Biomedical subjects
R Berlin
Publications and source records attributed to R Berlin.
Subungual melanoma: a 25-year review of cases.
The purpose of this study was to evaluate subungual melanoma as a site-specific entity, to determine the influence of regional nodal involvement, and to ascertain where possible the role of histologic grading of the primary site. Thirty-three patients with subungual melanoma whose median age was 56 yr underwent treatment between 1950 and 1975. There were 11 male and 22 female patients. Forty-eight per cent of lesions were 11 male and 22 female patients. Forty-eight per cent of lesions occurred on the hand. Of 23 clinical stage I patients, seven patients underwent amputation only, while 16 patients underwent amputation and regional nodal dissection. Histologic examination of the primary tumor suggested a trend towards thicker/ulcerated lesions to be associated with metastatic melanoma in regional lymph nodes and/or death due to disease. Early survival patterns favored female patients but there was no significant difference in 10-year survival when analysed by patient sex. Clinical/pathologic stages were the most significant factors affecting long-term survival with 5- and 10-year survivals of 66% and 55% in stage I patients and 22% and 0% in stage II patients.
Involuntary hospitalization: an issue for the consultation-liaison psychiatrist.
Little has been written about the issue of involuntary hospitalization in consultation-liaison psychiatry. Nevertheless, patients frequently seen in medical and surgical settings may be judged to be a danger to themselves or others because of psychiatric disorders that cloud cognition, impair judgment, or modify insight, and judicial or administrative proceedings leading to involuntary commitment may be needed. The C-L psychiatrist will be the physician most knowledgeable about the concepts of involuntary hospitalization, competency and informed consent. Clinical examples illustrate issues that may arise.
Plasma potassium and diurnal cyclic potassium excretion in the rat.
The relation of the plasma potassium concentration to the daily cyclic variation in potassium excretion was examined in undisturbed, unanesthetized male Sprague-Dawley rats maintained on a liquid diet in a 12-h light-dark environment. Potassium excretion increased from a light-phase minimum of 16 mu eq/h to a peak of 256 mu eq/h 3 h after the beginning of the dark phase. Plasma potassium concentration in arterial blood, sampled in rats at 90-min intervals during these changes in potassium excretion, showed no significant change and was in the range 4.50-4.99 meq/liter. In adrenalectomized rats receiving aldosterone and dexamethasone at constant basal rates by implanted pumps, the daily cycle of potassium excretion was the same as in the intact rats, and plasma potassium was not significantly different when measured at the time of minimum and maximum rates of potassium excretion (4.79 +/- 0.42 vs 5.16 +/- 0.47 meq/liter, mean +/- SD). These results indicate that plasma potassium concentration is not the efferent factor controlling diurnal cyclic changes in potassium excretion in adrenal intact rats and may not be the only significant factor in adrenalectomized-steroid replaced rats.
Historical aspects of nitrate therapy.
The exciting story of the development of nitrates as drugs in clinical medicine is briefly reviewed. Glyceryl trinitrate (nitroglycerin) was synthesised by Sombrero in 1847. Amyl nitrite was discovered a few years later and was used by Guthrie in 1859. The first report on the action of glyceryl trinitrate and amyl nitrite was published by Brunton in 1867, and further papers were published by Murell in 1879. Organic nitrates appeared in the 1930s. Krantz and co-workers synthesised and used mannide dinitrate, which was longer acting than the nitrates that had been used previously. Research on a similar drug, isosorbide dinitrate, was initiated by Porjé in Stockholm. The drug was first marketed in Sweden in 1946. Isosorbide dinitrate was independently synthesised in the United States by Harris and colleagues in the 1950s. The drug was used fairly extensively on both sides of the Atlantic. However, there was a temporary decrease in popularity around 1970 when Needleman and colleages reported oral nitrates to be of questionable value, as they underwent rapid biotransformation during first-pass metabolism in the liver. This opinion was later altered and today the drug enjoys worldwide acceptance in different formulations. Also, in recent years one of the active metabolites, isosorbide 5-mononitrate, has been marketed as an effective antianginal drug.
Vitamin B 12 injections.
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Cobalamin forms in plasma and tissue during treatment of vitamin B12 deficiency.
Thin-layer chromatography and bioautography were used to study the cobalamin pattern of plasma, erythrocytes, and hepatic tissue from patients with cobalamin deficiency on maintenance therapy with hydroxocobalamin (Vibeden), a cyanocobalamin depot preparation (Betolvex), or cyanocobalamin tablets (Behepan). The cobalamin pattern in plasma is dominated by the form in which it is administered. The results of assaying the erythrocytes and liver biopsies show that the cobalamins administered are converted to the coenzyme forms in vivo, irrespective of the type of cobalamin preparation.
Effects of blunt chest wall impact on the blood gases in the anaesthetized rabbit.
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LOcal effects of antibacterial therapy (benzyl-penicillin) on missile wound infection rate and tissue devitalization when debridement is delayed for twelve hours.
Spherical steel bullets (0.88 g, 6.00 mm in diameter, impact velocity around 1000 m/s, smooth-bore rifle) were used for infliction of trauma to the thigh of pigs. The aim was to find out the effect of early antibiotic therapy (benzyl-penicillin) on wound infection rate and on the local progressive tissue devitalization when debridement was delayed until 12 hours after infliction of trauma. The main study on infection and tissue devitalization contained 20 missile wounds; the pilot study on cell metabolism 13 wounds. In the first group 11 pigs, and in the second group 7 pigs were treated with penicillin. Debridement was performed 12 hours after the infliction of trauma. Bacteriological analyses were done on tissue samples from the wound after pc treatment. The contents of adenosine triphosphate, creatine phosphate, glucose, glucose 6-phosphate and lactate were analysed in tissue samples from the wound with and without pc-treatment 12 h after trauma. The usual growth of bacteria when debridement was delayed for 12 h was totally inhibited by the early provision of penicillin. The amount of devitalized tissue-removed in relation to transferred energy was significantly reduced after the treatment as compared to the non-pc-group. The results of the studies on cell metabolism point to a graded tissue damage and possibly reversible injuries in the periphery of the wound, and to less metabolic disturbances after pc-treatment. The results indicated that early general supply of antibiotics may confine the local tissue injury when delayed debridement is anticipated.
Effect of benzyl-pencillin on wound infection rate and on the extent of devitalized tissue twelve hours after infliction of experimental missile trauma.
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Multiple use of dialyzers: safety and efficacy.
The practice of multiple use of dialyzers was examined over a 15-month period on all 104 patients in a chronic maintenance hemodialysis facility. A computerized medical information system permitted analysis of the incidence of events in over 10,000 successive hemodialyses. It also allowed analysis of the events in 27 patients dialyzed for a total of 655 months successively in two units practicing single and multiple dialyzer use. The incidence of complications during dialysis, of complications that might be related to infection, and the rate of hospitalization was not greater when the 27 patients were dialyzed in the unit practicing multiple use as compared with the rates in the unit practicing single use. Events possibly associated with infection did not occur more frequently during dialyses in which the dialyzer had been used between 2 and 20 times than they did with the initial use of the dialyzer. With successive dialyzer use, there was no significant change in the ability to remove fluid or in the dialysance of urea and creatinine. The neutropenia that characteristically occurs early in dialysis was substantially less with reused dialyzers than with their initial use. Under the operating conditions described, we conclude that multiple dialyzer use over a 15-month period is safe, efficacious, and is not associated with an increased rate of infection, of morbidity from any cause, or of mortality.
Bacteriological findings in the first 12 hours following experimental missile trauma.
The purpose of this study was to investigate the rate and magnitude of bacterial growth in gunshot wounds following debridement one, 6 and 12 hours after infliction of a standardized missile trauma (spherical steel bullet, 0.88 g, 6.00 mm in diameter, impact velocity 1 000 m/sec). 39 pigs were shot in one or both thighs (n of wound, 54). The skin was not cleaned before the trauma but was disinfected preoperatively. Before trauma infliction, swab samples were taken from the nose, the rectum and the skin. At the operation, all muscle tissue judged to be devitalized was removed. Samples for bacteriological culturing were taken from the removed tissue and from the margins of the wound cavity. Isolated bacterial strains were classified and a semiquantitative evaluation of the number of, bacteria was performed. Bacterial growth in the devitalized tissue was indicated in about 70% of the wounds. Cultures from tissue judged as viable and left in the wound indicated contamination in 25% of the wounds in the 1-hour group, contamination in 37 and infection in 11% of the 6-hour group, and in the 12-hour group infection in 60 and contamination in 33%. The conclusion is that wound infection can be overcome by adequate surgical treatment within 6 hours but will be out of control after 12 hours' delay. Furthermore, the results indicate that the presence of a sparse mixed flora probably creates the necessary conditions for infection with other pathogenic strains.
Football head and neck injuries--an update.
In the last 5 years there has been a dramatic decrease in the deaths directly related to football participation. The incidence of serious spinal cord injuries, however, appears to be increasing. The number of quadriplegic athletes varies from an estimated 1 per 7,000 to 1 per 58,000 participants per year in different areas of the country. The majority of catastrophic head and neck injuries occurs while tackling or blocking, and defensive players are much more liable to sustain these injuries than offensive players. In addition to permanent and irreversible spinal cord damage, football players may suffer spinal concussions as well as spinal contusions. The latter may be manifested by severe burning paresthesias and dysesthesias in the extremities as the only symptoms. Furthermore, fracture-dislocations with ligamentous tears may be present in this syndrome, with no complaint of cervical pain. Adequate preconditioning and strengthening of the head and neck musculature prior to football participation are essential for the prevention of catastrophic head and neck injury. Furthermore, proper blocking and tackling techniques must be taught, and such punishing maneuvers as spearing, goring, and butt-blocking and tackling must be eliminated. Arbitrarily, most physicians discourage further football participation if an athlete has suffered three cerebral concussions. Strong consideration must be given, however, not only to the number and severity of the concussion, but also to any CAT scan evidence of cerebral edema, contusion, or hemorrhage. With this incredibly sensitive diagnostic tool, one concussion, which is associated with radiographic evidence of structural brain damage, may be enough to strongly discourage or forbid further football participation.
Energy transfer and regional blood flow changes following missile trauma.
The hemodynamic response to missile injury was studied in the hind legs of dogs. Spherical projectiles were used and velocity and mass were varied. The regional arterial blood flow to the injured thigh was recorded and the energy transfer to the tissues determined. In addition the presence within the aortic arch was recorded immediately after the impact of the missile. Missile penetration caused a marked peak of flow followed by a less pronounced elevation of the flow level for at least 30 minutes. The magnitude of the peak was related to the amount of energy transferred to the tissues. The origin of the circulatory changes is discussed. Shock waves of considerable magnitude were recorded within the aortic arch in connection with the bullet penetration.
Various technical parameters influencing wound production.
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The extent of muscle tissue damage following missile trauma one, six and twelve hours after the infliction of trauma, studied by the current method of debridement.
Spherical missiles with velocities around 1000 m/s were used to inflict missile trauma to one thigh of pigs. The determination of the impact and exit velocities made it possible to calculate the extent of energy transferred to the tissue. About one third of the pigs were treated surgically within one hour after the trauma, one third after a delay of 6 hours and one third after 12 hours. The surgical procedure consisted of debriding muscle tissue which showed impaired contractility and/or consistency and discoloration and/or lack of capillary bleeding - the current criteria of non-viability. The amount of debrided muscle tissue from each wound was weighed and the amount of debrided muscle tissue per joule transferred to the tissue was calculated. As compared to operations performed within one hour the average of the debrided muscle tissue per joule was greater after 6 hours delay and even still greater after 12 hours. However, the difference between the averages after 6 and 12 hours were not statistically significant.
Cell damage at different distances from wound channels caused by spherical missiles with high impact velocity 1 - 12 hours after injury.
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Drag and tumbling behaviour of small calibre projectiles in tissue simulant.
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