Biomedical subjects
R Emanuel
Publications and source records attributed to R Emanuel.
GP and GDP fee scales.
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A-void--an exploration of defences against sensing nothingness.
The author describes the potentially annihilating terror implicit in the experience of contact with the void--the 'domain of the non-existent' or nothingness, conceived as an immensely hostile object, terrifying space or a place of 'nameless dread'. All manifestations of existence are threatened by contact with the void, necessitating the deployment of a variety of defences. These various defences--universally employed to avoid contact with this domain--are then discussed. These include trying to search for a fixed sense of identity that can often propel people to seek refuge inside an object or state of mind, as described in Meltzer's 'claustrum' and Steiner's 'psychic retreat'. Other defences, including distraction and grandiosity, are also described. The author then goes on to discuss techniques for helping patients to tolerate contact with mental states engendered by the threat of potential contact with the void, in order to strengthen their capacity to feel and thus enlarge their repertoire of coping with anxiety in a non-reactive and thus growth-inducing manner. This involves discussion about psychoanalytically informed Buddhist understanding of these states and the nature of identity itself, as well as the correlation between these insights and those offered by Bion and other psychoanalytic writers.
Active learning in service delivery: an approach to initial clinical placements.
In their first clinical placement and using an active learning approach, students provided an extension to existing service provision. Therapist-led teams of six students carried out assessment, therapy and advice. Carefully structured preparation, supervision and feedback enabled them to discover and develop effective approaches for themselves. The learning experience and service provision were evaluated and modifications introduced over a three year period. Feedback from students and service users confirmed that the project had provided both effective learning and a valuable contribution to the local service.
An audit of MRI for bone and soft-tissue tumours performed at referral centres.
AIM: Magnetic resonance imaging (MRI) is essential in the pre-operative staging of suspected primary bone and soft-tissue sarcomas. Such lesions are ideally managed in specialist centres but it is becoming increasingly common for patients to undergo MRI before referral. The aim of this study was to assess the adequacy of such studies. MATERIALS AND METHODS: Fifty patients (30 men, 20 women; mean age 39 years, range 9-89 years) were included over a 1-year period. Tumours included 31 suspected primary bone tumours and 19 soft-tissue tumours. RESULTS: The total number of sequences used was 225 (mean 4, range 2-8). Enhancement was used in 19 cases. The commonest mistake was the failure to image the whole bone for 'skip' metastases in 50% of appropriate cases (high-grade malignant lesions of bone). Reports were available in 40 cases. Specific information regarding precise intraosseous and extraosseous extent of tumour and relationship to the neurovascular bundle and adjacent joint was commonly not included. CONCLUSIONS: This audit indicates that a greater awareness is needed amongst general radiologists of the MR imaging and reporting requirements for musculoskeletal tumours. In particular, all important axial imaging is sometimes omitted.Saifuddin, A. (2000). Clinical Radiology 55, 537-541.
An analysis of radiating pain at lumbar discography.
This study aimed to identify the morphological abnormalities of the intervertebral disc, as demonstrated by lumbar discography, that are associated with pain radiation to the hip, groin, buttock or lower limb. We carried out a retrospective review of 99 consecutive lumbar discogram reports. The association of disc degeneration, annular tears (partial or full thickness) and the level of disc injected was determined with respect to the presence and pattern of radiating pain. A total of 260 discs were injected, of which 179 were considered abnormal. Posterior annular tears were demonstrated in 84 discs, anterior annular tears in 15 discs and 45 discs had both anterior and posterior tears. A significant association was identified between isolated posterior tears and the production of concordant radiating pain (P = 0.0041). No difference was identified between partial thickness posterior tears and full thickness posterior tears associated with leak of contrast medium, with regard to radiating pain. Similarly, there was no significant association between disc level injected and the pattern of pain radiation. The results indicate that pain experienced in the buttock, hip, groin or lower limb can arise from the posterior annulus of the intervertebral disc without direct involvement of the nerve root.
Aggressive and impulsive behavior in military psychiatric inpatients.
OBJECTIVE: To determine if a history of aggressive/impulsive behavior adversely affected the return to full duty of a military psychiatric inpatient population. METHOD: Charts were reviewed for aggressive/impulsive behavior as indicated by self-report on a standardized admission form and by history in 211 consecutive admissions pooled from two separate 2-month intervals during a 9-month period. RESULTS: Seventy-three percent of the population was between the ages of 17 and 24 years. Sixty-eight percent of the population reported a history of at least one school suspension/expulsion, arrest, or military nonjudicial punishment (males, 74%; females, 45%). Seven percent of patients reporting aggressive/impulsive behavior were returned to full duty unconditionally, compared with 28% of patients not reporting said behavior. Eighteen percent of patients met the criteria for adult antisocial behavior. Only one patient with adult antisocial behavior was returned to full duty. CONCLUSIONS: This study found that a history of aggressive/impulsive behavior was positively correlated with substance abuse and negatively correlated with return to full military duty.
Second messenger regulation of mRNA for corticotropin-releasing factor.
An understanding of how second messengers and their ligands are coupled to CRF gene activation is necessary if we are to understand the regulation of the CRF gene in physiological and pathological states. The protein kinase A, protein kinase C and glucocorticoid second messenger systems mediate most of the regulation of the CRF gene. In in vitro systems, CRF gene expression is stimulated 20-30-fold by activation of either the protein kinase A or the protein kinase C system. Glucocorticoid is able to inhibit stimulation via both pathways, but appears to be more effective in repressing activation mediated by protein kinase C. Glucocorticoid negative regulation requires the presence of glucocorticoid receptor possessing an intact DNA-binding domain, suggesting that this effect involves binding of the receptor to the CRF promoter. These in vitro studies should serve to guide investigators towards the possible mechanisms underlying CRF gene regulation in vivo.
Clinical behavior of silver-palladium alloy castings: a five-year comparative clinical study.
A 5-year clinical comparison between silver palladium alloys (Albacast and Ney 76) and gold alloy (Firmilay) was conducted. Clinical evaluations for the castings of these materials placed in the same patients, were recorded immediately after cementation, at 3 months, 6 months, 1.5 years, 3 years, and 5 years. The changes in surface tarnish, discoloration, polish, and plaque accumulation was compared. The results indicated that gold alloys responded slightly better than Ney 76 alloy, but similar to Albacast alloy with adequate correlation between the four criteria evaluated.
Surface energy of chemomechanically prepared dentin.
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Epicardial monophasic action potentials.
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Use of monophasic action potential recordings during routine coronary-artery bypass surgery as an index of localised myocardial ischaemia.
In 8 patients undergoing routine coronary-artery bypass surgery, monophasic action potentials (MAPs) were measured by means of a hand-held pressure contact electrode to provide an index of local ischaemic changes. 4 patients received left internal mammary anastomoses (LIMA), and there were a total of 27 saphenous vein grafts (SVG). After completion of all grafts blood-flow to the myocardium was reduced for 90 s by means of different permutations of SVG and LIMA occlusion, either on or off bypass. In all patients MAPs indicated typical ischaemic changes. The high sensitivity of the method enables the study to be completed quickly and without hazard to the patient. The technique provides a new means to assess local ischaemia, the viability of specific areas of myocardium, and the efficiency of individual grafts during surgery.
Drainage of neoplastic pericardial effusions.
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Observations on the biphasic nature of digitalis electrophysiological actions in the human right atrium.
Cardiac electrophysiological effects of a digitalis glycoside have been investigated by right atrial intracardiac stimulation and recording in 12 patients with paroxysmal supraventricular tachyarrhythmias. Measurements were made of atrial effective refractoriness by pacing together with programmed premature extrastimulation. Simultaneous recordings of atrial action potential duration from a site close to the sinoatrial node and from a more distal atrial site were made using an endocardial contact-injury potential technique. All subjects received methyldigoxin 10.0 micrograms X kg-1 intravenously, while half were also pretreated with atropine. A biphasic response to methyldigoxin was observed, with initial action potential prolongation, maximal at 20 min post-infusion, followed by significant action potential shortening which persisted to the end of the study period at 40 min. The initial phase, that of prolongation, was associated with smaller increases in atrial effective refractoriness and increased vulnerability to atrial tachyarrhythmia initiation. During the subsequent phase of action potential shortening, the gap between the termination of effective refractoriness and completion of action potential repolarisation was narrowed, coinciding with diminished vulnerability to tachyarrhythmias. Slight but significant atrioventricular conduction delay was apparent 30 to 40 min after glycoside infusion, indicating enhanced vagal activity during the phase of action potential shortening. Prior atropinisation reduced the magnitude of both early and late components of the biphasic action potential response to digitalis, supporting the proposition that both components are mediated via cardiac muscarinic receptors. Since vagal effects on the atrioventricular junction appeared during the later phase, it is suggested that initial action potential prolongation by digitalis may have been effected via local acetylcholine release, while subsequent action potential shortening may have been caused by a combination of vagally and locally mediated activity.
Evidence of congenital heart disease in the offspring of parents with atrioventricular defects.
Fifty-two of the 56 offspring from 90 patients with proven atrioventricular defects were examined. There were five with congenital heart disease. The defects were concordant in three and discordant in two. The mother was the affected propositus in all cases. In this relatively small sample the incidence of congenital heart disease in the offspring of parents with atrioventricular defects was 9.6%, or 14.3% if only the female propositi were considered. This is a much higher figure than that reported for the simple forms of isolated congenital heart disease.
Asymmetric septal hypertrophy and hypertrophic cardiomyopathy.
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Staffing and facilities in cardiology in England and Wales July 1982. Second biennial survey.
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Analysis of exercise-induced changes in R wave amplitude in asymptomatic men with electrocardiographic ST-T changes at rest.
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