Home About us Contact
|
Home About us Contact | ||
|
|
||
Exceptional Cases (exceptional + case)
Selected AbstractsThe Art of Surgery: Exceptional Cases , Unique Solutions 100 Case StudiesANZ JOURNAL OF SURGERY, Issue 12 2002Mark Killingback FRACS No abstract is available for this article. [source] Peritoneal mesothelioma presenting as an acute surgical abdomen due to jejunal perforationJOURNAL OF DIGESTIVE DISEASES, Issue 4 2007Nikolaos S SALEMIS BACKGROUND: Peritoneal mesothelioma is a rare disease associated with poor prognosis. Acute abdomen as the first presentation is an extremely rare occurrence. We report an exceptional case of a patient who was found to have a jejunal perforation due to infiltration of peritoneal mesothelioma. METHODS: A 62-year-old man was admitted with clinical signs of peritonitis. Computerized tomographic scans showed a mass distal to the ligament of Treitz, thickening of the mesentery and a small amount of ascites. RESULTS: Emergency laparotomy revealed a perforated tumor 15 cm distal to the ligament of Treitz and diffuse peritoneal disease. Segmental small bowel resection and suboptimal cytoreduction were performed. Histopathology and immunohistochemistry showed infiltration of malignant mesothelioma. During the postoperative period pleural mesothelioma was also diagnosed. Despite adjuvant chemotherapy, the patient died of disseminated progressive disease 7 months after surgery. CONCLUSIONS: Peritoneal mesothelioma is a rare malignancy with grim prognosis. Small bowel involvement is a poor prognostic indicator. Our case of a small bowel perforation due to direct infiltration by peritoneal mesothelioma appears to be the first reported in the English literature. [source] Anti-Factor H Autoantibodies in a Fifth Renal Transplant Recipient with Atypical Hemolytic and Uremic SyndromeAMERICAN JOURNAL OF TRANSPLANTATION, Issue 5 2009M. Le Quintrec Hemolytic uremic syndrome (HUS) associated with anti-Factor H (anti-FH) autoantibodies is a recently described pathophysiological entity. Monitoring of anti-FH IgG titer may be a sensitive marker of disease activity and guide treatment to eliminate circulating anti-FH antibodies. We report here a case of atypical HUS (aHUS) in which anti-FH autoantibodies were detected during the course of a fifth kidney transplant, 30 years after the first flare of aHUS. This exceptional case suggests that early, specific management based on immunosuppressive therapy and plasma exchanges monitored by anti-FH IgG titer may result in long-term graft survival. [source] Long-Term Insulin-Independence After Allogeneic Islet Transplantation for Type 1 Diabetes: Over the 10-Year MarkAMERICAN JOURNAL OF TRANSPLANTATION, Issue 2 2009T. Berney Results of islet of Langerhans transplantation have markedly improved in recent years, but most patients still lose insulin independence in the long-term. We report herein the longest (over 11 years) case of insulin independence after allogeneic islet transplantation. The subject had a 27-year history of type 1 diabetes and received a single islet-after-kidney graft of 8800 islet equivalents (IEQ)/kg, pooled from 2 donors. Insulin was discontinued by 3 months posttransplant and the patient has remained off insulin ever since. Yearly follow-up studies have revealed normal metabolic control, including normal oral glucose tolerance test (OGTT). Reasons for success may involve choice of immunosuppression, low metabolic demand and low immune responsiveness as suggested by an excellent HLA matching and a high count of circulating regulatory T cells. This observation is so far an exceptional case, but clearly demonstrates the validity of the concept that long-term insulin independence after allogeneic islet transplantation is an achievable target. [source] Radiation of the Spider Genus Dysdera (Araneae, Dysderidae) in the Canary Islands: Cladistic Assessment Based on Multiple Data SetsCLADISTICS, Issue 4 2001Miquel A. Arnedo The volcanic archipelago of the Canary Islands, 100 km off the northwestern coast of Africa, harbors 43 endemic species of the mostly circum-Mediterranean spider genus Dysdera (Araneae, Dysderidae). This amounts to approximately one-fourth of all known Dysdera species in an area that represents 0.1% of the range of the genus. In order to address the origin of this extraordinary number of endemic species, the phylogenetic relationships among all the endemic taxa and a sample of 27 continental species were reconstructed. A simultaneous cladistic analysis was performed on 66 morphological characters, 471 bp of the cytochrome oxidase I and 424 bp of the 16S rRNA mitochondrial genes. The preferred most parsimonious tree supports a single origin for most of the endemic species (84%), although this tree is ambiguous regarding the total number of overseas colonizations (allowing a minimum of two and a maximum of four colonization events). Our data suggest that the Canary Islands have been the source of the colonizers of some of the remaining Macaronesian archipelagoes (certainly for the Selvagem Islands and the Cape Verdes and possibly for Madeira); the Azores have been independently colonized by dysderids from the continent. The present study provides a phylogenetic framework for an exceptional case of insular species radiation, an essential tool for unraveling the factors that have promoted this amazing diversification. Species radiations in oceanic archipelagoes are excellent models for the study of speciation processes. [source] Diffuse (anergic) cutaneous leishmaniasis responding to amphotericin BCLINICAL & EXPERIMENTAL DERMATOLOGY, Issue 4 2010B. Morrison Summary American cutaneous leishmaniasis is an important endemic zoonotic disease in the New World that comprises a spectrum of clinical manifestations. Diffuse cutaneous leishmaniasis (DCL) is a rare form of the disease characterized by antigen-specific immunodeficiency that often presents with multiple disfiguring non-ulcerated confluent nodules or plaques that involve large areas of the skin, resembling lepromatous leprosy. Relapse is invariable in advanced stages, despite aggressive chemotherapy, and a plethora of drugs has been tested with unchanging results. We report on a severe an exceptional case that resolved after treatment with amphotericin B, a drug considered only mildly effective, and discuss the therapeutic approach to this disease. [source] Women and Classical Translation in the Eighteenth CenturyGERMAN LIFE AND LETTERS, Issue 3 2006Hilary Brown Women in Germany first began to take up their pens in substantial numbers during the eighteenth century. One area where they apparently did not leave their mark was in the translation of classical literature, despite a wave of interest in the classics in the literary world at large. However, this article sheds new light on women's involvement in this field. It focuses on a handful of women who translated from Greek or Latin, namely Luise Gottsched (1713,62), Fräulein von Erath (?,1776) and Ernestine Christine Reiske (1735,98). It looks at the conditions in which they did so, at their presentation of the texts, and at contemporary reactions to their work. It shows that women could only make their way in this area in exceptional cases, and that they usually exercised a considerable degree of caution. Yet, in some rare instances, translation gave women a new freedom. A translator could put her name to works of a surprising nature, such as philosophy and erotica. Adopting the detached stance of translator meant she could publish texts which women at the time would probably never have dared to write themselves. Thus, the act of translation could open up new spheres of literary activity for women. [source] Household Decisions and Equilibrium EfficiencyINTERNATIONAL ECONOMIC REVIEW, Issue 4 2000Hans Haller A general equilibrium model is introduced where a household may consist of several members, each with individual preferences and/or resources. When households obey collective rationality, certain intrahousehold externalities can be fully internalized by the respective households so that competitive exchange among households is efficient. As a rule, however, such intrahousehold externalities are not fully internalized by individual household members acting in their personal interest so that competitive exchange among such individuals is only efficient in exceptional cases. [source] On the Relationship Between Short- and Long-term Interest Rates,INTERNATIONAL FINANCE, Issue 2 2004Teruyoshi KobayashiArticle first published online: 13 DEC 200 This paper addresses issues regarding the relationship between short- and long-term interest rates. In the real world, an expansionary (contractionary) policy is normally followed by a fall (rise) in long-term rates. However, there exist exceptional cases in which short- and long-term rates move in opposite directions. This paper attempts to provide a formal explanation for such unusual phenomena using a variety of new Keynesian models. It turns out that the simultaneous occurrence of different economic shocks, to which the central bank should react, can explain this behaviour of long rates. [source] Bound and unextractable pesticidal plant residues: chemical characterization and consumer exposurePEST MANAGEMENT SCIENCE (FORMERLY: PESTICIDE SCIENCE), Issue 7 2004Heinrich Sandermann Jr Abstract Plants are well known to incorporate pesticides into bound and unextractable residues that resist solubilization in common laboratory solvents and are therefore not accessible to standard residue analysis. A characterization of such residues has been proposed for incorporation rates above trigger values of 0.05 mg kg,1 parent pesticide equivalents, or percentage values of 10% (United States Environmental Protection Agency, 1995) or 25% (Commission of the European Communities, 1997) of the total radioactive residue. These trigger values are often exceeded. The present review describes the current status of the chemical characterization and animal bioavailability of bound and unextractable residues that may be xenobiotic in nature or result from natural recycling of simple degradation products. The latter case represents a mechanism of detoxification. Bound residues have been shown to be covalent or non-covalent in nature. With regard to the plant matrix molecules involved, incorporation into proteins, lignins, pectins, hemicelluloses and cutins has been demonstrated, and four covalent linkage types are known. Animal feeding experiments have revealed cases of low as well as high bioavailability. Many of the studies are limited by experimental uncertainties and by results only being reported as relative percentage values rather than absolute exposure. A preliminary value of absolute exposure from bound and unextractable residues is derived here for the first time from eight case studies. The mean exposure (ca 1.5 mg kg,1 pesticidal equivalents) exceeds some of the existing maximum residue levels (MRLs) of residual free pesticides that are typically in the range of 0.05,1 mg kg,1. A mathematical framework for the correction of current maximum residue levels is presented for cases of highly bioavailable bound residues. As bound pesticidal residues in food plants could represent a source of significant consumer exposure, an experimental test scheme is proposed here. It consists of basic chemical characterization, model digestibility tests and, in exceptional cases, animal bioavailability and additional toxicological studies. Copyright © 2004 Society of Chemical Industry [source] Latest news and product developmentsPRESCRIBER, Issue 22 2007Article first published online: 28 DEC 200 Glitazones: benefits outweigh the risks Following a review of the safety of rosiglitazone and pioglitazone, the European Medicines Agency (EMEA) has concluded that their benefits outweigh their risks in the approved indications. The review was prompted by reports of an increased risk of fractures in women and, in patients taking rosiglitazone, ischaemic heart disease. The EMEA concluded that prescribing information for rosiglitazone should now include a warning that, in patients with ischaemic heart disease, it should only be used after careful evaluation of each patient's individual risk, and the combination of rosiglitazone and insulin should only be used in exceptional cases and under close supervision. No change was considered necessary to the prescribing information for pioglitazone. Modern dressings no better? A systematic review has found only weak evidence that modern dressings are better than saline gauze or paraffin gauze for healing acute and chronic wounds (Arch Dermatol 2007;143: 1297-304). The analysis, which included 99 studies, found that only hydrocolloids were demonstrably better than older dressings for healing chronic wounds, and alginates were superior to other modern dressings for debriding necrotic wounds. There was no evidence that modern dressings offered superior overall performance to the older alternatives. Hospital inflation twice primary care level The cost of drugs prescribed in secondary care but dispensed in the community increased by 6.4 per cent in 2006 - twice the rate of inflation in primary care - according to the latest statistics on hospital prescribing in England. The increase follows a reduction in costs in 2005 after the introduction of the new PPRS scheme. Data from The Information Centre (www.ic.nhs.uk) show that hospital medicines make up about 24 per cent of the NHS drugs budget. Secondary care has a consistently better record than primary care in prescribing lower-cost alternatives within therapeutic categories, eg simvastatin and pravastatin among the statins, omeprazole and lansoprazole among PPIs, and ACE inhibitors among drugs acting on the renin angiotensin system. The most expensive drug prescribed by hospital specialists and dispensed in the community is interferon beta. MHRA limits the use of fibrates The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that fibrates should now be reserved for the treatment of isolated severe hypertriglyceridaemia. They should be considered for hypercholesterolaemia only when a statin or other treatment is contraindicated or not tolerated. In the latest Drug Safety Update, the MHRA says there is insufficient evidence of long-term benefits from fibrates, and first-line use is no longer justified because the evidence for the benefits of statins is robust. The MHRA also warns that some breastfeeding infants have increased susceptibility to the adverse effects of codeine taken by their mother, and that St John's wort may affect the hepatic metabolism of any anticonvulsant. Annual zoledronic acid infusion cuts mortality after hip fracture Once-yearly infusion of zoledronic acid (Aclasta) after hip fracture reduces deaths over a two-year period by 28 per cent compared with placebo, US investigators say (N Engl J Med 2007;357:1799-809). The HORIZON Recurrent Fracture Trial randomised 2127 men and women (mean age 75) within 90 days of surgery for hip fracture to zoledronic acid 5mg yearly or placebo. Mortality over 1.9 years of follow-up was 9.6 per cent with zoledronic acid and 13.3 per cent with placebo. Zoledronic acid also significantly reduced the rate of any new clinical fractures (by 35 per cent) and new clinical vertebral fractures(by 45 per cent),but the lower rate of hip fracture (2.0 vs 3.5 per cent with placebo) was not statistically significant. Rivastigmine patch for mild to moderate AD Rivastigmine (Exelon) is now available as a transdermal patch for the treatment of mild to moderate Alzheimer's disease. Applied once daily, the patch delivers 9.5mg per 24 hours and, says manufacturer Novartis, is associated with a lower incidence of nausea and vomiting than a comparable oral dose. The patch is available in two strengths: 4.6mg per 24hr is equivalent to oral doses of 3 or 6mg per day, and the 9.5mg per 24hr patch is equivalent to 9 or 12mg per day orally. The recommended dose of the patch is 9.5mg per day; both strengths cost £83.84 for 30 patches. Women more aspirin resistant than men? The cardioprotective effect of low-dose aspirin may be lower in women than men, say Canadian investigators (BMC Medicine 2007;5:29 doi: 10.1186/1741-70155-29). Their meta-analysis of 23 randomised trials involving a total of 113 494 participants found that aspirin significantly reduced the risk of nonfatal but not fatal myocardial infarction (MI). About one-quarter of the variation in its effects on nonfatal MI was accounted for by the sex mix of the trial population. Separating the results by sex showed the reduction in risk with aspirin use was statistically significant in men (relative risk, RR, 0.62) but not in women (RR 0.87). Look after physical health of mentally ill GPs and other primary care workers should take more responsibility for the physical health of their mentally ill patients, say advocacy groups. Mind and Body: Preventing and Improving Physical Health Problems in Patients With Schizophrenia points out that the mental health needs of patients with schizophrenia are met in secondary care, but their physical health needs should be met in primary care. In particular, the metabolic effects of antipsychotics may lead to obesity, diabetes and cardiovascular disease, and weight gain in particular is a frequent reason for nonadherence to treatment. The Mind and Body Manifesto was developed by SANE, The Mental Health Nurses Association, The National Obesity Forum and The Disability Rights Commission and sponsored by Bristol-Myers Squibb Pharmaceuticals Limited and Otsuka Pharmaceuticals (UK) Ltd. Copies are available from elizabeth.green@ ogilvyhealthworld.com. Health eCard costs Some costs quoted in our article on the Health eCard (The Health eCard: the way ahead for medical records?,5 October issue, pages 28-9) have been revised: the card and initial download will cost patients £39.50, and GPs will be entitled to charge patients £10 per annum for subsequent downloads. NICE appraisals of cytokine inhibitors in RA NICE has endorsed the use of the anti-TNF agents adalimumab (Humira), etanercept (Enbrel) and infliximab (Remicade), normally in conjunction with methotrexate, for the treatment of active RA when methotrexate and another DMARD have failed (also see New from NICE below). NICE has provisionally concluded, subject to consultation, that abatacept (Orencia) should not be recommended for the treatment of RA. Boots and BMJ launch health advice site www.askbootshealth.com is a new website providing information about health and medicines for the public produced by Boots using information provided by the BMJ Publishing Group. The website covers many of the topics already available from NHSDirect, with perhaps more information about available treatments. Diabetes care shows small improvement The third National Diabetes Audit in England and Wales has found that more people with diabetes were achieving the targets set by NICE for cholesterol levels, glycaemic control and blood pressure in 2005/06 - but younger patients were doing less well. Overall, the HbA1C target of ,7.5 per cent was achieved in 60 per cent of people with diabetes compared with 58 per cent in 2004/05. However, HbA1C was >9.5 per cent in 30 per cent of children and young people, of whom 9 per cent experienced at least one episode of ketoacidosis. More topics for NICE New topics referred to NICE include clinical guidelines on ovarian cancer, coeliac disease and stable angina, public health guidance on preventing cardiovascular disease, and technology appraisals on insulin detemir (Levemir) for type 1 diabetes, several treatments for cancer and hepatic and haematological disorders, and biological therapies for juvenile arthritis. New from NICE NICE appraisal on anti-TNFs for RA Since NICE published its first appraisal of agents acting against tumour necrosis factor-alpha (anti-TNFs) for the treatment of RA in 2002, the product licences for etanercept (Enbrel) and infliximab (Remicade) have changed and a new agent, adalimumab (Humira), has been introduced. The anti-TNFs act in different ways. Infliximab is a chimeric monoclonal antibody that binds to TNF-alpha, neutralising its activity. Etanercept, a recombinant human TNF-alpha receptor fusion protein, and adalimumab, a human-sequence antibody, both bind to TNF-alpha and block its interaction with cell surface receptors. Adalimumab also modulates some biological responses induced or regulated by TNF-alpha. These agents are recommended for adults with severe active RA (defined as a disease activity score - DAS28 - greater than 5.1) who have already tried two disease-modifying drugs, including methotrexate (if not contraindicated). Prior treatment should have been of at least six months' duration, including two months at the standard dose (unless limited by toxicity). Anti-TNFs should normally be prescribed with methotrexate; when this is not appropriate, etanercept and adalimumab may be prescribed as monotherapy. Treatment with an anti-TNF should be continued beyond six months only if there is an adequate response (defined as an improvement in DAS28 of at least 1.2). Data from the British Rheumatology Society Biologics register show that, after six months, 67 per cent of patients met NICE criteria for an adequate response; this declined to 55 per cent at 18 months. The basic annual cost of treatment is £9295 for adalimumab 40mg on alternate weeks or etanercept 25mg twice weekly; infliximab costs £3777 for a loading dose, then £7553-£8812 depending on dose. Assuming no progression of disability, the incremental costs per QALY (compared with sequential DMARDs) were £30 200 for adalimumab, £24 600 for etanercept and £39 400 for infliximab. There are no direct comparative trials of the anti-TNFs, and their clinical trial findings are not directly comparable. Unless other factors determine treatment choice, NICE therefore recommends the least expensive. If the first anti-TNF is withdrawn within six months due to an adverse event, a second may be tried. [source] "Publics" Administration and the Ethics of ParticularityPUBLIC ADMINISTRATION REVIEW, Issue 5 2003F. Neil Brady Ethical orientations that emphasize universal duties, ideals, and values are well known to public administrators. We pay attention to principle, policy, ideals, shared goals, and the provision of a variety of commonly held values, such as clean air and water, mosquito abatement, and public recreation. The word "public" often seems to be a synonym for "universal." However, this article explores particularity in ethics, especially as it applies to the life of the public servant. It identifies three distinct orientations that focus on the concrete,as opposed to the abstract,and it shows how the exceptional cases are not administrative problems; rather they provide a reality check for public administrators who suppose rules, plans, and programs to be their primary orientation toward the management of public concerns. [source] Validation of experimental charge densities: refinement of the macrolide antibiotic roxithromycinACTA CRYSTALLOGRAPHICA SECTION B, Issue 5 2010J. J. Holstein Multipole refinements of larger organic molecules have so far been limited to a few exceptional cases. We report an investigation of the detailed experimental electron-density distribution (EDD) of roxithromycin, a macrolide antibiotic consisting of 134 atoms. Although the experimental multipole refinement on high-resolution synchrotron data converged smoothly, validation of the electron density by calculation of an `experiment minus invariom' difference density revealed conformational disorder of the H atoms. Hydrogen disorder is shown to affect the EDD, the electrostatic potential and atomic properties as defined by Bader's quantum theory of atoms in molecules. A procedure to obtain the electron density distribution in the presence of disorder is proposed. [source] Prediction of the risk of Torsade de Pointes using the model of isolated canine Purkinje fibresBRITISH JOURNAL OF PHARMACOLOGY, Issue 3 2005Pascal Champeroux 1Torsade de Pointes (TdP) is a well-described major risk associated with various kinds of drugs. However, prediction of this risk is still uncertain both in preclinical and clinical trials. We tested 45 reference compounds on the model of isolated canine Purkinje fibres. Of them, 22 are clearly associated and/or labelled with a risk of TdP, and 13 others are drugs with published clinical evidence of QT prolongation, with only one or two exceptional cases of TdP. The 10 remaining drugs are without reports of TdP and QT prolongation. 2The relevance of different indicators such as APD90 increase, reverse use dependency, action potential triangulation or effect on Vmax was evaluated by comparison with available clinical data. Finally, a complex algorithm called TDPscreenÔ and based on two subalgorithms corresponding to particular electrophysiological patterns was defined. 3This latter algorithm enabled a clear separation of drugs into three groups: (A) drugs with numerous or several reports (>2 cases) of TdP, (B) drugs causing QT prolongation and/or TdP only, the latter at a very low frequency (2 cases), (C) drugs without reports of TdP or QT prolongation. 4The use of such an algorithm combined with a database accrued from reference compounds with available clinical data is suggested as a basis for testing new candidate drugs in the early stages of development for proarrhythmic risk prediction. British Journal of Pharmacology (2005) 144, 376,385. doi:10.1038/sj.bjp.0706070 [source] Discourse rights and the Drumcree marches: a reply to O'NeillBRITISH JOURNAL OF POLITICS & INTERNATIONAL RELATIONS, Issue 1 2002Glen Newey In a recent BJPIR article Shane O'Neill uses Habermas' discourse theory of rights to argue that the conflicts over marches in Drumcree can be resolved rationally in the nationalist residents' favour. I question this conclusion via a critique of Habermas' theory. Habermas' apparently unexceptionable requirement that political outcomes win universal acceptability is bought at the cost of vagueness: it fails to specify how acceptability is secured, or how the requirement itself is derived. So it cannot justify the exceptions to equal civil rights which O'Neill wants, such as exceptions to rights of freedom of expression or movement. Unionists can claim that their position respects Habermas' universal acceptability requirement. This exposes the limitations of attempts to impose abstract principles such as Habermas' on real political conflicts. A possible alternative to this is a form of Schmittian decisionism, in which rules either prove indeterminate, or are confronted with exceptional cases that call for executive intervention outside the framework of rules. Sensitivity to political context requires not derogations from rights, but respect for the autonomy of political processes. [source] | |||||||||||||||||||