Additional Clinical Cases Research Articles

Web-based adaptive training simulator system for cardiac life support

We introduce a web-based adaptive training simulator system to exercise cardiopulmonary resuscitation skills. Our purpose is to provide emergency physicians with an additional training tool for cardiac life support clinical cases, by integrating an adaptive learning environment with a web-based case simulator. Adaptive systems reflect some features of the user in the user model and apply this model to adapt various visible aspects of the system to the user. Our system follows a stage-based learning model with several steps to personalize student learning. First, students learn the theory and content of life support and take computerized tests to evaluate their declarative knowledge of these areas. Second, they practice with clinical case examples and complete an exam at the appropriate level of difficulty to assess their practical knowledge. Finally, they train with additional clinical cases. In order to evaluate the usefulness of the system, we used it in two traditional advanced life support courses at the Jaen Hospital in Spain, as an additional and complementary tool within the course. Results show that the use of adaptation techniques can improve student performance.

Hepatozoon spp.: pathological and partial 18S rRNA sequence analysis from three Brazilian dogs

Molecular and histopathological studies were carried out on samples from three Brazilian dogs with persistent hepatozoonosis parasitemia. Canine hepatozoonosis was confirmed by finding gametocytes in blood smears. Histopathological examination of skeletal muscle biopsy revealed muscle degeneration and atrophy, and degenerating/regenerating myofibers, similar to the muscle degeneration caused by Hepatozoon americanum . However, the large cystic structures typical of H. americanum were not observed in muscle biopsies from these dogs. Partial 18S rRNA sequences amplified by PCR from the three Brazilian samples demonstrated closest similarity to the Hepatozoon sp. Fukuoka described in Japan (>99% identity). These results indicate that both additional clinical cases and genes need examination in order to determine the phylogenetic relatedness among canid Hepatozoon species.

Feasibility study of beam orientation class‐solutions for prostate IMRT

IMRT is being increasingly used for treatment of prostate cancer. In practice, however, the beam orientations used for the treatments are still selected empirically, without any guideline. The purpose of this work was to investigate interpatient variation of the optimal beam configuration and to facilitate intensity modulated radiation therapy (IMRT) prostate treatment planning by proposing a set of beam orientation class-solutions for a range of numbers of incident beams. We used fifteen prostate cases to generate the beam orientation class-solutions. For each patient and a given number of incident beams, a multiobjective optimization engine was employed to provide optimal beam directions. For the fifteen cases considered, the gantry angle of any of the optimized plans were all distributed within a certain range The angular distributions of the optimal beams were analyzed and the most selected directions are identified as optimal directions. The optimal directions for all patients are averaged to obtain the class-solution. The class-solution gantry angles for prostate IMRT were found to be: three beams (0 degrees, 120 degrees, 240 degrees), five beams (35 degrees, 110 degrees, 180 degrees, 250 degrees, 325 degrees), six beams (0 degrees, 60 degrees, 120 degrees, 180 degrees, 240 degrees, 300 degrees), seven beams (25 degrees, 75 degrees, 130 degrees, 180 degrees, 230 degrees, 285 degrees, 335 degrees), eight beams (20 degrees, 70 degrees, 110 degrees, 150 degrees, 200 degrees, 250 degrees, 290 degrees, 340 degrees), and nine beams (20 degrees, 60 degrees, 100 degrees, 140 degrees, 180 degrees, 220 degrees, 260 degrees, 300 degrees, 340 degrees). The level of validity of the class-solutions was tested using an additional clinical prostate case by comparing with the individually optimized beam configurations. The difference between the plans obtained with class-solutions and patient-specific optimizations was found to be clinically insignificant.

Naturally acquired babesiosis in a reindeer (Rangifer tarandus tarandus) herd in Great Britain.

A provisional diagnosis of babesiosis was made in a reindeer herd in Scotland when seven animals died during 1997 and 1998. Additional clinical cases occurred, but the animals recovered after treatment. Thirty-one reindeer from the herd were tested for the prevalence of exposure to Babesia by the indirect fluorescent antibody test using a bovine isolate of Babesia divergens that had been passaged through gerbils. Infection rates were determined by Giemsa-stained blood smears. In addition, molecular identification of the infecting Babesiasp. was undertaken using SSU rRNA gene sequence analysis. It is likely that the organism causing babesiosis in this reindeer herd is B. divergens.

Clinical significance of nested polymerase chain reaction and immunofluorescence for detection of Pneumocystis carinii pneumonia

To study the clinical significance of a nested polymerase chain reaction (PCR) method compared to immunofluorescence (IF) for detection of Pneumocystis carinii. The medical records of 89 patients with 91 episodes of pneumonia were scrutinised retrospectively. The pneumonia episodes were divided into categories according to the likelihood that the patient had had clinical Pneumocystis carinii pneumonia (PCP). All respiratory tract samples from the 89 patients (34 broncho-alveolar lavage (BAL) and 57 sputa) were tested for Pneumocystis carinii by IF and nested PCR. Fifteen episodes, as diagnosed by IF, were classified as true PCP (combination of the groups with definite and probable PCP; sensitivity 60%, specificity 97%). Among the P. carinii DNA-positive episodes, detected with nested PCR, 24 were classified as true PCP (combination of the groups with definite and probable PCP; sensitivity 96%, specificity 59%), since all IF-positive samples were nested PCR positive. Only one pneumonia episode classified as a probable PCP, was negative with both methods, as applied to a BAL sample. IF applied to BAL or sputum seems to be the most specific method for diagnosis of clinical PCP. Additional clinical cases can be found by nested PCR, although this then gives a high risk of detecting subclinical colonisation of P. carinii.

Model-Updated Image-Guided Neurosurgery: Preliminary Analysis Using Intraoperative MR.

In this paper, initial clinical data from an intraoperative MR system are compared to calculations made by a three-dimensional finite element model of brain deformation. The preoperative and intraoperative MR data was collected on a patient undergoing a resection of an astrocytoma, grade 3 with non-enhancing and enhancing regions. The image volumes were co-registered and cortical displacements as well as subsurface structure movements were measured retrospectively. These data were then compared to model predictions undergoing intraoperative conditions of gravity and simulated tumor decompression. Computed results demonstrate that gravity and decompression effects account for approximately 40% and 30%, respectively, totaling a 70% recovery of shifting structures with the model. The results also suggest that a non-uniform decompressive stress distribution may be present during tumor resection. Based on this preliminary experience, model predictions constrained by intraoperative surface data appear to be a promising avenue for correcting brain shift during surgery. However, additional clinical cases where volumetric intraoperative MR data is available are needed to improve the understanding of tissue mechanics during resection.

Metabolic Epidermal Necrosis-Hepatocutaneous Syndrome

It is clear that cutaneous lesions of metabolic epidermal necrosis in the dog can occur either with a demonstrable glucagon-secreting tumor or with hepatic disease without any detectable glucagonoma. Additional clinical case reports of the disease in cats are needed to better characterize the disease in this species. The lesions of NME-MEN may not represent a specific physiological mechanism of cutaneous disease but instead a pathophysiological process that can be triggered by several systemic metabolic abnormalities. The fact that NME is observed in association with a variety of conditions supports the theory that an overall metabolic derangement results in the rash. The prognosis for canine MEN is poor; however, some affected dogs have been maintained for many months with dietary management. High-quality protein diets such as Hill's Prescription Diet a/d (Hill's Pet Products) or other "recovery" diets may be helpful. Zinc and essential fatty acid supplementation may help some patients. Dietary supplementation with cooked egg yolks may be helpful. It is prudent to avoid corticosteroids in these cases, as development of diabetes mellitus worsens the prognosis. Histopathological examination of the pancreas coupled with determination of plasma glucagon may help define the characteristics of GS versus HS in dogs. It is possible that some dogs diagnosed with MEN-HS may have an undetected pancreatic tumor. Although the hepatic ultrasound findings in dogs with MEN-HS are becoming well characterized, it is possible for dogs with pancreatic neuroendocrine tumors to also have abnormal hepatic ultrasonography. As the presence of MEN and hepatic disease does not necessarily rule out the presence of a pancreatic tumor, prospective studies correlating plasma glucagon levels with pancreatic histopathology in cases of MEN-GS versus MEN-HS seem warranted.

Does Gustave Dax Deserve to Be Forgotten? The Temporal Lobe Theory and Other Contributions of an Overlooked Figure in the History of Language and Cerebral Dominance

Gustave Dax played an important role in the early history of cerebral dominance for language. He not only sent the 1836 memoir of Marc Dax, his deceased father, to Paris in 1863, but saw to it that this important document was published before Paul Broca's own article on cerebral dominance appeared later in 1865. In addition, he supported his father's contention that the left hemisphere is special for speech with 140 additional clinical cases. Gustave Dax's own unique contribution, however, has been almost completely overlooked. Although his theory lacked specificity, he preceded Meynert, Schmidt, and Wernicke in suggesting that the left temporal lobe may be especially important for speech.

膀胱拡大術の臨床研究

Our cystoplasty regenerates and expands the bladder as performed and reported in a case report by the authors in “A Study on Cystoplasty by Regeneration of Contracted Bladder using Novectane (Liquid Synthetic Resin)-sprayed Thin Paper (1)”.This first case has been under postoperative clinical observation for more than two years and a half. The fact that the bladder capacity has increased from 50-60cc before the operation to 400cc and the residual urine is less than 10cc indicates long-lasting very favorable results of cystoplasty. Even 2 years after the cystoplasty it was not possible to discriminate the regenerated bladder wall from the original bladder wall under the cystoscopic examination. Both urine analysis and cystogram indicate a normal state.Case 1 has becomes the basis for further cystoplasty being performed by the author, H. Taguchi. Two additional clinical cases with more complicated conditions than Case 1 are reported below.Preoperative condition and Surgical Method:Case 2 is a 24 year old female. About 10 years ago she underwent nephrectomy of the right kidney because of kidney tuberculosis. Her main complaint was two-stage urination and micturition accompanied by a continuous sensation of residual urine. The PSP test by insertion of the Nelaton catheter gave a 15 minute value of 30% and a 2 hour value of 75%. Fig. 1 (1), (2) indicates the retrograde cystograms prior to the operation.Fig. 1. (1) shows bladder form after infusion of 60 cc contrast media.Fig. 1. (2) shows bladder form after infusion of about 200cc at maximum desire to urinate.Almost all cystograms indicated the same bladder shadows. Vesico-ureteral reflux was recognized reaching as far as the renal pelvis. Hydronephrosis was evident and the ureter was enlarged. The bladder capacity was less than 20cc.According to the pathological conditions of the subjects two different operations were applied. One operation (A) was performed to prevent vesico-ureteral reflux and consisted of triangular flap method, 2) according to which ureter was anastomosed to the original bladder. The other, operation (B), was aimed to increase the capacity of the bladder content and composed of cystoplasty, which was performed in the same method as in Case 1 by using an artificial bladder prepared from Novectanesprayed thin paper.Case 3 is a 50 year-old female. About 3 years ago she underwent nephrectomy of the right kidney because of kidney tuberculosis. And about 2 years ago she underwent nephrostomy of the left kidney because of a stricture in the lower end of the left ureter. Therefore, for more than a year, the bladder had not been used.Fig. 3 shows a pyelogram (pyelo-ureterogram), in which contrast media was injected from nephrostomy, and a retrograde cystogi am taken before operation. The lower end of the ureter is completely closed ey a stricture. The cystogram was taken at maximum desire to urinate and the bladder capacity was about 50cc. This patient visited our hospital because of urgent desire to urina te from the normal urethra. However, the PSP test revealed an unfavorable condition as with a 15 minute value of 5-10% and 2 hour value of 30-40%. Cystoplasty was performed in Case 3 by the same method as (A) and (B) of Case 2.The operation time was less than 2 hours in all three cases. The operation was performed under spinal anesthesia in Case 1, which was comparatively simple, and in Case 3 with lowered kidney function. The operation in Case 2 was performed under general anesthesia by tracheal insertion.In addition, bladder inflammation of these 3 cases were remedied before operation.Post-operative Observations:As in Case 1, in both Cases 2 and 3, the artificial bladder, in an utterly unchanged state, fell off completely within the bladder in about 3 weeks, concurrent with the completion of the granulation wall of the regenerated bladder1). It was possible to completely extirpate the

Tuberculosis Outbreak in an Alabama High School

The diagnosis of clinical tuberculosis in a student at an Alabama high school in March 1969 prompted skin testing of 379 students and 147 additional contacts. The skin positivity rate among the students was 77% and seven additional clinical cases were uncovered. In May 1969 seventeen students who had initially had negative or doubtful reactions had converted, but no new clinical cases were found. In October 1969 four new reactors (1.7%) among students who had attended the implicated school during the previous school year were found.

Complete heart block and aortic insufficiency in rheumatoid spondylitis ∗

The clinical and pathologic findings in a patient with complete heart block and aortic insufficiency associated with long-standing rheumatoid spondylitis are described. Aortic insufficiency was caused by shrunken aortic valve leaflets and dense scarring at the base of the aortic valve cusp. Histologically, the atrioventricular bundle was infiltrated by dense acellular scar tissue, and the atrioventricular bundle fibers were infiltrated with chronic inflammatory cells, thus leading to various atrioventricular conduction disturbances. Two additional clinical cases of complete heart block and aortic insufficiency in patients with rheumatoid spondylitis were treated with permanent transvenous pacemakers.

Carcinoid of the stomach with giant duodenal ulcer

M ERLING [1] in 1808 first described the neoplasms which are presently designated as carcinoid tumors. The term, carcinoid, was used by Oberndorfer [2] in 1907 to differentiate these tumors which run a benign course as compared to the usual malignant ones. Masson and Martin [3] in 1928 applied the name argentaffinoma to this group of tumors since they frequently contained cytoplasmic granules in the cells which reduced silver salts. It was not until 1952 that Biorck [4] reported an unusual case of the carcinoid syndrome in which a patient manifested flushing of the skin, pulmonary stenosis, and tricuspid insufficiency and who at autopsy was found to have a carcinoid tumor of the ileum with metastases to the liver. Many original investigations and additional clinical cases of this complex of symptoms now known as the carcinoid syndrome have been added to the literature. This syndrome according to Thorson [5] includes vasomotor changes of the skin, intestinal hyperperistalsis, bronchial spasm or asthma, psychosis, telangiectatic widening of small cutaneous veins, edema, anasarca, unusual endocardial lesions of the right side of the heart, and pellagra-like skin changes. The clinical symptoms vary markedly. The dramatic vasomotor changes are well recognized clues to diagnosis. Flushing usually begins in the face and spreads to the trunk and extremities, lasting from seconds to several minutes or even hours. In 1933 Vialli and Erspamer [6] discovered a substance called enteramine (5-hydroxytryptamine) which was later called serotonin by Rapport [7]. Systemic release of excessive amounts of serotonin by carcinoid tumors was reported by Lembeck [8] in 1953. The relation of the clinical symptoms to the hyperproduction of serotonin by these tumors and the presence of increased amounts of 5-hydroxyindoleacetic acid in the urine of the patients with carcinoid syndrome as an end product of the metabolism of serotonin are the most important recent discoveries leading to the physiologic understanding of this syndrome. However, questions still remain concerning the prognosis, treatment, and malignant nature of carcinoid tumors. Carcinoid tumors are chiefly found in the gastrointestinal tract; the appendix and the terminal ileum are the commonest sites. Other primary sites have been the ovaries, gallbladder, pancreas, mediastinum, and bronchus. These tumors may arise at any level of the gastrointestinal tract from the cardia to the rectum. The carcinoid syndrome occurs chiefly when the terminal ileum is the site of the primary tumor. The stomach is one of the less frequently involved areas. Von Askanazy [9] in 1923 reported the first two cases of gastric carcinoid as incidental autopsy findings. Since that time some seventy additional clinical and autopsy cases have been described in the literature. Gastric carcinoid rarely is associated with the carcinoid syndrome, only five cases being reported, and only two being diagnosed preoperatively. This paper describes a patient with a

Carcinoid Syndrome with Primary Carcinoid Tumor of the Stomach

Merling in 1808 was the first to describe histologically what are now designated carcinoid tumors. 1 Langhans2 in 1867, Beger3 in 1882, and Lubarsch4 in 1888 carefully studied these neoplasms and described them in greater detail. The term carcinoid was used by Oberndorfer5 in 1907 to differentiate them from usual malignancies because of their benign course. Masson and Martin6 in 1928 introduced the name argentaffinoma because of the presence of cytoplasmic granules in the cells of some which reduced silver salts. In 1952 Biorck ct aU reported an unusual case of curious flushing of the skin, pulmonary stenosis, and tricuspid insufficiency which at autopsy revealed a carcinoid tumor of the ileum with metastases to the liver. About this same time Isler and Hedinger8 from Zurich independently reported 3 similar cases. Waldenstrom9 ,10 a few months later reported 3 more patients with flushing attacks associated with metastasizing carcinoid tumors. Over the past 8 years original investigations and additional clinical cases have been added to the literature and numerous papers have been published elucidating' the metabolic pathways of some features of this disease. These reports introduced a symptom complex now known as the carcinoid syndrome. The syndrome, according to Thorson,l1 includes vasomotor changes of the skin, intestinal hyperperistalsis, attacks of bronchial spasm or asthma, telangiectatic widening of small cutaneous veins, edema,

Studies on the Intracardiac Phonocardiography

The intracardiac phonocardiographic method of our original conception has been an epock making advance in the study of heart sounds. In this paper with the accumulation of 50 additional clinical cases from the time of original reports the result are summarized and some extra views are expressed. 1) Our equipment utilizing the condensor-type pick up is believed to be for superior to those made and used in Europe and the United States from the view-point of sensitivity and frequency response when compared by actual use. 2) The characteristics of intracardiac sounds were discussed by grouping the deta under the headings of “the effect of blood flow”, “damping due to heart and blood-vessel wall”, “conduction of vibrations”, “Knocking sound”, etc. 3) The various components of the normal heart sounds were divided into the first sound, 2nd sound, 3rd sound, atrial sound, extra sound and murmurs. The results of the clinical and animal experiments were discussed. 4) The advantages of this method for determining the region of the murmur origin, its mechanisms and in clarifying the local blood movement within the heart and its importance as a diagnostic tool were discussed.