Biomedical subjects
Publications and source records attributed to A Paul.
Central neuraxial block is associated with increased vagal tone. We report a patient who developed laryngospasm and stridor under spinal anaesthesia. This was treated successfully with i.v. atropine and fluids. We propose that the laryngospasm was secondary to increased vagal tone under the spinal anaesthetic. Such a manifestation of increased vagal tone under spinal anaesthesia has not been reported previously.
The purpose of this study was to evaluate whether there was any significant difference in the rates of infection and of secondary surgical procedures to promote bone union, between early(6 h or less after arrival to hospital) and delayed(more than 6 h) surgical treatment of open tibial fractures. Three hundred and eighty-three open tibial fractures were evaluated. 184 fractures had early and 199 had delayed surgical treatment. The rates of infection and secondary surgical procedures to promote bone union of the two groups were compared with univariate and multivariate statistical methods. There was no statistically significant difference between early and delayed treatment groups with respect to overall infection (53/184 versus 51/199 infection rates, P = 0.96), deep infection (8/184 versus 8/199 infection rates, P = 1.0), and rates of secondary surgical procedures to promote bone union (24/184 versus 20/198, P = 0.77). We were unable to demonstrate any significant difference in infection rates or need of secondary procedures to promote bone union, between early and delayed surgical treatment of open tibial fractures.
Spontaneous intracranial hypotension (SIH) is an uncommon condition caused by cerebrospinal fluid leakage. We report of a 29-year-old woman with typical symptoms in whom initial cranial MRI and CT were normal . A clinical diagnosis of SIH, but the symptoms did not resolve with conservative therapy or a lumbar epidural blood patch. Repeat MRI revealed (indirect) findings consistent with SIH but failed to directly demonstrate a cerebrospinal fluid fistula. Subsequent CT myelography revealed leakage of contrast medium into the epidural space bilaterally along the nerve roots at C3-7. Following the myelography the patient reported dramatic clinical improvement with complete resolution of symptoms. The adhesive quality of the myelographic contrast medium might have precipitated closure of the meningeal tears. Myelography may be not only of diagnostic value but also therapeutic in SIH.
The liver is the most common target organ for metastatic disease. The majority of patients undergoing surgical treatment for liver metastases have colorectal primaries. Endocrine liver metastases, or metastases from other tumors such as mammary carcinoma, sarcomas, renal tumors or gastrointestinal stromal tumors (GIST) are appreciably less common for surgical treatment. The gold standard of treatment is resection of the metastatic lesions. In the meantime, advances in surgical techniques and improved perioperative patient management make it possible to perform extensive resections with acceptable morbidity and mortality rates. In the event of metastases that are not primarily resectable, various downstaging procedures are available, with the aid of which secondary resectability can be achieved. Among the interventional treatment options that should be applied only in palliative intent, radiofrequency ablation is in widespread use.
BACKGROUND: Hepatocellular carcinoma (HCC) arising in normal liver parenchyma is rare and the outcome after hepatectomy is not well documented. METHODS: Between June 1998 and September 2003, 33 patients without viral hepatitis underwent resection for HCC in a non-cirrhotic, non-fibrotic liver. Data were analysed with regard to operative details, pathological findings including completeness of resection, and outcome as measured by tumour recurrence and survival. RESULTS: Twenty-three major hepatectomies and ten segmentectomies or bisegmentectomies were performed. After potentially curative resection, 19 of 29 patients were alive at a median follow-up of 25 months, with calculated 1- and 3-year survival rates of 87 and 50 per cent respectively. Survival was significantly better after resection of tumours without vascular invasion (3-year survival rate 89 versus 18 per cent; P = 0.024). Disseminated recurrence developed in nine of 29 patients, leading to death within 28 months of operation in all but one of the nine. CONCLUSION: These data justify hepatic resection for HCC arising in non-cirrhotic, non-fibrotic liver without underlying viral hepatitis. Liver transplantation is rarely indicated because the outcome is good after resection of tumours without vascular infiltration, whereas vascular invasion is invariably associated with diffuse extrahepatic recurrence.
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The adequate management of brain dead donors on an Intensive Care Unit (ICU) is one of the major key points for a successful transplantation of harvested organs. In addition to an invasive monitoring like in any other ICU patient these patients needs a meticulous attention to their hemodynamic. The early administration of desmopressin to treat diabetes insipidus, a differentiated use of fluid resuscitation and a distinct catecholamine support are special features of an appropriate basic treatment. The administration of corticoids has to be considered if a sufficient circulation can not be regained.
We used electron-beam lithography to fabricate chemical nanostructures, i.e. amino groups in aromatic self-assembled monolayers (SAMs) on gold surfaces. The amino groups are utilized as reactive species for mild covalent attachment of fluorescently labeled proteins. Since non-radiative energy transfer results in strong quenching of fluorescent dyes in the vicinity of the metal surfaces, different labeling strategies were investigated. Spacers of varying length were introduced between the gold surface and the fluorescently labeled proteins. First, streptavidin was directly coupled to the amino groups of the SAMs via a glutaraldehyde linker and fluorescently labeled biotin (X-Biotin) was added, resulting in a distance of approximately 2 nm between the dyes and the surface. Scanning confocal fluorescence images show that efficient energy transfer from the dye to the surface occurs, which is reflected in poor signal-to-background (S/B) ratios of approximately 1. Coupling of a second streptavidin layer increases the S/B-ratio only slightly to approximately 2. The S/B-ratio of the fluorescence signals could be further increased to approximately 4 by coupling of an additional fluorescently labeled antibody layer. Finally, we introduced tetraethylenepentamine as functional spacer molecule to diminish fluorescence quenching by the surface. We demonstrate that the use of this spacer in combination with multiple antibody layers enables the controlled fabrication of highly fluorescent three-dimensional nanostructures with S/B-ratios of >20. The presented technique might be used advantageously for the controlled three-dimensional immobilization of single protein or DNA molecules and the well-defined assembly of protein complexes.
The effect of ethanol on the interaction between the anionic surfactant sodium dodecyl sulfate (SDS) and the nonionic polymer poly(vinylpyrrolidone) (PVP) has been investigated using a range of techniques including surface tension, fluorescence, electron paramagnetic resonance (EPR), small-angle neutron scattering (SANS), and viscosity. Surface tension and fluorescence studies show that the critical micelle concentration (cmc) of the surfactant decreases to a minimum value around 15 wt % ethanol; that is, it follows the cosurfactant effect. However, in the presence of PVP, the onset of the interaction, denoted cmc(1), between the surfactant and the polymer is considerably less dependent on ethanol concentration. The saturation point, cmc(2), however, reflects the behavior of the cmc in that it decreases upon addition of ethanol. This results in a decrease in the amount of surfactant bound to the polymer [C(bound) = cmc(2) - cmc] at saturation. The viscosity of simple PVP solutions depends on ethanol concentration, but since SANS studies show that ethanol has no effect on the polymer conformation, the changes observed in the viscosity reflect the viscosity of the background solvent. There are significant increases in bulk viscosity when the surfactant is added, and these have been correlated with the polymer conformation extracted from an analysis of the SANS data and with the amount of polymer adsorbed at the micelle surface. Competition between ethanol and PVP to occupy the surfactant headgroup region exists; at low ethanol concentration, the PVP displaces the ethanol and the PVP/SDS complex resembles that formed in the absence of the ethanol. At higher ethanol contents, the polymer does not bind to the ethanol-rich micelle surface.
By measuring the fringe visibility in a Young's double pinhole experiment, we demonstrate that quasi-phase-matched high-harmonic generation produces beams with very high spatial coherence at wavelengths around 13 nm. To our knowledge these are the highest spatial coherence values ever measured at such short wavelengths from any source without spatial filtering. This results in a practical, small-scale, coherent, extreme-ultraviolet source that is useful for applications in metrology, imaging, and microscopy.
Acute liver failure represents one of the most challenging conditions in intensive care treatment. In most cases there is no causal medical therapy available for survive making the intensive care treatment as the most important management tool, as bridge to transplant or still the recovery of the liver! These patients frequently develop multi-organ failure, placing them at risk of hemodynamic disorder, cerebral edema, coagulopathy and various renal and metabolic complications.
The morphology of micelles formed by two novel metallosurfactants has been studied by small-angle neutron scattering (SANS) and small-angle-X-ray scattering (SAXS). The two surfactants both contain a dodecyl chain as the hydrophobic moiety, but differ in the structure of the head group. The surfactants are Cu(II) complexes of monopendant alcohol derivatives of a) the face-capping macrocycle 1,4,7-triazacyclanonane (tacn), and b) an analogue based upon the tetraazamacrocycle 1,4,7,10-tetraazacyclododecane. Here, neutron scattering has been used to study the overall size and shape of the surfactant micelles, in conjunction with X-ray scattering to locate the metal ions. For the 1,4,7,10-tetraazacyclododecane-based surfactant, oblate micelles are observed, which are smaller to the prolate micelles formed by the 1,4,7-triazacyclononane analogue. The X-ray scattering analysis shows that the metal ions are distributed throughout the polar head-group region, rather than at a well-defined radius; this is in good agreement with the SANS-derived dimensions of the micelle. Indeed, the same model for micelle morphology can be used to fit both the SANS and SAXS data.
The outcomes of 19 consecutive living-donor renal transplants (LD-RTx) was compared with 41 cadaveric grafts (CD-RTx) performed at our institution using basiliximab, cyclosporine, and prednisone as standard immunosuppression. LD-RTx significantly shortened the waiting time on dialysis. However, patient survival (100% in both groups), 1-year graft survival (94.7% vs 90%), and rejection-free graft survival (76.9% vs 73.5%) was not significantly different. LD-RTx showed better glomerular filtration rates in the early phase after transplantation, a difference that faded with time. Graft function was similar after 1 and 2 years. LD grafts with double renal arteries were used successfully in four cases; heparin therapy was administered to avoid graft thrombosis. A significantly greater number of lymphoceles was observed with LD grafts (7/19 vs 1/41, P < .01). In conclusion with improved immunosuppression producing better results with CD grafts, the advantages of LD-RTx have vanished. LD grafts with double arteries may be used successfully and LD-RTx allows a shorter dialysis period. The high incidence of lymphoceles in our series awaits further evaluation.
A 40-year-old woman developed myelopathy manifesting as Brown Sequard syndrome after administration of Anti-venom (polyvalent enzyme-refined equine globulin supposed to neutralise 0.6 mg of standard cobra venom, 0.45 mg of standard krait venom, 0.6 mg of standard Russel's viper venom and 0.45 mg of saw scaled viper venom, manufactured by Serum Institute of India, Pune, India). It was concluded to be an immunological inflammation of the spinal cord after ruling out hematomyelia on imaging. The necessity of antivenom in semipoisonous snake bites have been addressed further in the article.
OBJECTIVES: To compare the validity, responsiveness to change, and user friendliness of four self completed, shoulder-specific questionnaires in primary care. METHODS: A cross sectional assessment of validity and a longitudinal assessment of responsiveness to change of four shoulder questionnaires was carried out: the Dutch Shoulder Disability Questionnaire (SDQ-NL); the United Kingdom Shoulder Disability Questionnaire (SDQ-UK); and two American instruments, the Shoulder Pain and Disability Index (SPADI) and the Shoulder Rating Questionnaire (SRQ). 180 primary care consulters with new shoulder region pain each completed two of the questionnaires, as well as EuroQoL and 10 cm visual analogue scales (VAS) for overall pain and difficulty due to the shoulder problem. Each participant was assessed by a standardised clinical schedule. Postal follow up at 6 weeks included baseline measures and self rated assessment of global change of the shoulder problem (seven point Likert scale). RESULTS: Strongest correlations were found for SDQ-UK with EuroQoL 5 score, and for SPADI and SRQ with shoulder pain and difficulty VAS. All shoulder questionnaires correlated poorly with active movement at the painful shoulder. SPADI and SRQ performed better on ROC analysis than SDQ-NL and SDQ-UK (areas under the curve of 0.87, 0.85, 0.77, and 0.77, respectively). However, SRQ scores changed significantly over time in stable subjects. CONCLUSIONS: Cross sectional comparison of the four shoulder questionnaires showed they had similar overall validity and patient acceptability. SPADI and SRQ were most responsive to change. Additionally, SPADI was the quickest to complete and scores did not change significantly in stable subjects.
BACKGROUND: In 1999 the Clinic for Internal Medicine and Integrative Medicine was founded in Essen as a regular part of the German inpatient health care system. Integrative medicine (standard internal medicine, evidence-based complementary and alternative medicine combined with intensified lifestyle modification) aims to help patients with chronic illness to cope with their condition more effectively and to achieve a health-promoting lifestyle. Techniques include cognitive restructuring, the elicitation of the relaxation response, and lifestyle education. The goal is to increase health-related quality of life (QoL) as well as control beliefs and to reduce morbidity in later life. AIM: To demonstrate changes in quality of life, lifestyle, and control beliefs after a two-week hospital stay. METHODS: Uncontrolled prospective observational study with 557 consecutive hospital patients. Outcome parameters were quality of life (SF36), control beliefs (GKU), and daily health-related behavior (nutrition, physical activity, relaxation) on admission, at discharge, as well as 3 and 6 months after discharge. RESULTS: Weekly physical activity increases by 29%, consumption of not recommendable foods decreases by 18%. The majority of patients (57%) engage in relaxation exercises 6 months after discharge (on admission 23%). The physical sum scale (SF36) increases from 33.9 (95% KI 32.5-35.3) on admission to 37.3 (35.8-38.9) 6 months after discharge, the mental sum scale from 41.2 (39.5-42.9) to 45.1 (43.5-46.7). The ratio internal/external control belief rises from 1.17 (95% KI 1.11-1.24) to 1.32 (1.24-1.40). Pretherapeutic ratio internal/external control belief and its increase are associated with rises in QoL. CONCLUSIONS: After integrative medicine treatment a lasting increase in QoL and lifestyle changes can be achieved. Reinforcement of internal control beliefs and own competence is possible and enhances outcomes in chronically ill patients.
The unique pathophysiology of end-stage liver disease (ESLD) has important implications on critical care treatment after liver transplantation. To determine hemodynamic parameters and responses, each patient must be carefully evaluated for the individual clinical appearance of cirrhosis and portal hypertension. Although data are limited, recent progress in the treatment of ESLD and its complications, such as hepatorenal syndrome (HRS), portopulmonary hypertension (PPH), and hepatopulmonary syndrome (HPS) is evident. The improved understanding of the pathophysiology of ESLD has resulted in novel treatments and approaches to the problems that emerge as patients get critically ill or undergo orthotopic liver transplantation (OLT). These issues become much more relevant with increased adult-to-adult living donor liver transplantation, where the scheduled operation allows a precise preoperative management in an Intensive Care Unit (ICU).
Septic arthritis is a potential catastrophic complication of intra-articular steroid injection. There is lack of evidence regarding the precautions that should be taken to avoid such a complication, as well as how often it is encountered. The aim of this study was to evaluate the antiseptic precautions taken during intra-articular steroid injection of the knee in the United Kingdom (UK), and estimate how often septic arthritis is encountered by health professionals in the UK following steroid injection of the knee. A questionnaire was posted to 100 orthopaedic surgeons, 100 rheumatologists and 50 general practitioners (GPs), asking them about the cases of septic arthritis following intra-articular steroid injection of the knee that they encountered during their practice and the precautions they take when injecting knees. The response rate was 76.4%; 57.6% of the respondents used alcohol swabs to clean the skin, and the remaining 42.4% used chlorhexidine or Betadine. Only 16.3% used sterile towels to isolate the injection site. There were 32.5% of respondents who routinely used sterile gloves when injecting, and a total of 46.6% used either sterile or non-sterile gloves. Also, 91.1% changed needles between drawing the steroid and injecting it into the joint. Only 24 respondents (12.6%) had encountered septic arthritis after steroid injection of the knee (18 once, 3 twice, 2 three times, 1 several times). We concluded that septic arthritis post intra-articular steroid injection of the knee is probably rare. There is a wide variation in the precautions taken to avoid such a complication. However, the trend seems to be towards minimal use of antiseptic techniques. Further large prospective studies are needed to determine how frequently septic arthritis of the knee is encountered post steroid injection, and the exact precautions that should be taken to avoid it.