Outpatient commitment.
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Ambulatory Care↗
Biomedical subjects
J M Ryan
Publications and source records attributed to J M Ryan.
Exercise-induced QRS changes (Athens QRS score) in patients with coronary artery disease: a marker of myocardial ischemia.
Previous studies have shown a good correlation between exercise-induced changes of Q-, R-, and S-waves (Athens QRS score) and the number of the obstructed coronary arteries. The present study was undertaken to test the hypothesis that abnormal Athens QRS score is related to exercise-induced myocardial ischemia. Patients who had exercise radionuclide ventriculography (n = 150) or thallium-201 scintigraphy (n = 124) within 1 month of cardiac catheterization were studied. Athens QRS score was calculated based on the exercise-induced changes of the Q-, R-, and S-waves. Changes in Athens QRS score were compared to the number of obstructed coronary arteries, segmental contraction abnormalities, and exercise-induced myocardial perfusion defects. Athens QRS score and coronary artery disease: The Athens QRS score was decreased as the number of obstructed coronary arteries increased (normal coronary arteries 3.7 mm, confidence interval 1.0 to 3.9, one vessel disease 1.2 mm, two vessel disease -0.6 mm, three vessel disease -1.3 mm, p < 0.001). Athens QRS score and segmental contraction abnormalities: The Athens QRS score decreased as the number of segmental contraction abnormalities increased (no segmental contraction abnormalities 2.5 mm, confidence interval 1.0 to 3.9, one segmental contraction abnormality -0.4 mm, two segmental contraction abnormalities -1.5 mm, three segmental contraction abnormalities -2.6 mm, p < 0.001). Athens QRS score and reversible myocardial perfusion defects: The Athens QRS score was decreased as the number of exercise-induced myocardial perfusion defects increased (no perfusion defect 2.4 mm, confidence interval 0.9 to 3.9, one perfusion defect -0.7 mm, two perfusion defects -2.6 mm, three perfusion defects -3.3 mm, p < 0.001). Abnormal values of the Athens QRS score were better correlated with the number of exercise-induced segmental contraction abnormalities or the myocardial perfusion defects than the number of obstructed coronary arteries (p < 0.001). Exercise-induced changes in Athens QRS score were directly related to the number of obstructed coronary arteries, to exercise-induced segmental contraction abnormalities and to exercise-induced myocardial perfusion defects. However, Athens QRS score changes were more closely related to the number of exercise-induced segmental contraction abnormalities or to the exercise-induced myocardial perfusion defects than to the number of obstructed coronary arteries. The data suggest that exercise-induced QRS changes, Athens QRS score are related to exercise-induced myocardial ischemia.
Coronary Angiography↗
Safe removal of combat body armour lightweight following battlefield wounding -- a timely reminder.
Medical Support Troop Bravo (MST Bravo) provides third line medical support for the United Kingdom Battle Group currently deployed on operation Grapple 2 in Bosnia Herzegovina. Standing operating procedures for the initial assessment and resuscitation of all casualties are based on the protocols taught on Advanced Trauma Life Support (ATLS) and Battlefield Advanced Trauma Life Support (BATLS) courses. These protocols dictate a period of initial assessment and resuscitation with the casualty immobilised in the supine position. Recent experience in casualty management at MST Bravo has identified inadvertent spinal movement taking place during removal of Combat Body Armour Lightweight (CBA) which might have detrimental effects for casualties with occult spinal injury. This has led to an appraisal of CBA removal and the identification of a drill for rapid, safe and reliable means of undressing without jeopardy to the integrity of the spine. The method is described.
Humans↗
The surgical management in war of penetrating wounds contaminated with chemical warfare agents.
Military surgeons in a future conflict may face the problem of wounds contaminated with chemical warfare (CW) agents. No useful guidelines for this eventuality exist-nor any assessment of the specific CW risk to such casualties or to the surgical teams operating on them. The principal hazard to surgeons is direct contact with contaminated clothing in the wound. Practices are recommended to reduce this threat significantly. Thorough wound excision augmented by lavage with a specific proprietary hypochlorite solution will provide effective wound decontamination without producing unacceptable tissue damage. The vapour hazard at surgery is very low-respirators are unnecessary but goggles or glasses should be worn to prevent conjunctival splashes of potentially contaminated body fluids.
Chemical Warfare Agents↗
Histochemical and myosin composition of vampire bat (Desmodus rotundus) pectoralis muscle targets a unique locomotory niche.
The vampire bat pectoralis muscle contains at least four fiber types distributed in a nonhomogeneous pattern. One of these fiber types, here termed IIe, can be elucidated only by adenosine triphosphatase (ATPase) histochemistry combined with reactions against antifast and antislow myosin antibodies. The histochemical and immunohistochemical observations indicate a well-developed specialization of function within specific regions of the muscle. In parallel, analyses of native myosin isoforms and myosin heavy chain isoforms indicate two points. First, the histochemical "type IIe" fiber is predominant in cranial portions of the muscle, and myosin extracted from these regions exhibits a unique electrophoretic mobility not observed in the myosin isoforms of more traditional laboratory mammals. Second, the type I fibers are confined to the pectoralis abdominalis muscle and a small adjacent region of the caudal part of the pectoralis. This pattern of type I fiber distribution is considered a derived character state compared to muscle histochemical phenotype and isoform composition in the pectoralis muscles of other phyllostomids we have studied (Artibeus jamaicensis, Artibeus lituratus, Carollia perspicillata). We relate this to the unique locomotory needs of the common vampire bat, Desmodus rotundus.
Animals↗
Exercise-induced QRS prolongation in patients with coronary artery disease: a marker of myocardial ischemia.
The objective of this study was to investigate the effect of myocardial ischemia on the QRS duration in patients with coronary artery disease since acute myocardial ischemia decreases conduction velocity through the ischemic myocardium and may produce QRS prolongation on the surface electrocardiogram. One hundred fifty patients who underwent cardiac catheterization and exercise radionuclide ventriculography within 1 month of each other were studied. Forty patients had normal coronary arteries and 110 had coronary artery disease. QRS duration decreased with exercise in patients with normal coronary arteries (-3.0 msec, confidence limits -6.2 to 0.2), but increased in patients with coronary artery disease; exercise-induced QRS prolongation was directly related to the number of diseased vessels (4.8 msec in patients with one, 7.8 msec in patients with two, and 13.3 msec in patients with three-vessel disease, p < 0.001). Likewise, QRS duration decreased with exercise in patients without exercise-induced segmental contraction abnormalities (-1.8 msec, confidence limits -3.7 to 0.1), but increased in patients with segmental contraction abnormalities (6.7 msec in patients with one, 13.5 msec in patients with two, and 21 msec in patients with three segmental contraction abnormalities, p < 0.0001). Exercise-induced QRS prolongation was better related to the number of segmental contraction abnormalities than to the number of diseased vessels (p < 0.01). It was concluded that exercise produces QRS prolongation in patients with coronary artery disease in direct relation to the number of diseased vessels and to exercise-induced segmental contraction abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Gulf war wounds: application of the Red Cross wound classification.
The Red Cross wound classification was applied to 63 casualties requiring surgery in the recent Gulf war. The majority of wounds affect only soft tissue, caused predominantly by antipersonnel fragments. Bullet wounds were fewer but tended to be more severe, often involving a fracture or vascular damage. We recommend minor modification to the classification to include scoring of significant neurological injury. Further, we feel that by recording the distribution of all wounds as well as scoring the casualty's two worst injuries, the incidence and pattern of multiple wounds are ascertained, which is useful in military surgical research. We believe that the Red Cross wound classification is valuable in assessing a wound as part of a secondary survey, but that this wound score has little part to play in triage. It may help to decide management of individual wounds in clinical practice and is useful for recording the nature of wounds for future analysis.
Evaluation Studies as Topic↗
Management of service personnel with a history of penicillin allergy: discussion paper.
A false label of penicillin allergy may have important consequences for wartime medical evacuation. This article outlines the antibiotic protocol for war wounds, the current status of tests to diagnose true penicillin allergy and suggests a strategy for the management of personnel with a history of such allergy.
Drug Hypersensitivity↗
The matrix metalloproteinase pump-1 catalyzes formation of low molecular weight (pro)urokinase in cultures of normal human kidney cells.
The enzyme responsible for the metalloproteinase activity which cleaves the Glu143-Leu144 bond of (pro)urokinase has been isolated from the conditioned medium of cultured normal human kidney cells. Using S-Sepharose and Cibacron Blue-agarose chromatography, then C-4 reversed phase high pressure liquid chromatography, a protein of about 20,000 Da was isolated. Through an identical amino-terminal sequence, the protein was shown to be the matrix metalloproteinase previously referred to in the literature as "pump-1" (putative metalloproteinase). When aprotinin was added during the course of the purification, the major species isolated was the zymogen form (28,000 Da) of pump-1. Pump-1 has been shown to efficiently cleave the susceptible bond of both pro-urokinase (single-chain) and active (two-chain) urokinase and thereby produce the corresponding low molecular weight forms. The amino-terminal sequences of the A and B chains of low molecular weight urokinase prepared by action of pump-1 on recombinant high molecular weight urokinase are identical to those of the low molecular weight urokinase isolated from human kidney cell culture. Since the reaction of urokinase with this metalloproteinase results in separation of its serine proteinase region from the domain which mediates binding to the urokinase receptor, it may be of importance in the regulation of the functional activity of the plasminogen activator in cellular processes.
Amino Acid Sequence↗
Elbow extensor muscles of the horse: postural and dynamic implications.
Based on histochemical and immunohistochemical evidence, horse elbow extensor muscles are composed of two morphologically distinct muscle groups. The long and lateral heads of the triceps brachii are large, predominantly type II (presumed fast) muscles. The long and lateral heads of the triceps together account for 96% of the weight of the elbow extensors (long head of triceps is 81%). The long and lateral heads contain three histochemical fiber types: types I, IIa and IIb. Type I muscle fibers account for approximately 18 and 27% of the fibers in the long and lateral heads of the triceps, respectively. In the lateral head, type IIa and IIb fibers account equally for the remaining 70%, while in the long head of the triceps type IIb fibers predominate (50%) over type IIa fibers (32%). In contrast, the much smaller medial head of the triceps (2% of triceps mass) and the anconeus (2% of mass) contain almost exclusively type I muscle fibers. It is hypothesized that the medial head and anconeus, with their slow fibers, contribute to the postural maintenance of the forelimb by preventing flexion at the elbow joint during passive stance. The larger long and lateral heads, with their generally fast fiber populations, are most likely important during dynamic activity.
Animals↗
Towards the 21st century: provision of battlefield surgical care.
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Forecasting↗
Use of disposable skin staplers for bowel anastomosis to reduce laparotomy time in war.
Laparotomy for penetrating wounds to the abdomen is demanding in terms of time, skill and resources. Any modification of existing techniques that will lessen these demands will be of benefit at surgery in forward areas in war. A previous paper (1) compared a method of small bowel anastomosis using disposable skin staplers with a two-layer handsewn anastomosis using fresh pig ileum. The stapled method was both significantly faster to perform and mechanically superior. In two further studies on a total of 12 pigs the stapled method has been compared with a single-layer and a double-layer handsewn small bowel anastomosis. All 12 pigs recovered from laparotomy without complication. Construction times were recorded. The quality of healing of the anastomoses was assessed by clinical observation, post-mortem and histological examination, and tensiometry. The skill required to perform the stapled anastomoses was estimated subjectively. The stapled technique was consistently faster than the handsewn methods. A Kolmogorov two-sample test showed an improvement in times when comparing the stapled method with the single layer, with a significance of P = 0.05. An improvement was also seen when the stapled method was compared with the double layer, with a significance of P = 0.01. There was no statistically significant difference between the construction times for the two handsewn methods. There was no evidence of anastomotic failure or haematoma at post-mortem and no adverse reaction to the metal staples. No features were identified on histology to indicate impaired healing with the stapled method. Tensiometry of the anastomoses showed that the stapled anastomosis is as mechanically reliable as the handsewn anastomosis. The level of skill required to perform the stapled anastomosisis judged to be within the capabilities of relatively junior surgeons once the technique has been mastered in an anastomosis workshop.
Anastomosis, Surgical↗
A survey of rugby injuries attending an accident & emergency department.
A prospective study was carried out on 242 patients attending an Accident & Emergency Department with injuries sustained while playing rugby football. The average age was 19.8 years. Head and neck injuries were more prevalent but less serious then in studies carried out before recent law changes. The lower limb was still the part of the body most frequently injured but again there were fewer serious injuries. There was a marked increase in upper limb injuries. Wing forward was the position most likely to give rise to injuries and prop was the least. Poor compliance is still a significant problem with rugby injuries can only lead to an improvement in the safety of the game.
Adolescent↗
Coronary artery dilatation requiring high inflation pressure.
A patient with rigid coronary lesions refractory to balloon dilatation is described. A Cordis Orion fixed wire balloon able to withstand 20 bar was required for successful dilatation.
Aged↗
Field surgery on a future conventional battlefield: strategy and wound management.
Most papers appearing in the surgical literature dealing with wound ballistics concern themselves with wound management in the civilian setting. The pathophysiology of modern war wounds is contrasted with ballistic wounds commonly encountered in peacetime, but it should be noted that even in peacetime the modern terrorist may have access to sophisticated military weaponry, and that patients injured by them may fall within the catchment area of any civilian hospital. Management problems associated with both wound types are highlighted; areas of controversy are discussed. The orthodox military surgical approach to ballistic wounds is expounded and defended.
Anti-Bacterial Agents↗
Assessment of the use of disposable skin staplers in bowel anastomoses to reduce laparotomy time in penetrating ballistic injury to the abdomen.
Laparotomy and anastomosis of the small bowel after penetrating injury to the abdomen is a lengthy procedure. This paper describes the use of skin staplers for bowel anastomosis and presents the results of a short series of experiments upon dead pigs to compare the staple technique with conventional handsewn anastomosis. The time taken to perform each small bowel anastomosis, the integrity of the anastomosis and the skill required were assessed. The staple technique was considerably faster (mean construction time: 5.4 min, range 4-6 min) than the handsewn technique (mean construction time: 12 min, range 10-14 min), at least halving the anastomosis time (Kolmogorov two-sample test P = 0.05). In addition, the stapled anastomosis had a higher intraluminal failure pressure (mean failure pressure: 65 cmH2O, 6.37 kPa, range 30-70 cmH2O) than the handsewn anastomosis (mean failure pressure: 38.6 cmH2O, 3.78 kPa, range 10-70 cmH2O).
Abdominal Injuries↗
Long distance travel for routine elective surgery: questionnaire survey of patients' attitudes.
OBJECTIVE: To carry out an audit and assess the acceptability of long distance travel to patients on a lengthy surgical waiting list. DESIGN: Audit and questionnaire survey. SETTING: Military hospital in Wiltshire. PATIENTS: 116 Patients on a general surgical waiting list at Leighton Hospital near Crewe. INTERVENTIONS: Preselection for medical fitness at a waiting list review clinic. RESULTS: Roughly half of patients offered the facility of travelling 120 miles (190 km) for their routine elective operation at the health authority's expense accepted. The average waiting list time declared by the patients who travelled was 28 months, and 13 patients stated that their condition prevented them from working. Only four patients regretted their decision to participate in the scheme. Lack of visitors did not cause undue concern. CONCLUSIONS: Some patients did not agree to travel for their operation but almost all of those who did so found the scheme satisfactory. Some minor problems were encountered but these could probably be overcome by ensuring use of appropriate transport, extending the postoperative stay when necessary, and more careful selection of patients for an anaesthetic. For efficient use of theatre time in such schemes it is crucial that the operating consultant surgeon should be in charge of case selection.
Attitude to Health↗
Interaction of penetrating missiles with tissues: some common misapprehensions and implications for wound management.
It is apparent from review of published papers and books that misunderstanding and confusion exists in the minds of many authors describing the interaction of penetrating missiles with tissues. These misapprehensions may influence the management of wounds by suggesting didactic approaches based upon a preconceived notion of the nature and severity of the wound for different types of projectiles. This review considers the biophysics of penetrating missile wounds, highlights some of the more common misconceptions and seeks to reconcile the conflicting and confusing management doctrines that are promulgated in the literature-differences that arise not only from two scenarios, peace and war, but also from misapprehensions of the wounding process. Wounds of war and of peacetime differ both in the nature of the wound and in the propensity for wound infection. Additionally, the limitations imposed by war dictate the type of management that may be practised and result in procedures that would be considered inappropriate by some in civilian clinical practice. Many of the procedures described in civilian peacetime settings, such as reliance on antibiotics alone for the control of infection in penetrating wounds, or minimal excision and debridement, can yield good results but would herald disaster if transposed to a war setting.
Anti-Bacterial Agents↗