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PubMed2001

Multimodal perioperative management--combining thoracic epidural analgesia, forced mobilization, and oral nutrition--reduces hormonal and metabolic stress and improves convalescence after major urologic surgery.

We sought in this prospective study to use a multimodal approach to reduce stress and improve recovery in patients undergoing major surgery. During an initial study period, 30 patients were randomly allocated to receive general anesthesia (GA; Group 1) or a combination of GA and intraoperative thoracic epidural analgesia (TEA; Group 2) when undergoing radical cystectomy. Parenteral nutrition was provided for 5 days after surgery. During the second period, 15 patients were treated with a multimodal approach (Group 3) consisting of intraoperative GA and TEA, postoperative patient-controlled TEA, early oral nutrition, and enforced mobilization. Data for plasma and urine catecholamines, plasma cortisol, the nitrogen balance, the postoperative inflammatory nutrition index, pain relief, fatigue, sleep, overnight recovery, recovery of bowel function, and mobilization were recorded up to the fifth postoperative day. Plasma concentrations of catecholamines and cortisol were comparable in all patients, but those in Group 3 had lower levels of urinary catecholamine excretion. Protein intake was more effective with parenteral nutrition. Nitrogen balances were less negative, and the postoperative inflammatory nutrition index score increased significantly in the traditional groups but not in Group 3. Multimodally treated patients reported less fatigue and better overnight recovery. Along with improved pain relief, recovery of bowel function, and ambulation, there were no differences in the postoperative complication rates among the three groups. The multimodal approach reduced stress and improved metabolism and recovery after radical cystectomy.

Adult↗
PubMed2006

[Three-week multimodal inpatient treatment of children with chronic pain. First results of the long-term follow-up].

OBJECTIVE: In children and adolescents we investigated the impact of a 3-week inpatient multimodal pain therapy on subjective burden of life, pain intensity, and number of days off from school 3, 6, or 12 months later. METHODS: At the beginning of therapy (inpatient setting) and 3, 6, and 12 months thereafter (outpatient setting) we collected the respective data using standardized questionnaires. For statistical analysis we used Wilcoxon's signed rank test. A p <0.05 was regarded as statistically significant. RESULTS: A total of 72 patients aged 7.5-18.2 years suffering daily pain entered the study, most of them being diagnosed with somatoform pain disease. After 3, 6, and 12 months, 65, 27, and 30 patients could be reevaluated. Mean pain intensity of the week before data acquisition was significantly less than at the beginning (2.9, 2.3, and 2.9 vs 6.3) as was the mean number of days off from school due to pain during the 4-week period before each day of data acquisition (1.8, 1.5, and 1.4 vs 9.2). Mean subjective burden of life was significantly less than at the beginning (24.5, 22.0, and 25.8 vs 37.8). CONCLUSION: Outpatient multimodal pain therapy has a sustained impact on children and adolescents suffering from chronic pain.

Adolescent↗
PubMed2005

Comprehensive pore structure characterization of silica monoliths with controlled mesopore size and macropore size by nitrogen sorption, mercury porosimetry, transmission electron microscopy and inverse size exclusion chromatography.

The porosity of monolithic silica columns is measured by using different analytical methods. Two sets of monoliths were prepared with a given mesopore diameter of 10 and 25 nm, respectively and with gradated macropore diameters between 1.8 and 7.5 microm. After preparing the two sets of monolithic silica columns with different macro- and mesopores the internal, external and total porosity of these columns are determined by inverse size-exclusion chromatography (ISEC) using polystyrene samples of narrow molecular size distribution and known average molecular weight. The ISEC data from the 4.6 mm analytical monolithic silica columns are used to determine the structural properties of monolithic silica capillaries (100 microm I.D.) prepared as a third set of samples. The ISEC results illustrate a multimodal mesopore structure (mesopores are pores with stagnant zones) of the monoliths. It is found by ISEC that the ratio of the different types of pores is dependent on the change in diameter of the macropores (serve as flow-through pores). The porosity data achieved from the mercury penetration measurement and nitrogen adsorption as well of scanning electron microscopy (SEM) and transmission electron microscopy (TEM) pictures are correlated with the results we calculated from the ISEC measurements. The ISEC results, namely the multimodal pore structure of the monoliths, reported in several publications, are not confirmed analyzing the pore structures of the different silica monoliths using all other analytical methods.

Adsorption↗
PubMed2003

[Possible conservative treatment methods for patients with spinal claudication].

The success of multimodal therapy for patients with symptoms of spinal canal stenosis lasting >6 months was investigated in a prospective study. Clinical (age, weight, height) and morphological data were collected for 36 patients (21 women and 15 men) with an average age of 67 years. The extent of narrowing in the spinal space (diameter of the dural sac <100 mm(2)) was measured by magnetic resonance imaging at segments L1-S1. Impairments in daily activities were assessed by questionnaire before a 3-week multimodal treatment regimen and 3 weeks and 6 months thereafter. In addition, depression status and walking distance on a treadmill were evaluated. Of the 180 segments examined, 124 evidenced a diameter of the dural sac of <100 mm(2). The average functional capacity improved with treatment from 46.7 to 53.5 (p<0.001) and the average depression status decreased from 13.5 to 11 (p>0.05). The average walking distance was 373 m before treatment and 565 m after treatment (p<0.001). Short-term improvement of the walking distance was achieved with the conservative treatment implemented. Medium- and long-term results remain unclear. Predictors for treatment success (age, sex, BMI, functional capacity, walking ability before treatment) could not be found. No scientific evidence can be gleaned from the literature in this regard so that further prospective studies should be performed.

Aged↗
PubMedDate not supplied

Effects of a multimodal pain rehabilitation program: a pilot study.

The purpose of this pilot study was to examine the effects of a multimodal pain rehabilitation program on pain perceptions, opioid usage, activity, down time, sleep, and role function status of 23 chronic pain patients. Data were collected at the start of the program, at the program's completion, and again during a follow-up period (3-11 months afterwards). At the end of the program, patients reported a significant reduction in pain levels, opioid usage, and hours of disturbed sleep. During the follow-up period, patients continued to report significant improvements in activity and role functions as well as significant reductions in opioid usage, sleep disturbance, and down time. These findings provided encouraging preliminary evidence that multimodal pain rehabilitation programs for chronic pain patients may be effective in pain management and functional restoration.

Activities of Daily Living↗
PubMedDate not supplied

Robust automatic coregistration, segmentation, and classification of cell nuclei in multimodal cytopathological microscopic images.

The paper describes the key component of the Multimodal Cell Analysis approach, a novel cytologic evaluation method for early cancer detection. The approach is based on repeated staining of a cell smear. The correlation of features and data extracted from the different stains, and related to relocated individual cells, may yield a dramatic increase of diagnostic reliability. In order to utilise the technique, fully automatic, adaptive image preprocessing techniques need to be applied, which are described in this article: coregistration of multimodal images, segmentation, and classification of cell nuclei. The presented feasibility study shows both efficiency and robustness of all steps being high regarding medical image material, and it strongly supports clinical application.

Cell Nucleus↗
PubMed1997

Integration of functional and anatomical brain images.

This article concerns the integration of functional and anatomical volumetric brain images. Integration consists of two steps: matching or registration, where the images are brought into spatial agreement, and fusion or simultaneous display where the registered multimodal image information is presented in an integrated fashion. Approaches to register multiple images are divided into extrinsic methods based on artificial markers, and intrinsic matching methods based solely on the patient related image data. The various methods are compared by a number of characteristics, which leads to a clear preference for one class of intrinsic methods, viz. voxel-based matching. Furthermore, two- and three-dimensional techniques to display multimodality image information are outlined.

Brain↗
PubMed2004

Remaining problems and controversies in the management of childhood head and neck soft tissue sarcomas: Retrospective (national) Multicenter Study of the Polish Pediatric Solid Tumors Group.

Soft tissue sarcomas in children are a heterogeneous group of malignant diseases. Among these, tumors localized in the head and neck region are especially difficult to treat. While multidisciplinary care has dramatically improved the prognosis of sarcoma patients, their treatment remains uncertain because of demand on radical surgical resection of the tumor. Achieving cure without deforming or mutilating the child remains the primary goal of treatment. This study is the multicenter (nationwide, 11 Polish centers) retrospective analysis of the treatment results in children having soft tissue sarcoma in the head and neck region during the previous decade (from 1991 to 2001). Late effects of the treatment are documented in long-term survivals. Eighty-five children from 1 to 212 months of age were included. Different multimodal treatment protocols were utilized (CWS-91, SIOP-MMT-91, and CWS-96). The median observation time was 25 months. Data on long-term effects were collected in 34 long-term survivals. Complete remission was achieved in 68 (80%) patients. Primary treatment failure occurred in 13 (15.3%) patients, all of whom succumbed in disease progression. Relapse occurred in 21 (30.9%) patients primarily achieving complete remission. Second primary neoplasm occurred in 3 children. The estimated 5-year event-free survival and the 5-year total survival rates for the whole group are 0.38 and 0.55, respectively. The main late effect documented in long-term survivals were cosmetic defects in 12 (35.3%) and visual field deficit or blindness in 8 (26.5%). Despite substantial improvement of the prognosis of pediatric soft tissue sarcomas, the multimodal treatment of head and neck region tumors remains controversial. Improved long-term outcome and focusing on psychosocial difficulties raise the important and difficult problem of functional results and cosmesis. Tumors localized in the orbit carry an excellent prognosis. However, the main late sequela is vision impairment and cosmetic defect due to the therapy given many years earlier. Two other tumor localizations--the parameningeal and nonparameningeal ones--still have bad prognosis. The observations made in this study confirm that main prognostic factors are the size of the primary tumor and the tumor stage. The worst prognosis remains invasive tumor (T2-stage) with a size over 5 cm. Individually adjusted multimodal therapy, which imperatively needs to be radical, though not mutilating, might minimize the late effects. Psychosocial problems in long-term survivors need to be focused on at the national level and better support must be provided in the future, involving a team of different medical and paramedical profiles.

Adolescent↗
PubMed2006

Nature: a rich source for developing multifunctional agents. Tumor-imaging and photodynamic therapy.

The purpose of this review is to call attention in the use of chlorophyll-a and bacteriochlorophyll-a to develop more than 600 photosensitizers (lambda (max) 660 nm-800 nm) during the last 15 years (1990-2005) at the Photodynamic Therapy Center, Roswell Park Cancer Institute, Buffalo. This article mainly includes the chemistry, preclinical results, and brief clinical data of some of the most effective photosensitizers. The utility of the tumor-avid photosensitizers in developing multimodality agents (imaging and therapy) is also presented.

Bacteriochlorophyll A↗
PubMed2006

Choice of neuroimaging in perioperative acute stroke management.

At the time of this publication, the fast examination time, wide availability, lack of contraindications, and high accuracy for detecting hemorrhage make NCCT the diagnostic study of choice for initial evaluation of patients who have preoperative stroke. NCCT also has a role in excluding patients who will not benefit from IV thrombolysis, including those who have ICH and patients who have ASPECTS less than 7 or ischemic signs exceeding one third of the MCA territory. Because optimal selection of inpatients who have acute stroke mandates not just brain tissue data but also information about the aortic arch, cervical and intracranial vasculature, and cerebral hemodynamics, additional imaging with multimodal CT technology can, in one scanning session, depicts early ischemic changes, demonstrates hypoperfusion/ischemic penumbra, and locates the vascular lesion. When combined with the clinical scenario, the information provided by CT often is sufficient to help clinicians decide on the appropriate treatment, especially determining eligibility for thrombolysis. The rapidly evolving field of neuroradiology will provide a newer armamentarium in the near future. Although MRI can provide more precise information, it is more time consuming and currently should be considered the method of choice for follow-up imaging, rather than initial imaging, in patients who have perioperative stroke.

Brain↗
PubMed2003

Multisensory integration, perception and ecological validity.

Studies of multimodal integration have relied to a large extent on conflict situations, in which two sensory modalities receive incongruent data concerning one aspect of the source. Exposure to such situations produces immediate crossmodal biases as well as longer lasting aftereffects, revealing recalibrations of data-to-percept matches. In the natural environment, such phenomena might be adaptive, by reducing the perturbing effects of factors like noise or growth-induced changes in receptor organs, and by enriching the percept. However, experimental results generalize to real life only when they reflect automatic perceptual processes, and not response strategies adopted to satisfy the particular demands of laboratory tasks. Here, we focus on this issue and review ways of addressing it that have been developed recently.

Journal Article↗
PubMed2004

Effects of intermediate bound states in dynamic force spectroscopy.

We revisit some aspects of the interpretation of dynamic force spectroscopy experiments. The standard theory predicts that the typical unbinding force f* is linearly proportional to the logarithm of the loading rate r when a single energy barrier controls the unbinding process. For a more complex situation of N barriers, it predicts at most N linear segments for the f* vs. log(r) curve, each segment characterizing a different barrier. Here we extend this existing picture using a refined approximation, provide a more general analytical formula, and show that in principle up to N(N + 1) / 2 segments can show up experimentally. As a consequence, the determination of the positions and even the number of the energy barriers from the experimental data can be ambiguous. A further possible consequence of a multiple-barrier landscape is a bimodal or multimodal distribution of the unbinding force at certain loading rates, a feature recently observed experimentally.

Binding Sites↗
PubMed1996

Reading with magnifiers.

The design of low vision aids for partially sighted people, such as magnifiers, is evaluated theoretically in order to identify meaningful directions of research for improving these aids. Both reading with and without a magnifier involves alternating sequences of locating and recognizing textual information. Little is known, however, about these processes in magnifier reading. On the basis of an extensive review of the literature, two topics are identified that stand out as being in need of experimental investigation: (1) the relationship between the (typo)graphical characteristics of printed text and the location and recognition of textual information, and (2) the interplay of location and recognition processes in magnifier reading, including the role of non-visual factors, such as movements of the hand, trunk, head and eyes in this interplay. With regard to the first topic, it is expected that the visibility and, hence, the recognition of textual information by partially sighted people can be improved by matching the fundamental spatial frequencies of graphical structures with the spatial contrast sensitivity of partially sighted people. With regard to the second topic, it is argued that persistent problems in the design of the magnifiers, such as the optimal window size, can only be resolved by studying reading with a magnifier as a (multimodal) perceptual-motor activity.

Data Display↗
PubMed2004

Assessment of jugular blood oxygen and lactate indices for detection of cerebral ischemia and prognosis.

Levels of jugular blood oxygen saturation (SjvO2) and lactate have been proposed as indicators of cerebral ischemia and prognosis. However, sensitivity and specificity of these markers remain unknown. We retrospectively analyzed records of a series of 43 comatose patients at risk for cerebral ischemia, mainly after head injuries or subarachnoidal hemorrhage. Their SjvO2, jugulo-arterial lactate difference (VADLactate), and lactate-oxygen index (LOI) were determined every 8 hours. An increase in VADLactate and LOI was found, indicative of ischemia on CT scan, with threshold values of 0.30 mmol/L and 0.15, respectively. Sensitivity and specificity were 100% and 64%, respectively, for the VADLactate threshold, and 90% and 55%, respectively, for the LOI threshold. Regarding prediction of a poor outcome, only an increase in VADLactate had a predictive value with a sensitivity of 100% and specificity of 67%. No threshold value with sufficient sensitivity and specificity was found for SjvO2, as indicator of either ischemia or outcome. During progression to brain death, VADLactate and LOI reached abnormal levels earlier than cerebral perfusion pressure or SjvO2. They reacted markedly to focal ischemia due to vasospasm. Hyperlactacidemia rendered VADLactate and LOI uninterpretable by causing a brain lactate influx. Present data, if confirmed by a prospective study, would justify inclusion of intermittent VADLactate and LOI determinations in the multimodal cerebral monitoring.

Brain Injuries↗
PubMed2005

Multimodal monitoring in the neurological intensive care unit.

BACKGROUND: Neurocritical care is a specialty that focuses on the critical care management of patients with catastrophic neurologic diseases. Brain ischemia and hypoxia are often central causes of brain damage in these patients. Until recently, the only methods widely accepted for monitoring in the neurological intensive care unit have been intracranial pressure and cerebral perfusion pressure monitoring. Recent developments in technology have resulted in several new monitoring techniques that can provide the neurointensivist with information, at the cellular level, that can help guide management. REVIEW SUMMARY: The brain requires a continuous blood-borne supply of oxygen and glucose for normal metabolism. Ischemia occurs when supply is insufficient to meet the metabolic demand. Cerebral blood flow can now be directly monitored using laser Doppler or thermal diffusion techniques. Transcranial cerebral oximetry can estimate regional cerebral oxygen saturation, although the reliability is questionable. Jugular bulb oximetry can provide a global assessment of oxygen delivery, and consumption and brain tissue oxygen tension monitoring can provide a focal measurement of cerebral oxygenation. Intracerebral microdialysis can provide information about glucose metabolism and the overall health of the neuron. CONCLUSIONS: New monitoring techniques can provide the neurointensivist with crucial information about brain physiology and metabolism. Combining these techniques ("multimodal monitoring") can produce a more accurate overall picture. This approach, along with new computer systems for integrating data at the bedside, may change the way patients with brain injury are monitored and treated in the future.

Brain↗
PubMedDate not supplied

Emotional awareness deficits in inpatients of a psychosomatic ward: a comparison of two different measures of alexithymia.

OBJECTIVE: The TAS 20 has demonstrated strong psychometric properties in a broad variety of studies in healthy populations. Much less work has been done in clinical contexts exploring the validity of the TAS 20 as a measure of the cognitive processing of emotions. The TAS 20, a self-report scale, tends to correlate with self-reported negative affect, but in a clinical context it is important to be able to differentiate between negative affect and the cognitive processing of emotion. We therefore used the TAS 20 and a performance measure, the Levels of Emotional Awareness Scale (LEAS), which in previous studies demonstrated no overlap with measures of negative affect, to explore the ability of the two measures to detect deficits in emotional awareness in a clinical sample. METHODS: Data from inpatients of a psychosomatic ward were collected at onset (N = 394) and at the end of multimodal psychodynamic treatment (N = 249). The sample consisted of six diagnostic groups (depression; anxiety and compulsive-obsessive disorders, adjustment disorders, somatoform disorders, psychological factors related to somatic disorders, eating disorders). Changes in the TAS 20 and LEAS were compared at the two time points controlling for the effects of gender, age, educational level, and associations with self-reported negative affect. RESULTS: In contrast to the LEAS, the TAS 20 correlated with negative affect at the onset and the end of treatment. The scores of the TAS 20 decreased with treatment in all diagnostic groups but the change in the TAS 20 was not statistically significant when negative affect was controlled. In contrast, LEAS scores increased with treatment in the groups with somatoform disorders and psychological factors related to somatic disorders, and this change was independent of negative affect. CONCLUSION: The LEAS captured a change in emotional awareness due to treatment, whereas the TAS 20 captured a change in negative affect. The LEAS appears to be a more specific measure of change in emotional awareness in clinical contexts than the TAS 20.

Adult↗
PubMed1999

Restrictions on inhibitory circuits contribute to limited recruitment of fast inhibition in rat neocortical pyramidal cells.

To further define the operational boundaries on fast inhibition in neocortex, whole cell recordings were made from layer V pyramidal neurons in neocortical slices to evaluate evoked inhibitory postsynaptic currents (IPSCs) and spontaneous miniature IPSCs (mIPSCs). Stimulating electrodes were placed in layers VI and I/II to determine whether simultaneous stimulation of deep and superficial laminae could extend the magnitude of maximal IPSCs evoked by deep-layer stimulation alone. The addition of superficial-layer stimulation did not increase maximal IPSC amplitude, confirming the strict limit on fast inhibition. Spontaneous miniature IPSCs were recorded in the presence of tetrodotoxin. The frequency of spontaneous mIPSCs ranged from 10.0 to 33.1 Hz. mIPSC amplitude varied considerably, with a range of 5. 0-128.2 pA and a mean value of 20.7+/-4.1 pA (n = 12 cells). The decay phase of miniature IPSCs was best fit by a single exponential, similar to evoked IPSCs. The mean time constant of decay was 6.4+/-0.6 ms, with a range of 0.2-20.1 ms. The mean 10-90% rise time was 1.9+/-0.2 ms, ranging from 0.2 to 6.3 ms. Evaluation of mIPSC kinetics revealed no evidence of dendritic filtering. Amplitude histograms of mIPSCs exhibited skewed distributions with several discernable peaks that, when fit with Gaussian curves, appeared to be spaced equidistantly, suggesting that mIPSC amplitudes varied quantally. The mean separation of Gaussian peaks ranged from 6.1 to 7.8 pA. The quantal distributions did not appear to be artifacts of noise. Exposure to saline containing low Ca(2+) and high Mg(2+) concentrations reduced the number of histogram peaks, but did not affect the quantal size. Mean mIPSC amplitude and quantal size varied with cell holding potential in a near-linear manner. Statistical evaluation of amplitude histograms verified the multimodality of mIPSC amplitude distributions and corroborated the equidistant spacing of peaks. Comparison of mIPSC values with published data from single GABA channel recordings suggests that the mean mIPSC conductance corresponds to the activation of 10-20 GABA(A) receptor channels, and that the release of a single inhibitory quantum opens 3-6 channels. Further comparison of mIPSCs with evoked inhibitory events suggests that a single interneuron may form, on average, 4-12 functional synapses with a pyramidal cell, and that 10-12 individual interneurons are engaged during recruitment of maximal population IPSCs. This suggests that inhibitory circuits are much more restricted in both the size of the unit events and effective number of connections when compared with excitatory inputs.

Animals↗