A massive, cooling-flow-induced starburst in the core of a luminous cluster of galaxies.

In the cores of some clusters of galaxies the hot intracluster plasma is dense enough that it should cool radiatively in the cluster's lifetime, leading to continuous 'cooling flows' of gas sinking towards the cluster centre, yet no such cooling flow has been observed. The low observed star-formation rates and cool gas masses for these 'cool-core' clusters suggest that much of the cooling must be offset by feedback to prevent the formation of a runaway cooling flow. Here we report X-ray, optical and infrared observations of the galaxy cluster SPT-CLJ2344-4243 (ref. 11) at redshift z = 0.596. These observations reveal an exceptionally luminous (8.2 × 10(45) erg s(-1)) galaxy cluster that hosts an extremely strong cooling flow (around 3,820 solar masses a year). Further, the central galaxy in this cluster appears to be experiencing a massive starburst (formation of around 740 solar masses a year), which suggests that the feedback source responsible for preventing runaway cooling in nearby cool-core clusters may not yet be fully established in SPT-CLJ2344-4243. This large star-formation rate implies that a significant fraction of the stars in the central galaxy of this cluster may form through accretion of the intracluster medium, rather than (as is currently thought) assembling entirely via mergers.

[Indicators of structural quality in palliative care for cancer pain patients in Lower-Saxony]. / Palliativmedizinische Betreuung von Tumorschmerzpatienten in Niedersachsen Indikatoren der Strukturqualität.

INTRODUCTION: Palliative care in Germany fails to reach established standards. To improve this situation the Chamber of Physicians of Lower-Saxony initiated SUPPORT in 1995. Prior to interventions structural quality of care was evaluated, specifically the rate of availability of opioid-prescription-forms and the ability to treat chronic pain (defined as a construct of knowledge, attitudes and skills) were examined. METHODS: The survey was carried out using a standardized questionnaire mailed to a representative stratified sample of 1200 physicians. RESULTS: Out of 865 answering physicians (response rate 72.1%) only 36.9% had their own opioid-prescription-forms. Differentiations regarding to specialty, working place (clinic vs. private practice) and treatment of cancer pain patients during the last three months shows a better result for GPs (84.6%), internists (48.6%), gynecologists (51%) and pain specialists (66.7%). Only 33.1% of respondents claimed knowledge of the WHO-3-step-analgesic-ladder. Again the aforementioned differentiations yield somewhat better results for GPs (49.2%), internists (51.5%), gynecologists (34.7%) and pain specialists (55.6%), however only two thirds of these physicians were able to identify the correct number of steps of the WHO-algorithm. CONCLUSIONS: These results verify an insufficient structural quality in palliative care in Lower-Saxony. In the authors' opinion effective improvements can only be achieved by implementing a parallel strategy:improvement of basic knowledge in pain management with sufficient transfer of this knowledge into practice as well as raising the rate of availability of opioid-prescription-forms,and, on the other hand, establishing local palliative-care-teams with nursing and medical expertise with 24/7 on-demand availability to optimize palliative care.

[Improvement of palliative outpatient treatment of terminally ill cancer patients - SUPPORT as example - The ethically preferable alternative to euthanasia]. / Optimierung der ambulanten palliativmedizinischen Betreuung terminal kranker Tumorpatienten am Beispiel SUPPORT - ethisch zu präferierende nach aktiver Sterbehilfe.

INTRODUCTION: Industrial countries are experiencing substantial increases in cancer prevalence. While advanced cancer therapies resulted in prolonged survival most neoplasms still are incurable. Especially advanced stages of cancer are often accompanied by severe pain and other disabling symptoms. Sufficient pain and symptom control is needed to maintain a decent quality of life for cancer patients. However, expert palliative care for patients suffering from cancer pain is still insufficient. These deficits have encouraged pro-euthanasia pressure groups demanding legitimation of physician-assisted-suicide in Germany. Acting under the guise of promoting patient's autonomy these groups are gaining additional momentum from similar legislation passed in the Netherlands. METHODS: Hospice movement and specialists in palliative medicine reject euthanasia as unethical and instead push for the global development of palliative care services. To address these issues the project SUPPORT was established in the Southern part of Lower-Saxony in 1996 with approval by the local ethics committee and sponsored by the German Ministry of Health. A palliative-care-team (PCT) of nurses and physicians with expert knowledge in palliative medicine supports patients after discharge from hospital by providing state-of-the-art palliative care at home. The PCT is available as a 24/7 standby service and can be called on demand by general practitioners, members of outpatient nursing services as well as by patients and their relatives. By cooperating with the PCT these professional and lay caregivers improve their knowledge and skills regarding pain and symptom control for terminally ill patients. RESULTS: During almost 4 years of practical work more than 50 % of the patients enrolled in the project died at home compared to about 20 % under regular conditions. These data point out quite impressively that due to the PCT-interventions recurrent hospitalisations in a majority of cancer pain patients can be avoided when expert knowledge and help is available at home for patients, their relatives and caregivers whenever needed. CONCLUSION: When sufficiently supported at home by palliative experts the number of patients dying at home is reasonably higher than the rate observed under regular conditions. This would also comply with the wishes of most patients who prefer to die in the privacy of their own home. The project data suggest that the concept of SUPPORT should be capable to improve the current state of palliative medicine in other areas of Germany as well.

Rapid X-ray flaring from the direction of the supermassive black hole at the Galactic Centre.

The nuclei of most galaxies are now believed to harbour supermassive black holes. The motions of stars in the central few light years of our Milky Way Galaxy indicate the presence of a dark object with a mass of about 2.6 x 106 solar masses (refs 2, 3). This object is spatially coincident with the compact radio source Sagittarius A* (Sgr A*) at the dynamical centre of the Galaxy, and the radio emission is thought to be powered by the gravitational potential energy released by matter as it accretes onto a supermassive black hole. Sgr A* is, however, much fainter than expected at all wavelengths, especially in X-rays, which has cast some doubt on this model. The first strong evidence for X-ray emission was found only recently. Here we report the discovery of rapid X-ray flaring from the direction of Sgr A*, which, together with the previously reported steady X-ray emission, provides compelling evidence that the emission is coming from the accretion of gas onto a supermassive black hole at the Galactic Centre.

[Basics of drug therapy of cancer pain]. / Grundlagen der medikamentösen Tumorschmerztherapie.

Industrial countries experience a significant increase of cancer prevalence. Despite recent advances in the treatment of various types of cancer still most of the patients cannot be cured. Especially the advanced incurable stages of cancer, however, often are accompanied by severe pain. Therefore, the high demand for a sufficient pain management and symptom control seems obvious. Throughout the last decades new drugs and techniques for the management of cancer pain have been developed. Most cancer patients should experience sufficient pain-management if existing recommendations for the pharmacological treatment of cancer pain (e.g. WHO-guidelines) are followed consequently. If, nevertheless, intractable pain or ongoing disabling symptoms continue despite proper therapy, every doctor should feel himself obliged to consult an expert in palliative medicine, in order not to tolerate avoidable suffering of his patient.

Chandra X-Ray Observations of the Hydra A Cluster: An Interaction between the Radio Source and the X-Ray-emitting Gas.

We present Chandra X-ray observations of the Hydra A cluster of galaxies, and we report the discovery of structure in the central 80 kpc of the cluster's X-ray-emitting gas. The most remarkable structures are depressions in the X-ray surface brightness, approximately 25-35 kpc in diameter, that are coincident with Hydra A's radio lobes. The depressions are nearly devoid of X-ray-emitting gas, and there is no evidence for shock-heated gas surrounding the radio lobes. We suggest that the gas within the surface brightness depressions was displaced as the radio lobes expanded subsonically, leaving cavities in the hot atmosphere. The gas temperature declines from 4 keV at 70 kpc to 3 keV in the inner 20 kpc of the brightest cluster galaxy (BCG), and the cooling time of the gas is approximately 600 Myr in the inner 10 kpc. These properties are consistent with the presence of an approximately 34 M middle dot in circle yr-1 cooling flow within a 70 kpc radius. Bright X-ray emission is present in the BCG surrounding a recently accreted disk of nebular emission and young stars. The star formation rate is commensurate with the cooling rate of the hot gas within the volume of the disk, although the sink for the material that may be cooling at larger radii remains elusive. A bright, unresolved X-ray source is present in the BCG's nucleus, coincident with the radio core. Its X-ray spectrum is consistent with a power law absorbed by a foreground NH approximately 4x1022 cm-2 column of hydrogen. This column is roughly consistent with the hydrogen column seen in absorption toward the less, similar24 pc diameter VLBA radio source. Apart from the point source, no evidence for excess X-ray absorption above the Galactic column is found.

Chandra X-Ray Detection of the Radio Hot Spots of 3C 295.

An observation of the radio galaxy 3C 295 during the calibration phase of the Chandra X-Ray Observatory reveals X-ray emission from the core of the galaxy, from each of the two prominent radio hot spots, and from the previously known cluster gas. We discuss the possible emission processes for the hot spots and argue that a synchrotron self-Compton (SSC) model is preferred for most or all of the observed X-ray emission. SSC models with near-equipartition fields thus explain the X-ray emission from the hot spots in the two highest surface brightness FR II radio galaxies, Cygnus A and 3C 295. This lends weight to the assumption of equipartition and suggests that relativistic protons do not dominate the particle energy density.

[Pain therapy in tumor patients and in palliative medicine. 1: Drug therapy]. / Schmerztherapie bei Tumorpatienten und in der Palliativmedizin. Teil 1: Medikamentöse Massnahmen.

Like other industrial countries Germany experiences a significant increase of cancer prevalence. Recent advances in the treatment of various types of cancer resulted in prolonged survivaltimes of patients. Cancer--especially in advanced incurable stages--often is accompanied by severe pain. Therefore, the need for sufficient pain management and symptomcontrol is obvious. Throughout the last decades new drugs and techniques for the management of cancer-pain have been developed. Most cancer-patients should experience sufficient pain-management if existing recommendations for the pharmacological treatment of cancer-pain (e.g. WHO-guidelines) are followed consequently. In case of intractable pain or ongoing disabling symptoms despite proper therapy consultation of an expert in palliative medicine should always be considered as well as the option to refer the patient to a specialized pain-management center.

[Pain therapy in tumor patients and in palliative medicine. 2: Invasive measures]. / Schmerztherapie bei Tumorpatienten und in der Palliativmedizin. Teil 2: Invasive Verfahren.

Anesthesiological and neurosurgical methods in the treatment of cancer pain have to be considered as parts of a holistic approach. To treat cancer pain patients appropriately, an interdisciplinary setting is essential. In the eyes of experienced pain specialists as well as physicians in palliative medicine invasive procedures are only of minor importance. Their use has been steadily decreasing while neuromodulatory (e.g. intraspinal opioids) or stimulatory (e.g. TENS, DBS, SCS) methods gained wider acceptance. The only neurolytic procedure which still has some importance is the neurolysis of the celiac ganglion for alleviation of pain in the upper abdomen mostly due to pancreatic cancer. This approach seems to be highly effective and tends to be afflicted with only minor complications. Other neurolytic blocks have shown solely local and temporal efficacy. In their majority they are unprecise and often accompanied by severe complications. Therefore these procedures should be scheduled only after carefully weighing risk versus benefit. Where suitable, the use of neurolytics is replaced by radiofrequency thermocoagulation, to a lesser degree by cryoanalgesia. Both procedures normally do not yield better analgesia but do result in fewer complications. Physicians tend to treat pain as a completely somatic disorder, but chronic pain states are always bio-psycho-social in nature. In order to achieve an effective pain treatment all influencing variables have to be taken into account. Anesthesiological and neurosurgical procedures are only a part of the possible and necessary treatment options. Especially before using one of the invasive methods described here, it seems imperative to involve the patient in the process of decision making more closely than currently practiced.

[Physical therapy in patients with COPD and tracheobronchial instability--comparison of 2 oscillating PEP systems (RC-Cornet, VRP1 Desitin). Results of a randommized prospective study of 90 patients]. / Physiotherapie bei Patienten mit COAD und tracheobronchialer Instabilität-Vergleich zweier oszillierender PEP--Systeme (RC-Cornet, VRP1 Desitin). Ergebnisse einer randomisierten Prospektivstudie an 90 Patienten.

UNLABELLED: In a randomized prospective study in 90 patients with COAD and tracheo-bronchial instability 3 groups were formed. Group 1: Therapy as group 3+ Physiotherapy with VRP1 Desitin, Group 2: Therapy as group 3+ Physiotherapy with RC-Cornet, Group 3: CONTROL GROUP: daily 40 mg prednisolon i.v., 2 x theophylline i.v. in relation to serum levels and 3 x inhalation of beta 2+ parasympathicolytic with a compressor inhaler. Therapy group 1 and 2 received the same drug and inhalation therapy as the controls. Controls of lung function before and after physiotherapy and visual analog scales for dyspnoea, cough, sputum and acceptance of the physiotherapy were performed at days 1, 4 and 7. With RC-Cornet the residual volume decreases statistically significant in comparison to VRP1 Desitin. Hyperventilation is also statistically significant smaller in RC-Cornet compared to VRP1 Desitin. The subjective improvement of sputum, dyspnoea and acceptance of the method of physiotherapy was statistically significant better for RC-Cornet. Regarding cough the significance was just failed by p < 0.055. RC-Cornet is a comfortable, effective, small accepted tool for the long term physiotherapy of patients with COAD and tracheobronchial instability.

[Prevalence of migraine in Germany.]. / Migräneprävalenz in Deutschland.

INTRODUCTION: There are no valid data available for Germany on the prevalence of migraine using the new diagnostic and classification criteria of the International Headache Society (IHS). SAMPLE AND METHODS: Therefore, a survey on migraine prevalence was carried out on a representative sample of 2000 residents aged 16 to 69 years of the states of the former West Germany. The questionnaire incorporated the new criteria of the IHS and the diagnosis of migraine was based on the corresponding classification. RESULTS: Some 23.4% of the sample suffered from headaches, and 3.6% were identified as having migraine according to the IHS classification. The prevalence of migraine was 5.3% in women and 1.7% in men. The highest prevalence of 5.7% was found in the group aged 40-49 years. By extending the 4-72 h IHS attack duration criterion to 2-72 h, the migraine prevalence increased from 3.6% to 4.4%. DISCUSSION: For methodological reasons our study may underestimate the true prevalence of migraine in Germany. Taking our rather "conservative" figures into account, our study reveals, however, that there are more than 2 million migraine sufferers in Germany between 16 and 69 years of age.

[Postoperative analgesia--a comparative study in laparoscopic cholecystectomy and lower abdominal laparotomy]. / Postoperative Analgesie--eine vergleichende Studie bei laparoskopischen Cholezystektomien und Unterbauchlaparotomien.

From September 1992 through February 1993 27 randomly chosen female patients were evaluated for differences in postoperative pain intensity (as determined by visual-analogue-scale (VAS)) and analgesic requirements via patient-controlled-analgesia (PCA), either after open lower-abdominal-laparotomy (n = 16, group 1) or after minimal-invasive-cholecystectomy (n = 11, group 2). The type of anaesthesia has been standardized, either as balanced or total intravenous anaesthesia. There were no statistically significant differences between the groups regarding to age, height, weight, intraoperative anaesthetic drug consumption, or duration of anaesthesia and surgery (205.6 vs 185.5 minutes; 139.1 vs 105.0 minutes). All patients could be extubated while still in the operation theatre. The 10-hour study period started after transfer to the recovery room. Heart- and respiratory-rate, systolic/diastolic blood pressure, endtidal pCO2, oxygen-saturation via pulsoxymetry (SaO2), and demands from PCA-pump were recorded, furthermore pain scores were determined every hour. The VAS-scores showed no significant differences between the two groups. The pain level as a whole was low, with the scores ranging from a maximum of 23.4 mm (group 1 after the first hour) to a minimum of 1.8 min (group 2 after 5, 8 an 10 hours). The overall analgesic requirements differed significantly (37.7 vs 17.3 mg piritramid, p < .01). There was a difference throughout the whole study period, although statistically significant only at the 1., 2. (p < .05), 5. and 6.-8. hour (p < .01). This study showed that pain scores were similar after laparoscopic upper or open lower abdominal surgery, both requiring adequate analgesic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[A multi-user documentation system for pain clinics.]. / Ein Patientendokumentationssystem für Schmerzkliniken und Schmerzambulanzen auf Basis vernetzter Personalcomputer.

In pain clinics, thorough documentation of patient-related data is essential for analysis of patient history, long-term evaluation of diagnostic and therapeutic procedures, and research on the etiology and epidemiology of chronic pain syndromes. With these requirements in mind, we realized a microcomputer documentation system based on a commercial data-base software concept (dBASE). Each patient's data are stored in three different sections: data for identification, basic data (mainly diagnostic findings), and treatment related follow-up data. The program was initially developed to run on a single IBM/XT- or AT-compatible computer (at least 640 kB RAM, 1 hard-disk-drive) with MS-DOS but has now been improved to work on a local area network (LAN) with the NOVELL-Netware operating system. Important features of our new system are: multi-user capability, flexible data management via menu-driven user dialogue, rapid data access, and high compatibility allowing data exchange with other standard software packages. The microcomputer documentation system offers listings for administration as well as effective patient scheduling thanks to a recall system by date of last contact, selected therapeutic procedures and any other item in the medical record. A mail-merge service can be applied, which is particularly useful for follow-up-studies. The documentation system means routine work can be standardized and performed in an economical manner, with the ultimate aim of enhancing the quality of pain therapy.