Are the three hydroxyphenyl radical isomers created equal?--The role of the phenoxy radical.

We have investigated the thermal decomposition of the three hydroxyphenyl radicals (˙C6H4OH) in a heated microtubular reactor. Intermediates and products were identified isomer-selectively applying photoion mass-selected threshold photoelectron spectroscopy with vacuum ultraviolet synchrotron radiation. Similarly to the phenoxy radical (C6H5-O˙), hydroxyphenyl decomposition yields cyclopentadienyl (c-C5H5) radicals in a decarbonylation reaction at elevated temperatures. This finding suggests that all hydroxyphenyl isomers first rearrange to form phenoxy species, which subsequently decarbonylate, a mechanism which we also investigate computationally. Meta- and para-radicals were selectively produced and spectroscopically detectable, whereas the ortho isomer could not be traced due to its fast rethermalization and rapid decomposition in the reactor. A smaller barrier to isomerization to phenoxy was found to be the reason for this observation. Since hydroxyphenyl species may be present under typical sooting conditions in flames, the resonantly stabilized cyclopentadienyl radical adds to the hydrocarbon pool and can contribute to the formation of polycyclic aromatic hydrocarbons, which are precursors in soot formation.

Perturbation-facilitated detection of the first quintet-quintet band in C2.

The first high-spin transition in C2 (1 (5)Πu - 1 (5)Πg) is observed by perturbation-facilitated optical-optical double resonance spectroscopy. The experiment is performed by applying unfolded two-color resonant four-wave mixing. C2 radicals in the initial a (3)Πu, v = 5 state are produced by using a discharge source in a molecular beam environment. The final quintet state is excited via intermediate "gateway" states exhibiting both substantial triplet and quintet character due to a perturbation between the 1 (5)Πg, v = 0 and the d (3)Πg, v = 6 states. Fifty seven rotational transitions in the P, Q, and R branches of all spin sub-states are measured and yield accurate molecular constants of the newly found upper level 1 (5)Πu. In addition, satellite transitions (ΔJ ≠ ΔN) are observed and allow an accurate determination of the spin-orbit constant. The results are compared with high-level ab initio computations at the multi-reference configuration interaction level of theory. The high-lying quintet state is found to be predissociative and displays a shallow potential that accommodates three vibrational levels only.

Atomic structure and crystalline order of graphene-supported ir nanoparticle lattices.

We present the atomic structure of Ir nanoparticles with 1.5 nm diameter at half height and three layers average height grown on graphene/Ir(111). Using surface x-ray diffraction, we demonstrate that Ir nanoparticles on graphene/Ir(111) form a crystallographic superlattice with high perfection. The superlattice arrangement allows us to obtain detailed information on the atomic structure of the nanoparticles themselves, such as size, shape, internal layer stacking and strain. Our experiments disclose that the nanoparticles reside epitaxially on top of the graphene moiré structure on Ir(111), resulting in significant lateral compressive intraparticle strain. Normal incidence x-ray standing wave experiments deliver additional information on the particle formation induced restructuring of the graphene layer.

Perturbation facilitated two-color four-wave-mixing spectroscopy of C3.

Perturbation-facilitated two-color resonant four-wave-mixing spectroscopy is realized to access the (dark) triplet manifold of the C3 molecule from the singlet X̃(1)Σg (+) ground state. The inherent nonlinear signal dependence and coherence of the technique result in a favorable detection of the excited triplet states of interest. The observation of a newly found (3)Δu electronic state is achieved by a two-step excitation via "gate-way" levels (i.e., singlet-triplet mixed levels). Additionally, by fixing the probe laser on a transition exhibiting mainly triplet-triplet character and scanning the pump laser, we demonstrate an effective spin-filtering in a four-wave mixing measurement where only transitions to the perturber (3)Σu(-) state appear exclusively in an otherwise congested spectral range of the Comet band. Ab initio calculations of excited triplet states complement our analysis with the electronic assignment of the observed resonances.

Matrix change of bone grafting substitute after implantation into guinea pig bulla.

BACKGROUND: Many different surgical techniques have been developed to remove open mastoid cavities. In addition to autologous materials, alloplastic substances have been used. A very slow absorption of these materials and extrusion reactions have been reported. We investigated a newly developed, highly porous bone grafting material to eliminate open mastoid cavities, in an animal model. To characterise the transformation process, the early tissue reactions were studied in relation to the matrix transformation of the bone material. MATERIAL AND METHODS: NanoBone (NB), a highly porous bone grafting material based on calcium phosphate and silica, was filled into the open bullae from 20 guinea pigs. The bullae were examined histologically. Energy dispersive X-ray spectroscopy (EDX) was used to investigate the change in the elemental composition at different sampling times. The surface topography of the sections was examined by electron microscopy. RESULTS: After 1 week, periodic acid-Schiffs (PAS) staining demonstrated accumulation of glycogen and proteins, particularly in the border area of the NB particles. After 2 weeks, the particles were evenly coloured after PAS staining. EDX analysis showed a rapid absorption of the silica in the bone grafting material. CONCLUSIONS: NanoBone showed a rapid matrix change after implantation in the bullae of guinea pigs. The absorption of the silica matrix and replacement by PAS-positive substances like glycoproteins and mucopolysaccharides seems to play a decisive role in the degradation processes of NB. This is associated with the good osteoinductive properties of the material.

Shedding light on a dark state: the energetically lowest quintet state of C2.

In this work we present a deperturbation study of the d (3)Π(g), v=6 state of C(2) by double-resonant four-wave mixing spectroscopy. Accurate line positions of perturbed transitions are unambiguously assigned by intermediate level labeling. In addition, extra lines are accessible by taking advantage of the sensitivity and high dynamic range of the technique. These weak spectral features originate from nearby-lying dark states that gain transition strength through the perturbation process. The deperturbation analysis of the complex spectral region in the (6,5) and (6,4) bands of the Swan system (d(3)Π(g)-a (3)Π(u)) unveils the presence of the energetically lowest high-spin state of C(2) in the vicinity of the d (3)Π(g), v=6 state. The term energy curves of the three spin components of the d state cross the five terms of the 1 (5)Π(g) state at rotational quantum numbers N ≤ 11. The spectral complexity for transitions to the v = 6 level of d (3)Π(g) state is further enhanced by an additional perturbation at N = 19 and 21 owing to the b (3)Σ(g)(-), v=19 state. The spectroscopic characterization of both dark states is accessible by the measurement of 122 "window" levels. A global fit of the positions to a conventional Hamiltonian for a linear diatomic molecule yields accurate molecular constants for the quintet and triplet perturber states for the first time. In addition, parameters for the spin-orbit and L-uncoupling interaction between the electronic levels are determined. The detailed deperturbation study unravels major issues of the so-called high-pressure bands of C(2). The anomalous nonthermal emission initially observed by Fowler in 1910 [Mon. Not. R. Astron. Soc. 70, 484 (1910)] and later observed in numerous experimental environments are rationalized by taking into account "gateway" states, i.e., rotational levels of the d (3)Π(g), v=6 state that exhibit significant (5)Π(g) character through which all population flows from one electronic state to the other.

[Cystic gastric tumor with calcifications]. / Zystischer Magentumor mit Verkalkungen.

In imaging techniques was seen a thickness of the gastric wall in a patient with pain for several months and loss of weight. Biopsies taken out of the tumor mass by gastroscopy and laparoscopy have not been ground-breaking. For this disease pattern is it not unusual that the diagnosis of heterotopic pancreatic tissue with pancreatitis is not confirmed until a resection of the stomach.

Inhibitors of retroviral DNA polymerase: their implication in the treatment of AIDS.

Compared to other T-lymphotropic human retroviruses, human T-cell leukemia (lymphotropic) virus I (HTLV-I) and HTLV-II, the acquired immunodeficiency syndrome (AIDS)-associated virus, HTLV-III, is a nontransforming cytopathic virus without immortalizing activity. Thus the virus replication is an important event in the manifestation of this disease, and the interruption of viral replication offers an important strategy for the control of AIDS. For this reason we have purified the reverse transcriptase (RT) from HTLV-III and from HTLV-III infected cells to study the structure-activity relationship of RT inhibitors developed in our laboratory. The cellular DNA polymerases from H9 cells were also purified to study the selectivity of RT inhibitors. Purified HTLV-III RT has several distinguishing features: (a) unlike the HTLV-I enzyme it is highly stable and can be kept for several weeks without any loss of activity; (b) using identical procedures of isolation the HTLV-III enzyme shows a much higher activity than does the enzyme from HTLV-I; (c) the Vmax for HTLV-III RT is by severalfold higher than that for the HTLV-I enzyme in the presence of (rC)n X (dG)12 and (rCm)n X (dG)12, and besides the usual template-primers used for RT assay this enzyme has a relatively high affinity for (rAm)n X (dT)12; and (d) the cationic requirements for the transcription of various template-primers are unusual. The purified enzyme has a molecular weight of 95,000-98,000, as judged by the gel filtration method. The purified HTLV-III RT was inhibited by a partially thiolated polycytidylic acid (5-mercaptopolycytidylic acid); the cellular DNA polymerase beta from H9 cells was not sensitive to 5-mercaptopolycytidylic acid. Germanin (synonym, suramin), an antiprotozoan drug, also inhibits HTLV-III RT activity, but the DNA polymerase alpha activity was also sensitive to Germanin. The nonspecific effect of Germanin is probably due to the high content of sulfonic acid residues. This paper describes new approaches for designing specific inhibitors of retroviral reverse transcriptases which may be useful in developing a potential drug against AIDS.

Intravascular ultrasound after low and high inflation pressure coronary artery stent implantation.

OBJECTIVES: We sought to characterize the differences seen after low or high pressure coronary artery stent deployment as assessed by intravascular ultrasound. BACKGROUND: Until 1992, the success of stent deployment was assessed by angiographic criteria only, but in 1993 the procedure was expanded to include postprocedural single-use intravascular ultrasound imaging. Ultrasound criteria for successful stent deployment were 1) symmetry, 2) minimal lumen diameter > 3.0 mm, 3) no echo-free spaces between the stent and the vessel, and 4) no uncovered dissections. METHODS: We used mechanical 4.8F or 3.5F 20- or 30-MHz monorail single-use intravascular ultrasound catheters. RESULTS: Fifty-two patients were included, 28 treated in 1991 and 1992 (group A) and 24 treated in 1993 or 1994 (group B); 87% of patients underwent elective stent implantation. The number of echocardiographic studies per patient increased from 1 +/- 0.1 (mean +/- SD) in group A to 2.0 +/- 0.85 in group B. Mean maximal balloon size increased from 3.3 +/- 0.33 to 3.73 +/- 0.24 mm and maximal inflation pressure from 6.9 +/- 1.1 to 15.8 +/- 2.4 bar (p < 0.001). The eccentricity index was 0.915 +/- 0.04 in group B versus 0.87 +/- 0.05 in group A. Minimal lumen diameter measured by echocardiography increased from 2.55 +/- 0.41 mm in group A to 3.14 +/- 0.37 mm in group B. The final mean values per cross-sectional area as a percent of calculated balloon area were similar in group A (67.5 +/- 23%) and group B (66.5 +/- 22.9%). No major acute complications occurred in either group; subacute thrombosis developed in two patients, both in group A. CONCLUSIONS: Intravascular ultrasound data confirm that high pressure stent deployment leads to increased minimal lumen area. Despite high pressure stent deployment, homogeneous stent geometry and optimal stent expansion were not observed in all patients.

Three-dimensional ultrasound imaging of the atrial septum: normal and pathologic anatomy.

OBJECTIVES: This study investigated the feasibility of producing three-dimensional gray scale ultrasound images of the atrial septum to demonstrate normal and pathologic anatomy. BACKGROUND: Two-dimensional echocardiography is the principal technique used for imaging the atrial septum. Although the diagnostic accuracy of two-dimensional echocardiography is high, its capability for displaying complex three-dimensional relations is limited. METHODS: Three-dimensional ultrasound images were reconstructed from tomographic images obtained during routine transesophageal echocardiographic examinations. Custom-made semi-automatic algorithms for image enhancement, interpolation and segmentation were used to produce volumetric gray scale images. Volume-rendered displays of the atrial septum were generated for analysis. Sequential three-dimensional images were generated through the cardiac cycle and displayed cinematographically to permit assessment of motion. RESULTS: The three-dimensional images obtained from six patients clearly demonstrated normal and pathologic anatomy of the atrial septum, including atrial septal defects, atrial septal aneurysm and aortic valve ring abscess. The images could be manipulated electronically to demonstrate spatial relations and internal structural details. CONCLUSIONS: Three-dimensional gray scale reconstruction of ultrasound images obtained by transesophageal echocardiography is feasible. These images clearly demonstrate anatomic details and spatial relations. The gray scale images may be interactively manipulated to optimize the clinician's visualization of the atrial septum and its associated pathologic conditions.

Intravascular ultrasound imaging in acute aortic dissection.

OBJECTIVES: This study was performed to determine the potential of intravascular ultrasound in the detection and delineation of aortic dissection. BACKGROUND: Intravascular ultrasound is a new technique capable of displaying real-time cross-sectional images of arterial vasculature. Its clinical use has been explored mostly in coronary and peripheral arterial circulation. METHODS: Intravascular ultrasound imaging of the aorta was performed using a 20-MHz ultrasound catheter in 28 patients with suspected aortic dissection. All patients underwent contrast angiography; 7 had computed tomography; and 22 had transesophageal echocardiography. RESULTS: Imaging of the aorta from the root level to its bifurcation was performed in all patients in an average of 10 min. No complications occurred. Dissection was present in 23 patients and absent in 5. In the patients without dissection, intravascular ultrasound revealed normal aortic anatomy. In all 23 patients with dissection, intravascular ultrasound demonstrated the intimal flap and true and false lumena. The longitudinal and circumferential extent of aortic dissection, contents of the false lumen, involvement of branch vessels and the presence of intramural hematoma in the aortic wall could also be identified. In cases where aortography could not define the distal extent of the dissection, intravascular ultrasound did. CONCLUSIONS: Our experience in this series of patients with aortic dissection indicates that intravascular ultrasound could be valuable in the identification and categorization of aortic dissection and in the description of associated pathologic changes that may be clinically important. It can be performed rapidly and safely and could serve as an alternative or adjunct diagnostic procedure in patients with aortic dissection.

Care of diabetic patients by optometrists in New York State.

OBJECTIVE: This study was undertaken to learn about the involvement of optometrists in the eye care of diabetic patients in New York and to collect baseline data for planning intervention programs in diabetic eye disease. RESEARCH DESIGN AND METHODS: This study was conducted by a mail survey being sent to all optometrists in New York whom we could identify through state sources (n = 2270). Three follow-up mailings were conducted. RESULTS: Eighty-six percent who received our mailing responded, 87% of whom reported that they see diabetic patients. Analysis was confined to this 87%. Routine retinal examinations were provided by 68% of the respondents who see diabetic patients, 62% of whom dilate the pupils. Sixty-eight percent who see diabetic patients diagnose retinopathy solely by their own examination, and 60% of these dilate. Follow-up of retinopathy was provided by 15% of optometrists who see diabetic patients, 90% of whom dilate the pupils of their diabetic patients. Twenty-five percent of respondents who see diabetic patients refer them to an ophthalmologist for diagnosis of retinopathy, and 67% refer all retinopathy patients to an ophthalmologist for follow-up. Although 91% of respondents recommended eye examinations at least annually for diabetic patients, only 68% specifically recommended annual examinations through dilated pupils. Those who dilate were significantly more likely to recommend annual dilated examinations than those who do not dilate, regardless of practice setting. CONCLUSIONS: These findings indicate that optometrists as a group see many diabetic patients. Intervention strategies should include increased emphasis on the use of dilation when examining diabetic patients and annual dilated retinal examinations.

The community ecology of diabetes patient classification and practice characteristics.

We examined the clinical and epidemiologic characteristics of diabetic subjects ascertained from five different sources (hospital, private practice, specialist practice, nursing home, and prevalence survey) in a medium-sized upstate New York community. Patients were categorized using the National Diabetes Data Group classification (based on weight and insulin requirement) and using an alternative clinical classification scheme based on age at onset and insulin use. Both classifications demonstrate marked differences in the distribution of diabetic subjects. Those seen in general medical practice reflect the prevalent population and tend to have fewer complications and less insulin requirement. Those seen in specialist practice or in hospital have higher complication frequencies. Thus, the source of patients may determine the epidemiologic picture of the disease, as well as the practitioners' perceptions. Use of the clinical classification scheme helps to identify a subgroup of diabetic subjects--those with onset past the age of 25 yr who use insulin--at greatest risk of complications. Further investigation of high-risk groups is warranted, particularly for the implementation and evaluation of diabetes control programs.

Biochemical heterogeneity of reverse transcriptase purified from the AIDS virus, HTLV-III.

The reverse transcriptase from AIDS virus, HTLV-III, was purified and characterized. The purified enzyme has a very high affinity for template primers (rC)n X (dG)12 and (rCm)n X (dG)12 compared to that for (rA)n X (dT)12. In addition, the HTLV-III reverse transcriptase was able to transcribe (rAm)n X (dT)12 very efficiently. The ionic requirements are unique in the sense that HTLV-III reverse transcriptase prefers Mg2+ as divalent ions to transcribe (rC)n X (dG)12 and (rA)n X (dT)12. The Mr of the enzyme is 95 000-98 000. Unlike the HTLV-I reverse transcriptase, the HTLV-III enzyme is highly stable and has a much higher activity in the presence of (rC)n X (dG)12; the Vmax for HTLV-III reverse transcriptase is several-fold higher than that for HTLV-I enzyme. The enzyme activity of the purified reverse transcriptase from HTLV-III was resolved into two peaks on a preparative isoelectric column, one at pH 5.75 and the other at pH 6.25. This leads us to conclude that the reverse transcriptase of HTLV-III is biochemically heterogeneous.

Novel features of retroviruses associated with human diseases.

The last decade has witnessed a new chapter in the history of retrovirology. As of now, four human retroviruses have been identified and molecularly characterized. They are associated with a wide spectrum of human diseases including cancer, immunodeficiency and neurological disorders. By virtue of their clinical relevance, their novel genes and regulatory mechanisms these viruses have become the focal point of research in retrovirology. The study of these viruses is of fundamental importance in understanding the mechanisms leading to transformation of human cells and distortion of the immunological state.

Serological relationship between reverse transcriptases from human T-cell lymphotropic viruses defined by monoclonal antibodies. Evidence for two forms of reverse transcriptases in the AIDS-associated virus, HTLV-III/LAV.

The immunological relationship between reverse transcriptases purified from human T-cell lymphotropic viruses (HTLV-I, HTLV-II, HTLV-III) was defined using monoclonal antibodies specific for HTLV-III reverse transcriptase, secreted by a mouse/mouse hybridoma clone (4F8) developed in our laboratory. The viral proteins from HTLV-I and HTLV-II do not bear any cross-reactive epitope to antibodies secreted by this clone. These antibodies specifically cross-react with HTLV-III reverse transcriptase. The antibodies failed to neutralize the catalytic activity of reverse transcriptase; however, after immunoprecipitation with a magnetic conjugate of goat anti-mouse IgG, the residual activity was completely inhibited. This shows that the antibodies are not directed towards the catalytic active center of the enzyme. Using an immunoblotting technique (Western blotting), we have found two cross-reactive proteins with HTLV-III lysate with molecular masses of 53 and 66 kDa. This suggests that HTLV-III possesses two reverse transcriptase activities with a common determinant recognized by the same epitope.

Classification of morphologic effects of percutaneous transluminal coronary angioplasty assessed by intravascular ultrasound.

The aim of this study was the assessment and classification of the morphologic effects of percutaneous transluminal angioplasty (PTCA) by intravascular ultrasound (IU). Fifty-eight patients were examined immediately after PTCA with a 4.8Fr, 20 MHz rotational tip IU system. In 10 patients (17%), IU images could not be analyzed due to failure of the imaging system or poor image quality. In 48 patients (83%; 40 men and 8 women, aged 55 +/- 9 years), IU images of 48 PTCA segments, as well as 41 distal and 44 proximal sites, were analyzed. The left anterior descending artery was studied in 30 patients, the right coronary artery in 17 and the left main coronary artery in 1. Calcium was present in 32 of 48 PTCA segments (67%). Plaque morphology was concentric in 18 patients (38%) and eccentric in 30 (62%). Seven distinct morphologic patterns were observed. In concentric plaques, plaque compression without significant wall alterations (type 1) was found in 2 patients (4%), superficial tears within the plaque (type 2) in 1 (2%) and deep tears (type 3) in 8 (17%). Deep tearing associated with submedial or subintimal dissection (type 4) was found in 2 patients (4%). Dissection between plaque and vessel wall without noticeable intimal tearing (type 5) was the most common morphology (n = 15; 31%) and occurred in concentric and eccentric plaques. In eccentric plaques, no significant tearing of the plaque (type 6) was found in 6 patients (13%), and tearing of the plaque close to its base with dissection (type 7) in 14 (29%).(ABSTRACT TRUNCATED AT 250 WORDS)

Extent of atherosclerosis and remodeling of the left main coronary artery determined by intravascular ultrasound.

This study used intravascular ultrasound (IU) to assess the incidence and extent of left main coronary artery (LMCA) disease and the effects of arterial remodeling. Sixty-nine patients undergoing cardiac catheterization were imaged with a 20 MHz rotational-tip IU device. Nine of the 69 studies (13%) could not be analyzed because of technical (n = 2) or anatomic (n = 7) reasons. Of the remaining 60 patients, 38 (63%) had at least 1 lesion in the left coronary artery perfusion territory by angiography; significant LMCA stenosis was present in 2 patients (3%). Intravascular ultrasonography demonstrated plaques in 27 of 60 LMCAs (45%), 6 of them in patients with normal angiograms. Twenty-four plaques (89%) were eccentric and calcium was present in 4 (15%). The mean minimal lumen diameter was 4.9 +/- 0.8 mm, the maximal lumen diameter was 5.6 +/- 0.8 mm, the planimetered lumen area was 22.6 +/- 6.0 mm2, the plaque area was 3.9 +/- 5.8 mm2, the vessel area was 26.5 +/- 5.9 mm2, and the area stenosis was 13 +/- 19%. In the 27 patients with plaque, plaque area was 8.7 +/- 5.7 mm2 and the area stenosis was 30 +/- 17%. The vessel area was significantly larger in diseased LMCAs (p < 0.001) and correlated with plaque area (r = 0.46). IU examination of the LMCA was feasible in 87% of patients and was more reliable for delineating plaques than angiography.

Comparison of measurement of left ventricular ejection fraction by Tc-99m sestamibi first-pass angiography with electron beam computed tomography in patients with anterior wall acute myocardial infarction.

The goal of this study was to compare measurements of left ventricular (LV) ejection fraction (EF) by first-pass radionuclide angiography ("first-pass angiography") using technetium-99m (Tc-99m) sestamibi with those by contrast-enhanced electron beam computed tomography ("electron beam tomography") as a reference technique in patients with an anterior wall acute myocardial infarction (AMI). Twenty-five patients with first Q-wave anterior wall AMI underwent paired electron beam tomographic and first-pass angiographic studies (mean, 1 day apart). Fourteen patients had 2 sets of measurements of the LVEF obtained by both methods (separated by at least 6 weeks), for a total of 39 paired measurements. LVEF by electron beam tomography was calculated from absolute systolic and diastolic LV chamber volumes. LV volumes by electron beam tomography were 199 +/- 51 ml at end-diastole and 111 +/- 42 ml at end-systole. Mean LVEF was 45 +/- 11% by first-pass tomography and 46 +/- 9% by electron beam tomography. The linear correlation coefficient between both methods was 0.82 (p <0.0001), with slope = 1.0, y-intercept = -1.1, and SEE = 6.1. The mean difference between the 2 methods was -0.7 +/- 6.0 EF units (p = 0.75). The correlation between the differences and means of both methods was 0.34 (p = 0.04), indicating a trend for first-pass angiography to overestimate LVEF in the higher range. LVEFs measured by first-pass angiography in patients with abnormal LV geometry and contraction patterns caused by anterior wall AMI agree well with those measured by electron beam tomography in the clinically relevant range.

Hepatic encephalopathy in liver cirrhosis: pathogenesis, diagnosis and management.

The pathogenesis of hepatic encephalopathy (HE) is unknown. Many theories have been proposed. Most established therapies are based on such theories but since no theory has have ever been proved, therapies have to be considered empiric. The spectrum of HE ranges from minimal cerebral functional deficits, which can only be found by sensitive psychometric tests, to coma with signs of decerebration. HE has arbitrarily been divided into stages. A number of precipitating factors are known and the first line of therapy should always be the elimination of these factors. The differential diagnosis includes all states of impaired consciousness and deficits in cerebral function in patients with chronic liver disease, and clinical and biochemical tests to differentiate are indicated. The therapeutic options for HE include: protein restriction only for a limited time in comatous patients; nonabsorbable antibiotics (aminoglycosides), which because of adverse effects are also limited to higher grades of HE: intestinal cleansing which is applicable in all degrees of HE; lactulose, branched chain aminoacids and ornithin aspartate which have been proven to be effective and can be applied long term in patients with lower grades of HE.