[Hypotension induced by spinal anesthesia during cesarean section : Current treatment concepts]

Arterial hypotension during cesarean delivery under spinal anesthesia can cause maternal and fetal adverse effects. Therefore, current guidelines recommend the continuous and preferably prophylactic use of vasopressors, emphasizing the use of alpha-agonists, such as phenylephrine. Besides a left lateral uterine displacement either an intravenous colloid preloading or a crystalloid co-loading is recommended. The blood pressure goal is to maintain a systolic arterial blood pressure of at least 90% of the initial baseline value and to avoid a drop to less than 80% of this baseline. To achieve this goal a prophylactic continuous phenylephrine infusion with an adjustable flow rate is recommended. It is advised to start with an initial dose of 25-50 µg/min, initiated immediately following the intrathecal injection of the local anesthetic and titrated according to the vital parameters. Parturients with cardiac diseases should be preoperatively evaluated following individual hemodynamic goals.

Beta-amyloid peptides(1-42) and (1-40) in the cerebrospinal fluid during pregnancy: a prospective observational study

To evaluate changes in concentrations of selected biomarkers, neurotrophic factors, and growth factors in the cerebrospinal fluid during pregnancy. A prospective observational study was conducted in 32 pregnant women undergoing gynecological and obstetrical surgery under spinal anesthesia in a university hospital. Beta-amyloid(1-42) and beta-amyloid(1-40) peptides, brain-derived neurotrophic factor, glial cell line-derived neurotrophic factor, and vascular endothelial growth factor were analyzed in cerebrospinal fluid using an enzyme-linked immunosorbent assay. Eight women in second trimester pregnancy who underwent spinal anesthesia for gynecological or obstetrical surgery were compared with 24 matched women in third trimester pregnancies. CSF concentrations of beta-amyloid(1-42) were significantly higher in third trimester pregnancies (p = 0.025). During third trimester, the beta-amyloid ratio correlated with the vascular endothelial growth factor (r_s = 0.657; p = 0.008). Higher concentrations of beta-amyloid(1-42) in cerebrospinal fluid of third trimester pregnancies and correlations between the beta-amyloid ratio and the vascular endothelial growth factor support the hypothesis that beta-amyloid peptides are involved in complex adaptive brain alterations during pregnancy.

National survey of obstetric anaesthesia clinical practices in the republic of Austria

BACKGROUND

The aim of this study was to describe the current obstetric anaesthetic practices in Austria by performing a comprehensive questionnaire survey.

METHODS

A questionnaire was sent via email to key anaesthesiologists from obstetric anaesthesia departments of 81 hospitals registered at the Austrian Ministry of Health.

RESULTS

Of 81 departments contacted, 65 (80%), covering 84% of annual births in Austria, responded to the 82-question survey. Epidural analgesia was offered universally, at a rate under 30% in 56 (86%) of respondent hospitals. The caesarean section rate was under 30% in 44 (68%) respondent obstetric units. All respondents provided spinal anaesthesia as the primary anaesthetic technique for elective caesarean section. Three (5%) respondents administered long-acting intrathecal morphine and 18 (28%) respondents did not routinely administer any intrathecal opioid. Wound infiltration for acute postoperative pain control was practiced in two (3%) respondent units. A transversus abdominis plane block was offered as rescue analgesia in 14 (22%) departments. Spinal hypotension was treated using a prophylactic phenylephrine infusion in two (3%) respondent hospitals. Prophylactic antibiotics were administered prior to skin incision by 31 (48%) respondents.

CONCLUSION

This survey reveals that obstetric anaesthetic practices in Austria differ in part from current European and American guidelines. Findings will direct the national workforce on obstetric anaesthesia that aims to introduce into Austria practice guidelines, based on international collaborations and guideline recommendations.

Optimizing Antitumor Efficacy and Adverse Effects of Pegylated Liposomal Doxorubicin by Scheduled Plasmapheresis: Impact of Timing and Dosing

Background:

Nanoscale drug delivery systems accumulate in solid tumors preferentially by the enhanced permeation and retention effect (EPR-effect). Nevertheless, only a miniscule fraction of a given dosage reaches the tumor, while >90% of the given drug ends up in otherwise healthy tissues, lead-ing to the severe toxic reactions observed during chemotherapy. Once accumulation in the tumor has reached its maximum, extracorporeal elimination of circulating nanoparticles by plasmapheresis can dimin-ish toxicities.

Objective:

In this study, we investigated the effect of dosing and plasmapheresis timing on adverse events and antitumor efficacy in a syngeneic rat tumor model.

Methods:

MAT-B-III cells transfected with a luciferase reporter plasmid were inoculated into female Fisher rats, and pegylated liposomal doxorubicin (PLD) was used for treatment. Plasmapheresis was performed in a discontinuous manner via centrifugation and subsequent filtration of isolated plasma.

Results:

Bioluminescence measurements of tumor growth could not substitute caliper measurements of tumor size. In the control group, raising the dosage above 9 mg PLD/kg body weight did not increase therapeutic efficacy in our fully immunocompetent animal model. Plasmapheresis was best done 36 h after injecting PLD, leading to similar antitumor efficacy with significantly less toxicity. Plasmapheresis 24 h after injection interfered with therapeutic efficacy, while plasmapheresis after 48 h led to fewer side effects but also to increased weight loss.

Conclusion:

Long-circulating nanoparticles offer the unique possibility to eliminate the excess of circulat-ing particles after successful accumulation in tumors by EPR, thereby reducing toxicities and likely toxici-ty-related therapeutic limitations

Pulmonary effects of bupivacaine, ropivacaine, and levobupivacaine in parturients undergoing spinal anaesthesia for elective caesarean delivery: a randomised controlled study

BACKGROUND

Spinal anaesthesia is the method of choice for elective caesarean delivery, but has been reported to worsen dynamic pulmonary function when using bupivacaine. Similar investigations are lacking for ropivacaine and levobupivacaine. We have therefore compared the pulmonary effects of intrathecal bupivacaine, ropivacaine and levobupivacaine used for caesarean delivery.

METHODS

Forced vital capacity, forced expiratory volume in the first second, and peak expiratory flow rate were measured in 48 parturients before and after onset of spinal anaesthesia using either 0.5% bupivacaine 10 mg, 1% ropivacaine 20 mg, or 0.5% levobupivacaine 10 mg. Apgar scores and umbilical arterial pH were recorded.

RESULTS

The final level of sensory blockade was not different between groups. Forced vital capacity was significantly decreased with bupivacaine (3.6+/-0.5 L to 3.5+/-0.4 L, P<0.05) and ropivacaine (3.2+/-0.4 L to 3.1+/-0.5 L, P<0.05), but not with levobupivacaine (3.6+/-0.5 L to 3.4+/-0.6 L). Forced expiratory volume during the first second was not decreased in any group. Peak expiratory flow rate was significantly decreased with ropivacaine (5.5+/-1.5 L/s to 5.0+/-1.1 L/s, P<0.05) and levobupivacaine (from 6.0+/-1.1 L/s to 5.2+/-0.9 L/s, P<0.01). Neonatal vital parameters did not differ between the three groups.

CONCLUSIONS

Decreases in maternal pulmonary function tests were similar following spinal anaesthesia with bupivacaine, ropivacaine, or levobupivacaine for caesarean delivery. The clinical maternal and neonatal effects of these alterations appeared negligible.

Nicotinic acetylcholine receptor-subunit mRNAs in the mouse superior cervical ganglion are regulated by development but not by deletion of distinct subunit genes

Mice with deletions of nicotinic ACh receptor (nAChR) subunit genes are valuable models for studying nAChR functions. We could previously show in the mouse superior cervical ganglion (SCG) that the absence of distinct subunits affects the functional properties of receptors. Here, we have addressed the question of whether deletions of the subunits alpha5, alpha7, or beta2 are compensated at the mRNA level, monitored by reverse transcription and quantitative real-time polymerase chain reaction. Relative to our reference gene, alpha3, which is expressed in all SCG nAChRs, mRNA levels of beta4 showed little change from birth until adult ages in intact ganglia of wild-type mice. In contrast, alpha4 declined sharply after birth and was barely detectable in adult animals. alpha5, alpha7, and beta2 subunit message levels also declined, though more slowly and less completely than alpha4. The subunits alpha6 and beta3 were detected by conventional polymerase chain reaction at very low levels, if at all, whereas alpha2 was never seen in any of our samples. The developmental profile of nAChR mRNA levels in the three knockout strains did not differ markedly from that of wild-type mice. Likewise, message levels of nAChR subunits were similar in cultures prepared from either wild-type or knockout animals. Our observations indicate a developmental regulation of nAChR subunit mRNAs in the SCG of mice after birth that was not affected by the three knockouts under investigation.

AML1 deletion in adult mice causes splenomegaly and lymphomas

AML1 (RUNX1) encodes a DNA-binding subunit of the CBF transcription factor family and is required for the establishment of definitive hematopoiesis. AML1 is one of the most frequently mutated genes associated with human acute leukemia, suggesting that genetic alterations of the gene contribute to leukemogenesis. Here, we report the analysis of mice carrying conditional AML1 knockout alleles that were inactivated using the Cre/loxP system. AML1 was deleted in adult mice by inducing Cre activity to replicate AML1 deletions found in human MDS, familial platelet disorder and rare de novo human AML. At a latency of 2 months after induction, the thymus was reduced in size and frequently populated by immature double negative thymocytes, indicating defective T-lymphocyte maturation, resulting in lymphatic diseases with 50% penetrance, including atypical hyperplasia and thymic lymphoma. Metastatic lymphomas to the liver and the meninges were observed. Mice also developed splenomegaly with an expansion of the myeloid compartment. Increased Howell-Jolly body counts indicated splenic hypofunction. Thrombocytopenia occurred due to immaturity of mini-megakaryocytes in the bone marrow. Together with mild lymphocytopenia in the peripheral blood and increased fractions of immature cells in the bone marrow, AML1 deficient mice display features of a myelodysplastic syndrome, suggesting a preleukemic state.

Optical measurement of surface tension in a miniaturized air-liquid interface and its application in lung physiology

We have previously shown that lamellar body-like particles, the form in which pulmonary surfactant is secreted, spontaneously disintegrate when they contact an air-liquid interface, eventually creating an interfacial film. Here, we combined these studies with a new technique enabling the simultaneous and non-invasive measurement of surface tension (gamma). This method is a refinement of the pendant-drop principle. A sapphire cone with a 300-microm aperture keeps the experimental fluid by virtue of surface coherence in a fixed and nearly planar position above the objective of an inverted microscope. The radius of curvature of the fluid meniscus is related to gamma and determines the pattern of light back-reflection upon epi-illumination. This method, which we name "inverted interface", has several novel aspects, in particular its microscopic dimensions. When using lamellar body-like particles freshly released by alveolar type II cells, we found that their conversion at the interface resulted in gamma-reduction close to 30 mN/m. After a fast initial decay, gamma-decrease proceeded slowly and in proportion to single particle conversions. These conversions ceased with time whereas gamma decreased further, probably due to reorganization of the already deposited material. The present investigation indicates that surface film formation by adsorption of large surfactant aggregates is an important mechanism by which gamma is reduced in the lung.

[Tumorectomy in conscious patient with suspected pregnancy associated breast cancer under cervical epidural anesthesia]

In this report we present a 35 year old pregnant woman (no significant disease in patient history, non smoker, primipara, gestational week 15) who had to undergo elective tumorectomy due to suspected pregnancy associated breast cancer. General anesthesia during pregnancy can potentially be harmful for the fetus (hypoxia, acidosis, premature delivery, teratogenicity). We decided to anesthetize the patient with a cervical segmental epidural block.

Tracing surfactant transformation from cellular release to insertion into an air-liquid interface

Pulmonary surfactant is secreted by alveolar type II cells as lipid-rich, densely packed lamellar body-like particles (LBPs). The particulate nature of released LBPs might be the result of structural and/or thermodynamic forces. Thus mechanisms must exist that promote their transformation into functional units. To further define these mechanisms, we developed methods to follow LBPs from their release by cultured cells to insertion in an air-liquid interface. When released, LBPs underwent structural transformation, but did not disperse, and typically preserved a spherical appearance for days. Nevertheless, they were able to modify surface tension and exhibited high surface activity when measured with a capillary surfactometer. When LBPs inserted in an air-liquid interface were analyzed by fluorescence imaging microscopy, they showed remarkable structural transformations. These events were instantaneous but came to a halt when the interface was already occupied by previously transformed material or when surface tension was already low. These results suggest that the driving force for LBP transformation is determined by cohesive and tensile forces acting on these particles. They further suggest that transformation of LBPs is a self-regulated interfacial process that most likely does not require structural intermediates or enzymatic activation.

Central role of a serine phosphorylation site within duck hepatitis B virus core protein for capsid trafficking and genome release

Viral nucleocapsids compartmentalize and protect viral genomes during assembly while they mediate targeted genome release during viral infection. This dual role of the capsid in the viral life cycle must be tightly regulated to ensure efficient virus spread. Here, we used the duck hepatitis B virus (DHBV) infection model to analyze the effects of capsid phosphorylation and hydrogen bond formation. The potential key phosphorylation site at serine 245 within the core protein, the building block of DHBV capsids, was substituted by alanine (S245A), aspartic acid (S245D) and asparagine (S245N), respectively. Mutant capsids were analyzed for replication competence, stability, nuclear transport, and infectivity. All mutants formed DHBV DNA-containing nucleocapsids. Wild-type and S245N but not S245A and S245D fully protected capsid-associated mature viral DNA from nuclease action. A negative ionic charge as contributed by phosphorylated serine or aspartic acid-supported nuclear localization of the viral capsid and generation of nuclear superhelical DNA. Finally, wild-type and S245D but not S245N virions were infectious in primary duck hepatocytes. These results suggest that hydrogen bonds formed by non-phosphorylated serine 245 stabilize the quarterny structure of DHBV nucleocapsids during viral assembly, while serine phosphorylation plays an important role in nuclear targeting and DNA release from capsids during viral infection.

Application of a dynamic 2-D mixing model to assess the impact of chemical spills on raw water quality

A non-steady-state two-dimensional river mixing model was used in conjunction with the Hec-2 water surface profile model to develop a "spill model" by which impact of chemical spills on the raw water quality of a water treatment plant can be assessed. The dynamic 2-D mixing model was applied to the North Saskatchewan River between Devon and the Rossdale Water Treatment Plant in Edmonton, Alberta. Hec-2 compatible data were used to estimate surface water elevations for the river under varying discharge conditions. To ensure accurate estimates of the surface water elevations, Hec-2 was calibrated using the high water mark data, which were collected by the Alberta Environment during the 1986 Edmonton flood. The calibrated Hec-2 model was then used to estimate surface water elevations using flowrates from 50 m3 s1 to 5000 m3 s1. The dynamic mixing model was modified so it could utilize the cross sectional geometry data and estimated water surface elevations obtained from the Hec-2 model. Several input files were prepared for the mixing model, representing various discharge conditions of the river. A user-friendly interface was developed allowing operators easy manipulation of the mixing model. Provisions were also incorporated to allow input of required spill data such as the location of the spill, types of chemicals involved, and the magnitude of the spill. The two-dimensional mixing model estimates the concentration of a conservative chemical(s) at any point downstream of the chemical spill.

Surfactant protein B labelled with [(99m)Tc(CO)3(H20)3](+) retains biological activity in vitro

Labelling of the hydrophobic surfactant protein B (SP-B) under non-reducing conditions was achieved with [(99m)Tc(CO)(3)(H2O)(3)](+) prepared according to Alberto et al. (JACS, 1998). The binding of radioactivity was protein-specific, with an overall radiochemical yield of 50%. Gel electrophoresis and Westernblot analyses showed no structural changes of SP-B. Spreading properties and surface activity of (99m)Tc-labelled SP-B in an air/water interface coincided with those of unlabelled SP-B. (99m)Tc-SP-B seems to be a promising agent to observe surfactant spreading under clinical conditions.

BACKGROUND

Therapeutic results for surfactant instillation in clinical trials are conflicting. The (99m)Tc-labelling of surfactant would allow to observe its spreading in the lung under clinical conditions.

METHODS

[(99m)Tc(CO)(3)(H2O)(3)](+) was prepared as described by Alberto et al. (JACS, 1998). This carbonyl complex was used for the direct labelling of surfactant protein B (SP-B) under non-reductive conditions by direct incubation with SP-B at elevated temperature followed by extraction into CHCl(3)/MeOH.

RESULTS

The hydrophobic protein SP-B was labelled with [(99m)Tc(CO)(3)(H2O)(3)](+). An overall radiochemical yield of about 50% was achieved. HPLC-analysis revealed a single radiolabelled species according to UV elution profile of SP-B, supported by paper and size exclusion chromatography. Gel electrophoresis confirmed that the dimer structure of SP-B was preserved. Spreading properties of (99m)Tc-labelled SP-B in an air/water interface coincided with those of unlabelled SP-B. Spreading of radioactivity observed in a glass trough of 26 cm x 27 cm with a gamma camera was completed during the first 7-9 sec after application of (99m)Tc-labelled SP-B. The corresponding decrease of surface tension to 45 mN/m at the peripheral surface tension sensors took 7 sec +/- 2 sec (MEAN +/- STD; n = 3).

CONCLUSIONS

Direct and specific (99m)Tc-labelling of the hydrophobic surfactant protein B was achieved using the [(99m)Tc(CO)(3)(H2O)(3)](+) precursor. This procedure can easily be used to prepare specifically labelled surfactant mixtures with spreading properties that coincide with those of unlabelled surfactant.

Effect of the hydrophobic surfactant proteins on the surface activity of spread films in the captive bubble surfactometer

The main function of pulmonary surfactant, a mixture of lipids and proteins, is to reduce the surface tension at the air/liquid interface of the lung. The hydrophobic surfactant proteins SP-B and SP-C are required for this process. When testing their activity in spread films in a captive bubble surfactometer, both SP-B and SP-C showed concentration dependence for lipid insertion as well as for lipid film refinement. Higher activity in DPPC refinement of the monolayer was observed for SP-B compared with SP-C. Further differences between both proteins were found, when subphase phospholipid vesicles, able to create a monolayer-attached lipid reservoir, were omitted. SP-C containing monolayers showed gradually increasing minimum surface tensions upon cycling, indicating that a lipid reservoir is required to prevent loss of material from the monolayer. Despite reversible cycling dynamics, SP-B containing monolayers failed to reach near-zero minimum surface tensions, indicating that the reservoir is required for stable films.

Functional Tests for the Characterization of Surfactant Protein B (SP-B) and a Fluorescent SP-B Analog

Surfactant protein B (SP-B) enhances lipid insertion into the alveolar air/liquid interface upon inhalation. The aim of this study was (i) to apply a palette of tests for a detailed biochemical and biophysical characterization of SP-B and (ii) to use these tests to compare native SP-B with a fluorescent (Bodipy) SP-B analog. The method of labeling was fast and resulted in a covalent fluorophore-protein bond. The ability of both proteins to spread a surfactant film on top of a buffer surface was determined in a spreading tray using the Wilhelmy plate technique to allow detection of alterations in surface tension and calculation of spreading velocities. In a captive bubble surfactometer surface tensions of spread films were measured. Similar biophysical properties were found for both native and Bodipy-labeled SP-B. It is concluded that the combination of tests used allows detection of small differences in structure and activity between the two proteins.

High-frequency oscillatory ventilation does not decrease endothelin release in lung-lavaged rabbits

High-frequency oscillatory ventilation (HFO) has been shown to reduce lung injury and pulmonary arterial pressure (PAP). We hypothesized that HFO leads to decreased endothelin 1 (ET-1) and endothelin 3 (ET-3) release when compared to conventional mechanical ventilation (CMV) in lung-lavaged rabbits.

DESIGN

Prospective, randomized, controlled animal study. In 26 adult New Zealand White Rabbits ventilated by CMV or HFO under hypoxemic and normoxemic conditions after lung lavage (CMV-hypo: n = 5; CMV-normo: n = 8; HFO-hypo: n = 7; HFO-normo: n = 6) we recorded systemic and PAP, measured blood gases, ET-1 and ET-3 and calculated intrapulmonary venous admixture during a 4-h experiment. ET-1 was significantly increased after lavage (p < 0.05) with no further increase until the end of the experiment. Neither pulmonary arterial nor systemic arterial ET-1 differed between CMV and HFO or between hypoxemia and normoxemia. Systemic arterial ET-3, however, was significantly higher in HFO-hypo than in the other two groups ventilated under normoxemic conditions at the end of the experiment (HFO-hypo vs. CMV-normo, p < 0.05; HFO-hypo vs. HFO-normo, p < 0.05). PAP showed a continuous increase in all groups (p < 0.05). We did not find any correlation between PAP and ET-1 or ET-3. Intrapulmonary venous admixture increased in animals ventilated under hypoxemic conditions, whereas it decreased after lung lavage in those ventilated under normoxemic conditions until the end of the experiment (HFO-normo, p < 0.05).

CONCLUSIONS

This study suggests that HFO does not decrease ET-1 and ET-3 release compared to CMV in lung-lavaged rabbits. Hypoxemia, however, may increase ET-3 release from the lungs, leading to an increased intrapulmonary shunt.

Persistence of phase coexistence in disaturated phosphatidylcholine monolayers at high surface pressures

Prior reports that the coexistence of the liquid-expanded (LE) and liquid-condensed (LC) phases in phospholipid monolayers terminates in a critical point have been compromised by experimental difficulties with Langmuir troughs at high surface pressures and temperatures. The studies reported here used the continuous interface of a captive bubble to minimize these problems during measurements of the phase behavior for monolayers containing the phosphatidylcholines with the four different possible combinations of palmitoyl and/or myristoyl acyl residues. Isothermal compression produced surface pressure-area curves for dipalmitoyl phosphatidylcholine (DPPC) that were indistinguishable from previously published data obtained with Langmuir troughs. During isobaric heating, a steep increase in molecular area corresponding to the main LC-LE phase transition persisted for all four compounds to 45 mN/m, at which collapse of the LE phase first occurred. No other discontinuities to suggest other phase transitions were apparent. Isobars for DPPC at higher pressures were complicated by collapse of the monolayer, but continued to show evidence up to 65 mN/m for at least the onset of the LC-LE transition. The persistence of the main phase transition to high surface pressures suggests that a critical point for these monolayers of disaturated phospholipids is either nonexistent or inaccessible at an air-water interface.

Localization of a candidate surfactant convertase to type II cells, macrophages, and surfactant subfractions

Pulmonary surfactant exists in the alveolus in several distinct subtypes that differ in their morphology, composition, and surface activity. Experiments by others have implicated a serine hydrolase in the production of the inactive small vesicular subtype of surfactant (N. J. Gross and R. M. Schultz. Biochim. Biophys. Acta 1044: 222-230, 1990). Our laboratory recently identified this enzyme in the rat as the serine carboxylesterase ES-2 [F. Barr, H. Clark, and S. Hawgood. Am. J. Physiol. 274 (Lung Cell. Mol. Physiol. 18): L404-L410, 1998]. In the present study, we determined the cellular sites of expression of ES-2 in rat lung using a digoxygenin-labeled ES-2 riboprobe. ES-2 mRNA was localized to type II cells and alveolar macrophages but not to Clara cells. Using a specific ES-2 antibody, we determined the protein distribution of ES-2 in the lung by immunohistochemistry, and it was found to be consistent with the sites of mRNA expression. Most of the ES-2 in rat bronchoalveolar lavage is in the surfactant-depleted supernatant, but ES-2 was also consistently localized to the small vesicular surfactant subfraction presumed to form as a consequence of conversion activity. These results are consistent with a role for endogenous lung ES-2 in surfactant metabolism.

Production of surfactant protein C in the baculovirus expression system: the information required for correct folding and palmitoylation of SP-C is contained within the mature sequence

Surfactant protein C (SP-C) is synthesized in the alveolar type II cells of the lung as a 21 kDa propeptide which is proteolytically processed to a 4.2 kDa mature active form. The main function of this extremely hydrophobic protein is to enhance lipid insertion into the air/liquid interface in the lung upon inhalation. This is necessary to maintain a relatively low surface tension at this interface during breathing. In this report we describe the production of mature human SP-C in the baculovirus expression system. The recombinant protein contains a secondary structure with a high alpha-helical content (73%), comparable to native SP-C, as determined by circular dichroism and attenuated total reflection Fourier transform infrared analysis. The expressed protein is a mixture of dipalmitoylated (15%) and non-palmitoylated SP-C. This suggests that the information required for palmitoylation is contained within the sequence of the mature protein. The activity of the protein to insert phospholipids into a preformed monolayer of lipids at an air/liquid interface was determined with a captive bubble surfactometer. Recombinant SP-C significantly reduced the surface tension at the air/liquid interface during dynamic expansion and compression. We conclude that correctly folded, dipalmitoylated and active SP-C can be expressed in the baculovirus expression system. Our results may facilitate investigations into the relation between structure and function of SP-C and into protein palmitoylation in general.

Hydrophobic lung surfactant proteins B and C remain associated with surface film during dynamic cyclic area changes

The biophysical activity of lung surfactant depends, to a large extent, on the presence of the hydrophobic surfactant proteins B (SP-B) and C (SP-C). The role of these proteins in lipid adsorption and lipid squeeze-out under dynamic conditions simulating breathing is not yet clear. Therefore, the aim of this study was to investigate the interaction of spread hydrophobic surfactant proteins with phospholipids in a captive-bubble surfactometer during rapid cyclic area changes (6 cycles/min). We found that SP-B and SP-C facilitated the rapid transport of lipids into the air-water interface in a concentration-dependent manner (threshold concentration > or = 0.05:0.5 mol% SP-B/SP-C). Successive rapid cyclic area changes did not affect the concentration-dependent lipid adsorption process, suggesting that SP-B and SP-C remained associated with the surface film.

A spreading technique for forming film in a captive bubble

Mechanisms underlying the surface properties of lung surfactant are extensively studied in in vitro systems such as the captive-bubble surfactometer (CBS), the pulsating-bubble surfactometer, and the Wilhelmy balance. Among these systems, the CBS is advantageous when a leakproof system and high cycling rates are required. However, widespread application of the CBS to mechanistic studies of dynamic surfactant protein-phospholipid interactions of spread film and to comparative studies between spread and adsorbed film is hampered because spreading of film is difficult. In addition, when film is formed by adsorption, the amount of material required is fairly large. We have developed an easy spreading technique that allows routine formation of film by spreading of small amounts of surfactant components at the air-water interface of an air bubble in a CBS. The technique is reliable, precise, and accurate, and the biophysical activity of film formed by spreading is similar to that of film formed by adsorption. This method will be useful for mechanistic studies of surfactant components under dynamic conditions and for comparative studies of spread films and adsorbed films.

Plasmalogens effectively reduce the surface tension of surfactant-like phospholipid mixtures

The alkenyl-acyl subclass of phosphatidylethanolamine (PtdEtn) and phosphatidylcholine (plasmalogens) are minor components of alveolar surfactant. Plasmalogens promote and stabilize hexagonal structures of phospholipids. In another study (W.R. Perkins, R.B. Dause, R.A. Parente, S.R. Michey, K.C. Neuman, S.M. Gruner, T.F. Taraschi, and A.S. Janoff. Science 273: 330-332, 1996), it was shown that polymorphic phase behavior may have an important role in the effective functioning of pulmonary surfactant. Therefore, we hypothesized that surface properties of phospholipid mixtures that contain plasmalogens are superior to plasmalogen-free mixtures. The effect of plasmalogens on surface tension of surfactant-like phospholipid mixtures (70 mol% dipalmitoyl phosphatidylcholine, 10 mol% phosphatidylglycerol, and 20 mol% PtdEtn) was measured. Using the pulsating bubble surfactometer, we show that an increasing amount of ethanolamine plasmalogens [plasmenylethanolamine (PlsEtn) results in reduction of surface tension (0 mol% PlsEtn 44.7 +/- 1.7, 2 mol% 33.5 +/- 1.7, 4 mol% 36 +/- 3.1, 6 mol% 26.2 +/- 2.9, and 8 mol% 22.2 +/- 0.3 mN/m). By means of the captive bubble surfactometer, minimal surface tension reached with 8 mol% PlsEtn was even lower (3.8 +/- 0.7 mN/m). With regard to morphological studies (B. Fringes, K. Gorgas, and A. Reith. Eur. J. Cell Biol. 46: 136-143, 1988), clofibrate treatment of rats might increase the plasmalogen content of alveolar surfactant. However, in the present study, we could not show that synthesis and secretion of plasmalogens are affected by clofibrate treatment.

Surfactant replacement therapy in acute respiratory distress syndrome from viral pneumonia

A modified natural surfactant was administered to a patient with life-threatening adult respiratory distress syndrome caused by viral pneumonia. Subsequently, there was a marked improvement in gas exchange. In order to assess the mechanism for improved oxygenation, computed tomography of the lungs was done. Quantitative analysis of the scans taken before and after surfactant administration indicates that improvement in gas exchange was largely due to the expansion of underinflated and collapsed lung areas. Although this is a single case report, it provides insight into the possible beneficial effect of instilled surfactant in severe respiratory distress from viral pneumonia.

Surface activity of rabbit pulmonary surfactant subfractions at different concentrations in a captive bubble

This study investigates the surface activity of rabbit pulmonary surfactant subfractions at different concentrations in a new pressure-driven captive bubble surfactometer, which provides more rigorous testing conditions than heretofore applied to this material. Subfractions were separated by centrifugation of lavage return into a third (P3; 1,000 x average g, 20 min), a fourth (P4; 60,000 x average g, 60 min), and a fifth (P5; 100,000 x average g, 16 h) pellet. At 2.0 mg phospholipid/ml, P3 and P4 demonstrated more rapid adsorption, lower minimum surface tensions on first and subsequent compressions, and lower monolayer compressibilities than did P5. This surface activity of P3 and P4 increased with concentration between 0.1 and 2.0 mg phospholipid/ml. Adsorption rate constants were approximately 10,000 times faster than desorption constants. We conclude that, in a normal lung, components of P3 and P4 determine alveolar surface tension. We speculate that under special circumstances even the less surface active P5 could have an important influence at the air-water interface.

[The prone position in ARDS. A successful therapeutic strategy]

As early as 1974, Brian advocated the prone position for ventilated patients. He suggested that this position might enhance ventilation of the dorsal parts of the lungs, thereby improving oxygenation. These considerations have been confirmed by several experimental and clinical studies. Better secretion removal, decreased intrapulmonary shunting, and an increased FRC are thought to be responsible for the observed improvement of oxygenation. However, the prone position never became very popular in the clinical treatment of the adult respiratory distress syndrome (ARDS). Routine performance of thoracic CT scans in ARDS patients demonstrated preferential distribution of pathological densities in the dependent lung areas. The prone position therefore could possibly benefit these patients, as shown by two recent studies. The aim of our study was to evaluate the influence of repeatedly turning the patient to the prone position on gas exchange and thoracic CT findings in multiple-trauma patients. METHODS. Seven ventilated intensive care patients with severe ARDS (Murray Score > 2.5, Quotient > 0.7, mean airway pressure > 18 cm H2O, thoracic CT scan showing dorsal atelectases) were included in the study. Patients were turned from the supine to the prone position at 12-h intervals using an air-cushion bed (Mediscus, Austria). Redistribution of dystelectatic or atelectatic dependent lung areas was verified by means of repeated thoracic CT scans (Figs. 1, 8). RESULTS. The patients were intermittently turned for 6.5 +/- 1.1 days. The course of gas exchange is shown in Figs. 2 and 3. Initially, improvement of the respiratory quotient could only be achieved during prone positioning, from the 2nd day in the supine position as well. Intrapulmonary shunting showed a similar trend (Figs. 4 and 5). No significant changes in cardiovascular parameters could be observed. Control thoracic CT scans showed uniform reduction of atelectases in dependent lung areas (Figs. 1 and 8). The inspiratory fraction of oxygen could be reduced significantly as of the 2nd day (Fig. 7). Constant levels of positive end-expiratory pressure and tidal volume were associated with decreasing mean and plateau airway pressures (Fig. 6). DISCUSSION. Repeatedly turning the patient to the prone position produced long-lasting improvement of arterial oxygenation, which persists up to the end of the weaning process. This is in good accordance with other studies, however, this is the first study to report an observation period of more than 6 days of repeatedly turning the patient. These positive effects on gas exchange can be attributed to sudden improvement of the ventilation-perfusion ratio within the lung areas that become dependent after turning to the prone position. Due to reduced hydrostatic pressure and relative hyperventilation, previously collapsed alveoli are recruited in the lung areas that become non-dependent after turning to the prone position.

Comparison of captive and pulsating bubble surfactometers with use of lung surfactants

We compared surface tension measures of surfactants with various surface activities by using a pulsating bubble surfactometer (PBS) and a captive bubble surfactometer (CBS). Rabbit lung lavage surfactant (60,000 x average g for 60 min), bovine surfactant extract (Survanta), and a synthetic lipid surfactant mixture (dipalmitoylphosphatidylcholine-egg phosphatidylglycerol-palmitic acid) were studied at 1.25 mg phospholipid/ml. The PBS was used either unmodified according to manufacturer's instructions or with the sample chamber capillary kept dry and the sample adsorbing at maximum bubble size (5 min). The CBS was used in a manner that imitated the unmodified PBS. We found that all three techniques indicated low surface tension on the first cycle for 60K. For Survanta, the CBS and the modified PBS reported low surface tension on the first cycle, whereas the unmodified PBS did not achieve this within 10 cycles. For the synthetic lipid surfactant mixture, only the CBS measured low surface tension within 10 cycles. Video observations indicate that the modified PBS performs better than the unmodified PBS because keeping the capillary dry prevents surface film from occupying this large surface during cycling, thereby allowing larger area compressions.

Evaluation of pressure-driven captive bubble surfactometer

We modified the captive bubble surfactometer [S. Schürch et al. J. Appl. Physiol. 67: 2389-2396, 1989] to facilitate the measurement of surface adsorption rates and to simplify its construction. We used a range of standards and monolayers of dipalmitoylphosphatidylcholine to check the calibration of the device against measurements made in a Wilhelmy surface balance and in the captive bubble by using a cathetometer, and we found good agreement. As a further test we measured the surface properties of rabbit lavage lung surfactant (60,000 x average g for 60 min) at 1.0 mg phospholipid/ml. This material adsorbed within 1 s to near-equilibrium surface tension, reached surface tensions of < 5 mN/m on the second compression, and formed very stable films. We conclude that a captive bubble surfactometer can provide accurate information about important surface properties of lung surfactant films.

Tidal volume, breathing frequency, and oxygen consumption at different pressure support levels in the early stage of weaning in patients without chronic obstructive pulmonary disease

The objective of this study was to evaluate the influence of different PSV levels on VT, F, VO2 in the early weaning phase of patients without chronic obstructive pulmonary disease. These parameters were tested for the predictive power for the success of the weaning. Patients on SIMV were studied during the first weaning attempt with PSV. Depending on their ventilatory support demands after 24 h they were divided into responders (patients breathing on CPAP) and nonresponders (patients being on a more invasive ventilatory mode). 14 ICU patients without pre-existing pulmonary disease being ventilated for at least 3 days entered the study. 2 of them could be studied a second time after failing the first weaning attempt. Beside the level of ventilatory support no other changes (drugs, nutrition) were allowed. VO2, VT, F were measured by a computer controlled, metabolic unit connected to the expiratory port of a Siemens Servo Ventilator. In addition, airway pressures, arterial pressure and heart rate were recorded. The measurements were performed at PSV of 5, 10 and 20 cmH2O. Arterial blood-gases were drawn at the end of each 60 min lasting PS period. Responders and nonresponders could be separated by the response of VO2, VT and F to a change in PS 10 to PS 20 cmH2O. Patients who significantly increased VT and significantly decreased F did not fulfil our weaning criteria. Our responders did not show a significant change in these two parameters, but a significant increase in VO2 at PS 20 cmH2O could be observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[The course of extravascular lung water in severely injured patients in intensive care with and without thoracic trauma]

In patients with multiple injuries, the development of permeability edema can be assumed. However, no uniform shape of this fluid accumulation can be found even in the presence of severe injuries. Based on the first clinical observations, our aim was to search for correlations between the development of extravascular lung water (EVLW) and the individual injury pattern in severely traumatized ICU patients. PATIENTS and METHODS. Our investigations were performed in 48 artificially ventilated ICU patients. According to the prevailing injury pattern patients were divided into three groups: group A: 18 patients (mean age: 32 years, mean Injury Severity Score (ISS) = 29) with isolated thoracic trauma; group B: 10 patients (mean age: 27 years, mean ISS = 42) with severe multiple trauma but without any thoracic injury; group C: 20 patients (mean age: 33 years, mean ISS = 43) with severe multiple trauma and concomitant thoracic trauma. In all patients (group A, B, C), EVLW was determined by means of a double indicator method on a daily basis from the patient's admission to the ICU (day of trauma) until day 10. Additionally, the hemodynamic parameters (heart rate, mean arterial pressure, mean pulmonary arterial pressure, pulmonary capillary wedge pressure and cardiac index) were determined at the same time. RESULTS. As shown in Fig 1, EVLW was slightly elevated on day 1. However, on day 2 EVLW decreased within normal values and remained in that range until the end of the observation period. On day 3 a slight and fleeting increase of EVLW, but within normal range, can be seen. In group B (Fig.2), EVLW can be observed within normal range within a period of 4 days. Starting from day 5 until day 7 a marked increase (p greater than 0.01) in EVLW can be seen. From that maximum point EVLW development reverses slightly until day 10--however, without returning to the normal range. In group C, a marked biphasic pattern can be seen due to EVLW maximum values on post-traumatic days 3 and 7. However, in this group the EVLW was in the pathological range during the whole observation period. No statistically significant differences could be seen, when looking at hemodynamic variables. CONCLUSION. Isolated thoracic trauma will not lead to a marked pathological elevation of EVLW within the lungs. Moreover, EVLW decreases rapidly within a short time period. Based on our results, it seems that severe extrathoracic injuries will intensify microvascular injury in the initial period, as shown in our patients in group C. Increase of EVLW at a later time (day 7), as observed in groups B and C, is possibly the expression of a mediator and activator-induced "septiformal" injury of the microvascular endothelium. This may be caused by the underlying massive peripheral soft-tissue trauma. Specific elevations of EVLW subsequent to the individual injury pattern can indicate that that process has begun and is responsible for the origin of the microvascular injuries.

Gamma scintigraphic imaging of lung microvascular permeability in adult respiratory distress syndrome

The sequence of lung microvascular permeability (LMVP) changes in early direct posttraumatic and late indirect pancreatitis-induced adult respiratory distress syndrome (ARDS) was studied and compared with that of a control group, as well as non-ARDS ICU patients. A computerized large field of view gamma camera was used to measure LMVP simultaneously over both lungs by In 113m-labeled transferrin and Tc 99m-labeled erythrocytes. The LMVP index (LMVPI) (%/h) was used to quantify LMVP in the dynamic scintigraphic measurement. In the control group the LMVPI was 2.6 +/- 2.8%/h for the right and 2.0 +/- 2.8%/h for the left lung. Similar values were found in mechanically ventilated ICU patients without ARDS (group A) on admission (right LMVPI 3.2 +/- 2.6, left LMVPI 2.6 +/- 2.7%/h) and 4 days later (right LMVPI 3.9 +/- 2.6, left LMVPI 2.3 +/- 1.8%/h). Interestingly, the initial evaluation of patients with direct early posttraumatic ARDS (lung contusion) (group B) showed significantly (p less than .01) elevated LMVP for the contused side (LMVPI 10.8 +/- 5.1%/h), but normal values for the nontraumatized lung (LMVPI 3.9 +/- 3.4%/h), whereas 4 days later the LMVP increased significantly (p less than .05) on the primarily healthy side (LMVPI 8.0 +/- 5.0%/h) while remaining elevated for the traumatized lung (LMVPI 10.9 +/- 6.0%/h).(ABSTRACT TRUNCATED AT 250 WORDS)

High-frequency pulsation (HFP) in a patient with Guillain-Barré syndrome

A patient with Guillain-Barré syndrome (GBS) developed a respiratory crisis despite recurrent treatment with plasma exchange. Thus mechanical ventilatory support became necessary. As an alternative to conventional ventilatory techniques high-frequency pulsation (HFP), a modified high-frequency jet-ventilation technique was used. According to the observations HFP may be a valuable technique for the continuous adaptation to the patient's individual respiratory demands in GBS.

[Biphasic positive airway pressure (BIPAP)--a new form of augmented ventilation]

Two modes of combining spontaneous breathing and mechanical ventilation are already in use: periodic mechanical support always followed by a period of spontaneous breathing (intermittent mandatory ventilation; IMV) and mechanical support of each spontaneous breath (inspiratory assistance; IA). Biphasic positive airway pressure (BIPAP), in contrast, is based on neither of the above mentioned principles. It is rather a mixture of pressure controlled (PC) ventilation and spontaneous breathing, which is unrestricted in each phase of the respiratory cycle. The BIPAP circuit switches between a high (Phi) and a low (Plo) airway pressure level in an adjustable time sequence. At both pressure levels the patient can breathe spontaneously in a continuous positive airway pressure system (CPAP). The volume displacement caused by the difference between Phi and Plo and the BIPAP frequency (F) contribute the mechanical ventilation to total ventilation. Duration of the Phi and the Plo phases can be independently adjusted. Similar to the I:E ratio during controlled ventilation, the phase time ratio (PhTR) is calculated as the ratio between the durations of the two pressure phases. A PhTR greater than 1:1 is called IR-BIPAP. A BIPAP system can be set up either as a continuous flow system, or as a demand valve system. A continuous-flow BIPAP system consists of a high-flow CPAP system, a reservoir bag, and a pneumatically controlled membrane valve in the expiratory limb. A magnetic valve operated by an impulse generator switches between Phi and Plo, controlling the pop-off pressures of the expiratory valve.(ABSTRACT TRUNCATED AT 250 WORDS)

[The use of a transcutaneous pO2/pCO2 combination electrode during volume therapy in a child in shock]

We report a 1-year-old boy in hemorrhagic shock due to a large subgaleatic hematoma following severe head trauma (blood pressure (BP) 30/15 mmHg; heart rate (HR) 110; Hb 45 g/l; arterial pH 7.16; BE-20 mEq/l). The child was intubated and ventilated; initial FIO2 was 0.9. In an attempt to monitor the cardiovascular system noninvasively a transcutaneous oxygen/carbon dioxide combielectrode was placed on the chest. Initially we observed a large difference between arterial pO2 (paO2 = 166 mmHg) and transcutaneous pO2 (tcpO2 = 7 mmHg) and arterial pCO2 (paCO2 = 16 mmHg) and transcutaneous pCO2 (tcpCO2 = 55 mmHg), reflecting poor skin perfusion and severe tissue acidosis. Under aggressive volume replacement tcpO2 rose along with BP and tcpCO2 returned to near arterial values. Even after stabilization of gross hemodynamic parameters such as HR and BP and despite reductions in FIO2, tcpO2 continued to increase with further volume replacement, reflecting an existing volume deficit.

[The PEEP wave: an automated technic for bedside determination of the volume/pressure ratio in the lungs of ventilated patients]

The volume/pressure (V/P) ratio in the lungs has been reported to be useful in the adjustment of mechanical ventilation equipment to suit individual pulmonary mechanics. Most of the techniques used so far (e.g. the super-syringe technique) need an apneic period of approximately 60-120 s, in which the pulmonary gas volume is reduced by the continuing oxygen uptake. Thus, a bias of 200-400 ml in volume is superimposed on the record. In contrast to the super-syringe technique, a new automatic procedure has been developed for which no apneic period is needed. This technique is called the PEEP wave technique: it is based on the imbalance between inspiratory and expiratory volumes after a sudden change in PEEP. The software of a Dräger Evita respirator was adapted to allow automatic application of a special sequence of respiratory cycles with stepwise increase and decreases in PEEP between two preselectable borderline levels. The equipment is switched to the next PEEP level when the difference between two consecutive expiratory tidal volumes is less than 15 ml. After the highest level of PEEP is reached the procedure is reversed until PEEP returns to its initial value. Constant inspiratory tidal volumes (Vti) are achieved by a high pressure servo valve (HPSV) under conditions of chocked flow, resulting in inspiratory tidal volumes which are independent of back-pressure. Thus, only the difference in expiratory tidal volumes (Vte) before and after a PEEP change is necessary to determine gain and loss in lung volume (delta FRC).(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of high frequency ventilation at different end-expiratory lung volumes on the development of lung damage during lung lavage in rabbits

The effects of high frequency ventilation in combination with sustained inflations was studied in the surfactant-deficient lungs of 18 New Zealand White rabbits (weight 1.9-2.1 kg) during anaesthesia with urethane and neuromuscular block with pancuronium. Lung damage was induced by repeated lung lavage. In nine rabbits (group I) baseline ventilator settings were maintained constant throughout the study and airway pressure was readjusted to achieve a constant tidal volume. In the other nine rabbits (group II), ventilation was reinstituted after lung lavage with one period of four sustained inflations followed immediately by high frequency ventilation. In group I there was a significant decrease in gas exchange for oxygen and deterioration in pulmonary mechanics, whereas in group II there was little change in baseline blood-gas values or pulmonary mechanics. These data suggest that, with adequate ventilatory management during the period of lung lavage, the lung damage produced by this manoeuvre may be obviated.

[High frequency ventilation with a conventional respiratory following heart surgery interventions]

This study was designed to compare the effects of Continuous Positive-Pressure Ventilation (CPPV) and, by using the same unmodified conventional ventilator, High-Frequency Positive-Pressure Ventilation (HFPPVkonv). First, CPPV and HFPPVkonv were studied in a lung model with both normal (R = 5 mbar/1/second) and elevated (R = 20 mbar/1/second) resistance. Our results indicate that in HFPPVkonv the large compressible volume of the conventional ventilator did not influence lung model ventilation at normal resistance. The adjusted (300 ml) tidal volume (VT) and the measured volume of actual expiration (270 ml) were about the same (Fig. 1). However, with elevated resistance air trapping occurred. The large compressible volume influenced model ventilation during both CPPV and HFPPVkonv (Fig. 2). As a second step we evaluated the effects of HFPPVkonv on gas exchange, airway pressure, and hemodynamics in 12 patients (aged 43-69) postoperatively after elective cardiac surgery. After a period of stabilization at the intensive care unit every patient was first ventilated with CPPV. The ventilator settings were: VT = 10-12 ml/kg, inspiratory: expiratory ratio (I:E) = 1:2, frequency (F) = 12/min, V = 60 1/min, PEEP = 5 cm, FiO2 = 40%. After 20 min of CPPV baseline measurements were made (series I). Then the initial ventilator settings of CPPV were switched to HFPPVkonv, the conventional ventilator remaining unmodified. The settings were changed as follows: I:E = 1:3, F = 60/min, V = 120 1/min, PEEP = 5 cm, FiO2 = 40%. During 60 min of HFPPVkonv variables were measured first after 20 min (series II) and again after another 40 min (series III). Minute volume had to be doubled after changing from CPPV to HPFFVkonv to achieve eucapnia. As a result of the new ventilatory settings, VT and hold showed a significant decrease (P less than 0.01) (Table 2).(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of re-expansion edema ('unilateral ARDS") after rapid pneumothorax drainage]

A rare complication after delayed re-expansion of pneumothorax is reported. A polytraumatized patient with stable vital functions was admitted to our ICU immediately after surgery. Later, oxygenation worsened treated by a rise in FiO2. Concomitant tachycardia was thought to be due to increasing body temperature. On day 3 of treatment in the ICU further deterioration in gas exchange (and in hemodynamics, with complete collapse of the left lung) was diagnosed on X-ray examination. Retrospectively, the development of this condition could be traced on the X-ray films taken during the previous 3 days. Thoracic drainage and suction resulted in complete re-expansion of the lung. After re-expansion worsening of gas exchange and unilateral ARDS-like configurations were observed on chest X-ray. Reversal of the I:E ration and a rise in PEEP improved gas exchange and the X-ray appearance immediately. In the next few days the intensity of the respiratory treatment could be reduced, and after a short period of CPAP the patient was discharged from the ICU. Three mechanisms for development of this "unilateral ARDS" are discussed: loss and suppressed regeneration of surfactant in prolonged atelectic alveolar compartments; increased capillary fluid escape due to suction; and increased complement activation and reduced degradation of edematogenic bradykinin in hypoxic alveolar compartments. Possible clinical implications for the treatment of longer duration pneumothorax are: fractionated drainage and respirator settings, reopening collapsed alveoli in an inhomogeneously diseased lung such as IRV.

[How much reintegration can be achieved in patients after severe craniocerebral injury?]

152 patients, who had suffered head and brain injury during the years 1980 to 1982 were interviewed by letter using a standardized questionnaire to assess the individual outcome. There were questions concerning activities of daily life, invalidity, work activities, social relationships with family and other persons, leisure activity and the grade of persisting sequelae. There were 106 replies, 16 patients had died meanwhile. According to their neurological symptoms on admission at the intensive care unit the patients were divided into two groups. Group I included patient, who showed symptoms of midbrain syndrome stage 1 and 2, while group II presented patients had midbrain syndrome stage 3 and 4. Activities of daily life (feeding, dressing, toiletting and ability to get out of bed and move around the room) were restored in the great majority of patients. 15 patients of group II were classified as invalid. Significant changes in social relationships with the family were seen in 50% of the patients. Further, a decrease of contacts with friends, and a significant decrease in leisure activity (sport) was noted. 28.4% of the patients of group I and 36.8% of the patients of group II, who were at work before the trauma, now were out of work. The others generally worked below their previous level. Persisting sequelae included headache, lack of concentration and weakness of extremities. These symptoms were more prominent in the patients of group II; surprisingly little complaints concerned sexual life and somatic problems. It was found, that severe head and brain injury had significantly changed the patient's life in most cases. Work activities were strongly impaired in about 30% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)