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The use of fluoroalkoxy groups, such as trifluoromethoxy and 2,2,2-trifluoroethoxy groups, in pharmaceutical and agrochemical development has increased dramatically in recent years. However, hexafluoroisopropoxy groups have remained significantly under-represented, presumably due to limited synthetic methods for accessing this substituent in good yields. Herein, we report a mild, photochemical nucleophilic aromatic substitution (S N Ar) approach for the synthesis of hexafluoroisopropyl aryl ethers from unactivated and abundant aryl halides. Notably, aryl chloride and bromide functionality are efficiently engaged by this methodology in addition to the traditional aryl fluoride nucleofuge. This method provided access to a diverse array of hexafluoroisopropyl aryl ethers, including multiple examples of late-stage functionalization of active pharmaceutical ingredients. A simple flow system was adapted for 10x scale-up, maintaining good yield for the reaction. Initial mechanistic studies indicate single electron oxidation of the arene as a key step in product formation., (© 2024 Wiley-VCH GmbH.)

This work presents a method to determine the type of Lamb mode (antisymmetric or symmetric) that propagates through a lithium-ion pouch cell. To determine the type of mode and the group velocity at a specific frequency, two- and three-transducer setups were created. For these setups, it is important that all transducers have the same polarization direction. Two transducers are affixed to the center of the cell at a distance of several centimeters from each other so that the group velocity can be determined. Using cross-correlation, the group velocity of the emerging mode can be calculated. The measurement setup and the processing method was first validated with experiments on acrylic glass and aluminum plates. The measurements were supported with FEM simulations and a numerically calculated model. The output voltages of the receiving piezo-elements obtained in the FEM simulation are in agreement with the underlying theories. The phase shift, which results from the output voltage of the piezo-elements mounted one above the other on different sides of the plate, shows the type of mode. The results of the experimental determination of the Lamb mode that propagates through a lithium-ion pouch cell were validated with a numerically calculated multi-layer model and therefore validate this novel experimental approach.

High mortality rates of invasive fungal disease (IFD), especially invasive aspergillosis (IA), in immunocompromised haematological patients and current diagnostic limitations require improvement of detection of fungal pathogens by defining the optimal use of biomarkers and clinical samples. Concurrent bronchoalveolar lavage (BAL) and peripheral blood samples of 99 haematological patients with suspected IFD were investigated within a multicentre prospective study. Diagnostic performance of a galactomannan (GM) enzyme immune assay (EIA), a 1,3-β-D-glucan assay (BDG), an Aspergillus PCR, and a multifungal DNA-microarray (Chip) alone or in combination were calculated. IFD were classified as proven (n=3), probable (n=34), possible (n=33), and no IFD (n=29) according to EORTC/MSG criteria. GM, PCR, and Chip showed superior diagnostic performance in BAL than in blood, whereas specificity of BDG in BAL was poor (48% (14/29)). The combination of GM (BAL) with BDG (blood) showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and DOR (diagnostic odds ratio) of 92% (34/37), 93% (27/29), 94%, 90%, and 153.0, respectively. Combining GM (BAL) with PCR (BAL) showed convincing diagnostic potential for diagnosing IA with sensitivity, specificity, PPV, NPV, and DOR of 85% (17/20), 97% (28/29), 94%, 90%, and 158.7. Addition of the DNA-microarray resulted in further detection of two mucormycetes infections. In 1 out of 15 Aspergillus DNA-positive samples a triazole resistance-mediating Cyp51A mutation was found. Combination of biomarkers is superior to their sole use in diagnosing IFD, particularly IA. Integrating blood and BAL samples into a diagnostic algorithm is an advantageous approach., (Copyright © 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Genetic lesions are crucial for cancer initiation. Recently, whole genome sequencing, using next generation technology, was used as a systematic approach to identify mutations in genomes of various types of tumors including melanoma, lung and breast cancer, as well as acute myeloid leukemia (AML). Here, we identify tumor-specific somatic mutations by sequencing transcriptionally active genes. Mutations were detected by comparing the transcriptome sequence of an AML sample with the corresponding remission sample. Using this approach, we found five non-synonymous mutations specific to the tumor sample. They include a nonsense mutation affecting the RUNX1 gene, which is a known mutational target in AML, and a missense mutation in the putative tumor suppressor gene TLE4, which encodes a RUNX1 interacting protein. Another missense mutation was identified in SHKBP1, which acts downstream of FLT3, a receptor tyrosine kinase mutated in about 30% of AML cases. The frequency of mutations in TLE4 and SHKBP1 in 95 cytogenetically normal AML patients was 2%. Our study demonstrates that whole transcriptome sequencing leads to the rapid detection of recurring point mutations in the coding regions of genes relevant to malignant transformation.

This study evaluated the efficacy and safety of imatinib in chronic eosinophilic leukaemia (CEL, n = 23) and hypereosinophilic syndrome (HES, n = 13). In CEL with FIP1L1-PDGFRA (n = 16) or various PDGFRB fusion genes (n = 5), complete haematological remission (CHR) was achieved in 95% (20/21) after 3 months. Complete molecular remission (CMR) was seen in 75% (12/16) of cases with FIP1L1-PDGFRA positive CEL by 6 months, and in 87% (13/15) after 12 months. CMR was achieved in three of five PDGFRB fusion positive patients after 3, 9 and 18 months respectively. All patients are currently on imatinib (100 mg; n = 13, 400 mg; n = 8) and no molecular relapse has yet been observed (median 26.7 months; range, 6.9-39.9). Imatinib was less effective in HES and CEL without known molecular aberration (n = 15); CHR was observed in 40% (6/15) of patients, two patients relapsed after 4.8 and 24.5 months. Three patients died due to imatinib-resistant progressive CEL (n = 2) or myocardial infarction (n = 1) unrelated to study treatment. Overall, imatinib was well tolerated with a low incidence of grade III/IV toxicities. These data confirmed the long-term efficacy of imatinib for PDGFR-rearranged CEL patients, and also showed that a minority of HES cases without known molecular aberrations may benefit from imatinib.

Background: Immunoglobulin A antibodies (anti-IgA) are rare but can cause transfusion-associated anaphylaxis. The detection of anti-IgA has traditionally been performed using a labor-intensive hemagglutination assay in a limited number of reference laboratories., Study Design and Methods: Two simple gel card assays are now available that can be used to screen for anti-IgA and IgA deficiency. A total of 24 serum samples that had been previously assayed for anti-IgA over a 3-year period were used to assess the DiaMed anti-IgA and IgA deficiency assays., Results: The DiaMed assays correctly identified patients (n = 6) who had significant IgA deficiency and anti-IgA. All patients with an abnormal anti-IgA titer by hemagglutination assay and who were also IgA-deficient had anti-IgA detected using the DiaMed screening test. One patient, previously shown to have an IgA level of less than 0.067 g per L, failed to be detected as IgA-deficient in the DiaMed IgA deficiency test; however, anti-IgA were not present. Samples with slightly increased anti-IgA titers tended to have normal IgA levels., Conclusion: The DiaMed gel card screening assays are appropriate screening tools for the investigation of transfusion-related anaphylactic reactions and can be used in any routine blood bank laboratory.

Background: Small cell lung cancer (SCLC) results in death within 1-2 months if left untreated. Although therapeutic standards only comprise first- and second-line chemotherapy due to poor prognosis, a subset of patients may warrant a trial of further chemotherapy, as demonstrated in the following case., Case Report: We present a 52-year-old man with confirmed anaplastic SCLC who survived 10 years while receiving 9 lines of chemotherapy including high-dose chemotherapy. Thoracic radiation, afterloading and radionuclide therapy supplemented the therapeutic management. Remarkably, he had two very long remission periods following topotecan., Conclusion: This case indicates that frequently repeated chemotherapy beyond second-line treatment in a subset of patients with limited-disease SCLC may result in long-term survival, even without ever achieving a complete remission. Close surveillance of responsiveness and appropriate in-time cytostatic treatment is proposed in the management of patients with SCLC who remain in good performance., (Copyright 2008 S. Karger AG, Basel.)

Background: High-dose chemotherapy (HDT) with autologous stem cell transplantation (ASCT) plays an important role in the treatment of aggressive non-Hodgkin's lymphoma (NHL). We report on a retrospective analysis of all patients with diffuse large B-cell lymphoma who were consecutively treated with HDT followed by ASCT at the University Hospital of Bonn, Germany, between 1996 and 2004., Methods: A total of 25 patients were transplanted for biopsy-proven diffuse large B-cell lymphoma (DLBCL). Eight patients received up-front HDT as first-line therapy, four patients received HDT due to incomplete response to conventional induction chemotherapy, and six patients were treated for primary refractory disease. Seven patients had recurrent lymphoma., Results: A complete remission (CR) was achieved in 14 of 25 patients (56%). Estimated 3-year survival for patients treated with upfront HDT, chemosensitive patients with incomplete response to first line therapy, and patients with chemosensitive relapsed disease was 87.5%, 50.0% and 60.0%, respectively. In contrast, no patient with primary refractory disease or relapsed disease lacking chemosensitivity lived longer than 8 months. Chemosensitivity was the only significant prognostic factor for overall survival (OS) in multivariate analysis., Conclusions: Our results confirm that HDT and ASCT is a highly effective therapy in patients with DLBCL leading to long-term survival in a substantial proportion of patients. Patients treated upfront for high-risk disease, incomplete response to conventional first-line therapy, or for chemosensitive relapse have a good prognosis. In contrast, patients with primary chemorefractory disease and patients with relapsed disease lacking chemosensitivity do not benefit from HDT with ASCT.

The FIP1L1-PDGFRA fusion gene is a recurrent molecular lesion in eosinophilia-associated myeloproliferative disorders, predicting a favorable response to imatinib mesylate. To investigate its prevalence, 376 patients with persistent unexplained hypereosinophilia were screened by the United Kingdom reference laboratory, revealing 40 positive cases (11%). To determine response kinetics following imatinib, real-time quantitative-polymerase chain reaction (RQ-PCR) assays were developed and evaluated in samples accrued from across the European LeukemiaNet. The FIP1L1-PDGFRA fusion transcript was detected at a sensitivity of 1 in 10(5) in serial dilution of the EOL-1 cell line. Normalized FIP1L1-PDGFRA transcript levels in patient samples prior to imatinib varied by almost 3 logs. Serial monitoring was undertaken in patients with a high level of FIP1L1-PDGFRA expression prior to initiation of imatinib (100 mg/d-400 mg/d). Overall, 11 of 11 evaluable patients achieved at least a 3-log reduction in FIP1L1-PDGFRA fusion transcripts relative to the pretreatment level within 12 months, with achievement of molecular remission in 9 of 11 (assay sensitivities 1 in 10(3)-10(5)). In 2 patients, withdrawal of imatinib was followed by a rapid rise in FIP1L1-PDGFRA transcript levels. Overall, these data are consistent with the exquisite sensitivity of the FIP1L1-PDGFRalpha fusion to imatinib, as compared with BCR-ABL, and underline the importance of RQ-PCR monitoring to guide management using molecularly targeted therapies.

The FIP1L1-PDGFRA fusion gene has been described in patients with eosinophilia-associated myeloproliferative disorders (Eos-MPD). Here, we report on seven FIP1L1-PDGFRA-positive patients who presented with acute myeloid leukemia (AML, n=5) or lymphoblastic T-cell non-Hodgkin-lymphoma (n=2) in conjunction with AML or Eos-MPD. All patients were male, the median age was 58 years (range, 40-66). AML patients were negative for common mutations of FLT3, NRAS, NPM1, KIT, MLL and JAK2; one patient revealed a splice mutation of RUNX1 exon 7. Patients were treated with imatinib (100 mg, n=5; 400 mg, n=2) either as monotherapy (n=2), as maintenance treatment after intensive chemotherapy (n=3) or in overt relapse 43 and 72 months, respectively, after primary diagnosis and treatment of FIP1L1-PDGFRA-positive disease (n=2). All patients are alive, disease-free and in complete hematologic and complete molecular remission after a median time of 20 months (range, 9-36) on imatinib. The median time to achievement of complete molecular remission was 6 months (range, 1-14). We conclude that all eosinophilia-associated hematological malignancies should be screened for the presence of the FIP1L1-PDGFRA fusion gene as they are excellent candidates for treatment with tyrosine kinase inhibitors even if they present with an aggressive phenotype such as AML.

Technical development work is presented, where the VUV photochemically induced oxidative degradation is used: (i) for analytic purposes, and (ii) for small to medium scale (< 10 m2/d) waste water treatment processes or ultrapure water production. In the first case, small Xe-excimer radiation sources with an integrated reaction space designed for optimal conditions, as far as incident photon flux density, turbulence and concentration of dissolved molecular oxygen are concerned, have been built and tested. Under conditions of exhaustive oxidation and/or mineralization of pollutants in a continuous regime, they may be used for sample pre-treatment modules prior TOC, TOX and electrochemical trace metal analysis. Under conditions of partial oxidation or mineralization, the same lamp/reactor combination may be used for functionalization purposes prior to e.g. GC or HPLC analyses. In the second case, mass transfer limitations between the non-irradiated bulk volume and the irradiated volume are overcome by the electrochemical generation of molecular oxygen within or close to the irradiated volume and by the design of the photochemical part of the reactor.

Background and Objectives: Athletes may illegally enhance endurance performance by transfusing homologous red blood cells (RBCs) and thereby increasing the oxygen carrying capacity of their blood. Detecting this dangerous practice is difficult by currently used methods. The aim of this work was to develop tests capable of detecting a mixed red cell population by flow cytometry, utilizing the likelihood of differences in minor blood group antigens., Design and Methods: Twelve antisera directed against blood group antigens, derived from donor plasma, were used in conjunction with a secondary antibody directly conjugated with fluorescein to label IgG-coated RBCs. Optimal concentrations of RBCs and antibodies were determined on panel cells used in blood banking for the identification of specific antibodies. Blood samples from 25 patients purportedly transfused with 1-3 units of RBCs were screened for evidence of transfusion, and the percentages of antigen-positive and antigen-negative red cells were automatically calculated by the software installed in the flow cytometer after setting gates around these populations on histograms of fluorescence., Results: Mixed RBC populations were identified in 22 of 25 patients tested. The three patients with antigenically homogeneous populations of RBCs were subsequently found not to have received their scheduled transfusions., Interpretation and Conclusions: This technique can detect small (<5%) populations of cells that are antigenically distinct from an individual's own RBCs. These results show the potential for flow cytometry to identify illicit homologous blood transfusion in athletes, and suggest the risk of false positives may be low.

Biallelic mutations in BRCA2/FANCD1 were recently recognized as a rare cause of Fanconi anemia (FA). Using immunodetection with an antiserum directed against the carboxyterminus of the BRCA2 protein, we screened 38 lymphoid cell lines from FA patients whom we could not previously assign, via retroviral complementation analysis, to any of six known FA complementation groups (FA-A, -C, -D2, -E, -F, or -G). Three of these 38 cell lines lacked the 380-kDa BRCA2 signal on immunoblots. DNA sequencing showed biallelic compound and truncating mutations in two of the immuno-negative cell lines, whereas a monoallelic frameshift mutation and an amino acid substitution were detected in the third cell line. Our data show that less than 10% of unassigned FA cell lines harbor truncating mutations in BRCA2/FANCD1. This finding strongly suggests the existence of (an) additional, as yet unknown FA gene(s)., (Copyright 2003 S. Karger AG, Basel)

Background and Objectives: Identification of fetal DNA in maternal plasma may allow genetic analysis without the use of invasive techniques. The aim of this study was to extract DNA from maternal plasma, identify fetal material through the presence of SRY or RHD gene sequences and assess the reliability of these results., Materials and Methods: A polymerase chain reaction (PCR) method of a commercial kit was used with primers for SRY or exon 10 of the RHD gene sequence., Results: Multiple plasma samples were collected from 60 women who were evaluable for either SRY or RHD, or both, fetally derived DNA sequences. Fetal DNA was present in the plasma throughout the pregnancies and for some hours or days after delivery., Conclusion: Fetal DNA can be reliably detected in maternal plasma from early in pregnancy and normally is cleared within days of delivery.

Background and Objectives: The Kleihauer slide test is in general use to screen obstetric patients for possible fetomaternal haemorrhage. Since 1993, Rh(D)-negative patients have been tested in our laboratory by a flow-cytometric method detecting Rh(D)-positive fetal cells, a method which offers improved sensitivity and accuracy. We report another flow-cytometric method of broader application which quantitates cells according to haemoglobin F (HbF) content., Materials and Methods: The red cells are fixed with glutaraldehyde and permeabilized by exposure to Triton X-100. A polyclonal sheep antibody to HbF is incubated with the cells followed by a fluorescein-labelled anti-sheep antibody., Results: Quantitation of the percentage of fetal cells following a FMH can be achieved irrespective of the blood groups of either mother or infant, and the presence of maternal F cells need not interfere since the intensity of staining is usually less than that of fetal cells. Two of 19 transfusion-dependent patients with beta-thalassaemia have been found to have red cells indistinguishable from fetal cells on the basis of HbF content, but these patients also have been found to give positive results by the Kleihauer test., Conclusions: The flow-cytometric method may serve to replace the traditional Kleihauer test since it appears to offer improved accuracy and objectivity.

Pregnant women who attended antenatal clinics at King George V Hospital, the Birth Centre or were referred by obstetricians from February 19 July, 1996 were screened for the platelet antigen HPA-1a by flow cytometry. Forty out of 2,300 (1.7%) were found to be negative for this antigen. Of the 28 women followed throughout their pregnancy, none developed antibody to HPA-1a. Platelet counts performed on samples from 17 babies born to 17 of these mothers were all normal. This study proves the simplicity and rapidity of flow cytometry for platelet antigen screening. The results were comparable with the Solid Phase Red Cell Adherence (SPRCA) method and with PCR. The lack of a plentiful supply of specific antibody and the rarity of fetomaternal alloimmune thrombocytopenia (FMAIT) argue against the introduction of routine screening for maternal HPA-1a status at the present time.

Methods are described for the identification and quantitation of mixed red cell populations using flow cytometry. Antibodies specific for a wide range of blood group antigens have been used and examples are given in which these analyses have proved to be of clinical use. These examples include monitoring of erythropoiesis following engraftment in allogeneic bone marrow transplant recipients and the detection of chimaeric states months or years after transplantation. The techniques involved are fast, simple and inexpensive.

We report a patient who, following an allogeneic bone marrow transplant for multiple myeloma, recovered autologous erythropoiesis which was rapidly followed by relapse of her multiple myeloma. We postulate that the loss of the graft (as demonstrated by loss of donor erythropoiesis) and subsequent relapse of the multiple myeloma may be support for the existence of a graft-versus-myeloma effect.

The loss of B antigenicity from the red blood cells of a patient with acute myeloid leukemia is reported. The patient had normal B transferase levels, but had reduced levels of H transferase. Flow cytometry was used to quantify the loss of B antigenicity and monitor the expression of the B antigen throughout the progression of the disease.

Rh(D)- and K-negative women who have become severely isoimmunized by pregnancy are at risk of fetal loss or damage in subsequent pregnancies. A flow cytometric method is described whereby the presence of Rh(D) or K antigen on fetal erythrocytes may be determined using chorion villus samples taken during the first trimester. This method has the advantage of speed and sensitivity with results being available within 2 h. Decisions as to management of the pregnancy or termination may thus be made with minimal delay.

A sensitive test for the presence of D-positive fetal red blood cells (RBCs) in the maternal circulation of D-negative women has been developed. It was used to investigate the possibility that the occasional failure in preventing alloimmunization might be due to the administration of inadequate amounts of prophylactic anti-D Rh immune globulin. The standard dose in Australia contains 125 microg of antibody, and can suppress immunization by an estimated 6 mL of packed D-positive RBCs. A fetomaternal hemorrhage (FMH) of this volume is detectable in the maternal circulation as approximately 0.25 percent of the total RBCs. Our test utilizes a commercially available human monoclonal IgG anti-D that has been biotinylated and used with a dye-conjugated streptavidin. Flow cytometry is used to quantitate fluorescing D-positive RBCs. To date, 2,288 tests have been performed on blood samples from D-negative women attending local antenatal clinics or at the time of delivery. Evidence for an FMH has been obtained in six cases (0.26%). In one case, the FMH was only 0.1 percent, and in another (confirmed by the Kleihauer-Betke method), fetal cells constituted only 0.2 percent. Additional Rh immune globulin was not given to these patients. In the other four cases, the D-positive fetal cells were estimated to be 0.7,0.5,0.5, and 0.4 percent, and additional prophylactic Rh immune globulin was administered. Although the prevalence of FMH is low, screening D- negative women at risk of alloimmunization has proved to be simple, fast, and inexpensive.

The relatively short lifetime of rare-gas discharge pump light sources for high-power cw solid-state lasers is caused mainly by vaporized cathode emitter material reacting with the thermally highly loaded quartz wall. The introduction of new bipolar electrodes without special emitter materials mounted on hot-ended molybdenum-cup seals, together with 60-kHz ac operation, makes possible the application of a tungsten halide cleaning cycle within the lamp bulb. This new type of high-power rare-gas pump light source exhibits 20% better radiation efficiency, 20% lower Nd:YAG laser threshold, and considerably extended lifetime.

Plasma diagnostics results of electron densities and gas temperatures in commercial low-pressure deuterium lamps at current densities from 38 A/cm(-2) to 306 A/cm(-2) are presented. These plasma parameters are obtained by comparing measured and calculated Balmer line profiles, taking into account Stark broadening, Doppler broadening, and the influence of fine structure and the apparatus profile. Results for the plasma spot show a steady increase of electron density from 1.6 x 10(13) cm(-3) to 5.0 x 10(13) cm(-3) and of gas temperature from 1800 to 6800 K.

An approach to generating 'intelligent alarms' is presented that aggregates many information items, i.e. measured vital signs, recent medications, etc., into state variables that more directly reflect the patient's physiological state. Based on these state variables the described decision support system AES-2 also provides therapy recommendations. The assessment of the state variables and the generation of therapeutic advice follow a knowledge-based approach. Aspects of uncertainty, e.g. a gradual transition between 'normal' and 'below normal', are considered applying a fuzzy set approach. Special emphasis is laid on the ergonomic design of the user interface, which is based on color graphics and finger touch input on the screen. Certain simulation techniques considerably support the design process of AES-2 as is demonstrated with a typical example from cardioanesthesia.

Over a period of 6 months all inquiries related to environmental issues and environmental human health problems were recorded by the city administration (city phone, n = 71), the public health office (n = 123) and by pharmacies (n = 94). There was an institutional difference in the spectrum of the questions. Waste problems predominated at the city phone, questions related to nutrition at the pharmacies. More questions were raised by women, questioners were younger than the average population. The questions were based on own experience and on media reports to about the same extent. A relation to health complaints was presumed in 30% of the city phone calls, to about 50% at the pharmacies. Quality of the consultation was assessed by the advisors themselves.

Percutaneous endoscopic approaches to cholelithiasis are an alternative to extracorporeal shockwave lithotripsy which offer advantages of fewer restrictions on stone size and type as well as avoidance of fragmented stone passage complications. Endoscopic techniques would be facilitated by methods of welding gallbladder tissues. The technical constraints imposed by the endoscopic approach favor nonsuture methods of fusing gallbladder tissues. To evaluate a laser method for fusing biliary tissue, we have compared the healing response of laser-welded versus polyglycolic acid suture-closed incisions in canine gallbladder tissue in vivo. The laser used was a thulium-holmium-chromium:YAG laser producing 200-microsecond, 300-millijoule pulses at 2.15 microns. Serial sacrifice of dogs that underwent laser or suture closure of incisions made in the fundus of the gallbladder revealed that all repairs healed without evidence of leakage or infection. Laser-welded cholecystotomy sites had complete fibrous healing of the wound by two weeks postoperatively and reepithelialization by three weeks after operation. Suture-closed wounds were still without complete epithelization four weeks after the procedure. Laser welding may be a useful technique in endoscopic biliary surgery.

The knowledge base system ELDAR (ELectrolyte DAta Regensburg), consisting of data base, method base, rule base, and communication manager, classifies the knowledge of electrolyte solutions into factual, algorithmic, and rule knowledge. In this paper information is given on the factual knowledge of ELDAR and the mapping of facts in Codd's relational data model with an extension of its "1st Normal Form" to repeating attributes. ELDAR offers equal user interfaces for all factual knowledge services, such as literature, data, thesaurus, module, parameter, basic data, and rule retrieval.

The combination and aggregation of separate information sources to generate more ;intelligent' alarms using a knowledge-based approach is described. The approach gas developed as part of the knowledge-based anesthesia decision support system, AES-2, which monitors the patient's physiological state during anesthesia and eventually suggests therapeutic actions. Integration of the alarm system into a conventional information system is discussed. The state variable model used and the modeling of uncertainty are examined. The tools that support knowledge acquisition, design of knowledge-base prototypes. and test of the knowledge base of the AES-2 are described. A simulation example is given.

Knowledge-based decision support systems for use in cardio-anesthesia can provide online support to the anesthesiologist by generating intelligent alarms. However, the acquisition and validation of a consistent knowledge base for this application bears problems related to the transfer of clinical experiences into a rule system. An interactive simulator of the human circulation is presented that supports the process of knowledge acquisition and testing. The simulator can be controlled in realtime by an anesthesiologist during the simulation run thus providing a basis for interdisciplinary discussion of routine as well as critical situations. The output data can be transferred to a knowledge-based system for test purposes. The simulator is currently being used for the development of the Anesthesia Expert Assist System AES-2. With regard to the special application a model of the heart-function was integrated which enables the simulation of heart insufficiency. Simulation runs under various conditions are presented and discussed. The simulator was implemented on an ATARI ST personal computer.

Laser tissue fusion results from the conversion of light to thermal energy, creating tissue heating and protein denaturation. Accurately controlled tissue heating from smaller, less expensive, non-laser sources should be able to duplicate the fusion or welding of tissues, which has been demonstrated with a variety of lasers. We examined the capability of high-frequency electrical diathermy to create effective tissue fusion with limited collateral thermal damage. Using an electrical diathermy device with up to 14 W output power at 13.56 MHz, the cystic ducts of freshly harvested canine gallbladders were fused shut. Immediately after closure of the cystic ducts, bursting pressure was determined. Welding time was approximately 60 s. Mean bursting strengths immediately after closure were 207 mm Hg (+/- 94.3) in air (n = 10) and 202 mm Hg (+/- 44.7) under water immersion (n = 9). Histologic sectioning revealed a full-thickness denaturation of collagen fibers with fusion. Our preliminary investigations suggest that high-frequency electrical diathermy may provide practical advantages for fusion of biliary tissues when compared with conventional suture closure and laser fusion.

Percutaneous endoscopic approaches to cholelithiasis would be facilitated by methods for welding gallbladder tissues. We evaluated the bursting pressure and histologic appearance of canine gallbladder tissue welded with a thulium-holmium-chromium:YAG (THC:YAG) laser producing a 2.15 microns pulsed output. The tissue absorption characteristics at this wavelength as well as the pulsed nature of the output permit tissue welding with limited collateral thermal damage. The THC:YAG is compatible with a flexible fiberoptic delivery system. Bursting strengths of the welded junctions averaged 42 mm Hg, which is above physiologically encountered pressures. Histologic sections of the bonded tissues revealed tissue fusion and limited thermal injury to the surrounding tissue. We feel that THC:YAG laser welding may be a useful technique in the clinical development of percutaneous endoscopic biliary surgery.

Laser welding offers several potential advantages over suture closure, including improved healing, lack of a nidus for stone formation, and greater speed and ease. We examined in vitro gallbladder cystic duct welds created by two different systems, the thulmium-holmium-chromium (THC):YAG (2,150 nm) and argon ion (488-514 nm) lasers, in an effort to define suitable parameters for tissue fusion. Mean bursting pressures for argon welds were 95 mm Hg at 1.5 W CW and 26 mm Hg at 1.5 W, 50 msec chopped delivery. For the THC:YAG laser, the mean bursting pressure for welds created with 300 mJ pulses was 45 mm Hg. Full-thickness tissue fusion and limited collateral thermal damage were observed histologically for both the CW argon and pulsed THC:YAG welds. Examination of the suggested mechanisms of tissue fusion for these photothermal lasers suggests that increased duration of tissue heating at the appropriate temperature results in more extensive collagen crosslinking and a stronger weld.