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Biomedical subjects

M Kruger

Publications and source records attributed to M Kruger.

At least 19 recordsLinked to original sources

Effects of the mutation R145G in human cardiac troponin I on the kinetics of the contraction-relaxation cycle in isolated cardiac myofibrils.

Familial hypertrophic cardiomyopathy (FHC) has been linked to mutations in sarcomeric proteins such as human cardiac troponin I (hcTnI). To elucidate the functional consequences of the mutation hcTnI(R145G) on crossbridge kinetics, force kinetics were analysed in murine cardiac myofibrils carrying either the mutant or the wild-type protein. The mutation was introduced into the myofibrils in two different ways: in the first approach, the endogenous Tn was replaced by incubation of the myofibrils with an excess of reconstituted recombinant hcTn containing either hcTnI(WT) or hcTnI(R145G). Alternatively, myofibrils were isolated either from non-transgenic or transgenic mice expressing the corresponding mcTnI(R146G) mutation. In myofibrils from both models, the mutation leads to a significant upward shift of the passive force-sarcomere length relation determined at pCa 7.5. Addition of 5 mm BDM (2,3-butandione-2-monoxime), an inhibitor of actomyosin ATPase partially reverses this shift, suggesting that the mutation impairs the normal function of cTnI to fully inhibit formation of force-generating crossbridges in the absence of Ca(2)(+). Maximum force development (F(max)) is significantly decreased by the mutation only in myofibrils exchanged with hcTnI(R145G) in vitro. Ca(2)(+) sensitivity of force development was reduced by the mutation in myofibrils from transgenic mice but not in exchanged myofibrils. In both models the rate constant of force development k(ACT) is reduced at maximal [Ca(2)(+)] but not at low [Ca(2)(+)] where it is rather increased. Force relaxation is significantly prolonged due to a reduction of the relaxation rate constant k(REL). We therefore assume that the impairment in the regulatory function of TnI by the mutation leads to modulations in crossbridge kinetics that significantly alter the dynamics of myofibrillar contraction and relaxation.

Animals↗

Neonatal cholinesterase inhibitor poisoning: materno-fetal exchange of pesticide.

This is a case report of a neonatal cholinesterase inhibitor poisoning after non-accidental ingestion of a carbamate containing pesticide by the mother prior to delivery. The mother presented with symptoms of cholinesterase inhibitor poisoning at 40 weeks of gestation. A fetal bradycardia was present. The mother improved after administration of intravenous atropine. Spontaneous labour ensued and a term female infant weighing 3200 g was delivered. The infant had signs of cholinergic stimulation and decreased levels of serum cholinesterase. The neonate presented with a marked tachycardia. The heart rate normalized after administration of atropine. Therefore, we concluded that the tachycardia was due to the cholinesterase inhibitor substance, causing catecholamine release by stimulation of nicotinic receptors. Another potential contributing factor to the tachycardia, although unlikely in our patient, was the atropine administered to the mother prior to delivery. Mother and infant recovered well. We conclude that infants can present with tachycardia associated with cholinesterase inhibitor toxicity. Despite the side-effects intravenous atropine should not be withheld in the treatment of mother and infant.

Adult↗

Expression of ERRP in normal and neoplastic pancreata and its relationship to clinicopathologic parameters in pancreatic adenocarcinoma.

INTRODUCTION AND AIMS: Epidermal growth factor (EGF) and its receptor (EGFR) play crucial roles in cellular signaling in many malignancies, including pancreatic neoplasia. Attenuation of EGFR signaling has been considered novel strategy for the management of human malignancies in several ongoing clinical trials. We recently isolated a novel negative regulator of EGFR, termed EGF receptor related protein (ERRP), whose expression appears to attenuate EGFR activation. In the current study, the expression of ERRP in normal and neoplastic pancreas was investigated and correlated with the clinicopathologic parameters in pancreatic ductal adenocarcinoma (DA). METHODOLOGY: Using rabbit polyclonal antibody that specifically interacts with ERRP, immunohistochemical staining was performed on 45 benign pancreata and 106 cases of DA. The intensity and percentage of cells with cytoplasmic and membranous staining were scored as 0, 1, 2, or 3. A combined score was calculated as intensity x percent/3, and for comparative analysis, the data were arbitrarily divided into three groups: <20, 20-49, and > or =50. The expression of ERRP was correlated with patient age, gender, race, tumor size, stage, grade, and survival. RESULTS: ERRP was expressed in most benign ductal epithelium and islet cells, but not in normal acinar cells. In pancreatic ductal adenocarcinoma, ERRP expression frequency decreased progressively from well (WD) to moderate (MD) to poorly differentiated (PD) carcinoma (58%, 43%, and 15% respectively, < 0.001). ERRP expression was correlated with survival in DA showing decreased median survival with decreased ERRP score ( = 0.0035). Median survival of the lower intensity (0 or 1) group was less than that of the higher intensity (2 or 3) group (8 14 months, = 0.002). The higher expressing group (> or =50% of cells) had longer median survival (17 months) than the lower expressing (<50% of cells) group (10 months, = 0.003). Stepwise multiple regression analyses revealed that ERRP expression score and tumor grade are the significant predictors of survival in pancreatic ductal carcinomas ( < 0.03). CONCLUSION: ERRP is usually expressed in benign ductal epithelium, but not in ductal adenocarcinoma. Its expression decreases with decreasing tumor differentiation. Low levels of ERRP are associated with poor clinical outcome, suggesting that progressive loss of ERRP, a negative regulator of EGFR, may partly stimulate aggressive tumor cell growth in pancreatic adenocarcinoma.

Animals↗

The concentration of three anti-seizure medications in hair: the effects of hair color, controlling for dose and age.

BACKGROUND: This paper assess the relationship between the quantity of three anti-seizure medications in hair and the color of the analyzed hair, while controlling for the effects of dose, dose duration, and patient age for 140 clinical patients undergoing anti-seizure therapy. Three drugs are assessed: carbamazepine (40 patients), valproic acid (40 patients), and phenytoin (60 patients). The relationship between hair assay results, hair color, dose, dose duration, and age is modeled using an analysis of covariance. The covariance model posits the hair assay results as the dependent variable, the hair color as the qualitative categorical independent variable, and dose, dose duration, and age as covariates. The null hypothesis assessed is that there is a no relationship between hair color and the quantity of analyte determined by hair assay such that darker colored hair will demonstrate higher concentrations of analyte than lighter colored hair. RESULTS: The analysis reveals that there is a significant relationship between dose and concentration for all hair color categories independent of the other covariates or the categorical independent variable. CONCLUSION: There does not appear to be any relationship between carbamazepine concentration and hair color. There is a weak relationship between hair color and valproic acid concentration, which the data suggest may be mediated by age. There is a significant, moderate relationship between phenytoin concentration and hair color such that darker colored hair has greater concentration values than lighter colored hair.

Age Factors↗

Identification of Id4 as a regulator of BRCA1 expression by using a ribozyme-library-based inverse genomics approach.

Expression of the breast and ovarian cancer susceptibility gene BRCA1 is down-regulated in sporadic breast and ovarian cancer cases. Therefore, the identification of genes involved in the regulation of BRCA1 expression might lead to new insights into the pathogenesis and treatment of these tumors. In the present study, an "inverse genomics" approach based on a randomized ribozyme gene library was applied to identify cellular genes regulating BRCA1 expression. A ribozyme gene library with randomized target recognition sequences was introduced into human ovarian cancer-derived cells stably expressing a selectable marker [enhanced green fluorescence protein (EGFP)] under the control of the BRCA1 promoter. Cells in which BRCA1 expression was upregulated by particular ribozymes were selected through their concomitant increase in EGFP expression. The cellular target gene of one ribozyme was identified to be the dominant negative transcriptional regulator Id4. Modulation of Id4 expression resulted in inversely regulated expression of BRCA1. In addition, increase in Id4 expression was associated with the ability of cells to exhibit anchorage-independent growth, demonstrating the biological relevance of this gene. Our data suggest that Id4 is a crucial gene regulating BRCA1 expression and might therefore be important for the BRCA1 regulatory pathway involved in the pathogenesis of sporadic breast and ovarian cancer.

BRCA1 Protein↗

Giant bronchial carcinoid tumors: a multidisciplinary approach.

BACKGROUND: Bronchial carcinoid tumors account for approximately 2% of all lung tumors. Although they were considered benign lesions, they are now categorized malignant, occasionally with poor prognosis. The clinical symptoms can be highly variable and are often present for many years before diagnosis. Whereas some carcinoids are entirely asymptomatic, others are accompanied by carcinoid or paraneoplastic syndromes. METHODS: We describe the multidisciplinary management of a 34-year-old female patient with a massive actively secreting bronchial carcinoid tumor of the right lung. Furthermore, we provide a review of the literature regarding the operative treatment and the perioperative management of pulmonary carcinoid tumors with respect to surgical, anesthetic, radiologic, and pathologic considerations. RESULTS: In the reported case, the first symptoms were chronic watery diarrhea, skin flushing, progressive shortness of breath, and increasing right shoulder pain. When the patient initially presented at our institution, the tumor had already reached an enormous size and it involved the right and left atrium as well as the atrial septum. Using an evidence-based, multidisciplinary approach the patient was treated successfully with extended surgical resection. CONCLUSIONS: Carcinoid tumors are potentially curable even if they reach a significant size and thus an aggressive strategy is warranted. The management of such cases requires careful investigation, planning, and treatment with collaborative expertise provided by a multidisciplinary team. We demonstrated that this approach can lead to a favorable outcome in what first appeared to be a formidable and unresectable tumor.

Adult↗

Validation of a modified Early Warning Score in medical admissions.

The Early Warning Score (EWS) is a simple physiological scoring system suitable for bedside application. The ability of a modified Early Warning Score (MEWS) to identify medical patients at risk of catastrophic deterioration in a busy clinical area was investigated. In a prospective cohort study, we applied MEWS to patients admitted to the 56-bed acute Medical Admissions Unit (MAU) of a District General Hospital (DGH). Data on 709 medical emergency admissions were collected during March 2000. Main outcome measures were death, intensive care unit (ICU) admission, high dependency unit (HDU) admission, cardiac arrest, survival and hospital discharge at 60 days. Scores of 5 or more were associated with increased risk of death (OR 5.4, 95%CI 2.8-10.7), ICU admission (OR 10.9, 95%CI 2.2-55.6) and HDU admission (OR 3.3, 95%CI 1.2-9.2). MEWS can be applied easily in a DGH medical admission unit, and identifies patients at risk of deterioration who require increased levels of care in the HDU or ICU. A clinical pathway could be created, using nurse practitioners and/or critical care physicians, to respond to high scores and intervene with appropriate changes in clinical management.

Adolescent↗

Hepatitis B--a major threat to childhood survivors of leukaemia/lymphoma.

This prospective descriptive study was undertaken to determine: the proportion of paediatric oncology patients with prior exposure to hepatitis B at cancer diagnosis; the risk and risk factors for acquisition of hepatitis B infection during chemotherapy; and the development of a prevention policy. Sixty African children were included in this study. At the time of cancer diagnosis, 67.7 per cent had not been exposed to hepatitis B, and none had active infection. After follow-up (median of 20 months; range 4-81 months) 23.3 per cent had active hepatitis B infection, which was subclinical in the majority of cases. The diagnosis of leukaemia/lymphoma posed a major risk factor for the acquisition of active hepatitis B infection (chi-square 7.0; p-value = 0.008), probably due to intensive chemotherapy regimens and severity of immunosuppression. No association with gender, age, place of origin, or number of blood transfusions was found. Patients with leukaemia/lymphoma were at an increased risk for horizontal transmission of hepatitis B. A policy of active surveillance for infective carriers of hepatitis B infection and passive immunization of seronegative immunosuppressed patients must be implemented to limit the endemic infection in paediatric oncology units.

Adolescent↗

Relation of the static compliance curve and positive end-expiratory pressure to oxygenation during one-lung ventilation.

BACKGROUND: Positive end-expiratory pressure (PEEP) is commonly applied to the ventilated lung to try to improve oxygenation during one-lung ventilation but is an unreliable therapy and occasionally causes arterial oxygen partial pressure (PaO(2)) to decrease further. The current study examined whether the effects of PEEP on oxygenation depend on the static compliance curve of the lung to which it is applied. METHODS: Forty-two adults undergoing thoracic surgery were studied during stable, open-chest, one-lung ventilation. Arterial blood gases were measured during two-lung ventilation and one-lung ventilation before, during, and after the application of 5 cm H(2)O PEEP to the ventilated lung. The plateau end-expiratory pressure and static compliance curve of the ventilated lung were measured with and without applied PEEP, and the lower inflection point was determined from the compliance curve. RESULTS: Mean (+/- SD) PaO(2) values, with a fraction of inspired oxygen of 1.0, were not different during one-lung ventilation before (192 +/- 91 mmHg), during (190 +/- 90), or after ( 205 +/- 79) the addition of 5 cm H(2)O PEEP. The mean plateau end-expiratory pressure increased from 4.2 to 6.8 cm H(2)O with the application of 5 cm H(2)O PEEP and decreased to 4.5 cm H(2)O when 5 cm H(2)O PEEP was removed. Six patients showed a clinically useful (> 20%) increase in PaO(2) with 5 cm H(2)O PEEP, and nine patients had a greater than 20% decrease in PaO(2). The change in PaO(2) with the application of 5 cm H(2)O PEEP correlated in an inverse fashion with the change in the gradient between the end-expiratory pressure and the pressure at the lower inflection point (r = 0.76). The subgroup of patients with a PaO(2) during two-lung ventilation that was less than the mean (365 mmHg) and an end-expiratory pressure during one-lung ventilation without applied PEEP less than the mean were more likely to have an increase in PaO(2) when 5 cm H(2)O PEEP was applied. CONCLUSIONS: The effects of the application of external 5 cm H(2)O PEEP on oxygenation during one-lung ventilation correspond to individual changes in the relation between the plateau end-expiratory pressure and the inflection point of the static compliance curve. When the application of PEEP causes the end-expiratory pressure to increase from a low level toward the inflection point, oxygenation is likely to improve. Conversely, if the addition of PEEP causes an increased inflation of the ventilated lung that raises the equilibrium end-expiratory pressure beyond the inflection point, oxygenation is likely to deteriorate.

Adult↗

Identification of eIF2Bgamma and eIF2gamma as cofactors of hepatitis C virus internal ribosome entry site-mediated translation using a functional genomics approach.

The 5'-untranslated region of hepatitis C virus (HCV) is highly conserved, folds into a complex secondary structure, and functions as an internal ribosome entry site (IRES) to initiate translation of HCV proteins. We have developed a selection system based on a randomized hairpin ribozyme gene library to identify cellular factors involved in HCV IRES function. A retroviral vector ribozyme library with randomized target recognition sequences was introduced into HeLa cells, stably expressing a bicistronic construct encoding the hygromycin B phosphotransferase gene and the herpes simplex virus thymidine kinase gene (HSV-tk). Translation of the HSV-tk gene was mediated by the HCV IRES. Cells expressing ribozymes that inhibit HCV IRES-mediated translation of HSV-tk were selected via their resistance to both ganciclovir and hygromycin B. Two ribozymes reproducibly conferred the ganciclovir-resistant phenotype and were shown to inhibit IRES-mediated translation of HCV core protein but did not inhibit cap-dependent protein translation or cell growth. The functional targets of these ribozymes were identified as the gamma subunits of human eukaryotic initiation factors 2B (eIF2Bgamma) and 2 (eIF2gamma), respectively. The involvement of eIF2Bgamma and eIF2gamma in HCV IRES-mediated translation was further validated by ribozymes directed against additional sites within the mRNAs of these genes. In addition to leading to the identification of cellular IRES cofactors, ribozymes obtained from this cellular selection system could be directly used to specifically inhibit HCV viral translation, thereby facilitating the development of new antiviral strategies for HCV infection.

5' Untranslated Regions↗

Selective versus non-selective laser photocoagulation of placental vessels in twin-to-twin transfusion syndrome.

OBJECTIVE: We have recently described a surgical technique for the treatment of twin-to-twin transfusion syndrome (TTTS) that allows precise identification of vascular anastomoses (selective laser photocoagulation of communicating vessels, or S-LPCV). The purpose of this study was to compare S-LPCV with the previous non-selective technique (NS-LPCV) that targeted all vessels crossing the dividing membrane. MATERIALS AND METHODS: Patients with TTTS were treated with NS-LPCV from May 1994 to June 1997 and with S-LPCV from July 1997 to December 1999. TTTS was defined as polyhydramnios of > or = 8 cm maximum vertical pocket (MVP) in the recipient twin and oligohydramnios of < or = 2 cm MVP in the donor twin. Outcome was measured as survival per number of pregnancies and per number of fetuses together with limited morbidity data. RESULTS: NS-LPCV was used in 18 patients and 74 were treated with S-LPCV. Three patients interrupted their pregnancies electively after surgery (S-LPCV) and were removed from further analysis. Survival of at least one fetus was higher in S-LPCV (83.1%) than in NS-LPCV (61.1%) (P = 0.04), mostly due to a lower rate of dual intra-uterine fetal demise in S-LPCV (5.6%) than in NS-LPCV (22%) (P = 0.05). There were more hydropic fetuses in the NS-LPCV group (27%) than in the S-LPCV group (5.4%), but this difference did not account for the results. There was no difference in the survival per number of fetuses between the two groups. CONCLUSIONS: S-LPCV represents an important evolution in the surgical treatment of TTTS. The use of this technique by all centers should allow better comparison of fetal survival and morbidity rates. S-LPCV should be the standard technique in trials comparing amniocentesis versus laser for the treatment of severe TTTS.

Arteriovenous Anastomosis↗

The legendary superior strength of the Pfannenstiel incision: a myth?

OBJECTIVE: This study was undertaken to determine whether there is a difference in the frequency of fascial dehiscence between midline vertical lower abdominal and Pfannenstiel incisions among women undergoing obstetric and gynecologic operations. STUDY DESIGN: A case-control study of 48 cases of fascial dehiscence complicating 17, 995 major operations (8950 cesarean deliveries and 9405 gynecologic procedures) during a 6-year period at Wayne State University Hutzel Hospital, Detroit, was performed. Univariate analysis identified significant independent variables related to fascial dehiscence. Stepwise logistic regression analysis then identified those risk factors that were independently associated with fascial dehiscence. RESULTS: Among the 48 patients who underwent repair of fascial dehiscence after a major obstetric or gynecologic operation, 27 were from the obstetric service and 21 were from the benign and cancer gynecologic services. Wound dehiscence occurred in 10 vertical incisions and 17 Pfannenstiel incisions among the obstetric patients and in 12 vertical and 9 Pfannenstiel incisions among the gynecologic patients. The risk for dehiscence with vertical lower abdominal incisions was not increased with respect to that associated with Pfannenstiel incisions (P =.39, 2-tailed). This finding was true for all patients (odds ratio, 1.3; 95% confidence interval, 0.7-2.6), obstetric patients (odds ratio, 1.3; 95% confidence interval, 0.5-3.4), and gynecologic patients (odds ratio, 1.5; 95% confidence interval, 0.5-4.0). Forty-seven of the 48 case patients had documented wound infections, compared with 1 of the 144 control subjects (P <.0001, odds ratio, 37.8; 95% confidence interval, 14.8-96.8). CONCLUSION: Wound infection was the most important risk factor for fascial dehiscence among women who underwent major obstetric and gynecologic operations. Our results do not support the long-held belief that Pfannenstiel incisions are stronger than lower abdominal vertical incisions and reduce the risk for fascial dehiscence.

Abdomen↗

Prevalence of attention-deficit/hyperactivity disorder and conduct disorder among substance abusers.

BACKGROUND: This cross-sectional study sought to determine the prevalence of attention-deficit/hyperactivity disorder (ADHD) and conduct disorder among adults admitted to 2 chemical dependency treatment centers. It was hypothesized that ADHD alone or in combination with conduct disorder would be overrepresented in a population of patients with psychoactive substance use disorders. METHOD: Two hundred one participants were selected randomly from 2 chemical dependency treatment centers. Standardized clinical interviews were conducted using the Structured Clinical Interview for DSM-IV, the Addiction Severity Index, and DSM-IV criteria for ADHD. Reliabilities for the diagnostic categories were established using the Cohen kappa, and the subgroups of individuals with and without ADHD and conduct disorder were compared. RESULTS: Forty-eight (24%) of the participants were found to meet DSM-IV criteria for ADHD. The prevalence of ADHD was 28% in men (30/106) and 19% in women (18/95; NS). Seventy-nine participants (39%) met criteria for conduct disorder, and 34 of these individuals also had ADHD. Overall, individuals with ADHD (compared with those without ADHD) were more likely to have had more motor vehicle accidents. Women with ADHD (in comparison with women without ADHD) had a higher number of treatments for alcohol abuse. Individuals with conduct disorder (in comparison with those without conduct disorder) were younger, had a greater number of jobs as adults, and were more likely to repeat a grade in school, have a learning disability, be suspended or expelled from school, have an earlier age at onset of alcohol dependence, and have had a greater number of treatments for drug abuse. They were more likely to have a lifetime history of abuse of and/or dependence on cocaine, stimulants, hallucinogens, and/or cannabis. CONCLUSION: A significant overrepresentation of ADHD exists among inpatients with psychoactive substance use disorders. Over two thirds of those with ADHD in this sample also met criteria for conduct disorder. Our sample had a very large overlap between ADHD and conduct disorder, and the major comorbidities identified here were attributable largely to the presence of conduct disorder. Individuals who manifest conduct disorder and/or ADHD represent a significant proportion of those seeking treatment for psychoactive substance use disorders. They appear to have greater comorbidity and may benefit from a treatment approach that addresses these comorbidities specifically through medical and behavioral therapies.

Adolescent↗

Posttransplantation: emerging and future therapies.

Liver transplantation in patients infected with hepatitis B virus (HBV) commonly results in reinfection that, if untreated, often compromises the viability of the allograft and negatively influences survival. Posttransplant treatment with hepatitis B immune globulin (HBIG) is now the standard of care, but patients appear to require lifelong treatment to prevent reinfection. In the past several years, new management strategies in patients with HBV have been developed, with an aim to decrease HBV-DNA replication before transplantation. Such an approach should increase the success of transplantation by decreasing the risk of reinfection and thus preventing recurrent disease posttransplantation. Nucleoside analogues, either alone or in conjunction with HBIG, are currently in use and are being studied in clinical trials as a means of preventing viral recurrence. Ganciclovir, famciclovir, and lamivudine all have demonstrated efficacy, although they vary in terms of effectiveness. Resistance may develop with the use of these agents and leads to reinfection by the mutant virus. Combination therapy may minimize the risk of viral mutation. Research continues to search for more effective ways to prevent and, if necessary, treat viral recurrence in patients undergoing liver transplantation for HBV.

2-Aminopurine↗

Effect of palm oil on plasma lipoprotein concentrations and plasma low-density lipoprotein composition in non-human primates.

Palm oil (PO) contains approximately 43% of palmitic acid. It is the most abundant saturated fatty acid in the diet and it is generally considered the primary cholesterol (C)-raising fatty acid. However, the effect of palmitic acid on plasma cholesterol appears to depend on the cholesterol content of the diet. The aim of this study was to determine the effect of PO with either a high-fat, high-C or moderate-fat, moderate-C diet on lipoprotein C and low-density lipoprotein (LDL) composition. Fifty adult, male vervet monkeys were randomly assigned to the high-fat diet group (HFD: 35%E fat, approximately 0.106 mg C/kJ; n = 30) and the moderate-fat diet group (MFD: 30%E fat, approximately 0.027 mg C/kJ; n = 30). Baseline LDL-C, high-density lipoprotein (HDL)-C and body weight were used to stratify the vervets into comparable experimental groups within each dietary group. The HFD group was divided into two groups of 10 each: one group continued with the HFD in which 8.1%E was derived from lard (AF); in the other group, AF was substituted isocalorically with PO. The MFD group was divided into three groups of 10 each: one group continued with the MFD in which 11.8%E was derived from AF; in the other two groups, the AF was substituted isocalorically with either sunflower oil (SO) or PO. This article presents preliminary results on plasma lipoproteins and LDL composition after 6 months of dietary intervention. Plasma total and LDL-C was higher in all the groups, but the mean changes elicited by PO with either the HFD or MFD were no different from that observed with AF and SO. There was no difference in the mean change of LDL molecular weight within the HFD and MFD. It is concluded that PO is no different from AF (HFD and MFD) or SO (MFD) in its cholesterolaemic effect.

Animal Nutritional Physiological Phenomena↗

Dissociation of CH4 at high pressures and temperatures: diamond formation in giant planet interiors?

Experiments using laser-heated diamond anvil cells show that methane (CH4) breaks down to form diamond at pressures between 10 and 50 gigapascals and temperatures of about 2000 to 3000 kelvin. Infrared absorption and Raman spectroscopy, along with x-ray diffraction, indicate the presence of polymeric hydrocarbons in addition to the diamond, which is in agreement with theoretical predictions. Dissociation of CH4 at high pressures and temperatures can influence the energy budgets of planets containing substantial amounts of CH4, water, and ammonia, such as Uranus and Neptune.

Diamond↗

Pain management in cardiothoracic practice.

All analgesia regimens have benefits and side effects, and personal expertise can greatly influence the efficacy of regional techniques. A multimodal approach to analgesic management allows physicians to achieve maximum analgesic efficacy while limiting side effects. An appropriate analgesic plan takes into account the extent of pain associated with the type of incision and adjusts this according to each patient's individual needs. As we enter the new millennium, thoracic and cardiac surgery is becoming more innovative, and the life expectancy of people in the first world is constantly increasing. Older people with less physiologic reserve and more multisystem dysfunction are undergoing more major surgical procedures, and adequate pain control in the postoperative period is becoming increasingly important.

Analgesia↗