Temporary Substitution Research Articles

The International Rugby Board (IRB) Pitch Side Concussion Assessment trial: a pilot test accuracy study

Background‘On the field and on the run’ assessments of head impact events in professional rugby have resulted in a high proportion of players subsequently diagnosed with confirmed concussion not leaving...

Methadone at tapered doses for the management of opioid withdrawal.

The evidence of tapered methadone's efficacy in managing opioid withdrawal has been systematically evaluated in the previous version of this review that needs to be updated To evaluate the effectiveness of tapered methadone compared with other detoxification treatments and placebo in managing opioid withdrawal on completion of detoxification and relapse rate. We searched: Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 4), PubMed (January 1966 to May 2012), EMBASE (January 1988 to May 2012), CINAHL (2003- December 2007), PsycINFO (January 1985 to December 2004), reference lists of articles. All randomised controlled trials that focused on the use of tapered methadone versus all other pharmacological detoxification treatments or placebo for the treatment of opiate withdrawal. Two review authors assessed the included studies. Any doubts about how to rate the studies were resolved by discussion with a third review author. Study quality was assessed according to the criteria indicated in the Cochrane Handbook for Systematic Reviews of Interventions. Twenty-three trials involving 2467 people were included. Comparing methadone versus any other pharmacological treatment, we observed no clinical difference between the two treatments in terms of completion of treatment, 16 studies 1381 participants, risk ratio (RR) 1.08 (95% confidence interval (CI) 0.97 to 1.21); number of participants abstinent at follow-up, three studies, 386 participants RR 0.98 (95% CI 0.70 to 1.37); degree of discomfort for withdrawal symptoms and adverse events, although it was impossible to pool data for the last two outcomes. These results were confirmed also when we considered the single comparisons: methadone with: adrenergic agonists (11 studies), other opioid agonists (eight studies), anxiolytic (two studies), paiduyangsheng (one study). Comparing methadone with placebo (two studies) more severe withdrawal and more drop-outs were found in the placebo group. The results indicate that the medications used in the included studies are similar in terms of overall effectiveness, although symptoms experienced by participants differed according to the medication used and the program adopted. Data from literature are hardly comparable; programs vary widely with regard to the assessment of outcome measures, impairing the application of meta-analysis. The studies included in this review confirm that slow tapering with temporary substitution of long- acting opioids, can reduce withdrawal severity. Nevertheless, the majority of patients relapsed to heroin use.

The conservation of ground layer lichen communities in alvar grasslands and the relevance of substitution habitats

Semi-natural calcareous grasslands (alvars) are biodiversity hotspots in Northern Europe, particularly for herb layer plants. In the last century, traditional management has ceased, and the area of grasslands has declined due to extensive encroachment. We were interested in the drivers of ground layer (alias terricolous or epigeic) lichen communities. Our survey consisted of 86 habitat fragments in western Estonia, covering four types of historic alvar grasslands and three types of alvar-like habitats. We found that the ground lichen communities were primarily soil-type-specific, but were also affected by historic disturbances and land use change. In contrast to knowledge about herb layer communities, for which shrub encroachment has been shown to be main driver, the increased density of the herb layer and the reduced diversity of microhabitats were major drivers for the ground layer lichen community. These drivers caused a decrease in species richness, but only within the species of conservation value, and also led to a shift in the composition of lichen growth form from the dominance of squamulose and crustose towards fruticose lichens. We conclude that the traditional practice of restoring alvars by cutting shrubs is insufficient to maintain ground layer lichen biodiversity. Alvar maintenance practices should include grazing, which creates various small-scale ground disturbances and increases microhabitat heterogeneity. Alvar-like habitats originating from large-scale historic disturbances appeared to be suitable for calcicolous epigeic lichens, and can therefore be considered to be temporary substitution habitats, i.e. refugia for the regional species pool.

Periprocedural Bridging Anticoagulation: Current Perspectives

Perioperative management of patients on chronic anticoagulant use involves balancing individual risk for thromboembolism and bleeding. Discontinuation of antithrombotic therapy can place patients at increased risk of thromboembolic complications, whereas continuing antithrombotic therapy can increase procedure-related bleeding risk. Temporary perioperative substitution of low-molecular weight heparin or unfractionated heparin in place of warfarin, "the bridge therapy" is often used in the periprocedural period, but the indications and timing of this is still uncertain. This review addresses the risk stratification of patients according to thromboembolic risk, indications, timing, and duration, and a practical approach to bridge therapy.

Experience in Clinical Application of Perftorane for Intensive Therapy in Patients with Severe Combined Injuries Resulted from Explosion in Coal-Mine

Twenty victims with severe combined injuries caused by explosion in the coal-mine were included into the study. The components of such injuries were barotrauma, mechanical injury, skin and inhalation burns, carbon oxide poisoning intensified by syndrome of mutual aggravation. The ultimate cause of death was the affection of oxygen transport system. Temporary substitution of affected blood - lung system with oxygenated perftorane enabled to decrease considerably the lethality rate in miners with negative and doubtful survival prognosis. Efficacy of perftorane inclusion into intensive therapy was stipulated by its chemical inertness owing to which it can transport oxygen under conditions of blood poisoning by carbon oxide and unfit for breathing atmosphere in the mine after explosion.

Über die Entwicklung der Substitution bei Opiatabhängigkeit in der medizinischen Rehabilitation

Die Modellversuche zur Substitutionsbehandlung bei Opiatabhängigkeit in Deutschland zielten auf ein bewährtes Versorgungsmuster: die medizinische Rehabilitation. Bis heute aber ist lediglich eine übergangsweise Fortführung einer Substitution zugelassen. Die Inanspruchnahme dieses Angebots ist gegenüber der substitutionsgestützten Behandlung zu Lasten der Krankenkassen sehr gering, das Potenzial der Substitution nicht ausgeschöpft. Der Bericht zur Entwicklung der Substitution in Deutschland mündet in die Forderung an die Sozialleistungsträger zur Überprüfung ihrer Vereinbarungen.

Perioperative management of warfarin and antiplatelet therapy

Perioperative management of patients on warfarin or antiplatelet therapy involves assessing and balancing individual risks for thromboembolism and bleeding. Discontinuing anticoagulant and antiplatelet therapy is usually necessary for major surgery but increases the risk of thrombotic events. Bridge therapy, the temporary perioperative substitution of low-molecular-weight heparin or unfractionated heparin in place of warfarin, is an effective means of reducing the risk of thromboembolism but may increase the risk of bleeding. The timing of warfarin withdrawal and timing of the preoperative and postoperative components of bridge therapy are critical to balancing these risks. Perioperative management of antiplatelet therapy requires special care in patients with coronary stents; the timing of surgery relative to stent placement dictates management in these patients.

Apatite Formation on α-Tricalcium Phosphate/Poly(D,L-Lactide-Co-Glycolide) Nanocomposite

In this study, a biocomposite comprising nanostructured α-tricalcium phosphate (α-TCP) in a poly(D,L-lactic-co-glycolic acid) (PLGA) matrix was fabricated by a modified solution evaporation method. As a potential temporary bone fixation and substitution material, its bioactivity was evaluated by its ability to form bone-like apatite layer in simulated body fluid (SBF). Owing to the increased surface area covered by the osteoconductive bioceramic of α-TCP, rapid apatite formation was observed. After 7 days of immersion, enhanced nucleation of apatite was observed on the nanocomposite. At day 14, dense lamellar-like apatite was formed on the nanocomposite whilst apatite nucleation had only just started to develop on the surface of pure PLGA. At the same time, a preliminary in-vitro cell culture study was conducted using human osteoblast-like (HOB) cells. A significant increase in cell number with culturing time was observed for the nanocomposite. After 9 days incubation, a confluent lamellar-like apatite layer was formed on the composite surface. This apatite layer was also shown beneath the proliferating HOB cells at Day 16.

Smart Bag vs. Standard bag in the temporary substitution of the mechanical ventilation

To compare in intubated patients manually ventilated in order to mirror the ventilator, the respiratory and hemodynamic effects induced by a bag device equipped with an inspiratory gas flow-limiting valve (Smart Bag, 0-Two Medical Technologies Inc., Mississauga, ON, Canada) and a Standard bag. Non-randomized crossover study comparing 13 respiratory and eight hemodynamically paired parameters. Eight intubated patients were manually ventilated, each by three different intensive care workers yielding 24 sets of data for comparison. Data were collected during two sessions of manual ventilation, first with the Standard bag and then with the Smart Bag. Between each session, the patient was reconnected to the ventilator until return to the baseline. Patients, included after coronary surgery, were sedated and paralyzed. Intensive Care Unit, university hospital. Compared with Standard bag, the Smart Bag provided a decrease of inspiratory flow (23 +/- 4.7 vs. 47.3 +/- 16.5 l/min) with a decrease of peak pressure (13.3 +/- 2.9 vs. 21.9 +/- 7.3 cmH2O) and tidal volume (9.4 +/- 2.8 vs. 12.4 +/- 2.7 ml/kg). While the expiratory time was similar, the inspiratory time increased (1.83 +/- 0.58 vs. 1.28 +/- 0.46 s) with the Smart Bag, limiting the respiratory rate (14 +/- 5 vs. 17 +/- 6 cycles/min) and the minute volume (8.8 +/- 2.9 vs. 14.4 +/- 4.9 l/min). Finally, it limited the fall of the ETCO2 (27.9 +/- 5.1 vs. 24.3 +/- 5.7 mmHg) and probably the risks of severe respiratory alkalosis. The bags similarly affected hemodynamic states. In intubated patients manually ventilated, the Smart Bag limits the risks of excessive airway pressure and the fall of the ETCO2, with hemodynamic effects similar to those of the Standard bag.

Hypophysen- und Nebennierenoperationen

Laparoscopic adrenalectomy and transsphenoidal pituitary surgery are currently established as the surgical procedures of choice with a low complication rate. Beyond potential surgical complications, one has to consider endocrine sequelae such as adrenal insufficiency and hypopituitarism. Without adequate endocrine treatment patients are prone to develop potentially lethal complications such as Addisonian crises or pituitary coma. Therefore, all patients should be seen by an endocrinologist before and after surgery. Patients with bilateral adrenalectomy require lifelong substitution of glucocorticoids and mineralocorticoids. Cushing's syndrome patients with unilateral adrenalectomy need temporary substitution. After pituitary surgery, all patients require functional assessment of their pituitary function, and, if necessary, adequate replacement therapy.

The Farmer, the Fairies, and the Computers

Using a temporary substitution of format, the author offers a fairy tale to demonstrate that we can’t expect understanding when computers take the place of humans in our interactions with service providers.

Quantification of Changes in Electroencephalographic Power Spectra in a Patient with Budd-Chiari-Syndrome after Implantation of a Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS)

We examined a 41-year-old female with a subacute Budd-Chiari Syndrome (BCS) before and after implantation of a transjugular intrahepatic portosystemic stent shunt (TIPSS) by means of digital electroencephalography (EEG). After TIPSS implantation hepatic decompression had been achieved and the liver function as well as the clinical status improved daily. Simultaneously, the digital EEG showed a decrease in the power of the theta band and an increase in the physiological alpha frequency band. The theta/alpha ratio decreased after TIPSS, despite an elevated arterial ammonia level. The patient had a well-preserved liver parenchyma before the occurrence of the BCS. After portal decompression by TIPSS, the liver function normalized and the liver resumed efficient synthesis and parts of its detoxification task. This regeneration capacity was documented by a rise in cholinesterase after TIPSS. After temporary substitution of albumin the serum albumin concentration returned to normal. Thus, some neurotoxic substances with high albumin-binding capacity may not be absorbed by the central nervous system (CNS). Furthermore, it appears likely that the length of time the brain is exposed to neurotoxic substances plays a role in the clinical and electroencephalographic changes. Compared to the conventional EEG the theta/alpha ratio reflected better metabolically conditioned electroencephalographic changes after TIPSS.

Methadone at tapered doses for the management of opioid withdrawal.

Despite widespread use in many countries of tapered methadone for detoxification from opiate dependence, the evidence of efficacy to prevent relapse and promote lifestyle change has not been systematically evaluated. To determine whether tapered methadone is effective to manage withdrawal from opioids. We searched: the Cochrane Controlled Trials Register (Issue 1, 2000), MEDLINE (OVID 1966-2000), EMBASE (1980-2000); scan of reference list of relevant articles; personal communication; conference abstracts; unpublished trials from pharmaceutical industry; Internet (NIDA, Clinical Trials.org, BMJ). All randomised controlled trials which focus on the use of tapered methadone (length of treatment max 30 days) versus all other pharmacological detoxification treatments, placebo and different modalities of methadone detoxification programs for the treatment of opiate withdrawal. Trials including patients with additional diagnoses such as benzodiazepine dependence were also eligible. One reviewer (LA) assessed studies for inclusion and undertook data extraction. Inclusion decisions and the overall process were confirmed by consultation between reviewers. Qualitative assessments of the methodology of eligible studies were carried out using validated checklists. Where possible analysis was carried out according to the "intention to treat" principles. 20 studies were included in the review, with 1357 people randomised. 10 studies compared methadone with adrenergic agonists, 7 studies compared different modalities of methadone detoxification, 2 studies compared methadone with other opioid agonists, 1 study compared methadone with chlordiazepoxide one with placebo. The conclusions of the 10 studies that compared methadone with adrenergic agonists showed no substantial clinical difference of the two treatments in terms of retention in treatment, degree of discomfort and detoxification success rates. The conclusions of the 6 studies that compare different methadone reduction schedules, showed that different types of methadone withdrawal schedule produce different responses in terms of time course of withdrawal, the severity of withdrawal response and possibly in terms of subsequent engagement with treatment. Regarding the studies that compare methadone with other opioid agonists, in Sorensen 1982 methadyl acetate performed similarly to methadone on most process and outcome measures, while in Tennant 1975, methadone reduced severity of withdrawal and had fewer drop-outs than did a propoxyphene group. In Drummond 1989, using chlordiazepoxide vs methadone, the results suggest that the two drugs had similar results in terms of overall effectiveness.San 1992 compared methadone with placebo and found more severe withdrawal and more drop outs in the placebo group. The results indicate that tapered methadone and other medications used in the included studies are effective in the treatment of the heroin withdrawal syndrome, although symptoms experienced by subjects differed according to the medication used and the program adopted. It seems that regardless of which medication is selected for heroin detoxification, the rates of subsequent heroin abstinence are about equal. This suggests that the medications are similar in terms of overall effectiveness. Improvements were achieved when other services such as counseling and other supporting services were offered contemporaneously with detoxification. Data from literature are hardly comparable; programs vary widely with regard to duration, design and treatment objectives, impairing the application of meta-analysis. Results of many outcomes could not be summarised because they were presented either in graphical form or provided only statistical tests and p-values. For most studies standard deviation for continuous variables were not provided. The studies included in this review confirm that slow tapering with temporary substitution of long acting opioids, accompanied by medicaopioids, accompanied by medical supervision and ancillary medications can reduce withdrawal severity. Nevertheless the majority of patients relapsed to heroin use. However this cannot be considered a goal for a detoxification as heroin dependence is a chronic, relapsing disorder and the goal of detoxification should be to remove or reduce dependence on heroin in a controlled and human fashion and not a treatment for heroin dependence.

Acute liver failure

Zusammenfassung Das akute Leberversagen stellt einen seltenen Notfall vergleichbar der akuten Herzinsuffizienz mit kardiogenem Schock oder dem akuten Nierenversagen dar. Die Ursachen für ein akutes Leberversagen sind je nach geographischer Region verschieden und variieren in ihrer Häufigkeit. In unseren Breiten finden sich häufig Viren, Medikamente und Toxine als ätiologisches Agens. Die Einwirkung der Noxe führt zur Nekrose und/oder gesteigerten Apoptose der Hepatozyten mit Ausfall leberspezifischer Funktionen, sobald die Zahl funktionstüchtiger Zellen eine kritische Grenze unterschreitet. Klinisch äußert sich dies Syndrom durch das rasche Auftreten einer hepatischen Encephalopathie innerhalb von 7 Tagen nach Beginn der Lebererkrankung (fulminantes Leberversagen). Bei vorbestehender chronischer Leberschädigung definiert sich das Leberversagen über die Zeit, innerhalb der eine hepatische Encephalopathie nach Beginn eines Ikterus auftritt (hyperakutes, akutes und subakutes Leberversagen). Der Ausfall der Leberfunktion löst zahlreiche extrahepatische lebensbedrohliche Komplikationen aus, wie Hirnödem, Kreislaufversagen, Infektionen, Gerinnungsstörungen und Nierenversagen. Intensivmedizinische und hepatologische Kenntnisse und eine enge Kooperation mit einem Lebertransplantationszentrum sind wesentliche Voraussetzungen für eine erfolgreiche Therapie. Der permanente oder auxiliäre vorübergehende Leberersatz durch Implantation einer gesunden menschlichen Leber ermöglicht in 60–70% der Fälle ein dauerhaftes Überleben. Fortschritte wurden durch den temporären extrakorporalen Ersatz bestimmter Leberfunktionen erreicht. Hierdurch kann möglicherweise zukünftig die Zeit bis zur Regeneration der eigenen Leber oder bis eine Spenderleber zur Verfügung steht überbrückt werden. Diese Systeme sind für einen Einsatz in der täglichen Routine jedoch noch nicht ausreichend evaluiert.

Lithium—Sulfoxide—Lithium Exchange for the Asymmetric Synthesis of Atropisomers under Thermodynamic Control.

AbstractFor Abstract see ChemInform Abstract in Full Text.

Lithium-sulfoxide-lithium exchange for the asymmetric synthesis of atropisomers under thermodynamic control.

Ortholithiation and reaction with (-)-menthyl p-toluenesulfinate introduces a sulfoxide substituent ortho to the stereogenic Ar-CO axis of an aromatic amide. The sulfoxide exerts a powerful conformational bias on the axis, such that after rapid equilibration at ambient temperature essentially only one of two diastereoisomeric Ar-CO atropisomers is populated. Sulfoxide-lithium exchange by treatment with t-BuLi regenerates the ortholithiated amide in an enantiomerically pure and conformationally stable form. Rapid electrophilic trapping of the organolithium therefore generates highly enantiomerically enriched atropisomeric tertiary aromatic amides. The overall process, involving temporary substitution of lithium to sulfoxide to lithium, amounts to a dynamic resolution under thermodynamic control.

A Study of the Correspondence of Urban Expansion in Relation to Transport Coordination in Osaka City during the Interwar Period (1918-1939)

This paper clarifies that transport coordination in Osaka City was not only controlled by the economy, but also by urban expansion similar to urban planning by examining the territoriality of urban transportation. The territoriality generally consisted of intraurban and suburban transportations. The contents of this paper can be summarized as follows:1) The municipal monopoly of urban transport facilities in Osaka City is generally considered to have begun in 1903. The system functioned well as long as the municipal area did not grow. After the second expansion of the municipal area in 1925, many inconsistencies developed.2) The municipal tramway under the municipal monopoly was profitable by the first half of the 1920s and it played a leading role. Later, however, due to the increasing number of buses and taxis, it declined in profitability.3) Rapid transit was planned as a part of overall urban planning in the 1920s. One purpose was to integrate intraurban and suburban transportations as a means of controlling urban expansion.Another purpose of urban planning was the construction of transport facilities, not the functional coordination of the various means of transportation. Moreover, plans for rapid transit paid little attention to its relationship to other means of transportations.4) The most disruptive influence on the municipal monopoly was the opening of the Osaka Bus Company. At first, Osaka Bus was only a supplement to the municipal tramway. However, it drained off numerous passengers because it possessed bus lines in the central part of the municipal area. One purpose of the later opening of a competing municipal bus line was to integrate intraurban and suburban transportations as a temporary substitution for rapid transit that tended to be constructed late. However, that bus line was not authorized to operate within the central municipal area.5) Essentially, the rise of transport coordination in Osaka City was a de facto amendment of the municipal monopoly on the range and scope of urban transportation to its integration.6) The new municipal monopoly of urban transport facilities which adapted territoriality of urban transportation was completed by the municipal tramway, bus, and rapid transit, and merger with Osaka Bus in 1938. Wartime regulation was indispensable for its realization, but the result was a reinstatement of the municipal monopoly of urban transport facilities. It is clear that the essential purpose of transport coordination in Osaka City was to strengthen the municipal monopoly of urban transport facilities, which had been undermined between 1918 and 1939. Although wartime regulation was indispensable for its realization, such a purpose was common to urban planning at the same time. From these conclusions, it is clear that transport coordination in Osaka City was not only controlled by the economy, but also by urban expansion.

The indication for heroin prescription - considerations with the historical example of the opiate addicted Swiss author Friedrich Glauser (1896 - 1938)

Traditional indications for the prescription of opioids to addicts are continuous opioid abuse despite qualified addiction treatment or temporary substitution treatment, if temporarily detoxification is not possible due to external circumstances. These criteria are demonstrated by an historical example, the treatment of the opioid addicted Swiss author Friedrich Glauser (1896-1938). From a modern public health perspective, however, opioid abuse is mainly conceptualised as risk behaviour with aversive consequences for the individual abuser and the public. These consequences should be reduced by prescription of hygienically safe heroin. In this concept, the failure of former addiction treatment is not a necessary condition for heroin prescription. Difficulties in reaching an agreement about indications for heroin prescription are partially results of inherent contradictions between an individual centered traditional medical concept and a public health concept about the goals of opioid addiction treatment.

The Use of Fibroblast Derived Temporary Skin Substitute for Prolonged Wound Coverage

The Use of Fibroblast Derived Temporary Skin Substitute for Prolonged Wound Coverage

Colic in breast‐milk‐fed infants: treatment by temporary substitution of Neocate infant formula

Infant colic is a common problem characterized by excessive crying and fussing. We examined whether colic symptoms of exclusively breast-milk-fed infants would be improved by temporary substitution of Neocate, an amino acid-based infant formula, for breast milk. Six infants with colic were studied using Barr-type infant behavior diaries for a 3-5 d baseline period while they continued exclusive breast-milk-feeding, followed by a 4-8 d intervention period of exclusive Neocate feeding. All infants showed improvement in distressed behavior during intervention; five of the six improved within 1-2 d. For the period after 1 d of Neocate feeding, the total recorded crying and fussing time was reduced by an average of 42%, representing a decrease of 1.0 to 3.1 h daily. A significant difference was found between cry and fuss time at baseline versus during exclusive Neocate use. Concurrent with Neocate intervention, mothers strictly avoided all milk and dairy products. After colic symptoms improved, infants were reintroduced to breast milk, which was reasonably well tolerated in four of the six infants. Two infants had rapid recurrences of crying and fussing upon return to breastfeeding and required an additional period of Neocate feedings before subsequent reintroduction to breastfeeding. All infants exhibited colic symptoms when directly or indirectly challenged with bovine IgG (BGG), suggesting that BGG may play an etiologic role in colic. We propose that a brief intervention with Neocate, coupled with strict maternal avoidance of milk and dairy products under direct supervision of a lactation consultant, may be an effective treatment for colic in some breast-milk-fed infants.