Search

Three-dimensional technology is increasingly being used in acetabular fracture treatment. No systematic reviews are available about the added clinical value of 3D-assisted acetabular fracture surgery compared to conventional surgery. Therefore, this study aimed to investigate whether 3D-assisted acetabular fracture surgery compared to conventional surgery improves surgical outcomes in terms of operation time, intraoperative blood loss, intraoperative fluoroscopy usage, complications, and postoperative fracture reduction, and whether it improves physical functioning. Pubmed and Embase databases were searched for articles on 3D technologies in acetabular fracture surgery, published between 2010 and February 2021. The McMaster critical review form was used to assess the methodological quality. Differences between 3D-assisted and conventional surgery were evaluated using the weighted mean and odds ratios. Nineteen studies were included. Three-dimensional-assisted surgery resulted in significantly shorter operation times (162.5 ± 79.0 versus 296.4 ± 56.0 min), less blood loss (697.9 ± 235.7 mL versus 1097.2 ± 415.5 mL), and less fluoroscopy usage (9.3 ± 5.9 versus 22.5 ± 20.4 times). The odds ratios of complications and fracture reduction were 0.5 and 0.4 for functional outcome in favour of 3D-assisted surgery, respectively. Three-dimensional-assisted surgery reduces operation time, intraoperative blood loss, fluoroscopy usage, and complications. Evidence for the improvement of fracture reduction and functional outcomes is limited.

Background: It is well-established that the etiology of type 2 diabetes differs between individuals. Insulin resistance (IR) may develop in different tissues, but the severity of IR may differ in key metabolic organs such as the liver and skeletal muscle. Recent evidence suggests that these distinct tissue-specific IR phenotypes may also respond differentially to dietary macronutrient composition with respect to improvements in glucose metabolism.Objective: The main objective of the PERSON study is to investigate the effects of an optimal vs. suboptimal dietary macronutrient intervention according to tissue-specific IR phenotype on glucose metabolism and other health outcomes.Methods: In total, 240 overweight/obese (BMI 25 – 40 kg/m2) men and women (age 40 – 75 years) with either skeletal muscle insulin resistance (MIR) or liver insulin resistance (LIR) will participate in a two-center, randomized, double-blind, parallel, 12-week dietary intervention study. At screening, participants undergo a 7-point oral glucose tolerance test (OGTT) to determine the hepatic insulin resistance index (HIRI) and muscle insulin sensitivity index (MISI), classifying each participant as either “No MIR/LIR,” “MIR,” “LIR,” or “combined MIR/LIR.” Individuals with MIR or LIR are randomized to follow one of two isocaloric diets varying in macronutrient content and quality, that is hypothesized to be either an optimal or suboptimal diet, depending on their tissue-specific IR phenotype (MIR/LIR). Extensive measurements in a controlled laboratory setting as well as phenotyping in daily life are performed before and after the intervention. The primary study outcome is the difference in change in disposition index, which is the product of insulin sensitivity and first-phase insulin secretion, between participants who received their hypothesized optimal or suboptimal diet.Discussion: The PERSON study is one of the first randomized clinical trials in the field of precision nutrition to test effects of a more personalized dietary intervention based on IR phenotype. The results of the PERSON study will contribute knowledge on the effectiveness of targeted nutritional strategies to the emerging field of precision nutrition, and improve our understanding of the complex pathophysiology of whole body and tissue-specific IR.Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT03708419, clinicaltrials.gov as NCT03708419.

Leopard (Panthera pardus) conservation has a strong international dimension. Hunting trophy export quotas established for African range states under the Convention on International Trade in Endangered Species (CITES) are a case in point. We test these quotas, and the methods for their establishment, against the benchmark of the general principles of precaution, sustainable use and adaptive management. The various national approaches and the CITES regime condoning them largely fail this test. For decades, CITES bodies have endorsed apparently arbitrary quotas lacking robust scientific bases, without regular adjustment. Thus, the quotas have been inadequately performing their assigned function within the Convention’s framework. The way in which the CITES leopard quota regime has been operating is fundamentally at odds with the principles of sustainable use, precaution and adaptive management. To remedy this, we offer recommendations on how to embed a science-based, sustainable, precautionary and adaptive approach to quota-setting within the CITES system.

A low-calorie diet (LCD) is an effective strategy to lose weight and improve cardiometabolic risk factors, however, sexual dimorphism may be present. This study aims to investigate sexual dimorphism in cardiometabolic risk factors following weight loss and after weight maintenance. 782 overweight/obese participants (65% women) of the DiOGenes trial followed an 8-week LCD (~800 kcal/day), with a 6-months follow-up weight maintenance period on ad libitum diets varying in protein content and glycemic index. Men lost more body weight during the LCD period (−12.8 ± 3.9 vs. −10.1 ± 2.8 kg, respectively, p &lt, 0.001), but regained more weight during the follow-up period than women (1.5 ± 5.4 vs. −0.5 ± 5.5 kg, respectively, p &lt, 0.001). Even though beneficial LCD-induced changes in cardiometabolic risk factors were found for both sexes, improvements in HOMA-IR, muscle and hepatic insulin sensitivity, triacylglycerol, HDL−, LDL− and total cholesterol, diastolic blood pressure, cholesterol esters, sphingomyelins and adiponectin were more pronounced in men than women (std. ß range: 0.073–0.144, all q &lt, 0.05), after adjustment for weight change. During follow-up, women demonstrated a lower rebound in HDL-cholesterol, triacylglycerol and diacylglycerol (std. ß range: 0.114–0.164, all q &lt, 0.05), independent of changes in body weight. Overall, we demonstrated sexual dimorphism in LCD-induced changes in body weight and cardiometabolic risk profile, which may be attributed to differences in body fat distribution and metabolic status.

The EU Habitats Directive is a key biodiversity conservation instrument. It contains legal obligations for the 28 EU member states in order to safeguard a ‘favourable conservation status’ (FCS) for selected species and habitat types. The crucial FCS concept itself, however, remains subject to considerable confusion regarding its proper interpretation and operationalization, impairing the Directive’s effective implementation. Diminishing this confusion is the purpose of this review. It focuses specifically on large carnivores—wolf (Canis lupus), brown bear (Ursus arctos), Eurasian lynx (Lynx lynx) and wolverine (Gulo gulo). These pose particular challenges, given their low densities, transboundary populations, and human-wildlife conflict potential. Large carnivores are also the only species for which specific guidance has been adopted by the European Commission— and subsequently contested. Our methodology combines legal analysis with an understanding of the species’ ecology and associated social, economic and cultural dimensions. We analyze the methods and processes through which EU law is interpreted, implemented, and enforced, by member states, European Commission, and EU Court of Justice—which is the ultimate authority regarding EU law interpretation. On that basis, we engage three particularly complex interpretation questions which are also of great practical significance: (1) the appropriate scale to achieve FCS (national or transboundary population level); (2) the respective roles of demographic, genetic and ecological factors in determining FCS; and (3) the use of extinction versus carrying capacity as benchmark. Regarding these questions, we identify approaches that are workable and effective, as well as likely to be endorsed by the EU Court.

Cardiometabolic diseases are one of the leading causes for disability and mortality in the Western world. The prevalence of these chronic diseases is expected to rise even further in the next decades. Insulin resistance (IR) and related metabolic disturbances are linked to ectopic fat deposition, which is the storage of excess lipids in metabolic organs such as liver and muscle. Notably, a vicious circle exists between IR and ectopic fat, together increasing the risk for the development of cardiometabolic diseases. Nutrition is a key-determining factor for both IR and ectopic fat deposition. The macronutrient composition of the diet may impact metabolic processes related to ectopic fat accumulation and IR. Interestingly, however, the metabolic phenotype of an individual may determine the response to a certain diet. Therefore, population-based nutritional interventions may not always lead to the most optimal (cardiometabolic) outcomes at the individual level, and differences in the metabolic phenotype may underlie conflicting findings related to IR and ectopic fat in dietary intervention studies. Detailed metabolic phenotyping will help to better understand the complex relationship between diet and metabolic regulation, and to optimize intervention outcomes. A subgroup-based approach that integrates, among others, tissue-specific IR, cardiometabolic parameters, anthropometrics, gut microbiota, age, sex, ethnicity, and psychological factors may thereby increase the efficacy of dietary interventions. Nevertheless, the implementation of more personalized nutrition may be complex, costly, and time consuming. Future studies are urgently warranted to obtain insight into a more personalized approach to nutritional interventions, taking into account the metabolic phenotype to ultimately improve insulin sensitivity and reduce the risk for cardiometabolic diseases.

As the population is aging rapidly, there is a strong increase in the number of individuals with chronic disease and physical limitations. The decrease in skeletal muscle mass and function (sarcopenia) and the increase in fat mass (obesity) are important contributors to the development of physical limitations, which aggravates the chronic diseases prognosis. The combination of the two conditions, which is referred to as sarcopenic obesity, amplifies the risk for these negative health outcomes, which demonstrates the importance of preventing or counteracting sarcopenic obesity. One of the main challenges is the preservation of the skeletal muscle mass and function, while simultaneously reducing the fat mass in this population. Exercise and nutrition are two key components in the development, as well as the prevention and treatment of sarcopenic obesity. The main aim of this narrative review is to summarize the different, both separate and combined, exercise and nutrition strategies so as to prevent and/or counteract sarcopenic obesity. This review therefore provides a current update of the various exercise and nutritional strategies to improve the contrasting body composition changes and physical functioning in sarcopenic obese individuals.

This chapter introduces the open-source software VIKI. VIKI is a software package that eases the configuration of complex robotic systems and behavior by providing an easy way to collect existing ROS packages and nodes into modules that provide coherent functionalities. This abstraction layer allows users to develop behaviors in the form of a collection of interconnected modules. A GUI allows the user to develop ROS-based software architectures by simple drag-and-drop of VIKI modules, thus providing a visual overview of the setup as well as ease of reconfiguration. When a setup has been created, VIKI generates a roslaunch file by using the information of this configuration, as well as the information from the module definitions, which is then launched automatically. Distributed capabilities are also guaranteed as VIKI enables the explicit configuration of roslaunch features in its interface. In order to show the potential of VIKI, the chapter is organised in the form of a tutorial which provides a technical overview of the software, installation instructions as well as three use-cases with increased difficulty. VIKI functions alongside your ROS installation, and only uses ROS as a runtime dependency.

Igor Yanson showed 38 years ago for the first time a point-contact measurement where he probed the energy resolved spectroscopy of the electronic scattering inside the metal. Since this first measurement, the pointcontact spectroscopy (PCS) technique improved enormously. The application of the scanning probe microscopy (SPM) techniques in the late 1980s allowed achieving contacts with a diameter of a single atom. With the introduction of the mechanically controlled break junction technique, even spectroscopy on freely suspended chains of atoms could be performed. In this paper, we briefly review the current developments of PCS and show recent experiments in advanced scanning PCS based on SPM techniques. We describe some results obtained with both needle-anvil type of point contacts and scanning tunneling microscopy (STM). We also show our first attempt to lift up with a STM a chain of single gold atoms from a Au(110) surface.

The ongoing refugee crisis in Europe has seen many countries rush to construct border security fencing to divert or control the flow of people. This follows a trend of border fence construction across Eurasia during the post-9/11 era. This development has gone largely unnoticed by conservation biologists during an era in which, ironically, transboundary cooperation has emerged as a conservation paradigm. These fences represent a major threat to wildlife because they can cause mortality, obstruct access to seasonally important resources, and reduce effective population size. We summarise the extent of the issue and propose concrete mitigation measures., While cooperation across national boundaries has emerged as a key concept in wildlife conservation, this Perspective reveals that, at the same time, there has been a dramatic increase in the extent of security fencing along international borders, which has dramatic consequences for this approach.

Species migrating across boundaries represent the classic case for international cooperation in biodiversity conservation. Climate change is adding fresh challenges to such cooperation, on account of the shifting ranges and particular vulnerabilities to climate change of migratory wildlife. In view of the need to help migratory species adapt to climate change with minimal losses, this article performs an in-depth analysis of the present and potential future role in respect of climate adaptation of the main intergovernmental regime for migratory species conservation, the 1979 Bonn Convention on the Conservation of Migratory Species of Wild Animals (CMS) and its various daughter instruments.

The contamination of the world's oceans by human garbage, especially plastics, ranks among those environmental problems whose resolution appears remote, despite the considerable public attention paid to the 'Great Garbage Patch' in the Pacific, 'plastic soup', and the like. This 'marine litter' (or 'marine debris') problem is characterized by diffuse sources and an array of adverse environmental impacts, including entanglement of and ingestion by albatrosses, fulmars, turtles, seals and a variety of other marine wildlife. This article explores the evolving role of international law in the efforts to manage marine litter, including recent developments involving the Convention for the Protection of the Marine Environment of the North-East Atlantic (OSPAR Convention) and the European Union's Marine Strategy Framework Directive (MSFD).

This article reviews the Bern Convention on the Conservation of European Wildlife and Natural Habitats and the European Union's Wild Birds and Habitats Directives from the perspective of the need to help nature adapt to climate change in order to attain biodiversity conservation goals. It concludes that even though none of the three instruments explicitly state this, both the Bern Convention and the EU directives currently subject Member States to legal obligations to take the measures necessary to facilitate the adaptation of biodiversity in Europe to climate change. These measures include the restoration and protection of robust populations and habitats, as well as the establishment of adequate connectivity in order to enable recovery of populations following climate-related impacts and to enable climate-induced range shifts.

The precautionary principle and the ecosystem approach are often mentioned in one breath. This article explores the differences, similarities and relationship between the two concepts. In a comparative and integrated assessment, it addresses, among other things, the purpose, core elements and status of the precautionary principle and the ecosystem approach under international law, the role of scientific information in their application, and the management actions associated with their implementation.

Fires involving mass burn casualties require extreme efforts and flexibility from the regular health care system. The cafe fire in Volendam, which occurred shortly after midnight on the first of January 2001, resulted in the worst indoor mass burns incident in Dutch history. During the extensive medical evaluation of this disaster, it became obvious that information on similar incidents is relatively scarce in the literature. This article systematically reviews the existing information in the medical literature on indoor fires and provides findings and knowledge used in the evaluation of the medical management after indoor fires and for future mass burn casualty preparedness, mitigation and response. Methods: A literature review was undertaken for bum disasters with characteristics similar to the indoor Volendam fire disaster. In all fires, the following aspects were investigated: characteristics of the fire; the initial emergency response; triage and on-site treatment; primary and secondary distribution; hospital admission; severity of the sustained injuries and mortality. Results: A total of nine similar indoor fires were selected. The number of people involved was reported in seven fires (range 137-6000). All reports provided the mortality rate (range 1.4% to over 50%). Data regarding the emergency response could be collected in half of the studies. On-scene triage was performed in five fires. The number of hospitals participating in the primary distribution ranged from 1 to 19. Except for the Volendam fire, all patients were primarily distributed to general hospitals. Conclusion: Characteristics of indoor fires, which are relevant for disaster preparedness, mitigation and response are not frequently reported in medical literature. The current articles on indoor fires, mainly report on numbers of casualties and the mortality. Limited data are available to provide insight in the characteristics of management and medical treatment and to come up with suggestions for improvement of future burn incidents management. The evaluation of disasters should be based on uniform methods and structured reports and effective record keeping is essential to achieve this. (c) 2005 Elsevier Ltd and ISBI. All rights reserved

Aims of study: The cafe fire at Volendam occurred shortly after midnight on the first of January 2001 and resulted in one of the worst mass burn incidents in recent Dutch history. The aim of this study was to provide insight into medical and organisational requirements of a major burns incident. Methods: Shortly after the fire, two university hospitals and a burn center in the region of the accident developed a plan for evaluation of medical care given during and after this major burn incident. A multidisciplinary research group investigated the management of victims at the scene, in the emergency departments (ED) and during admission in the hospitals. All 245 casualties were included in this study. Results: A brief severe fire occurred in a crowded cafe with around 350 young visitors on a small embankment of a relatively isolated town, resulting in a unusually high number of severely injured burn victims. Four died immediately. The ensuing rescue effort was hampered by poor access and chaotic circumstances. At the scene of the incident, mobile medical teams ensured orderly transport and treatment priority for the injured. There were 245 victims with a median total body surface area burned of 12%. Inhalation injury was present in 96 patients. A total of 182 victims were admitted, with 112 to intensive care. Ten patients died in the hospital. Seventy-eight patients were secondarily transported, many to specialised centers in the Netherlands and abroad. In total, 36 hospitals in three countries participated. Conclusion: An incident with high numbers of burn victims poses a challenge to any health care system. The difficult circumstances at the site demonstrated the need for robust organisational structures. The primary and secondary distribution of patients required coordination, general hospitals were able to provide initial medical care to these major burn casualties. (C) 2005 Elsevier Ltd and ISBI. All rights reserved

Integration of farmers' knowledge and perception with researchers' knowledge is important for planning resource-conserving technologies. In many places in the world, farmer participation has been shown to be essential in the planning of sustainable land management. The findings of a participatory approach (PA) for integrated conservation planning in the Danangou catchment—a small catchment situated in the heart of Loess Plateau—are presented in this paper. The work was carried out by an interdisciplinary team during the period 1997–2000. The PA is an interactive learning process between local farmers and researchers. The process was facilitated by several visualisation and diagramming methods. This formed part of an integrated conservation planning approach, where three tools including PA, land evaluation and soil erosion modelling were combined within the entire conservation planning process. The Danangou catchment is characterised by its distribution of cropping systems on all degrees of slope to meet the food needs of the villagers. Farmers' criteria on land suitability, including slope aspect and soil workability, were evaluated. Farmers approved several biological and physical conservative measures, which provided one of the important bases for formulating different land use scenarios (LU scenarios). The factors influencing farmers in choosing different LU scenarios were analysed, including (1) current household economy in relation to production from the land; and (2) prediction of changes in the household economy due to different LU scenarios. The farmers' vision on implementation of the LU scenarios, i.e. gradually converting cropping land, conforms well with the plans of the local government. However, due to the poor living standard and lack of off-farm employment, any effort to improve land use towards more sustainable practices seemed to be difficult to implement without support from the government in terms of food, seedlings and also sources of employment for the villagers. The strategy for conversion work in connection with the central government policy on re-greening the Loess Plateau must focus first on areas where off-farm activities are available or potentially available. A diversity of conservation alternatives was found to meet the needs of different farmers' groups. It is recommended that alternatives be developed by an active collaboration between farmers, extensionists and researchers.

The focus of this report is on the interplay between the European Union’s Regulation 1143/2014 on the Prevention and Management of the Introduction and Spread of Invasive Alien Species (IAS Regulation), and the Bern Convention on the Conservation of European Wildlife and Natural Habitats. The report explores options for extending the scope of (some of) the measures laid down in the IAS Regulation to Europe at large, beyond the EU, using the framework of the Bern Convention. It also explores options for synergies between the Regulation and Bern Convention work on IAS more generally.

The details of metal-molecule coupling play a pivotal role in the functionality of molecular junctions. Molecules that have intrinsic switchable properties may lose this capability after coupling to electrodes. On the other hand, connecting passive molecules to electrodes may lead to a switchable molecular device ('extrinsic switching'). Here, we first discuss this general matter, and then focus on two specific cases, one of intrinsic switching (for photochromic diarylethenes) and one of extrinsic switching (for hydrogen molecules) in gold-molecule-gold structures.

BACKGROUND: Although it is known that the transfusion of stored RBCs does not always improve tissue O2 consumption under conditions of limited tissue oxygenation, the efficiency of O2 delivery to the microcirculation by stored RBCs has never been determined. STUDY DESIGN AND METHODS: In a rat hemorrhagic shock model, the effects of resuscitation with fresh or 28-day-old RBCs stored in CPD plasma, saline-adenine-glucose-mannitol, and CPDA-1 plasma were investigated. Systemic hemodynamic and intestinal oxygenation measures were monitored. Intestinal microvascular PO2 was determined with the O2-dependent quenching of palladium-porphyrin phosphorescence, and the RBC deformability was measured with a Laser-assisted optic rotational cell analyzer. RESULTS: Hemodynamic and oxygenation measures were significantly decreased during hemorrhagic shock. Intestinal oxygen consumption and mesenteric venous pO2 were restored with the transfusion of both fresh and stored RBCs, except for CPD-stored RBCs. The intestinal microvascular pO2 improved only with the transfusion of fresh RBCs. Deformability of the stored RBCs was significantly decreased. CONCLUSION: In contrast to that of fresh RBCs, the transfusion of stored RBCs did not restore the microcirculatory oxygenation, possibly because of impaired O2 unloading, but, except for CPD-stored RBCs, the storage-induced changes were not enough to impair intestinal VO2 and mesenteric venous pO2.

Background A critical point in oxygen supply for microvascular oxygenation during normovolemic hemodilution has not been identified. The relation between organ microvascular oxygen partial pressure (microPO2) and organ oxygen consumption (VO2) during a decreasing oxygen delivery (DO2) is not well understood. The present study was designed to determine the systemic hematocrit and organ DO2 values below which organ microPO2 and VO2 cannot be preserved by regulatory mechanisms during normovolemic hemodilution. Methods Eighteen male Wistar rats were randomized between an experimental group (n = 12), in which normovolemic hemodilution was performed with pasteurized protein solution (PPS), and a control group (n = 6). Systemic hemodynamic and intestinal oxygenation parameters were monitored. Intestinal microPO2 was measured using the oxygen-dependent quenching of palladium-porphyrin phosphorescence. Results Baseline values in hemodilution and control group were similar. Hemodilution decreased hematocrit to 6.2 +/- 0.8% (mean +/- SD). Constant central venous pressure measurements suggested maintenance of isovolemia. Despite an increasing mesenteric blood flow, intestinal DO2 decreased immediately. Initially, microPO2 was preserved, whereas mesenteric venous PO2 (P(mv)O2) decreased; below a hematocrit of 15%, microPO2 decreased significantly below P(mv)O2. Critical DO2 was 1.5 +/- 0.5 ml x kg(-1) x min(-1) for VO2, and 1.6 +/- 0.5 ml x kg(-1) x min(-1) for microPO2. Critical hematocrit values for VO2 and microPO2 were 15.8 +/- 4.6% and 16.0 +/- 3.5%, respectively. Conclusions Intestinal microPO2 and VO2 were limited by a critical decrease in DO2 and hematocrit at the same time. Beyond these critical points not only shunting of oxygen from the microcirculation could be demonstrated, but also a significant correlation between intestinal microPO2 and VO2.

SummaryThe administration of protamine to patients undergoing cardiopulmonary bypass (CPB) to neutralize heparin and to reduce the risk of bleeding, induces activation of the classical complement pathway mainly by heparin-protamine complexes. We investigated whether C-reactive protein (CRP) contributes to protamine-induced complement activation.In 24 patients during myocardial revascularization, we measured complement, CRP, and complement-CRP complexes, reflecting CRPmediated complement activation in vivo. We also incubated plasma from healthy volunteers and patients with heparin and protamine in vitro to study CRP-mediated complement activation. During CPB, CRP levels remained unchanged while C3 activation products increased. C4 activation occurred after protamine administration. CRP-complement complexes increased at the end of CPB and upon protamine administration. Incubation of plasma with heparin and protamine in vitro generated complement-CRP complexes, which was blocked by phosphorylcholine and stimulated by exogenous CRP. C4d-CRP complex formation after protamine administration correlated clinically with the incidence of postoperative arrhythmia.Protamine administration during cardiac surgery induces complement activation which in part is CRP-dependent, and correlates with postoperative arrhythmia.

In 1996 in Curacao, acute aluminum (Al) intoxication sickened patients in a dialysis center that used tap water to prepare dialysate. The mortality rate was 32%. A new factory-lined cement-mortar water distribution pipe had recently been installed. It is known that substantial amounts of barium, cadmium, and chromium can leach from cement-mortar linings. This article shows that high concentrations of Al can leach from cement mortars for at least two years in soft, aggressive water. The newly installed pipe, cement containing four times as much Al as usual, corrosive water, the high pH and temperature of the water, long residence time, and perhaps the corrosion inhibitor polyphosphate may have promoted this leaching. Certification of cements used to line water pipes is warranted. Central water treatment plants must distribute noncorrosive water, especially plants that use membrane desalination or other reverse osmosis or nanofiltration processes. Dialysis units should be promptly informed of any impending change in water treatment that might increase the Al content of tap water and also of any accidental pollution of the water distributed. Dialysis centers should always practice extended purification of tap water used for dialysate. Although Al as a risk factor for Alzheimer`s disease in the generalmore » population is still debated, there is no doubt that Al causes dialysis encephalopathy.« less

The Loess Plateau of China is faced with a continuous loss of land and productivity due to soil erosion. In 1998, an interdisciplinary project started with the objective to develop alternative land use and conservation strategies to reduce soil and water losses in an agricultural watershed. This project (EROCHINA, funded by the European Union and the Dutch Ministry of Agriculture, Nature Management and Fisheries) is a close cooperation between three European and three Chinese research organizations. The approach of this project consists of a participatory conservation planning to optimize land use and conservation measures, given the technical and socio-economical abilities of the land users and the related national, provincial and county regulations and restrictions. The EROCHINA project is innovative as land evaluation and soil erosion modeling are integrally used within the participatory conservation planning methodology. In this process, land evaluation is used to offer alternative land use scenarios based on the suitability of the land. These alternatives are presented to the farmers for discussion and finetuning. The deterministic hydrological and soil erosion model LISEM is used to assess the effectiveness of the alternative scenarios. In an iterative process between farmers and researchers, an optimal future land use and management strategy will be derived for the region under consideration.

This chapter is intended to contribute to the identification of the legal challenges involved in the adaptation of biodiversity, and of biodiversity law, to climate change, and of suitable ways to address these challenges. In doing so, the chapter focuses primarily, albeit not exclusively, on international legal instruments. The chapter is structured as follows. The next, second section concisely introduces the various impacts of climate change on species and ecosystems, as well as the biodiversity adaptation measures commonly recommended in the scientific literature. The third section provides an overall analysis of the role of biodiversity law in this regard, including by distilling and combining key findings from previous studies. This is complemented in the fourth section by an in-depth analysis of one type of action which is universally regarded as crucial to a successful adaptation of biodiversity to climate change, namely the maintenance and restoration of adequate connectivity in order to allow organisms to disperse naturally through landscapes in pursuit of suitable climatic conditions. The fifth section contains concluding observations.

THE SWORD OF Damocles hovering over the European Union's nature conservation legislation has finally been stashed. Instead of “opening” the legislation for renegotiation, the European Commission will work to improve its implementation ([ 1 ][1]). The 1979 Birds Directive ([ 2 ][2]) and 1992

The impact of a heterogeneous distribution of actinic light within a leaf chamber for photosynthetic measurements by gas exchange on the photosynthesis-irradiance relationship was investigated. High-resolution light distributions were measured over the area of a commercially available clamp-on leaf chamber equipped with build-in red and blue LEDs, as well as over the area of a custom-made leaf chamber with external light source, using a low-cost digital camera and freely available software. The impact of the measured heterogeneity on the photosynthesis-irradiance response curve was calculated for two realistic scenarios. When the average light intensity over the leaf chamber area was estimated accurately, heterogeneity had minor effects on the photosynthesis-irradiance response curve. However, when the irradiance was measured in the chamber centre, which is common practice, and assumed to be homogeneous, for both leaf chambers the photosynthesis-irradiance response curve was subject to considerable error and led to serious underestimation of the light-limited quantum yield of photosynthesis. Additionally, mixed light sources with different heterogeneity patterns per light source, such as in the clamp-on leaf chamber, potentially increase errors due to heterogeneous physiological responses to light spectrum. High-resolution quantification of the leaf-chamber light distribution enables calculation of the correct average light intensity and already resolves the most pressing problems associated with heterogeneity. To exclude any light-distribution related errors in gas-exchange measurements a leaf chamber and actinic irradiance source design with a homogeneous light distribution is an absolute requirement.

The effects of stepwise isovolemic hemodilution on systemic and regional hemodynamics, oxygen flux, and circulating catecholamines were studied in six pigs anesthetized with midazolam and fentanyl. Reduction of the hematocrit from 28 to 9% resulted in doubling of the cardiac output, mainly due to an increase in stroke volume. Regional blood flows, measured using the radioactive microsphere technique, showed an increase in blood flow to all organs except liver (hepatic artery fraction) and adrenals, with a redistribution of cardiac output in favor of heart and brain (increase in blood flow 420 and 170%, respectively). Oxygen flux to most organs did not decrease until hematocrit decreased to 9%, while total body oxygen consumption was well maintained. Left ventricular oxygen consumption increased, but because left ventricular blood flow also increased, left ventricular extraction ratio did not increase. Circulating catecholamines did not play any role in these regulatory mechanisms.

OBJECTIVE To determine the accuracy of in vivo mixed venous hemoglobin saturation (Svo2) measurements with a fiber optic thermodilution catheter during acute changes in hematocrit. DESIGN Comparison of fiberoptic in vivo Svo2 values with in vitro Svo2 values obtained with a multiwavelength spectrophotometer. SETTING Operating room in a university hospital. PATIENTS Six consecutive patients who are Jehovah's Witnesses. MEASUREMENTS AND MAIN RESULTS Before and after each step of hypervolemic hemodilution and after every 500 mL of blood loss, blood gases were analyzed and hemodynamic, hemoglobin, hematocrit, and in vitro and in vivo Svo2 measurements were made. Hematocrit values were measured in the range of 40% to 18%. Plotting all in vivo Svo2 values (n = 74) against the in vitro Svo2 measurements obtained during the entire study period gives r2 = .86. The accuracy of in vivo Svo2 measurements was not affected by changes in hematocrit or cardiac output. The Svo2 catheter value at the beginning of the study differed from the in vitro Svo2 value by -0.86 +/- 2.56% and at the end of the study period of 8 to 10 hrs by 0.71 +/- 3.04%. CONCLUSIONS The accuracy of the studied fiberoptic continuous measuring Svo2 system was not affected by changes in hematocrit or cardiac output. No significant drift in the in vitro Svo2 measurements was observed.

In a major incident, correct triage is crucial to emergency treatment and transportation priority. The aim of this study was to evaluate the triage process pursued at the site of the fire disaster in Volendam, the Netherlands on January 1, 2001. On-site (OS) and Emergency Department (ED) data regarding total body surface area burned (Tl3SA) and inhalation injury (INH) were compared with the final (FIN) assessment of these two parameters after hospital admission. Finally, the effect of OS intubation and the time of arrival at a hospital were evaluated. There were 245 injured. Mean age was 17.3 years. Final median TBSA was 12%; 96 patients (39%) had inhalation injury. Agreement between TBSA-OS (n = 46) and TBSA-FIN was poor (Pearson's correlations coefficient [PCC] = 0.77; R 2 = 0.60). TBSA-ED (n = 78) was more accurate (PCC = 0.96; R 2 = 0.93). INH-OS (n 79, sensitivity 100%, specificity 24%) and INH-ED (n 198, sensitivity 99%, specificity 36%) were sensitive but not specific. Eight patients were intubated on-site. No differences in outcome were found between this group and the patients who were intubated in the hospital. There was no difference in time of arrival at a hospital (p = 0.55). TBSA was not estimated reliably in a non-clinical environment. The diagnosis of inhalation injury was adequate but resulted in over-triage on-site and at the ED. Triage did not lead to transport priorities for the severely wounded. In a major burn accident, a field triage protocol for rapid evaluation of burn injuries may be useful. Detailed assessment of injuries of burn casualties is practical only in a specialized clinical setting. (c) 2008 Published by Elsevier Inc

We study the interaction between single apex atoms in a metallic contact, using the break junction geometry. By carefully 'training' our samples, we create stable junctions in which no further atomic reorganization takes place. This allows us to study the relation between the so-called jump out of contact (from contact to tunnelling regime) and jump to contact (from tunnelling to contact regime) in detail. Our data can be fully understood within a relatively simple elastic model, where the elasticity k of the electrodes is the only free parameter. We find 5 < k < 32 N/m. Furthermore, the interaction between the two apex atoms on both electrodes, observed as a change of slope in the tunnelling regime, is accounted for by the same model.

LEDs may be a suitable light source for future use as assimilation lighting in protected greenhouse cultivation. LEDs have properties which offer advantages compared to other light sources, but which also raise specific research questions. The narrow band spectrum of LEDs enables manufacturers to produce LED based lightsources specifically suitable for photosynthesis and other horticulturally relevant plant properties. The low radiated heat also makes LEDs suitable for interlighting (i.e. lighting from within the canopy), for which high pressure sodium lamps are not suitable. However, when using LEDs, crops must be able to acclimate their photosynthetic functioning to narrow band lighting (NBL) to efficiently use this light. Also, daylight-adapted leaves must be able to re-acclimate to NBL if LEDs would be used for interlighting in a high-wire grown crop. If low photosynthesis rates in older, lower leaves of the crop are also due to leaf age, besides low light, interlighting would be less effective. For investigating the intrinsic effect of NBL, we used 9 different arrays comprised of a single LED type (peak wavelengths in the range 460-668 nm) at lightlimited irradiance (50 μmol m s). Spirodela polyrrhiza (Lemnaceae) was cultivated as its leaves can not change in distance or orientation towards the light source. This enabled us to compare the effects of the different light sources on parameters such as growth rate and photosynthetic pigment composition. In order to separate the effect of light intensity and leaf age on photosynthesis, tomato plants were grown horizontally, so that older leaves were not shaded by younger leaves. Re-acclimation of leaves to NBL was investigated by illuminating older leaves (low in the canopy) using different LED arrays in a high-wire grown tomato crop. The light-harvesting apparatus of Spirodela polyrrhiza acclimated to the different NBL regimes within 6 days. Leaf age proved to be an irrelevant factor for photosynthetic capacity (Pmax) of greenhouse grown tomato plants. Pmax of leaves at a low position in a high-wire grown tomato crop, with a low Pmax, did re-acclimate to the higher light intensities supplied by the supplemental NBL by progressively increasing their Pmax. However, as it took 14 days for Pmax to increase from 5.6 to 12.4 μmol CO2 m s, maintaining a continuously higher light level within the canopy would be more effective. INTRODUCTION Recently, light emitting diodes (LEDs) are subject of debate and research with respect to their possible future use for assimilation lighting in protected plant cultivation. At this moment LED lighting systems are too expensive and, more important, not efficient enough in terms of light output per Watt energy use, for large scale replacement of high pressure sodium (HPS) assimilation lamps for commercial greenhouse horticulture. However, the light-output efficiency of LEDs increased dramatically in recent years and production costs of LED systems aimed at the horticulture will decrease Proc. XXVII IHC-S6 High-Qual. Crop Prod. under Protect. Cultiv. Ed.-in-Chief: D.J. Cantliffe Acta Hort. 761, ISHS 2007 184 if demand would be sufficient. So as well as yielding new, fundamental knowledge on plant functioning, research on plant responses to LED lighting is highly relevant for the horticultural industry. Compared to other light sources used for plant production, LEDs have several properties which are potentially useful in relation to horticulture. LEDs emit light in a relatively narrow band spectrum, so they can be manufactured with a wavelength output tailored to the plant responses desired by growers. In order to enhance production, LED arrays with wavelengths favourable for photosynthesis would be desired. However, wavelengths influencing other plant properties such as morphology (blue light enhances compactness of plants) could be desirable for ornamental horticulture. Also, nutritional qualities of food crops may be influenced by the illumination spectrum used (e.g. antioxidant content; see e.g. Oelmuller and Mohr, 1985). At this moment, LEDs produce more heat than HPS lamps per Watt energy input, due to their lower energy/light conversion efficiency. However, the radiated heat of LEDs is very low compared to HPS lamps. This affords the opportunity to cool LED lighting systems and to reuse the (low caloric) heat for e.g. greenhouse heating. The low radiated heat output also makes LEDs suitable for interlighting, i.e. lighting inside the canopy, instead of or in combination with lighting above the canopy. Previous research on interlighting with HPS lamps (Hovi et al., 2004) indicated that interlighting may be more efficient than lighting from above. Interlighting could contribute to a more effective use of light by crops, as inside the canopy light levels are low, whereas above the canopy solar radiation already provides a considerable photosynthetic photon flux (PPF) during daytime. Especially in high-wire cultivated crops (e.g. tomato, cucumber and sweet pepper) with low photosynthesis rates lower in the canopy (see e.g. Xu et al., 1997), interlighting could offer a means to enhance production. The considerable percentage of radiated heat HPS lamps produce makes it impossible to situate HPS lamps close to the leaves of a crop. LEDs, on the other hand, with their low radiated heat output and overall lower temperature, can be in contact with the leaves. Though this may not be good for photosynthesis, the leaf will not be burned. LED light output is proportional to electric current through the device, so light intensity can be controlled in a versatile way. Therefore, the light output of LED lighting systems can be easily, rapidly and efficiently adjusted to match environmental conditions or production requirements within the greenhouse, such as natural light or the stage of the crop in the production cycle. Also if lighting systems would be used comprised of different LED types, emitting light with different spectra, light quality could be adjusted to the needs of the crop. For example, the use of near far red light (690 nm) was found to increase the leaf area of developing leaves (Goins, 2002), which would result in a more effective use of the available light in early stages of the production cycle. A socially relevant issue concerning assimilation lighting, called “light pollution” (public agitation and the disturbance of the natural rhythm of birds etc. due to lighted greenhouses at night) may be reduced by the replacement of HPS lamps by LEDS for assimilation lighting. The human eye is much more sensitive to yellow/orange light (the dominant colour of HPS lamps) than it is to red light (a potentially useful colour for LED lighting systems), so an equal amount of μmols PPF can give a very different perception of light intensity for the (human) eye (Fig. 1). Mammals and birds are also more sensitive to yellow/orange light than to red (Goldsmith, 2006). Furthermore, interlighting would reduce radiation loss from the greenhouse considerably due to increased light interception within the canopy. Nonetheless, several questions need to be addressed, concerning the possible use of LEDs for assimilation lighting. In order to grow crops efficiently using narrow band lighting (NBL), plants have to be able to acclimate their photosynthetic apparatus to NBL. Any imbalance in excitation of the photosystems I and II would lead to a loss of quantum yield for CO2 fixation in a leaf. Also, the dynamics of re-acclimation to NBL of daylightadapted leaves in a crop are essential for the efficiency of interlighting in a canopy. As the production time of a leaf in a high-wire grown crop is relatively short (approximately 8

This chapter will be concerned with where when and how of precautionary action where, i.e., in what areas of the world and to what environmental sectors does the precautionary principle find application? When precisely is action called for, i.e., when are thresholds crossed? And how, finally, is one to determine what action to take?. The chapter on precautionary action, the third essential ingredient of the precautionary principle, has reflected on the where, when and how of such action. In summary, the precautionary principle must be 'widely applied'. This includes, to say it with Birnie and Boyle, "application to problems of global environmental risk, such as climate change and biological diversity, as well as domestically, in furtherance of the objective of sustainable development. Precautionary action is appropriate wherever there are sufficiently qualified threats of environmental harm.Keywords: precautionary action; precautionary principle; third leg; tripod

Virtually all of the numerous articulations of the precautionary principle that can be encountered in state practice boil down to the basic understanding that when (more or less grave) environmental harm looms ahead, preventive or abatement action is appropriate even if the issues are surrounded by uncertainty. The three common elements can be inferred, and this where the Delphic tripod, announced in the title of the current chapter, comes into play. The most fundamental feature of the tripod of Apollo, namely that it rest on three legs, is in its commonness with the precautionary principle. The three legs of the precautionary tripod, are (1) a threat of harm, (2) uncertainty and (3) action.Keywords: Apollo's Tripod; precautionary principle

Application of GRP/PVC-Foam sandwich structures on naval ships strongly depends on the mechanical strength and collapse behaviour of the joints of the structure. Quasi-static and dynamic experiments were executed to determine the failure modes and failure progression of T-joints. The results were used to determine the focus of the material tests, and to determine the main properties of failure models that were developed.

Summary Transfusion of homologous blood should be avoided when possible, and one technique that diminishes perioperative requirement for donor blood is haemodilution. In children its effects on systemic haemodynamics and systemic oxygenation have not been reported. Six children aged 4-12 yr were anaesthetised for major surgery and blood was withdrawn to reduce packed cell volume to 25%. Cardiac index increased from 3·1 (SD 0·5) L min -1 m -2 at baseline to 4·4 (0·5) L min -1 m -2 at the end of surgery, when packed cell volume was 16 (1)%; this change, compensating for the decline in oxygen carrying capacity, was associated with a fall in systemic vascular resistance and a rise in stroke volume. Oxygen extraction from haemoglobin rose from 0·22 (0·05) to 0·33 (0·06). Perioperative blood loss was 40% of circulating blood volume; however, owing to reinfusion of autologous blood (and use of a cell saver in three patients), the haemoglobin one day after operation was only 19% lower than preoperatively (9·9 [1·5] vs 12·5 [2·5] g/dL). In this study, children seemed at least as able as adults to compensate for the effects of haemodilution, which allowed major surgery without transfusion of homologous blood.

Background During severe isovolemic hemodilution, determination of critical hematocrit levels for the microvascular oxygenation of different organs might provide more insight into the effect of the redistribution of blood flow and oxygen delivery on the oxygenation of different organs. The effect of an increased amount of dissolved oxygen on tissue oxygenation during severely decreased hematocrit levels is not clear. Methods Fifteen anesthetized pigs were randomized between an experimental group (n = 10), in which severe isovolemic hemodilution was performed with 6% hydroxyethylstarch (1:1), and a time-matched control group (n = 5). Systemic, intestinal, and cerebral hemodynamic and oxygenation parameters were monitored. Microvascular oxygen partial pressure (muPo(2) ) was measured in the cerebral cortex and the intestinal serosa and mucosa, using the oxygen-dependent quenching of Pd-porphyrin phosphorescence. In the final phase of the experiment, fraction of inspired oxygen was increased to 1.0. Results Hemodilution decreased hematocrit from 25.3 +/- 3.0 to 7.6 +/- 1.2% (mean +/- SD). Systemic and intestinal oxygen delivery fell with the onset of hemodilution; intestinal oxygen consumption deceased at a hematocrit of 9.9%, whereas the systemic oxygen consumption decreased at a hematocrit of 7.6%. During hemodilution, the intestinal and cerebral oxygen extraction ratios increased from baseline with 130 and 52%, respectively. Based on the intersection of the two best-fit regression lines, determined by a least sum of squares technique, similar critical hematocrit levels were found for systemic oxygen consumption and the cerebral and intestinal mucosa muPo(2); the intestinal serosa muPo(2) decreased at an earlier stage (P < 0.05). Hyperoxic ventilation improved the muPo(2) values but not systemic or intestinal oxygen consumption. Conclusions During isovolemic hemodilution, the diminished oxygen supply was redistributed in favor of organs with a lower capacity to increase oxygen extraction. It is hypothesized that redirection of the oxygen supply within the intestines resulted in the preservation of oxygen consumption and mucosal muPo(2) compared with serosal muPo(2).

As postulated, acute isovolemic hemodilution induces a decrease in systemic vascular resistance (SVR) almost parallel to the decrease in blood viscosity, whereas cardiac index (CI) increases significantly without increase in myocardial contractility, while oxygen affinity of hemoglobin is unaffected (Messmer et al., 1973). Over a wide range of hematocrit (Hct) levels, the rise in CI compensates for the decreased oxygen transport capacity, thereby maintaining oxygen transport to the tissue unaltered. Nearly all data in the literature about the effects of hemodilution are obtained from experiments in dogs. Dogs, however, differ from humans in anatomy, distribution of coronary arteries and in sympathetic responses (Weaver et al, 1986). Therefore in this study cardiovascular responses, hemodynamics, oxygen transport to tissue and the oxygen affinity of hemoglobin during normoxic acute isovolemic moderate hemodilution were studied in pigs. Ample evidence exist to demonstrate that the pig is closely related to the human both anatomically and physiologically. The cardiovascular system and metabolism show similarities with respect to the size and distribution of coronary vessels, blood pressure, heart rate, cardiac index, regional distribution of cardiac output and maximum oxygen consumption (Swindle, 1984; Mc Krinan et al, 1986; Weaver et al., 1986).

16 patients underwent acute hypervolaemic haemodilution with dextran 40 and Ringers lactate, to see whether this procedure could avoid preoperative blood transfusion. Packed cell volume (PCV) and oxygen extraction decreased, and cardiac index and pulmonary wedge pressure increased, although end-systolic area was unchanged. PCV was not significantly different between patients who lost less than or greater than 20% of their initial blood volume. This preoperative manoeuvre, which reduces loss of red blood cells, allowed major surgery to be completed safely without blood transfusion.

40 patients (24 male, 16 female, aged 21-59 years) of American Society of Anesthesiologists class I or II who were undergoing routine surgery took part in a randomised, double-blind comparison of the anaesthetic efficacy and potency of xenon and nitrous oxide and their effects on the circulatory and respiratory systems. During anaesthesia, for each rise in blood pressure of more than 20% of the preanaesthetic (baseline) value, the patient received 0·1 mg fentanyl. The total amount of fentanyl required per patient was used as an index of the anaesthetic potency of the study gases. Patients in the xenon group required on average only 0·05 mg fentanyl, whereas those in the nitrous oxide group required 0·24 mg fentanyl; the duration of anaesthesia was similar in the two groups. Changes in blood pressure were significantly greater throughout the study in the nitrous oxide than in the xenon group. Thorax-lung compliance fell during the study period in the nitrous oxide group but not in the xenon group. Thus, xenon is a potent and effective anaesthetic which can be safely used under routine conditions.

We report the effects of acute hypervolaemic haemodilution, induced before operation, on haemodynamics and systemic oxygenation. Major surgery in an anaemic Jehovah's Witness patient was facilitated with this technique. Some hours after operation, a perioperative decrease in haemoglobin concentration of less than 5% was observed, in spite of a blood loss of nearly 50% of the calculated blood volume.

Background Complement activation during cardiopulmonary bypass (CPB) surgery is considered to result from interaction of blood with the extracorporeal circuit. We investigated whether additional mechanisms may contribute to complement activation during and after CPB and, in particular, focused on a possible role of the acute-phase protein C–reactive protein (CRP). Methods and Results In 19 patients enrolled for myocardial revascularization, perioperative and postoperative levels of complement activation products, interleukin-6 (IL-6), CRP, and complement-CRP complexes, reflecting CRP-mediated complement activation in vivo, were measured and related to clinical symptoms. A biphasic activation of complement was observed. The ratio between the areas under the curve of perioperative and postoperative C3b/c and C4b/c were 3:2 and 1:46, respectively. IL-6 levels reached a maximum at 6 hours post-surgery. CRP levels peaked on the second postoperative day. Each complement-CRP complex had peak levels on the second or third postoperative day. By multivariate analysis, maximum levels of CRP on the second postoperative day were mainly explained by C4b/c levels after protamine administration, leukocyte count on the second postoperative day, and preoperative levels of CRP. Peak levels of C4b/c after protamine administration ( P =.0073) and on the second postoperative day correlated with the occurrence of arrhythmia on the same day ( P =.0065). Conclusions Cardiac surgery with CPB causes a biphasic complement activation. The first phase occurs during CPB and results from the interaction of blood with the extracorporeal circuit. The second phase, which occurs during the first 5 days after surgery, involves CRP, is related to baseline CRP levels, and is associated with clinical symptoms such as arrhythmia.

Abstract Associations between birth weight and blood pressure have been found in children and adults. In this longitudinal study, the objective was to assess the relation between birth weight and blood pressure level and the change in blood pressure from childhood and young adolescence into adulthood. A cohort of 483 children from a middle-class community in the town of Zoetermeer in the Netherlands had annual measurements of blood pressure during an average follow-up period of 14 years. For 330 of these participants, initially aged 5 through 21 years, birth weight data were collected, which were related to blood pressure level and blood pressure change. An inverse association between birth weight and systolic blood pressure was found, with adjustment for current body height and weight, sex, and use of alcohol, cigarettes, and oral contraceptives. This inverse association was found for the total follow-up in 5- to 37- year-olds (regression coefficient: −2.4 mm Hg/kg; 95% confidence interval: −3.9 to −1.0, as well as in most individual age groups: 5 through 9 years (−0.6 mm Hg/kg, −3.2 to 2.0); 10 through 14 years (−2.5 mm Hg/kg, −4.7 to −0.4); 15 through 19 years (−3.1 mm Hg/kg, −4.9 to −1.2); 20 through 24 years (−2.7 mm Hg/kg, −4.6 to −0.9); 25 through 29 years (−2.0 mm Hg/kg, −3.9 to −0.01); and 30 through 37 years (−1.9 mm Hg/kg, −4.6 to 0.7). For diastolic blood pressure, there appeared to be an inverse association with birth weight in the age group of 30 through 37 years, both unadjusted (−2.0 mm Hg/kg, −4.6 to 0.5) and adjusted for risk factors other than sex (−2.3 mm Hg/kg, −4.7 to 0.1), although these findings were of borderline statistical significance. The results were independent of gestational age and were similar in the group of subjects with low birth weight but normal gestational age (−2.7 mm Hg/kg, −4.3 to −1.0). In relation to systolic blood pressure, birth weight showed a significant interaction with body mass index (regression coefficient, 0.02; SE=0.01; P =.05). There was no relation between birth weight and change in systolic or diastolic blood pressure with age. Our longitudinal study shows that birth weight is consistently inversely associated with systolic blood pressure level from childhood to young adulthood and with diastolic blood pressure in young adulthood. Birth weight is not related to change of blood pressure with increasing age. Low birth weight in combination with high current body mass index seems to be of particular importance in the development of high blood pressure.

We have studied the influence of motivation of care providers on the incidence and duration of postoperative hypoxaemia in the recovery room. In a prospective, switch-back designed cohort study, we have compared the incidence of low pulse oximeter saturation values (SpO2) during pre-intervention, intervention and post-intervention phases. Low SpO2 values were classified as either hypoxaemia (SpO2or = 90%, minimum duration 1 min) or artefact. Pulse oximetry trend data from 1350 patients, 450 in each group, were analysed. During the intervention phase, motivation was increased by adding an explicit instruction to prevent and treat low SpO2 values and making personnel aware that they were being studied (Hawthorne effect). The incidence of hypoxaemia decreased significantly from 17.8% during the pre-intervention phase to 11.6% during the intervention phase (relative risk (RR) 0.65, 95% confidence interval (CI) 0.47-0.90; P0.01). The incidence of severe hypoxaemia (SpO2or = 85%, 1 min) decreased from 7.8% to 3.3% (RR 0.43, CI 0.24-0.76; P0.01). The number of patients who had severe hypoxaemia for more than 5 min decreased from 13 to 1 (RR 0.08, CI 0.02-0.36; P0.01). In the post-intervention period, the incidence of hypoxaemia returned to pre-intervention values. The results of this study suggest that motivation of care providers to prevent and treat low SpO2 is an important determinant of postoperative hypoxaemia in the recovery room.

A pilot study of a perfluorochemical (PFC) emulsion was undertaken to determine whether administration of a perflubron emulsion could result in measurable changes in mixed venous oxygen tension. Seven adult surgical patients received a 0.9-g PFC/kg intravenous dose of perflubron emulsion after acute normovolemic hemodilution (ANH). Hemodynamic and oxygen transport data were collected before and after ANH, immediately after PFC infusion, and at approximate 15-min intervals throughout the surgical period. There were no clinically significant hemodynamic changes associated with the administration of the PFC emulsion. There was a significant increase in mixed venous oxygen tension (PVO2) after the PFC infusion, while cardiac output and oxygen consumption were unchanged. As surgery progressed, the hemoglobin concentration decreased with ongoing blood loss while PVO2 values remained at or above predosing levels. Peak perflubron blood levels were 0.8 g/dL immediately postinfusion, and approximately 0.3 g/dL at 1 h. This pilot study demonstrates that administration of perflubron emulsion results in measurable changes in mixed venous oxygen tension during intraoperative ANH.

Though it is generally accepted that venous blood oxygen tension (PO2) reflects (but does not measure) PO2 of the tissue from which it is issuing, it is generally impractical, except under unusual circumstances, to monitor PO2 in venous blood draining from individual tissues or organs. Hence, the mixed venous PO2 (PvO2) is usually taken as an acceptable estimator of the oxygen delivery/consumption ratio in the whole body and is used as a guide to the oxygenation status of the whole body. It would be logical therefore to use PvO2 as an indication for the need for blood transfusion during surgical procedures and in the trauma situation.

Several metabolic tests have been used to estimate the initial function of the transplanted liver. Most of them are clearance tests of exogenous or endogenous substances. Hyperkalemia and hypoglycemia during the immediate postoperative period are signs for poor liver function, while decreases in lactate and amino-acids levels, indicate good transplant function (Shapiro et al., 1986). Unfortunately, measurements of these latter parameters are only available postoperatively. Therefore intraoperatively, other available parameters must be relied on. A persistent reperfusion hyperglycemia peroperatively seems to be an early prognostic sign for impaired graft function (Mallett et al., 1989).