[Medical end-of-life decisions - the challenge to adjust laws to ethical demands]
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Editorial↗
Biomedical subjects
L Martin
Publications and source records attributed to L Martin.
Enhancement of sensitivity to hyperthermia by lonidamine in human cancer cells.
Human glioma (87MG) and squamous cell carcinoma of the head and neck UMSCC-1 were shown to be sensitized to hyperthermia by Lonidamine treatment before and during hyperthermia. The degree of thermal sensitization increased with increasing heating times and temperatures. In addition, the thermal sensitization by Lonidamine as well as cellular thermal sensitivity were dependent on pH and increased with the more acidic pH. Even though plateau phase cells were more thermally resistant than exponentially growing cells, Lonidamine treatment caused thermal sensitization under both conditions. These data show that Lonidamine may hold potential to enhance the effectiveness of hyperthermia in cancer treatment and that especially in tumours with low pH an enhanced therapeutic gain may be achieved.
Antineoplastic Agents↗
Longitudinal forces acting on a knitted polyester arterial prosthesis when implanted as a thoracic aorta substitute in the dog.
The longitudinal forces under which arterial prostheses are held in situ are of great importance. The tension caused by the longitudinal force may be one of the factors involved in the formation of anastomotic false aneurysms. In order to measure the changes in the longitudinal force at both proximal and distal end-to-end anastomoses over different periods of implantation, we devised an experimental study in which the changes in length of a warp-knitted polyester VP1200K (Vascutek Ltd., Inchinnan, Scotland) arterial prosthesis, used as a thoracic aorta substitute in the dog, were recorded photographically at implantation and removal. The longitudinal forces acting at the two sites were then calculated using a linear relationship between the longitudinal force and the changes in length of a virgin prosthesis, which was found experimentally in vitro using a computerized laser calibration system. One-tailed Student's t-test showed no significant difference between the length indicator values at the two anastomotic sites at different periods of implantation except during the 1-month period. Textile analysis of the explanted prostheses and histopathologic observations confirmed this similar behavior at the two anastomotic sites. These observations were contrary to the theoretic prediction regarding the effect of forces applied by drag and tissue ingrowth. Nevertheless, analysis of variance confirmed that there was no difference evident at the two sites between different implantation periods. These observations may explain why the formation of anastomotic false aneurysms is less common at end-to-end anastomoses.
Animals↗
Pumpless respiratory assistance using a membrane oxygenator as an artificial placenta: a preliminary study in newborn and preterm lambs.
Newborns suffering from severe respiratory difficulties and not responding to conventional methods have been successfully treated by extracorporeal circulation with a membrane oxygenator (ECMO). However, the technique needs a highly specialized staff, excellent laboratory support, and continuous surveillance of the procedure to prevent complications. In a series of experiments on newborn and preterm lambs, we have investigated a relatively simpler technique of respiratory support that involves a pumpless arteriovenous bypass by cannulating both umbilical arteries and the umbilical vein. A highly efficient microporous membrane oxygenator (MO) with very low resistance was selected. This type of perfusion that mimics the placental circulation, besides providing an additional amount of oxygen to the blood, has proven to be very effective for CO2 extraction. Before its application in humans, however, improvements in the catheters to be inserted in the umbilical vessels, some modifications in the design of the MO, and improvements in the blood compatibility of all foreign surfaces in contact with blood are needed.
Animals↗
Longitudinal forces acting at side-to-end and end-to-side anastomoses when a knitted polyester arterial prosthesis is implanted in the dog.
In a previous study, which investigated the tensions at the proximal and distal end-to-end anastomoses of a vascular prosthesis, no significant differences were found in the longitudinal forces between the two anastomotic sites after different periods of implantation. The present follow-up study was devised to study the longitudinal forces at a proximal side-to-end and a distal end-to-side anastomosis using a warp knitted polyester prosthesis implanted as a canine thorocoabdominal bypass. The external surface of the prosthesis contained a specially printed "tension indicator" design, which enabled changes in length to be assessed photographically at the two anastomoses at the time of implantation and at sacrifice. The longitudinal force at each site was then calculated using a relationship obtained experimentally between the total longitudinal force and the changes in length of the virgin graft in vitro. The in vitro measurements on the prosthesis were performed using a computer-controlled laser calibration system. Although the results showed a tendency toward a gradual loss in longitudinal force at both anastomoses over 7 months in situ, statistical analysis showed no significant difference in the longitudinal force at the two anastomotic sites after any period of implantation. Histopathological and textile analysis also showed that the characteristics of the prostheses were similar at both anastomotic sites. This does not mean, however, that the intramural stress concentrations experienced by the two sites were the same. While comparing the level of the longitudinal forces measured in this study with those observed in the previous thoracic aorta study using end-to-end anastomoses, no significant differences were observed due to the different types of anastomoses. It would appear that the longitudinal force is not one of the main etiological factors that cause the formation and localization of anastomotic failure.
Anastomosis, Surgical↗
The clinical equipment coordinator: a new role in the hospital industry.
The increase in use, complexity, and cost of medical equipment requires a management response in both large and small hospitals. This paper describes the position of Clinical Equipment Coordinator (CEC) as it developed at Anaheim Memorial Hospital in Anaheim, California. The CEC can be highly effective in coordinating contract or shared services for a small hospital. In the larger hospital with an in-hospital Clinical or Biomedical Engineering Department, the CEC can take on the responsibilities of coordinating the services of the department. A detailed Job Description is presented along with typical forms and guidelines.
Biomedical Engineering↗
Become involved in political process: one person can make the difference.
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Legislation as Topic↗
[Inverted papilloma of the sino-nasal tract (author's transl)].
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Biopsy↗
Pitfalls in diagnosis of occupational lung disease for purposes of compensation--one physician's perspective.
Occupational caused lung disease (OLD) is almost always compensable, either by application to workers' compensation agencies or by a civil lawsuit. For this reason the diagnosis usually comes under close scrutiny. Several pitfalls can occur when a physician diagnoses a patient as having lung disease of occupational origin, especially when compensation is at issue. These pitfalls can trap both the attorney advocate and his client, and lead to a result opposite of that intended (e.g., the claim one supports can be denied). For purposes of discussion I have categorized the pitfalls as follows: A. Making an unsupported medical diagnosis (looking for a "quick fix"). B. Echoing an unsupported diagnosis made by someone else. C. Inadequate clarification of 'impairment' and 'disability.' D. Ignoring or minimizing relevant medical history. E. Arguing against yourself. F. Ignoring the possibility of a rare or unusual diagnosis. G. Not obtaining or reviewing independent chest x-rays and reports. H. Attributing causation with certainty when it is unwarranted by the facts. I. Relying on a claimant's own smoking history. J. Misinterpreting pulmonary function and arterial blood gas tests. K. Missing the real cause of a patient's complaint. L. Diagnosing occupational lung disease without attempting to remove the patient from the cause. M. Confusion over basic terminology and pathophysiology in OLD. N. Using sloppy or incorrect language, including misspelling. O. Not saying "I don't know," when you don't know. Pitfalls in diagnosis generally arise from either physician bias or inadequate evaluation. Although most pitfalls seem to be made by physicians on the plaintiff's side, they are also made by physicians on the defendant's side, as when bias interferes with recognizing a condition that is occupational in origin. Ideally, the fact that diagnosis of OLD involves the legal profession should not affect a physician's objectivity or clinical approach. Physicians have an obligation to help assure that deserving patients receive compensation, and that claimants without a compensable occupational illness are not unjustly rewarded. However, the attorney's need to prove a diagnosis "with medical certainty," and the defendant's need to refute that diagnosis with equal certainty, often skew what would otherwise be a straightforward diagnostic process. Resulting pitfalls in diagnosis can, in the end, trap the physician advocate and the side he is trying to help.
Clinical Competence↗
Knowledge acquisition and evaluation of an expert system for managing disorders of the outer eye.
The aim of the current study was to develop and evaluate an expert system for diagnosing outer eye disorders, intended to support family physicians and nurse practitioners in the management of patients with minor eye complaints. The knowledge in the program was gathered from the scientific literature and from 6 experienced ophthalmologists and 6 ophthalmic nurses. Fourteen diagnoses must be considered, and the differential diagnosis is dependent upon 32 signs and symptoms. The program calculates the most likely diagnosis, presents photographs of the typical ocular findings, and provides information regarding management and treatment. The program's output was compared with the diagnosis made by 8 other ophthalmologists at a Swedish university clinic, based on data from 157 patients with disorders of the outer eye, who visited the emergency ward during a one-week period. The concordance between the diagnosis made by the ophthalmologists and the program was 96%. In conclusion, the expert system for disorders of the outer eye provided essentially the same diagnostic information as an examination by an ophthalmologist. Support from the program would make it possible for family physicians and nurse practitioners to manage most of these patients.
Diagnosis, Computer-Assisted↗
[Disposable versus reusable biopsy forceps. A prospective cost analysis in the gastrointestinal endoscopy unit of the Dijon University Hospital].
AIMS: The goal of this study was to compare the cost of a biopsy session performed with a disposable and a reusable endoscopic biopsy forceps. MATERIAL AND METHODS: Over a 10-month period, 15 new reusable forceps (10 gastric and 5 colonic) were prospectively tracked. A biopsy session performed with a reusable forceps included its current purchase price, the sterilization cost and the number of uses. A biopsy session performed with a disposable forceps was calculated with its current purchase price and its incineration cost. RESULTS: At the end of the study, only one reusable forceps had broken and the number of uses was 65. The cost of a biopsy session performed with a gastric reusable forceps was euro 7.52 (including euro 1.92 of sterilization cost) and euro 8.67 for a reusable colonic forceps (with the same sterilization cost). The cost of a biopsy session performed with a gastric or a colonic disposable forceps was euro 11.98. From 44 uses for a colonic forceps and 37 uses for a gastric one, a biopsy session performed with a reusable forceps was already cheaper. CONCLUSION: In this study, a biopsy session performed with a reusable forceps was less expensive than with a disposable one. However, the extra cost generated by the disposable forceps may be offset by an easier inventory control and the reduction of the cross contamination risk.
Biopsy↗
[Post-radiotherapy eruption in a patient treated with valproic acid. Rowell's syndrome?].
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Anti-Inflammatory Agents↗
[Genital papules revealing a Churg-Strauss syndrome].
INTRODUCTION: Cutaneous lesions are rarely inaugural in Churg and Strauss syndrome. We report the case of a patient in whom recurrent papular lesions of the penis revealed a Churg-Strauss granulomatous angeitis. OBSERVATION: A 54 year-old man consulted for recurrent non-infiltrated and painless erythematous papules of the penis over the past 4 years. His past history revealed severe asthma, which had appeared at the same time, nasal polyposis and chronic sinusitis. Other than the genital organs, the clinical examination was normal. Histological exploration of a cutaneous biopsy of the penis showed a necrotic granulomatous vasculitis. The usual biological examinations were normal. Research for proteinuria, hematuria and measurement of polynuclear anticytoplasm antibodies were negative. Pulmonary X-ray revealed a bilateral interstitial syndrome with micronodules. The broncho-alveolar wash revealed moderate granulocyte alveolitis with numerous eosinophilic polynuclears. The electromyogram showed a reduction in the sensitive potential of the nerves explored in the 4 limbs. Churg-Strauss granulomatous angeitis was diagnosed. Treatment with 0.8 mg/kg/day of prednisone was initiated. The cutaneous lesions disappeared rapidly. Since three months later there had been no relapse, corticosteroid therapy was slowly and progressively reduced. Nine months later, the patient exhibited new papular lesions of the glans penis and progressive relapse of asthma. Treatment with cyclophosphamide (Endoxan(R)) combined with systemic corticosteroids was initiated. DISCUSSION: In view of the concomitance of necrotic granulomatous vasculitis in the cutaneous biopsies, severe, recent corticosteroid-dependent asthma, eosinophil-rich pulmonary infiltrate, allergic rhinitis, chronic sinusitis and the onset of a neuropathy, the diagnosis of Churg-Strauss syndrome was retained. The absence of hypereosinophilia in the blood during diagnosis can be explained by the oral corticosteroid therapy at low doses because of the asthma and sinusitis. However, hypereosinophil blood levels had been reported in several prior hemograms. Damage to the genital organ is exceptional during Churg-Strauss syndrome and is usually of granulomatous prostatitis form. Only one other case has been reported. Our observation is original in that it was isolated to the genital skin, which led to the diagnosis of Churg and Strauss granulomatous angeitis with systemic involvement.
Administration, Oral↗
[Exceptional etiologies in upper digestive tract bleeding ].
7 cases, considered as being true etiological exceptions selected from 756 upper gastrointestinal bleeding, are presented. The causes of bleeding were: pancreatic pseudocyst with intracystic hemorrhage broken into duodenum (2 cases), the nonepithelial gastroduodenal tumor (3 cases), the aneurysm of gastroduodenal artery broken into duodenum (1 case) and the aortoduodenal fistula in one patient with a bilateral aorto-iliac by-pass (1 case). The etiological diagnosis could not be established in any cases before the operations. All the cases were operated on, the operation being imposed by the severity of bleeding and having the haemostasis as a main purpose.
Adult↗
[Postoperative intestinal fistulae].
58 (6.25%) intestinal fistulae raised after 928 operations performed for varied surgical small bowel diseases were studied. The primary operation was performed for bowel obstruction, acute peritonitis, small bowel tumours, postoperative eviscerations and for entro-mesenteric infarction. We also noticed that the surgery was performed for the small bowel diseases in 47 (81%) acses and for the diseases belonging to other abdominal viscera in the rest, having an emergency character in 81% of cases. The small bowel fistulae were single (51 cases) or multiple having the following topographic distribution: jejunal fistulae in 25 (43.4%) cases and ileal fistulae in 33 cases (56.6). The coming out of the fistulae was directly in 41 (70%) cases and trough an intermediate route in 17 (30%) cases. The onset of the fistulae was certainly pointed by the coming out moment, early only in 39.6% of cases. This underlining the importance of an active exploration of the operative wound, imposed by the general and/or local premonitory symptoms. The treatment was complex, using conservative and/or surgical procedures; 23 (39.6%) patients were operated on. The mortality rate was of 29.4%. The parenteral nutrition and the therapeutical option for the conservative methods were the main therapeutical acquisitions, which improved the results and the prognosis of the intestinal fistulae.
Humans↗
[Critical evaluation of surgical treatment in slip hiatal hernia].
448 hiatal hernias, admitted in the last 20 years (1974-1998), 431 (96.3%) sliding hiatal hernias and 17 (3.8%) paraoesophageal hernias, are presented. The hiatal hernias were noticed under the well known etiopathologic circumstances: the predominance of the patients belonging to the female sex (66.07%), aged over 40 (83.25%); we also found in the natural history of the patients increasing abdominal pressure factors (10.79%), metabolic and deficiency disturbances (34.19%) or the concomitance of such a diseases, which admits a low trophicity of the connective tissue as a main pathogenic factor (35.12%). 231 (52.56%) cases were pure hiatal hernias and in 217 (48.44%) cases the hiatal hernia was associated with biliary and/or gastro-duodenal lesions, the hiatal hernia being considered as secondary. The clinical diagnosis was suggested by the gastrooesophageal reflux syndrome for the pure hiatal hernias associated with respiratory (30.32%) and/or cardiac (27.4%) signs. In the associated forms with biliary and/or gastro-duodenal lesions, the clinical picture was that of the hiatal hernia in 30.6% of cases and of the associated lesion in the rest. The clinical diagnosis was confirmed by x-ray examination in 82.7% of cases; the endoscopy was performed in 159 cases and proved the gastrooesophageal reflux and/or its consequences in 47.2% of cases. 420 (93.75%) cases were uncomplicated and in 28 (6.25%) cases we noticed one of the following complications: upper gastro-intestinal bleeding, incarceration or venous thrombosis of the hernial pouch. 336 (75%) patients were operated on, using a large scale of surgical procedures, surgical indication being established on clinical, radiological and endoscopic criteria, with utmost strictness for pure hiatal hernias (surgical treatment 68.3%) and generously for the associated forms. Both the early and late results were good: the mortality rate of 0.44% and the recurrence rate of 3.97%.
Adult↗
The effect of metal chelators on lipid peroxidation in stored erythrocytes.
Lipid peroxidation, an autocatalytic free radical process, is increased in a wide variety of conditions including various hemolytic anemias and hemoglobin disorders. Increased erythrocyte lipid peroxidation occurs in the presence of iron species and some heme moieties. In this study, greatly reduced concentrations of malondialdehyde (MDA), an indicator of lipid peroxidation, were observed in stored blood anticoagulated with citrate, phosphate, dextrose, and adenine (CPDA-1) upon the addition of deferoxamine mesylate (DM), diethylenetriaminepentaacetic acid (DTPA), and ethylenediaminetetraacetic acid (EDTA) (P less than 0.001). Human transferrin has essentially no effect on lipid peroxidation. Conversely, penicillamine and butylated hydroxytoluene significantly increased lipoperoxide production. Although bathophenanthroline disulfonic acid (BPD) appeared to be very effective in reducing lipid peroxidation, its complex chromatographic patterns which were due to the presence of multiple thiobarbituric acid reactive substances, were difficult to fully evaluate. The addition of appropriate metal chelators to stored blood may be effective in increasing the viability and longevity of transfused red cells.
Anticoagulants↗