attempts to exchange ideas on the state-of-the-art in this area of immunology. Both basic and clinical research, including new centres of attention, are described. The growing role of immunology in medicine opens new avenues to the under- standing of trauma and sepsis and will allow the design of novel therapeutic approaches.

The decisive factor in trauma is that many processes first occur at the cellular level before they can be determined in laboratory tests, and recognition of them has only recently found its way into intensive care practice. Yet knowledge of the pathophysiology of these processes is essential for an early diagnosis of multiple organ failure and the implementation of adequate therapy, which ultimately make the patient's survival possible. Professor Schlag, an internationally renowned scientist and clinician, has been concerned with the basic pathophysiological principles of shock for many years. In this book he has brought together for the first time an international team of authors primarily from the USA and Europe, who present their collective findings of trauma, shock, development of the organ in shock and early failure and of sepsis-like syndrome, and development of septic multiple organ failure. Patienten mit Multiorganversagen haben immer noch eine schlechte Prognose in der intensivmedizinischen Behandlung, insbesondere wenn sie noch zusatzlich in einen septischen Schock geraten. Hier hilft auch oft eine breite Abdeckung mit modernsten Antibiotika nicht weiter. Neue Ansatze fur eine Therapie dieser problempatienten haben sich in den letzten Jahren durch Erkenntnisse der pathophysiologischeen Vorgange die zum Schock fuhren ergeben. Herr Professor Schlag hat als anerkannte Kapazitat auf dem Gebiet der Traumatologie und Schockforschung fur dieses erste umfassende Werk zu den Grundlagen des Multiorganversagens eine beeindruckende Liste von mehr als 50 international renommierten Autoren zusammenbekommen. Das Buch ist nicht nur eine Aufarbeitung aller Grundlagen des Schocks und Multiorganversagens sondern zudem ein ausgezeichnetes Nachschlagewerk fur jeden intensivmedizinisch tatigen Klinikarzt, egal ob er aus der Anasthesie, der Inneren Medizin oder der Unfallchirurgie kommt."

Dieser Band gibt die Referate des 4. Internationalen An{sthesie-Symposiums, 15.-17. Juni 1989 wieder. Amerikanische und europ{ische Spezialisten der unter- schiedlichsten Fachgebiete diskutieren neueste Entwicklungen der Labor- und klinischen Forschung.

There is a tendency of an increasing number of signals and derived variables to be incorporated in the monitoring of patients during anesthesia and in intensive care units. The addition of new signals hardly ever leads to thedeletion of other signals. This is probably based on a feeling of insecurity. We must realize that each new signal that is being monitored brings along its cost, in terms of risk to the patient, investment and time. It is therefore essential to assess the relative contribution of this new signal to the quality of the monitoring process; i. e. given the set of signals already in use, what is the improvement when a new signal is added? Beyond a certain point the addition of new information leads to new uncertainty and degrades the result (Ream, 1981) In the diagnostic process, it is possible to evaluate "result" in an objective, qualitative way. The changes in the sensitivity and specificity of the diagnosis as a result of the addition or deletion of a certain variable can be calculated on the basis of false negative, false positive, correct negative and false negative scores. Different methods for multiple regression analysis have been implemented on computers (Gelsema, 1981) which can support such decision processes. In monitoring, the situation is much more complex. Many definitions of monitoring have been given; the common denominator is that monitoring is a continuous diagnostic process based upon a (semi)continuous flow of information. This makes simple assessment methods useless.