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Zur Therapie des steroidrefraktaren Schubes bei Multipler Sklerose (MS) ist der Plasmaaustausch (PA) eine leitliniengerechte Option. Die selektive Immunadsorption (IA) ersetzt zunehmend den PA bei der Behandlung von autoimmunvermittelten neurologischen Erkrankungen. Zur IA bei MS gibt es nur wenige Daten. Ziel dieser Untersuchung war, die Effektivitat und Sicherheit der IA als Eskalationstherapie bei MS-Patienten zu untersuchen. Insgesamt 14 Patienten mit steroidrefraktarem MS-Schub wurden retrospektiv analysiert. Die Patienten erhielten je 6 IA unter Verwendung des nichtregenerierbaren Tryptophan-Immunadsorbers. Das behandelte Plasmavolumen betrug 2 l/IA. Zielkriterium war die Besserung der Schubsymptomatik. Zur Bestimmung des MS-bedingten Behinderungsgrades wurden die Kurtzke-Skala, EDSS (Expanded Disability Status Scale) und FS (Functional System Score) verwendet; bei Patienten mit Optikusneuritis wurde zusatzlich der Visus bestimmt. Bei 12 von 14 Patienten verbesserte sich das Hauptsymptom des MS-Schubes nach IA klinisch relevant, kein Patient verschlechterte sich. Dies entspricht einer Ansprechrate von 86%. Zur Wirksamkeitsbeurteilung wurde bei Patienten mit Optikusneuritis (n=8) der Visus herangezogen, bei Patienten mit spastischen Paresen (n=4) und Patienten mit einer Schwindelsymptomatik (n=2) wurden der EDSS und das FS vor und nach der IA Serie verglichen. Sowohl im EDSS als auch im FS und Visus kam es im Mittel zu einer signifikanten Verbesserung nach IA (p≤0,05). Die IA war sicher durchfuhrbar und hatte eine gute Vertraglichkeit ohne schwerwiegende Nebenwirkungen. Die Immunadsorption erwies sich zur Behandlung von steroidrefraktaren MS-Schuben als sicher und effektiv. Die Ansprechrate war den bisherigen Ergebnissen zum PA vergleichbar. Die IA stellt eine selektive, schonende Alternative zum PA dar. Die mit der Substitution von Fremdeiweisen verbundenen Risiken und Unvertraglichkeiten entfallen.

The effect of severe burns on the expression of the glucocorticoid-inducible RM 3/1 and HLA-DR antigens in blood monocytes was studied in patients with less than or more than 50% total body surface area (TBSA) burned. All patients showed a strong increase in the portion of RM 3/1+ monocytes within 1 day after injury. In patients with more than 50% TBSA, RM 3/1 cells decreased after 2 days; in those with less than 50% TBSA, cells decreased after 3 days. HLA-DR + monocytes decreased within 4 days in both groups. In patients with less than 50% TBSA, HLA-DR + monocytes slowly increased thereafter to basic levels. In patients with more than 50% TBSA, HLA-DR + monocytes further decreased, then slowly increased, however, did not reach basic levels. This long-lasting decrease was evidenced in the nonsurvivors. These results show that severe burns differently affect monocyte antigens. The induction of the anti-inflammatory subtype RM 3/1 and the decrease of the immunoregulatory HLA-DR antigens may contribute to the immunosuppression observed after burn injury.

In many cases the complexities of skin-flap microcirculation are difficult to assess despite all the subjective and objective examination techniques available today. Adequate microcirculation is essential for tissue viability, so any method employed for studying microcirculation should provide as accurate an assessment of the prevailing conditions as possible. Of all the clinical methods, the fluorescence technique using the dye sodium fluorescein has so far provided the most reliable results. However, the pharmacokinetic properties of this tracer have prevented the technique from becoming established in clinical practice. The fluorescent dye indocyanine green (Cardio Green), on the other hand, has far more favorable pharmacokinetics. In an experimental animal model, the fluorescence technique using indocyanine green (indocyanine green angiography, ICGA) was used to study postoperative changes in the microcirculation of a skin flap. On the day of operation, indocyanine green angiography revealed a state of hemodynamic imbalance for which the organism was able to compensate in the postoperative phase with the aid of humoral, physical, and metabolic factors. With indocyanine green angiography it was possible to quantify objectively the new hemodynamic equilibrium. Basically, microcirculation may be quantified in temporal and spatial terms. The significant objectivity of indocyanine green angiography and short intervals between each examination favor its possible and meaningful use in clinical practice and give cause for continuing studies.

In this tutorial paper we present some recent developments in parametric semi-infinite programming. We mainly focus our attention to two problems: The determination of one-sided derivatives of the value-function with a special application to the problem of finding zeros of that function and, secondly, the problem of following a path of solutions. For the latter, a continuation method is presented which can be shown to be applicable to an open and dense class of problems

The in vitro cultivation of keratinocytes and their application in the form of confluent sheets to cover various kinds of skin defects involves a number of problematical steps which could be improved by using single cell suspensions instead. Therefore we developed a method to apply keratinocytes suspensid as single cells in a fibrin gel. By testing the feasibility of this method in different experimental animal models we found that it facilitates cultivation as well as application of the cells, moreover, this method allows a much more flexible use of the cells, i.e. it is easier to consider the clinical condition of the patient than by the conventional method.

Instrumental monitoring is being increasingly employed in the postoperative phase after microsurgery. For this purpose, laser Doppler flowmetry has proven to be very useful. Monitoring of the perfusion of tissue with blood is mainly by clinical examination, which, however, requires the physical presence of the observer, and this is generally not possible on a continuous basis. By connecting up a laser Doppler unit with a computer and telephone modem and making use of the in-house radio system, it proved possible to produce an automatic emergency call system that responds to a worsening of perfusion and alerts the responsible doctor. For this purpose, the software program "call-doc" was developed, which provides the necessary monitoring and control functions. A general perfusion-independent emergency call can also be triggered at the touch of a button.

Starting from a number of motivating and abundant applications in §2, including control of robots, eigenvalue computations, mechanical stress of materials, and statistical design, the authors describe a class of optimization problems which are referred to as semi-infinite, because their constraints bound functions of a finite number of variables on a whole region. In §§3–5, first- and second-order optimality conditions are derived for general nonlinear problems as well as a procedure for reducing the problem locally to one with only finitely many constraints. Another main effort for achieving simplification is through duality in §6. There, algebraic properties of finite linear programming are brought to bear on duality theory in semi-infinite programming. Section 7 treats numerical methods based on either discretization or local reduction with the emphasis on the design of superlinearly convergent (SQP-type) methods. Taking this differentiable point of view, this paper can be considered to be complementar...

Treatment of soft tissue defects in the heel often causes problems because of the anatomical structures of the foot and the foot's function in bearing the entire weight of the body. Various types of flap surgery have been tried, to deal with these problem areas. As ever, all the skin flaps lacked the normal quality of the plantar skin, which has fibrous septa with reduced flexibility. In view of the quality of the skin and subcutaneous tissue and the quality of the nerve supply, the technique of neurovascular island flaps for the plantaris medialis was used over the last 4 years in 14 patients, to conceal small to medium-sized heel defects. In this report, we examine anatomy, indication, technique, and results with regard to plantaris medialis island flaps. Their use is discussed in comparison with other types of flaps already used in this region.

Disturbances of cochlear microcirculation are among the most discussed causes of sudden sensorineural hearing loss. Increased levels of cholesterol and fibrinogen seem to act as risk factors for inner ear disorders. Fibrinogen/LDL apheresis greatly reduces the concentration of plasma fibrinogen thus leading to improved cochlear blood flow. In a retrospective case series remission rates of 152 patients suffering from sudden sensorineural hearing loss and resistant to former treatment were investigated after treatment with a single apheresis. Complete remission was reported in 11% of patients, partial remission in 43%. 37% had no change of hearing threshold and 2% reported a decrease in hearing. Rates of complete remissions decreased from 22% within the first 2 weeks after onset of hearing loss to 14% after 6 weeks. In the same period of time rates of partial remissions decreased from 33% to 13%. The present study shows that apheresis achieved complete or partial remission in 54% of patients even after unsuccessful treatment with another therapy and the therapeutic window lies by approximately 6 weeks.

In [R. Hettich and P. Zencke, Teubner Studienbucher Mathematik, Leipzig, Stuttgart, 1982] and [G. Speich, Ph.D. thesis, University of Bonn, Bonn, 1981] a Newton-type differential correction algorithm for general rational Chebyshev approximation has been introduced that has been shown to be globally convergent and superlinearly convergent under assumptions weaker than the common condition of unique solutions. Using recent results on parametric semi-infinite programming [Math. Programming, 38 (1987), pp. 323–340], it can be shown that all essential assumptions can be dropped without destroying superlinear convergence. Moreover, additional constraints on the problem, such as restrictions on the range, can be treated without destroying the favorable properties of the algorithm.

Coagulase-negative staphylococci have gained increasing importance in burns, whereas interest is no longer focussed on Pseudomonas bacteria. By means of microbiological analysis of swabs taken from patients, environment and staff, we trailed the routes of infection in an intensive-care unit for burns. Analysis of patients: In 27 out of 11 patients the same biotype of Staphylococcus epidermidis could be identified; 22 of these occurred in swabs from wounds. The phagotypification of Staphylococcus aureus showed the same phagotype in 28 out of 41 swabs taken from infected wounds of 10 patients. The pathogen mostly caused the destruction of already healed grafts in a later phase of the treatment. Further microbiological analysis showed a severe infestation of the patients by enterococci. Analysis of environment: Here, greatly increased counts of coagulase-negative staphylococci of the same lysotype as in the patients could be demonstrated. Analysis of staff: The naso-pharyngeal area is of minor importance in the spreading of germs, whereas that of protective clothing and especially the hands should be considered to be more crucial. Regular environmental tests enable rapid detection of hygienic errors so that appropriate countermeasures can be taken.

In experiments on mice we were able to show that the negative effects attributed to burn toxins could almost completely be prevented by one single early treatment of the burned skin with a 0.04 M solution of cerium nitrate [Ce(NO3)3]. The survival rate was 10% for animals which were grafted with burned skin. Treatment with Ce(NO3)3 increased the survival rate to 74%. A reflection of this protective effect was the prevention of the burn-induced disturbance of the acceptor control ratio in isolated liver cell mitochondria. Repeated use of Ce(NO3)3 showed adverse effects due to an increased absorption. An effective treatment of burns with Ce(NO3)3 is without problems and can be done in any hospital.

For convex quadratic semi-infinite programming problems aFortran-package is described. A first coarse grid is successively refined in such a way that the solution on the foregoing grids can be used on the one hand as starting points for the subsequent grids and on the other hand to considerably reduce the number of constraints which have to be considered in the subsequent problems. This enables an efficient treatment of large problems with moderate storage requirements. Powell's (1983) numerically stable convex quadratic programming implementation is used to solve the QP-subproblems.

In this paper we consider the use of the scaling algorithm for LP for generating good starting vertices for the simplex method. To this end the original scaling algorithm has been modified on several points. For instance to enable the identification of a vertex variables which tend to zero are eliminated. Besides a vertex the algorithm also gives a LU-decomposition of s corresponding basismatrix. The numerical results obtained so far are encouraging, often the generated vertex is already the optimal one.

It is shown that the problem of approximating the eigenvalues and eigenfunctions of a homogeneous membrane as well as that of approximating (in the sense of Chebyshev) a function by generalized rational functions can be treated as semi-infinite programming problems depending on a real parameter.

Three ways to find approximate solutions of semi-infinite programming problems are considered: by discretization, exchange algorithms, and methods we call continuous because they make no use of discretization in the usual sense. Examples as well as theoretical considerations indicate that in general the first two ways only are useful in getting low accuracy approximations to a solution which preferably should be improved by a method of the third type.

It is possible to link a Laser-Doppler to a DOS-compatible personal computer in order to monitor microcirculation of the free flap after plastic surgery. We connected such a system to a second computer by telephone modems, in order to control the Laser-Doppler via the telephone line from a distant location using only commercially available hardware and software. The aim was to develop a low-cost system which would not require the purchase or construction of any specialised equipment. Using this system, it was possible to show the Laser-Doppler waveforms to colleagues who were not at the patient site, for their (more experienced) opinions without any further delays. Preliminary tests on five cases showed that it was indeed possible to transfer recorded information about the blood flow rate of free skin flaps from one computer to a remote one, without any loss of information. In these cases, the measured blood flow and clinical surveillance of the blood supply were adequate, thus making revision of the tissues not necessary. This preliminary study suggests that standard 'off-the-shelf' personal computer tools may be useful in improving the monitoring of microcirculation after plastic surgery.

Instrumental monitoring is being increasingly employed in the postoperative phase after microsurgery. For this purpose, laser Doppler flowmetry has proven to be very useful. Monitoring of the perfusion of tissue with blood is mainly by clinical examination, which, however, requires the physical presence of the observer, and this is generally not possible on a continuous basis. By connecting up a laser Doppler unit with a computer and telephone modem and making use of the in-house radio system, it proved possible to produce an automatic emergency call system that responds to a worsening of perfusion and alerts the responsible doctor. For this purpose, the software program "call-doc" was developed, which provides the necessary monitoring and control functions. A general perfusion-independent emergency call can also be triggered at the touch of a button.

Our investigation should clarify the question of whether cardiopulmonary exercise testing (CPX) offers additional information of clinical relevance in patients with pulmonary sarcoidosis. We investigated the relationship between changes of lung function including the diffusing capacity and the changes of gas exchange. Furthermore, we determined the correlation of functional and morphological lung changes on the basis of radiological parameters and on the influence of a steroid therapy over the gas exchange. Forty-seven patients with histologically diagnosed pulmonary sarcoidosis were examined. The lung function test includes the measurement of lung volumes with spirometry and the diffusing capacity of carbon monoxide in the single breath technique. Minute ventilation, oxygen uptake at maximum, oxygen pulse, functional dead space/tidal volume ratio, anaerobic threshold, and alveolar-arterial oxygen difference were measured continuously during exercise. We found significant correlations between the lung volumes and the CPX data. An increased relative minute ventilation and an increased alveolar-arterial oxygen difference with exercise allows a more objective differentiation in radiological stages I and II than does the lung function at rest. A steroid therapy improves the effectivity of alveolar ventilation and an improvement of the ventilation-perfusion-match. The CPX detects early changes of pathological gas-exchange, before the lung function at rest is evident pathologically. It offers additional information on the pathophysiology of sarcoidosis, and is useful in reviewing steroid therapy.

Previous clinical observations have suggested that the application of glycerol-preserved donor skin as a temporary wound dressing provokes a weaker rejection reaction than fresh, vital donor skin. Like others, we frequently observed that considerable parts of the allodermis not only remained on the wound for an extended period of time, but even became re-epithelialized in some cases. In order to quantify this effect, we applied the mixed lymphocyte culture (MLC) test in a rat model, using the two highly inbred, histoincompatible rat strains DA and Lewis as donor and recipient respectively. Using the methodology of the Euro Skin Bank, Beverwijk, The Netherlands, split thickness skin, excised from the back of the rats, was equilibrated in 98 per cent glycerol. The immunological reaction after grafting vital DA-skin, glycerolized DA-skin onto Lewis rats, and vital as well as glycerolized Lewis-skin onto Lewis rats was compared. The results of these experiments do not support the clinical observations that the glycerolization procedure results in decreased immunogenicity of donor skin.

Die Grose der Vollhauttransplantate kann durch Vordehnung mittels Expander verdreifacht werden. Dies ermoglicht, einen Hebedefekt von uber 20 cm Durchmesser primar zu verschliesen. Ein Rotationslappen im clavicularen Thoraxbereich konnte im Verhaltnis 4:1 gegenuber der Lappenbasis vergrosert werden. Die Wangen sowie die Ober- und Unterlippe konnen unter Verwendung der vorderen Halsregion rekonstruiert werden. Diese Lappen werden auch fur die Rekonstruktion von Narbenbildungen in der Mitte des ventralen Halses mittels Z-Plastik, durch die eine diagonale Narbe uber dem ventralen Hals entsteht, verwendet. Die praoperative Expansion der umgebenden Haut und die Rekonstruktion mit Vollhaut und Verschiebe-Schwenklappen stellt die fur Gesicht und Hals besseren Voraussetzungen dar als die sehr selten indizierten freien Lappen.

Herpetic whitlow is a rare viral infection, that should be treated nonoperatively and managed by a hand surgeon. There is a high risk of infection for dentists and other medical personal. The authors present a case, describe findings, possible complications, and treatment.

Coagulase-negative staphylococci have gained increasing importance in burns, whereas interest is no longer focussed on Pseudomonas bacteria. By means of microbiological analysis of swabs taken from patients, environment and staff, we trailed the routes of infection in an intensive-care unit for burns. Analysis of patients: In 27 out of 11 patients the same biotype of Staphylococcus epidermidis could be identified; 22 of these occurred in swabs from wounds. The phagotypification of Staphylococcus aureus showed the same phagotype in 28 out of 41 swabs taken from infected wounds of 10 patients. The pathogen mostly caused the destruction of already healed grafts in a later phase of the treatment. Further microbiological analysis showed a severe infestation of the patients by enterococci. Analysis of environment: Here, greatly increased counts of coagulase-negative staphylococci of the same lysotype as in the patients could be demonstrated. Analysis of staff: The naso-pharyngeal area is of minor importance in the spreading of germs, whereas that of protective clothing and especially the hands should be considered to be more crucial. Regular environmental tests enable rapid detection of hygienic errors so that appropriate countermeasures can be taken.

Der primare Verschlus von Defektwunden an der Hand bietet den besten Schutz fur die Vitalitat tieferer Strukturen. Wie bei allen Verletzungen spielt die Erstversorgung bei Weichteilschaden an der Hand eine entscheidende Rolle fur den Ablauf der gesamten Behandlung. Jede Weichteilwunde, die nicht spannungslos primar verschlossen werden kann, bedarf der sofortigen plastisch-chirurgischen Deckung. Sowohl bei der primaren Versorgung der Weichteildefekte als auch in der sekundaren Phase stehen von der freien Hauttransplantation bis hin zur freien Lappentransplantation mit mikrovaskularen Gefasanschlussen verschiedene Defektdeckungsmoglichkeiten zur Verfugung.

Limitierende Faktoren der primaren Excision und Deckung von Verbrennungsdefekten sind Blutverlust und beschrankte Hautentnahmeflache. Mehr als 20% der verbrannten Korperoberflache kann meist nicht in der primaren Sitzung versorgt werden. Hande und und Gesicht werden ausnahmslos primar excidiert und gedeckt. Die verzogerte primare Excision der Restnekrosen wird 2–3 Wochen nach Lokalbehandlung mit J-PVP-Losung, 5%iger Tanninlosung und 10%iger Silbernitratlosung durchgefuhrt. Zweitgradige Verbrennungen sind dann abgeheilt. Die drittgradigen Defekte werden excidiert und mit Eigenhaut oder gemischten Fremd-Eigenhautinseltransplantaten gedeckt.

In judging the infusion therapy of burn injuries, not only the circulatory and pulmonary effects are considered but also the local effect on burned tissue. Local edema leads to hypoxia as well as to the burn-specific sludge phenomenon. Microcirculation and edema are often adversely influenced by our therapeutic efforts. Therapeutic proteinase inhibition, for example, has a beneficial effect on edema formation but reduces spontaneous fibrinolytic activity and thus increases the sludge phenomenon. Standardized experimental scalds of 30% of the body surface in rabbits increased density of the lungs, as determined by computed tomography. Colloidal infusion therapy was found to diminish fluid shift into the lung more than crystalloid infusion therapy. However, all tested infusion regimens, using identical quantity, increased edema formation in the burned skin. Biseco ® (natural serum proteins containing igG, igA and igM; Fa. Biotest, Frankfurt, F.R.G.) and Solcoseryl ® (a protein-free extract of calf blood stimulating the oxygen efficiency; Fa. Solco Basel) were demonstrated to diminish local edema formation as well as lung edema secondary to burn injuries.

An implementation of Karmarkar's algorithm is described which can be characterized by two features. On the one hand only approximate projections are used in determining directions of search and, secondly, variables which are likely to be non-basic are successively eliminated. We demonstrate by examples that the resulting algorithm lies favorable properties with regard to speed and stability.

In a previous paper [6] we considered the problem of approximating (in the Chebyshev-norm) a real-valued functionf(x) on a compact subsetX m ,m?1, by an element of a set of functionsa(p, x),p?P,P

For the problemP(λ): MaximizecTz subject toz∈Z(λ), whereZ(λ) is defined by an in general infinite set of linear inequalities, it is shown that the value-function has directional derivatives at every point\(\bar \lambda \) such thatP(\(\bar \lambda \)) and its dual are both superconsistent. To compute these directional derivatives a min-max-formula, well-known in convex programming, is derived. In addition, it is shown that derivatives can be obtained more easily by a limit-process using only convergent selections of solutions ofP(λn), λn →\(\bar \lambda \) and their duals.

The paper describes a computer-assisted infusion and nutrition programme, running on an IBM-compatible PC/XT or PC/AT, for a surgical intensive care unit specializing in burn treatment. Using inputs of patient and laboratory data relevant to infusion planning, the programme generates a schedule for balanced enteral or parenteral nutrition of adult and adolescent patients from the age of 14 upwards. Potential side effects and metabolic complications in nutrition therapy are minimized. Graphics provide a rapid status check on individual parameters whenever required.

Successful treatment of severely burned patients with the Chinese method of intermingled skin grafting has raised questions concerning the pathophysiological and immunological mechanisms which allow the survival of mixed allogeneic and autologous tissue. In creating a rat model and measuring systemic immunological status by means of mixed lymphocyte reactions (MLR) and histology, we found comparable levels of sensitization in intermingled and allografted rats, however, allografts were rejected and intermingled graft survival was significantly prolonged. We interpret our results to indicate that the survival of intermingled grafts is dependent upon an as yet undefined local protective effect exerted by the presence of auto-skin islands in the allotypic portion of intermingled grafts.

The progress of 18 episodes of septic shock in nine patients with burn injuries after administration of a Pseudomonas immunoglobulin is presented. In nine instances the septic shock was treated successfully. The mean burn index of these nine patients was 96. In six of the nine patients the septic shock was accompanied by simultaneous inhalation trauma and in six by acute kidney failure. In four cases the sepsis was caused by P. aeruginosa and in five by staphylococci. Despite the different causative agents, successful treatment was possible in these cases. The mean burn index for the four patients who eventually died was 119; all patients in this group were suffering from an inhalation trauma and acute kidney failure requiring dialysis. In these cases even the use of Pseudomonas immunoglobulin had no decisive effect.

Stability of update-formulae in linear programming is considered under the assumption that the formula itself is evaluated exactly, i.e. only the effect of an input error in a first step is studied. It is shown that orthogonal decomposition methods but also the revised Simplex-method are stable in that sense. However, this is not true for variants of orthogonal decomposition which do not use the orthogonal factor explicitely.