Surgical treatment of comminuted die-punch patellar fracture.
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Adult↗
Biomedical subjects
M Stephen
Publications and source records attributed to M Stephen.
Shamanism, psychosis and autonomous imagination.
This paper focuses on traditional healers (balian) in Bali, Indonesia, to raise new arguments concerning the nature of the initiatory sufferings reportedly experienced by shamans in many cultures. Our evidence suggests that a) contrary to our expectations, an initiatory madness or illness is experienced by a minority rather than the majority of balian, and b) whether or not a balian undergoes initiatory sufferings seems to be linked to gender and to the methods of healing employed - thus women healers who employ trance possession are those most likely to report an initiatory madness or illness. This leads to the central argument of the paper: c) the nature of the initiatory sufferings, where they do occur, can be clearly distinguished on several grounds from the onset of mental illness among Balinese, both emically in terms of cultural understandings, and ethically in terms of objective criteria. Finally we discuss the concept of "autonomous imagination," suggesting that the key to becoming a balian is not overcoming an initiatory madness but gaining control over this special mode of imagery thought. We further suggest that Western ideas concerning the self and self healing, the superficial resemblance of the initiatory sufferings to schizophrenia, and the dramatic nature of the initiatory sufferings when they occur, have combined to give a misleading prominence to the role of an initiatory madness in shamanism.
Adult↗
Long-term survival following extra-neural metastasis from a pineoblastoma.
A young woman presented with a pineoblastoma treated initially with whole neuraxis radiotherapy. She had biopsy confirmed metastatic disease to the left lateral pelvis which was treated on 2 separate occasions, and biopsy confirmed metastatic disease to the subcutaneous tissues of the left thigh. She currently remains well 8 years after the primary diagnosis and 6 years after the first systemic relapse.
Acetabulum↗
Protection of the small bowel during abdominal radiation therapy with a tissue expander prosthesis.
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Adult↗
Endotension: an explanation for continued AAA growth after successful endoluminal repair.
PURPOSE: To present and analyze several cases that illustrate persistent sac pressurization following endovascular abdominal aortic aneurysm (AAA) repair. METHODS AND RESULTS: Four patients with successful endovascular AAA exclusion presented in follow-up with an expanding aneurysm. Two had initial sac diameter decrease, but by 18 and 24 months, respectively, the AAA had enlarged and become pulsatile. There was no endoleak evident, but the proximal attachment stents had mig rated distally in both cases. One patient developed endoleak with aneurysm expansion at 6 months; contained rupture occurred at 12 months. The last case had slowly evolving aneurysm expansion over 36 months but no endoleak. All endografts were removed and successfully replaced with conventional grafts. Intrasac thrombus was implicated as the means of pressure transmission that precipitated AAA expansion in these cases. CONCLUSIONS: Excluded AAAs can increase in size owing to persistent or recurrent pressurization (endotension) of the sac even when there is no evidence of endoleak. One proposed mechanism is pressure transmission via thrombus that lines the attachment site. Endotension may also represent an indiscernible, very low flow endoleak that allows blood to clot at the source of leakage.
Aged↗
The interchain disulfide linkage of T-cell antigen receptor-alpha and -beta chains is a prerequisite for T-cell activation.
Complementary DNAs encoding the T-cell antigen receptor (TCR)-alpha and mutant TCR-beta chains, lacking the interchain disulfide bond-related cysteine, were introduced into a TCR-alpha and -beta protein-deficient T-cell line. TCR-alpha and the mutant TCR-beta chains assembled with the CD3-epsilon, -gamma, -delta, and -zeta subunits and were efficiently transported to the cell surface; however, the hybrid TCR molecules exhibited a diminished response to T-cell activation by major histocompatibility complex-bound antigen, superantigen, and TCR cross-linking. These results suggest that the interchain disulfide bond between the TCR clonotypic chains is not required for TCR assembly and cell surface expression, but it plays an important role in maintaining the functional integrity of the TCR complex.
Animals↗
Consuming the dead: a Kleinian perspective on death rituals cross-culturally.
The author argues that Melanie Klein's theories of mourning shed light on certain funerary practices encountered widely in ethnographic literature, namely 'second burial'. Pointing out that the death of a loved person is experienced in fantasy as the destruction of the internalised mother imago, the author shows how various Kleinian processes involved in infantile fears of maternal loss--such as persecutory anxiety, guilt, depression, and attempts at reparation--are clearly expressed in rituals of mourning cross-culturally. The argument is illustrated with two extensive case studies, Bali (Indonesia) and the Mekeo of coastal Papua New Guinea. A number of other cultures are considered briefly to indicate the relevance of Kleinian theory to the symbolism of death rituals more broadly, including the role played by sorcery and witchcraft beliefs, fears of malevolent ghosts, repeated re-burial, mortuary gift exchange, cremation, mortuary cannibalism, and the denial of death in modern western funeral rites.
Attitude to Death↗
Portosystemic shunting for paediatric portal hypertension.
The records of 22 patients who received portosystemic shunting for portal hypertension from 1985 to 1995 inclusive at the Royal Alexandra Hospital for Children (RAHC) were retrospectively reviewed. There were 11 girls and 11 boys. The average age at operation was 8 years, 3 months (range, 2 years, 3 months to 16 years, 7 months). The aetiology was idiopathic portal cavernomatous transformation (n = 9), billiary atresia (n = 4), cystic fibrosis (n = 3), documented neonatal portal vein thrombosis (n = 3), congenital hepatic fibrosis (n = 2), and portal vein obstruction after liver transplant (n = 1). The major presenting problem was upper gastrointestinal haemorrhage. Two patients had recurrent melaena from Roux-en-Y jejunal loop and caecal varices, respectively. Before receiving shunts, 12 patients had endoscopic sclerotherapy, 1 had gastric transection, and 2 had gastric varices oversewn. Portal pressure at preoperative splenoportogram averaged 28 mm Hg (range, 20 to 41). Urgent shunts were performed on 13 patients. Two disadvantaged patients had prophylactic shunts for severe hypersplenism. The types of shunts used were reversed splenorenal (n = 13), splenoadrenal (n = 6), inferior mesenteric renal (n = 1), portocaval (n = 1), inferior mesenteric caval (n = 1), and superior and inferior mesenteric caval (n = 1). In all, 22 patients had 23 shunts. The patency rate was 96% on 6 months to 10 years follow-up (average, 5.8 years). No spleen was lost. There were 2 late deaths. Two cystic fibrosis patients and one child with extrahepatic portal hypertension experienced post-shunt encephalopathy. Three patients rebled in the early postoperative period despite a patent shunt. Two patients subsequently received liver transplantation without any additional difficulties. Thus, portosystemic shunting using a method appropriate for the patient is a reliable option for treating children with portal hypertension in whom variceal sclerotherapy is inappropriate or has failed.
Adolescent↗
Concurrent comparison of endoluminal repair vs. no treatment for small abdominal aortic aneurysms.
UNLABELLED: Endoluminal repair of abdominal aortic aneurysms (AAA) requires the aneurysm to have a proximal neck of at least 1.5 cm between the renal arteries and the aneurysm. Therefore, there may be advantages in performing endoluminal repair in the early stages of aneurysm development. However, the results of endoluminal repair performed in patients with small aneurysms with favourable morphology are not known. The aim of this study was to determine whether a randomised trial of endoluminal repair vs. no treatment for small aneurysms would be justified by using a concurrent comparison of endoluminal repair vs. no treatment for AAA 5 cm or less in diameter in patients presenting to the same centre during a 4-year period. METHODS: Data on 117 patients presenting with AAA 5 cm or less in diameter were entered into a registry. The decision to perform endoluminal repair vs. no treatment was based on the patient's preference following surgical consultation and investigation by computed tomography. This study reports the mortality, morbidity and survival of patients presenting between June 1992 and August 1996. During this time 43 patients had endoluminal repair and 67 patients had no treatment for small AAA. Seven patients were unfit for any intervention. Despite patient selection for different management in each group, close analysis revealed that the groups were similar with regard to co-morbidities and risk factors, as well as age, sex, and size of aneurysm. Follow-up was by progress CT scanning and ranged from 1 to 51 months (mean 18 months (NT) and 22 months (ER)). RESULTS: Endoluminal repair failed in six of 43 patients (14%) and resulted in 11 (25%) local vascular complications. There were two perioperative deaths and one late death in this group. Twenty-one of 67 AAA (31%) patients in the no treatment group enlarged beyond 5 cm in diameter during the study period. There was one death from aneurysm rupture and one death from myocardial infarction in this group. CONCLUSIONS: The patients in the endoluminal repair group have gained an asset in having their aneurysms repaired at a cost of early morbidity following operation. These results suggest that a randomised trial of endoluminal repair vs. no treatment will become justified in the subset of patients with small AAA 5 cm or less, if the incidence of complications can be reduced by further improvements in endoluminal technology.
Age Factors↗
Conversion from endoluminal to open repair of abdominal aortic aneurysms: a hazardous procedure.
AIM: The purpose of this study was to analyse the technical problems associated with conversion from endoluminal repair of abdominal aortic aneurysms (AAA) to open repair and document the outcome in patients with this clinical course. METHODS: Between May 1992 and May 1996 endoluminal repair of AAA was undertaken in 113 patients. Forty-eight of these had medical co-morbidities which led to them being rejected for open repair at other medical centres. Conversion from endoluminal to open repair was required in 18 patients. Thirteen of these occurred at the original operation (primary conversion) and five occurred at a later operation (secondary conversion). Seven of the 18 patients undergoing conversion had serious medical co-morbidities. Three different methods of open repair were used. The technique selected was determined by the cause of failure leading to conversion. Standard open AAA repair was used in patients requiring conversion for access problems (n = 2) and balloon malfunction, where the device ended up entirely within the aneurysmal sac (n = 1). Modifications to the standard technique were required in patients in which the endograft was correctly positioned immediately below the renal arteries and/or where part of the endograft was within one or both common iliac arteries (n = 11). Supra-coeliac control was required for patients with aortic rupture (n = 1), renal arteries covered by the endograft (n = 2) and situations where the delivery catheter was trapped within the aorta above a twisted bifurcated graft (n = 1). The mean volume of contrast used was 225 ml and the mean operative time was 5.25 h in patients undergoing primary conversion. RESULTS: Conversion to open repair was achieved in all 18 patients. Renal impairment requiring dialysis occurred in three patients. There were three perioperative deaths, all of which were procedure-related (17%), and one late death. All four deaths occurred from among the group of seven patients with preoperative co-morbidities. CONCLUSIONS: Converting an endoluminal to an open AAA repair may require modifications to the standard open technique and result in a much higher than generally accepted morbidity and mortality rate. Patients rejected for open repair because of co-morbidities ran the same chance of requiring conversion as those without co-morbidities (15-17%). If conversion was required, however, they stood a 3 in 7 or 43% chance of dying.
Aged↗
The role of diet, fluoride and saliva in caries prevention.
Saliva is rich in calcium and phosphates, facilitating remineralization of early carious lesions. There is evidence that remineralization is associated with an increase in the size of enamel crystals and a consequent increase in resistance to caries. The contribution of sucrose to the implantation, colonization and metabolic activities of cariogenic bacteria has been clearly established, and has led to the search for sucrose substitutes. Recent report from Australia and the United States of America have reconfirmed the safety and efficacy of fluoride in preventing dental caries. The use of fluoride in various forms thus remains the cornerstone of most caries prevention programme.
Cariostatic Agents↗
A prospective study of anatomico-pathological changes in abdominal aortic aneurysms following endoluminal repair: is the aneurysmal process reversed?
AIM: The aim of this prospective study was to analyse early anatomico-pathological changes in abdominal aortic aneurysms (AAA) following endoluminal repair to determine if the natural history of continued expansion of AAA is reversed. MATERIALS AND METHODS: Sixty-seven of 85 patients undergoing endoluminal AAA repair between May 1992 and August 1995 had their operations prior to the end of February 1995 and were potentially available for follow up at 6 months or longer after operation. Excluded were: patients with failed endoluminal repairs (n = 14), patients who died within 6 months of operation (n = 5), patients with anastomotic AAA (n = 1), leaving 47 patients in the study group. Based on contrast enhanced CT performed preoperatively, within 10 days of operation and 6, 12 and 18 months after operation patients were divided into two groups: those in whom the AAA maximum transverse diameter (MTD) decreased Group I (n = 39) and those in which it increased Group II (n = 8). The following parameters were analysed: diameter of the supra coeliac aorta, MTD and the dimensions of the proximal and distal necks of the AAA plus extravasation ("leak") of contrast into the aneurysmal sac. RESULTS: Leak of contrast was seen in 0 of 39 patients in Gp I and 5 of 8 patients in Gp II. Patients in Group I experienced a progressive diminution in AAA mean MTD. The diameters of the proximal and distal necks increased but there was no shortening of the length of the necks in this group. In Group II the AAA MTD was dependent on whether or not the aneurysmal sac was isolated from the circulation. The diameter of the proximal and distal necks increased irrespective of this fact. CONCLUSION: We conclude that in early follow up AAA which diminish in diameter following endoluminal repair remain isolated from the general circulation. Co-incident with this decrease in AAA diameter, the proximal and distal necks increase in diameter but do not undergo any shortening in length. This paradoxical increase in neck diameter, was not progressive in the period of follow-up.
Aged↗
An outbreak of Serratia marcescens infection among obstetric patients.
An outbreak of S. marcescens infection occurred among 17 obstetric patients during May-June 1990. Simultaneously 11 newborns were also affected. All the 28 strains were identical in their biochemical characteristics, serotype and phage type as well as antimicrobial susceptibility pattern. The source of infection was traced to a contaminated batch of cream, consisting of 0.5 per cent savlon in carboxy methyl cellulose base, used while doing pelvic examination. The affected patients were treated with appropriate antibiotics and there was no mortality. No further infection was reported after the removal of the contaminated cream.
Adult↗
Care of the febrile child: an annotated bibliography.
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Child↗
Retention of skills by advanced trained ambulance staff.
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Allied Health Personnel↗
Immunosuppressive activity, lymphocyte subset analysis, and acute toxicity of FK-506 in the rat. A comparative and combination study with cyclosporine.
The immunosuppressive and toxic properties of the recently discovered macrolide antibiotic FK506 were examined in comparison and in conjunction with cyclosporine administration in the rat. Male Sprague-Dawley rats were immunized systemically with sheep erythrocytes and received, from the same time, either FK506 (1 mg/kg/day) intramuscularly or CsA (25 mg/kg/day) by gavage, or both drugs in combination. Seven days after immunization, the splenic plaque-forming cell response and circulating antibody titers were reduced greater than 90% in animals receiving either FK506 or CsA and in the drug combination group. These immunosuppressive effects of FK506 and CsA were accompanied by significant increases in the incidences of splenic OX-8+ cells and by corresponding reductions in the W3/25+:OX-8+ ratio. No further changes in T cell populations were observed in animals given both drugs. A progressive monocytosis was found in response to CsA, but not in FK506-treated rats. Increases in plasma urea were observed in FK-506 and drug-combination or CsA-treated rats on day 7, whereas creatinine levels were raised only in the FK-506 groups. Elevated bilirubin levels and alterations in liver enzyme activities were observed in CsA-treated rats by day 4, whereas FK-506 alone produced no similar effects. CsA-treated rats also exhibited elevated blood and urinary glucose levels from day 4. No biochemical evidence of additive drug toxicity was detected. The only histological abnormalities observed were thymic medullary atrophy in all drug-treated animals, together with very minor reductions in bone marrow cellularity in a proportion of those rats given FK-506. These findings show that, at the dosage selected, the powerful immunosuppressive activities of FK-506 were associated with little evidence of acute toxicity and with no indications of additive toxicity with CsA.
Animals↗
Spleen lymphocyte populations and expression of activation markers in rats treated with the potent new immunosuppressive agent FK-506.
Rats were immunized systemically with sheep red blood cells (SRBC) and treated with either FK-506 (1 mg/kg/day) or cyclosporin A (CsA) (25 mg/kg/day) for 7 days. Profound (greater than 90%) suppression of the production of splenic IgM-secreting plasma cells and circulating antibody levels was observed in animals receiving either drug. Immunosuppression was accompanied by significant increases in the incidence and absolute numbers of OX8+ (T-cytotoxic/suppressor) lymphocytes in the spleen, and there were corresponding reductions in the W3/25+:OX8 (CD4+:CD8+) ratio. The magnitude of these changes was not affected by drug combination. There were no significant alterations in B cells with either agent, whilst a small but significant increase in the incidence of macrophages was observed in all drug-treated groups. Neither FK-506 nor CsA affected IL-2 receptor (OX39) or MHC class II (OX6) antigen expression. This study demonstrates the remarkable immunosuppressive potency of FK-506 and its underlying capacity, like CsA, to affect regulatory T-lymphocyte subsets in vivo.
Animals↗