WorldWideScience
 
 
1

New drilling fluids for difficult conditions  

Energy Technology Data Exchange (ETDEWEB)

This paper discusses new inhibiting and salt-saturated clay solutions used for drilling of wells in complex geologic conditions, as well as the experience with these solutions in industrial conditions. Provides a comparative evaluation of the inhibiting properties of the solutions and recommendations for using the inhibiting system in relation to properties of the drilled rock media.

Pen' kov, A.I.; Chernikova, G.V.; Kovalyouva, Z.S.; Levik, N.P.; Ryabchenko, V.I.

1982-01-01

2

Face Recognition Under Difficult Lighting Conditions  

Directory of Open Access Journals (Sweden)

Full Text Available Face recognition has received a great deal of attention from the scientific and industrial communities over the past several decades owing to its wide range of applications in information security and access control, law enforcement agencies, surveillance and more generally image understanding. Most of these methods were initially developed with face images collected under relatively well-controlled conditions and in practice they have difficulty in dealing with the range of appearance variations that commonly occur in unconstrained natural images due to illumination, pose, facial expression, aging, partial occlusions, etc. Unfortunately, facial appearance depends strongly on the ambient lighting conditions. This paperpresents a robust technique for identifying the faces in the various lighting conditions. The proposed method normalizes the acquired images under different lighting conditions in the first step. In the next step it captures as much as possible of the available information with relatively few training samples. The results show that our proposed method outperforms several existing preprocessors for a range of feature sets, data sets and lighting conditions.

V.Sikanthgoud; M.Venugopal Roa

2013-01-01

3

An introduction to flux measurements in difficult conditions.  

UK PubMed Central (United Kingdom)

The origins of the aerodynamic techniques now widely used at sites around the world to measure continuous biosphere-atmosphere exchange of carbon and energy are briefly reviewed. A survey of the current state of this approach concludes that the technique often fails when standard analysis routines are applied to data from single towers in complex flows. In the daytime, problems are signaled by failure to close the surface energy balance because turbulent energy fluxes are routinely underestimated. Complex flows are more prevalent at night when they lead to failure to measure all the respired CO2. At such times, the aerodynamic methodology is commonly supplemented by biological models. A set of papers from a workshop on "Flux Measurements in Difficult Conditions" held at the National Center for Atmospheric Research (NCAR) in January 2006 are introduced next. Two papers review the causes and magnitude of these flow-based problems. Four papers describe intensive field experiments that detail the mechanisms that cause problematic complex flows. These experiments show, inter alia, that the technique of replacing nighttime eddy flux measurements by biological models can also be systematically biased. Finally, two model studies are used both to illustrate the physics behind these complex flows and to motivate an approach to systematic correction of single-tower results.

Finnigan J

2008-09-01

4

Infant difficult behaviors in the context of perinatal biomedical conditions and early child environment  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Background Problems experienced within the first year of an infant's life can be precursors of later mental health conditions. The purpose of this study was to examine the frequency and continuity of difficult behaviors in infants at 3 and 6 months of age and the associations of these difficulties with biomedical and psychosocial factors. Methods This study was a part of an ongoing prospective birth-cohort study. Study participants were 189 uniparous mothers and their full-term newborns. The index of infant difficult behavior was constructed. This index was then associated with the following factors: delivery mode, newborn function after birth, maternal emotional well-being, risk behavior, subjective evaluation of the quality of the relationship of the couple, and attitudes toward infant-rearing. Results Common difficult behaviors, including crying, sleeping and eating problems, were characteristic for 30.2% of 3 month old and for 22.2% of 6 month old full-term infants. The expression of infant difficult behaviors at the age of 3 months increased the likelihood of the expression of these difficulties at 6 months by more than 5 times. Factors including younger maternal age, poor prenatal and postnatal emotional well-being, prenatal alcohol consumption, low satisfaction with the couple's relationship before pregnancy, and deficiency of infant-centered maternal attitudes towards infant-rearing increased the likelihood of difficult behaviors in infants at the age of 3 months. Low maternal satisfaction with the relationship of the couple before pregnancy, negative emotional reactions of both parents toward pregnancy (as reported by the mother) and the deficiency of an infant-centered maternal attitude towards infant-rearing increased the likelihood of infant difficult behaviors continuing between the ages of 3 to 6 months. Perinatal biomedical conditions were not related to the difficult behaviors in infants. Conclusions Our study suggests that early onset of difficult behavior highly increases the risk for the continuation of difficult behavior during infancy. In general, the impact of prenatal psychosocial environment on infant behavior decreases from the ages of 3 to 6 months; however, some prenatal and preconceptional psychosocial factors have direct associations with the continuity of difficult behaviors through the first half-year of an infant's life.

Sirvinskiene Giedre; Zemaitiene Nida; Zaborskis Apolinaras; Markuniene Egle; Jusiene Roma

2012-01-01

5

Red Indian Lake fishway, an innovative design for difficult conditions  

International Nuclear Information System (INIS)

[en] Red Indian Lake Dam is a large concrete gravity structure, 10-12 m high and 245 m long, in the Exploits River watershed in Newfoundland. The watershed is an ideal habitat for production of Atlantic salmon. Since 1985, the watershed above the dam has undergone an extensive stocking program to optimize the salmon production capacity of the upper reaches of the system. To sustain this development, a fishway was needed to permit returning salmon to bypass Red Indian Lake Dam, the last remaining migrational barrier. The difficulties with installing a fishway at the dam site included extreme variation in upstream water levels, the need to retrofit a fishway into an existing structure, and the necessity to attract fish into the fishway in competition with other flows from power plant, spillway, or waterfall. After examining several design approaches, an innovative design was developed incorporating two separate but interrelated flow ways: one to handle attraction water and the other for transportation water. The latter passage leads to a trap at the upper end of the fishway from which salmon are hoisted via a hopper/monorail system across the dam and into the lake. Construction of the fishway was staged over four phases between December 1985 and December 1988. 3 refs., 1 fig

1993-01-01

6

Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new?  

Directory of Open Access Journals (Sweden)

Full Text Available The purpose of this article is to review the fundamental aspects of obesity, pregnancy and a combination of both. The scientific aim is to understand the physiological changes, pathological clinical presentations and application of technical skills and pharmacological knowledge on this unique clinical condition. The goal of this presentation is to define the difficult airway, highlight the main reasons for difficult or failed intubation and propose a practical approach to management Throughout the review, an important component is the necessity for team work between the anaesthesiologist and the obstetrician. Certain protocols are recommended to meet the anaesthetic challenges and finally concluding with "what is new?" in obstetric anaesthesia.

Rao Durga; Rao Venkateswara

2010-01-01

7

Difficult Asthma  

Directory of Open Access Journals (Sweden)

Full Text Available Difficult asthma is a distinct entity of asthma, comprising approximately %5 of asthmatic patients. There is no agreed definition of difficult asthma. It will include asthma uncontrolled by new standard therapy, steroid dependent, steroid resistant and severe asthma. In this study difficult asthma; clinical features, risk factors, pathophysiology and novel therapies are summarized by literatures.

Ahmet Uslu; Tülay Özdemir

2003-01-01

8

Difficult sinking cut in severe winter conditions improves productivity at Lac des Iles Mines  

Energy Technology Data Exchange (ETDEWEB)

The Lac des Iles Mine, in an isolated area of Northwestern Ontario is a relatively new open pit mine. They encountered problems with the equipment and production scheduling when ramping down to begin production on the subsequent benches. A co-operative effort between Lac des Iles Mine operations, ICI Explosives, and the mines drilling and blasting contractor, Consbec Inc., resulted in a decision being made to use full depth sinking cuts to provide access to the next bench. The sinking cut was carried out under a combination of extremely difficult conditions--shattered rock, collapsing holes, flowing water and frozen explosives{hor_ellipsis}--in severe Canadian winter and under a tight schedule. This paper will outline the problems associated with the changes in the blast design, drilling, loading and blasting of the sinking cut. Details will be provided that outline the procedures that were developed, and the types of explosives that were used in order to overcome the problems and achieve significant operational cost savings in the process.

Moffat, C.; Kita, J.; Walker, R.

1996-12-01

9

Improvement of reliability of opencast mining techniques in difficult geological, mining and climatic conditions. [United Kingdom  

Energy Technology Data Exchange (ETDEWEB)

The Opencast Executive of the National Coal Board of the United Kingdom is a development and management organization responsible for finding, evaluating, planning, developing and supervising opencast coal mining operations. These operations are carried out by civil engineering and other specialized contractors who have the necessary expertise and technical capability in drilling, mining, restoration and rehabilitation of opencast sites. The paper describes various considerations for the improvement of reliability of opencast mining. Topics covered are: geological and geotechnical investigations; geotechnical engineering stability assessments, including strata discontinuities, geological faulting, bedding dip, previous underground workings; previous opencast backfill, superficial deposits, Permo-Trias deposits, topography and ground water; field investigation and geotechnical parameters; geological site report; diggability assessment; rock quality evaluation and climatic conditions.

1983-11-30

10

Ways and means of dewatering opencast mines, particularly at great depth or in difficult mining conditions  

Energy Technology Data Exchange (ETDEWEB)

Contains the report submitted by the Group of Experts on Open-cast Mines at its fourth session in Ankara, Turkey, on 9-13 May 1983. Reviews the need for and the importance of dewatering in opencast mining; exploration of hydrogeological conditions; dewatering techniques (filter well dewatering of large areas, road/fall-filter dewatering, surface dewatering by ditches); and special techniques of dewatering (dewatering of spoil dumps, horizontal boreholes, waterproofing wells).

1985-06-01

11

New developments with fabric filters. Filter media especially for use under difficult chemical and thermal conditions  

Energy Technology Data Exchange (ETDEWEB)

Desirable recovery of valuable or reusable powdery products and a worldwide movement towards more severe anti-pollution legislation has increased the demands for more efficient and economical purification of industrial waste gases. Dust collection and gas cleaning with fabric filters advances more and more into fields where dusts have to be separated from aggresive carrier gases. Moisture and aggresive components impair the separation process, vary the water and acid dew point conditions and frequently influence bag life. Dry scrubbing with fabric filters is introduced and practical examples from the author's experience and case histories are submitted.

Dietrich, H.

1981-01-01

12

How I treat patients with indolent and smoldering mastocytosis (rare conditions but difficult to manage).  

Science.gov (United States)

Indolent systemic mastocytosis (SM) patients have a varied clinical presentation, ranging from predominantly cutaneous symptoms to recurrent systemic symptoms (eg, flushing, palpitations, dyspepsia, diarrhea, bone pain) that can be severe and potentially life threatening (anaphylaxis). Mastocytosis patients without skin involvement pose a diagnostic challenge; a high index of suspicion is needed in those with mast cell-degranulation symptoms, including anaphylaxis following Hymenoptera stings or other triggers. Modern-era molecular and flow-cytometric diagnostic methods are very sensitive and can detect minimal involvement of bone marrow with atypical/clonal mast cells; in some cases, full diagnostic criteria for SM are not fulfilled. An important aspect of treatment is avoidance of known symptom triggers; other treatment principles include a stepwise escalation of antimediator therapies and consideration of cytoreductive therapies for those with treatment-refractory symptoms. The perioperative management of mastocytosis patients is nontrivial; a multidisciplinary preoperative assessment, adequate premedications, and close intra- and postoperative monitoring are critical. Smoldering mastocytosis is a variant with high systemic mast cell burden. While its clinical course can be variable, there is greater potential need for cytoreductive therapies (eg, interferon-alpha, cladribine) in this setting. A systematic approach to the diagnosis and treatment of indolent SM using a case-based approach of representative clinical scenarios is presented here. PMID:23426950

Pardanani, Animesh

2013-02-20

13

How I treat patients with indolent and smoldering mastocytosis (rare conditions but difficult to manage).  

UK PubMed Central (United Kingdom)

Indolent systemic mastocytosis (SM) patients have a varied clinical presentation, ranging from predominantly cutaneous symptoms to recurrent systemic symptoms (eg, flushing, palpitations, dyspepsia, diarrhea, bone pain) that can be severe and potentially life threatening (anaphylaxis). Mastocytosis patients without skin involvement pose a diagnostic challenge; a high index of suspicion is needed in those with mast cell-degranulation symptoms, including anaphylaxis following Hymenoptera stings or other triggers. Modern-era molecular and flow-cytometric diagnostic methods are very sensitive and can detect minimal involvement of bone marrow with atypical/clonal mast cells; in some cases, full diagnostic criteria for SM are not fulfilled. An important aspect of treatment is avoidance of known symptom triggers; other treatment principles include a stepwise escalation of antimediator therapies and consideration of cytoreductive therapies for those with treatment-refractory symptoms. The perioperative management of mastocytosis patients is nontrivial; a multidisciplinary preoperative assessment, adequate premedications, and close intra- and postoperative monitoring are critical. Smoldering mastocytosis is a variant with high systemic mast cell burden. While its clinical course can be variable, there is greater potential need for cytoreductive therapies (eg, interferon-alpha, cladribine) in this setting. A systematic approach to the diagnosis and treatment of indolent SM using a case-based approach of representative clinical scenarios is presented here.

Pardanani A

2013-04-01

14

Graphic daylighting design method: including clear sky conditions  

Energy Technology Data Exchange (ETDEWEB)

The University of Washington Graphic Daylighting Design Method (GDDM) has been developed as a graphic design tool for architects in assessing both qualitative and quantitative aspects of daylighting design. Use of the method is based on a catalogue of Patterns of daylight distribution in isolux contours over a horizontal reference plane from window and skylight opening. Investigations are now being conducted into extending its use to cover clear Sky conditions and various modifiers such as external obstructions, jambs, and shading devices. Directions being pursued in extending its use to cover critical design conditions are reported.

Millet, M.S.; Adams, C.; Bedrick, J.R.

1980-01-01

15

Photovoltaic field emulation including dynamic and partial shadow conditions  

International Nuclear Information System (INIS)

In this paper the development of a new laboratory prototype for the emulation of a photovoltaic (PV) field is presented. The proposed system is based on a DC/DC step-down converter topology and allows to obtain the solar array I-V curves, taking into account the environmental changes in solar irradiance and cell temperature. The DC/DC converter control strategy is deduced by using a comprehensive mathematical model of the PV field whose parameters are obtained from the knowledge of: (a) maximum power point data, measured when the PV plant power converter is running, (b) open circuit voltage and short-circuit current, measured off-line. This approach allows the most accurate representation of the PV source. Computer simulations and experimental results demonstrate that the proposed circuit acts as a highly accurate and efficient laboratory simulator of the photovoltaic array electrical characteristics both in steady state and transient conditions. Partial shading and fluctuating conditions can be reproduced too. Moreover the dynamic behaviour of the proposed laboratory emulator is suitable to its effective connection to power electronic interface to the utility or to load through a DC/DC boost converter.

2010-01-01

16

Photovoltaic field emulation including dynamic and partial shadow conditions  

Energy Technology Data Exchange (ETDEWEB)

In this paper the development of a new laboratory prototype for the emulation of a photovoltaic (PV) field is presented. The proposed system is based on a DC/DC step-down converter topology and allows to obtain the solar array I-V curves, taking into account the environmental changes in solar irradiance and cell temperature. The DC/DC converter control strategy is deduced by using a comprehensive mathematical model of the PV field whose parameters are obtained from the knowledge of: (a) maximum power point data, measured when the PV plant power converter is running, (b) open circuit voltage and short-circuit current, measured off-line. This approach allows the most accurate representation of the PV source. Computer simulations and experimental results demonstrate that the proposed circuit acts as a highly accurate and efficient laboratory simulator of the photovoltaic array electrical characteristics both in steady state and transient conditions. Partial shading and fluctuating conditions can be reproduced too. Moreover the dynamic behaviour of the proposed laboratory emulator is suitable to its effective connection to power electronic interface to the utility or to load through a DC/DC boost converter. (author)

Di Piazza, Maria Carmela; Vitale, Gianpaolo [National Research Council (CNR), Institute of Intelligent Systems for Automation (ISSIA), Section of Palermo Via Dante, 12, 90141 Palermo (Italy)

2010-03-15

17

Immunotherapy with Mycobacterium vaccae as an addition to chemotherapy for the treatment of pulmonary tuberculosis under difficult conditions in Africa.  

Digital Repository Infrastructure Vision for European Research (DRIVER)

A study to assess the impact of immunotherapy with Mycobacterium vaccae on the treatment of pulmonary tuberculosis was conducted under existing conditions in Kano, a large city in Northern Nigeria. Whilst it did not quite meet all the criteria of a well-controlled randomized or double-blind trial, t...

Onyebujoh, PC; Abdulmumini, T; Robinson, S; Rook, GA; Stanford, JL

18

Dermatitis artefacta and artefactual skin disease: the need for a psychodermatology multidisciplinary team to treat a difficult condition.  

UK PubMed Central (United Kingdom)

BACKGROUND: Dermatitis artefacta (DA) is a factitious skin disorder caused by the deliberate production of skin lesions by patients with a history of underlying psychological problems. The patient may not be fully aware of this, and the true extent of this disorder, especially in children, is currently unknown. Management of these patients is challenging as many fail to engage effectively with their dermatologist. OBJECTIVES: To explore the various clinical presentations and strategies employed to treat DA in our local population, and note outcomes in order to evaluate effectiveness of our management. METHODS: A retrospective case note review was conducted of 28 patients attending the regional psychodermatology clinic at the Royal London Hospital from January 2003 to December 2011. RESULTS: Out of 28 patients identified with DA, the majority of patients were female, and the most frequent sites for skin lesions were the face and upper body. Anxiety, depression and personality disorders were common underlying psychiatric diagnoses. Ninety-three per cent of patients were successfully managed (i.e. the DA resolved or was in remission at the time of writing) in our combined psychodermatology clinic by a multidisciplinary psychocutaneous medicine team. Thirty-two per cent of our cases were children (aged < 16 years) and one of these was referred to local child protection services; 46% of patients had a concomitant mental health disease at the time of presentation with DA. CONCLUSIONS: A multidisciplinary psychocutaneous team is important in this condition particularly as the patient is likely to require psychological intervention (to facilitate the resolution of the precipitant), in addition to dermatological (to make the diagnosis and, importantly, to exclude organic disease) and psychiatric (to manage concomitant psychiatric disease) input. Our findings indicate that our model of a psychodermatology multidisciplinary team will achieve greater successful treatment of patients with DA and we are the first to describe this important service in the U.K.

Mohandas P; Bewley A; Taylor R

2013-09-01

19

The difficult airway.  

Science.gov (United States)

Securing the airway in a dyspneic patient is a challenging task because of the myriad causes and presentations. Initial assessment may demonstrate factors indicative of upper airway abnormalities; however, they may not be specific nor sensitive enough to accurately predict difficult intubation. A well-equipped airway cart must be immediately available. A standardized escalating approach to secure the airway in a difficult situation begins with a rapid sequence of attempts at standard intubation, followed by attempted tube introduction over a bougie or using a flexible endoscope or laryngeal mask, and finally surgical interventions including cricothyrotomy or tracheotomy. PMID:18435999

Liess, Benjamin D; Scheidt, Troy D; Templer, Jerry W

2008-06-01

20

F1 occurrence including L condition in TUCUMAN and BUENOS AIRES  

International Nuclear Information System (INIS)

[en] An analysis of the occurrence of the F1 layer including the L condition has been done, using data from two Argentine stations: TUCUMAN and BUENOS AIRES, at different seasons and solar activity conditions. The comparisons between observations and the F1 occurrence predicted by the IRI-90 model show the need of reviewing the use of the DuCharme et al. (1973) formula adopted by the model to predict the occurrence of the intermediate F1 layer including the L condition. (author). 6 refs, 6 figs, 2 tabs

1997-01-01

 
 
 
 
21

Management of "difficult" wounds.  

UK PubMed Central (United Kingdom)

Pressure sores (PSs) and wounds in immunocompromised children are rather rare conditions. No doubt, their management is often complex and difficult, even for experienced pediatric plastic surgeons. As there are no algorithms for standard care, the therapeutic approach is individual.Successful PS management always implies primary and secondary prevention. With a PS present, rapid relief of pressure is crucial. If local wound care fails to restore skin integrity within a short period of time, surgical defect closure is mandatory. Overall, full-thickness skin grafts and local flap surgery are the most suitable methods regarding result quality, procedure complexity, and risks. Negative pressure wound therapy (NPWT) plays an instrumental role in wound bed preparation before definitive coverage. Recurrence rate is high (the complication). It does not much depend on the surgical technique employed, but rather depends on whether the various pathogenic factors leading to PS can be eliminated or alleviated.In both temporarily and permanently immunocompromised children, wound healing is significantly impaired. At the same time, these patients have no or low host defense activity. Thus, they are at high risk not only for local wound infection but also for potentially life threatening septic complications. Rapid and definitive wound closure is therefore essential. When conservative therapy fails, simple surgical techniques granting rapid and definitive wound closure should be used.

Neuhaus K; Meuli M; Koenigs I; Schiestl C

2013-10-01

22

Management of "difficult" wounds.  

Science.gov (United States)

Pressure sores (PSs) and wounds in immunocompromised children are rather rare conditions. No doubt, their management is often complex and difficult, even for experienced pediatric plastic surgeons. As there are no algorithms for standard care, the therapeutic approach is individual.Successful PS management always implies primary and secondary prevention. With a PS present, rapid relief of pressure is crucial. If local wound care fails to restore skin integrity within a short period of time, surgical defect closure is mandatory. Overall, full-thickness skin grafts and local flap surgery are the most suitable methods regarding result quality, procedure complexity, and risks. Negative pressure wound therapy (NPWT) plays an instrumental role in wound bed preparation before definitive coverage. Recurrence rate is high (the complication). It does not much depend on the surgical technique employed, but rather depends on whether the various pathogenic factors leading to PS can be eliminated or alleviated.In both temporarily and permanently immunocompromised children, wound healing is significantly impaired. At the same time, these patients have no or low host defense activity. Thus, they are at high risk not only for local wound infection but also for potentially life threatening septic complications. Rapid and definitive wound closure is therefore essential. When conservative therapy fails, simple surgical techniques granting rapid and definitive wound closure should be used. PMID:24008551

Neuhaus, Kathrin; Meuli, Martin; Koenigs, Ingo; Schiestl, Clemens

2013-09-05

23

[Unanticipated difficult extubation].  

Science.gov (United States)

Complications at extubation remain an important risk factor in anaesthesia. Airway related complications at extubation are relatively frequent but are usually dealt with by simple basic measures. We report a new case of respiratory complications associated with tracheal extubation in a 59-year-old woman. Her medical history included obesity, no criteria difficult intubation and no adverse events during her previous anesthetic procedures. At the end of surgery, immediately after extubation, the patient developed respiratory distress requiring reintubation. A second extubation performed in postoperative recovery room was complicated by a new respiratory distress with reintubation. The patient was then admitted to the ICU. The examination on admission was unremarkable. Chest X-ray and a chest CT scan were performed in search of an etiology. Both tests showed a large thyroid "goitre plongeant" (plunging goiter) and compressive. In the suites, a thyroidectomy was performed with excision of a large cervical plunging goiter para- and retropharyngeal bilateral chest, allowing extubation successfully. The postoperative course was uneventful. PMID:23707204

Badaoui, R; Abou Arab, O; Bernard, E; Vouriot, D; Popov, I; Dupont, H

2013-05-23

24

[Unanticipated difficult extubation].  

UK PubMed Central (United Kingdom)

Complications at extubation remain an important risk factor in anaesthesia. Airway related complications at extubation are relatively frequent but are usually dealt with by simple basic measures. We report a new case of respiratory complications associated with tracheal extubation in a 59-year-old woman. Her medical history included obesity, no criteria difficult intubation and no adverse events during her previous anesthetic procedures. At the end of surgery, immediately after extubation, the patient developed respiratory distress requiring reintubation. A second extubation performed in postoperative recovery room was complicated by a new respiratory distress with reintubation. The patient was then admitted to the ICU. The examination on admission was unremarkable. Chest X-ray and a chest CT scan were performed in search of an etiology. Both tests showed a large thyroid "goitre plongeant" (plunging goiter) and compressive. In the suites, a thyroidectomy was performed with excision of a large cervical plunging goiter para- and retropharyngeal bilateral chest, allowing extubation successfully. The postoperative course was uneventful.

Badaoui R; Abou Arab O; Bernard E; Vouriot D; Popov I; Dupont H

2013-06-01

25

Adaptive approach to load shedding including pumped-storage units during under frequency conditions  

Energy Technology Data Exchange (ETDEWEB)

An adaptive approach is proposed to load shedding including the consideration of pumped-storage units during under frequency conditions. Based on the idea of average or uniform frequency behaviour, a load-frequency control model is utilised in the scheme design. At this stage, Taiwan Power Company (Taipower) owns ten pumped-storage units that amount to about 13% of the total rating capacity. These units can be operated in generating mode during peak period, to reduce generation cost, or operated in pumping mode during off-peak period, to consume the surplus power. As the difference between the peak load and off-peak of Taipower is considerable, pumped-storage units are playing a critical role in Taipower operations. Once disturbances take place in off-peak periods, pumped-storage units can be thus shed with a high priority. As they are useful in both restoring system frequency and decreasing the degree of service interruptions, these pumped-storage units have been included in the proposed load-shedding scheme design and tested through the utility data. From test results and comparisons with the existent utility shedding scheme, they have demonstrated the feasibility and practicality of the method for such applications. (Author)

Huang, S.-J.; Huang, C.-C. [National Cheng Kung Univ., Dept. of Electrical Engineering, Tainan (Taiwan)

2001-03-01

26

Amino acid composition, including key derivatives of eccrine sweat: potential biomarkers of certain atopic skin conditions.  

UK PubMed Central (United Kingdom)

The free amino acid (AA) composition of eccrine sweat is different from other biological fluids, for reasons which are not properly understood. We undertook the detailed analysis of the AA composition of freshly isolated pure human eccrine sweat, including some of the key derivatives of AA metabolism, to better understand the key biological mechanisms governing its composition. Eccrine sweat was collected from the axillae of 12 healthy subjects immediately upon formation. Free AA analysis was performed using an automatic AA analyser after ninhydrin derivatization. Pyrrolidine-5-carboxylic acid (PCA) and urocanic acid (UCA) levels were determined using GC/MS. The free AA composition of sweat was dominated by the presence of serine accounting for just over one-fifth of the total free AA composition. Glycine was the next most abundant followed by PCA, alanine, citrulline and threonine, respectively. The data obtained indicate that the AA content of sweat bears a remarkable similarity to the AA composition of the epidermal protein profilaggrin. This protein is the key source of free AAs and their derivatives that form a major part of the natural moisturizing factor (NMF) within the stratum corneum (SC) and plays a major role in maintaining the barrier integrity of human skin. As perturbations in the production of NMF can lead to abnormal barrier function and can arise as a consequence of filaggrin genotype, we propose the quantification of AAs in sweat may serve as a non-invasive diagnostic biomarker for certain atopic skin conditions, that is, atopic dermatitis (AD).

Mark H; Harding CR

2013-04-01

27

Amino acid composition, including key derivatives of eccrine sweat: potential biomarkers of certain atopic skin conditions.  

Science.gov (United States)

The free amino acid (AA) composition of eccrine sweat is different from other biological fluids, for reasons which are not properly understood. We undertook the detailed analysis of the AA composition of freshly isolated pure human eccrine sweat, including some of the key derivatives of AA metabolism, to better understand the key biological mechanisms governing its composition. Eccrine sweat was collected from the axillae of 12 healthy subjects immediately upon formation. Free AA analysis was performed using an automatic AA analyser after ninhydrin derivatization. Pyrrolidine-5-carboxylic acid (PCA) and urocanic acid (UCA) levels were determined using GC/MS. The free AA composition of sweat was dominated by the presence of serine accounting for just over one-fifth of the total free AA composition. Glycine was the next most abundant followed by PCA, alanine, citrulline and threonine, respectively. The data obtained indicate that the AA content of sweat bears a remarkable similarity to the AA composition of the epidermal protein profilaggrin. This protein is the key source of free AAs and their derivatives that form a major part of the natural moisturizing factor (NMF) within the stratum corneum (SC) and plays a major role in maintaining the barrier integrity of human skin. As perturbations in the production of NMF can lead to abnormal barrier function and can arise as a consequence of filaggrin genotype, we propose the quantification of AAs in sweat may serve as a non-invasive diagnostic biomarker for certain atopic skin conditions, that is, atopic dermatitis (AD). PMID:23075272

Mark, Harker; Harding, Clive R

2012-11-20

28

Difficult bile duct stones.  

Science.gov (United States)

Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression, stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary. PMID:16539873

McHenry, Lee; Lehman, Glen

2006-04-01

29

76 FR 9283 - Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care...  

Science.gov (United States)

...provider-preventable condition PE Pulmonary embolism POA Present on admission PPC...Retained After Surgery. Air Embolism. Blood Incompatibility...Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE). + Total Knee...

2011-02-17

30

76 FR 32815 - Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care...  

Science.gov (United States)

...provider-preventable condition PE Pulmonary embolism POA Present on admission PPC...Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE). + Total Knee Replacement...exception of Deep Vein Thrombosis/Pulmonary Embolism following total knee...

2011-06-06

31

[The difficult venous access].  

UK PubMed Central (United Kingdom)

Venipunctures in children are difficult. Some factors can hardly be influenced, for example, a well-developed subcutaneous fat tissue. Technical devices may help to identify invisible veins. With the help of ultrasound deep peripheral veins on the wrists and ankles can be presented and punctured. Stiff resistance of a child thwarts any successful puncture. Children should therefore be adequately sedated, if cannot be induced by mask. Missing practice venipuncture and inadequate knowledge of appropriate puncture sites can be met easily by practicing and reading.The possibility of intraosseous puncture today is standard of anesthesia care for children. Within in a few seconds, a secure access to the vein system can be created.

Strauß JM; Denk A

2013-04-01

32

Effect of street conditions, including saline aerosol, on growth of the Small-leaved limes  

Directory of Open Access Journals (Sweden)

Full Text Available There is increasing number of trees dying in large urban agglomerations. The problem is mostly pronounced in the case of street trees. In Polish cities, apart of pollutions generated by traffic, an important factor that causes death of trees is high salt concentration as a result of winter salt application for de-icing of streets. The aim of the study was to assess the growth of limes (Tilia cordata) planted along highly trafficked Warsaw street and exposed, among others, to salt in a form of saline aerosol. The assessment of shoot length, tree height and crown volume, based on the photographic method of the three increment assessments, showed very restrained growth of the studied limes. In the years 2006-2008 the trees performed so poorly as in similar period of 2003-2005 and grew worse than limes form natural habitats. In 2009 we even observed decrease in size of street trees as compared to 2008 which suggests both very bad condition of street habitats and the studied trees. Salt concentration measured on the surface of tree buds and shoots (EC) was higher in street trees than in trees from natural habitats, which indicates that saline aerosol is the source of sodium chloride. We observed highly diversified reactions of individual trees to the whole complex of street conditions. It is therefore recommended to select for propagation individuals from among most tolerant and vigorously growing plants (genotypes) to be used in street planting.

JACEK BOROWSKI; MA?GORZATA PSTR?GOWSKA

2010-01-01

33

Simulation of indoor temperature and humidity conditions including hygrothermal interactions with the building envelope  

Energy Technology Data Exchange (ETDEWEB)

The hygrothermal behaviour of the building envelope affects the overall performance of a building. Numerous tools exist for the simulation of the heat and moisture transfer in the building envelope and whole building simulation tools for energy calculations. However, working combinations of both models for practical application are just about to be developed. In this paper such a combined model, that takes into account moisture sources and sinks inside a room, input from the envelope due to capillary action, diffusion and vapour absorption and desorption as a response to the exterior and interior climate conditions as well as the well-known thermal parameters will be described. The new model is validated by performing a series of field experiments and the moisture buffering capacity of the building envelope is investigated. In the conclusions the possible range of future applications of hygrothermal building performance models is addressed and the needs for further research are identified. (Author)

Kuenzel, H.M.; Holm, A.; Zirkelbach, D. [Fraunhofer-Institut fuer Bauphysik, Holzkirchen (Germany); Karagiozis, A.N. [Oak Ridge National Lab., Oak Ridge, TN (United States)

2005-04-01

34

Robust Face Recognition under Difficult Lighting Conditions  

Directory of Open Access Journals (Sweden)

Full Text Available — This paper addresses the problem of illumination effects on Face recognition and works for an approach to reduce their effect on recognition performance. More broadly, a simple and efficient preprocessing chain that eliminates most of the effects of changing illumination while still preserving the essential appearance details that are needed for recognition.Using local ternary patterns (LTP), a generalization of the local binary pattern (LBP) local texture descriptor that is more discriminant and less sensitive to noise in uniform regions. We also show that replacing comparisons based on local spatial histograms with a distance transform based similarity metric further improves the performance of LBP/LTP based face recognition; and Robustness is still improved by adding Kernel principal component analysis (PCA) feature extraction.

S.S. Ghatge; V.V. Dixit

2012-01-01

35

Belgian platemill hot charges in difficult conditions  

Energy Technology Data Exchange (ETDEWEB)

The platemaking specialist Forges de Clabecq has achieved important savings through hot charging slabs into the mill despite the problems of a variable order book. A combination of redesigned plant and schedule management could result in 50M therms per year saved. This article outlines the necessary structural changes in plant and equipment which were implemented to bring this about. Flame cutting yards were built. These were supplied with machines equipped with torches. All operations are computer controlled. Pyrometers measure slab temperatures and adjust machine position to obtain correct slab weight. A mechanical deburring device was developed for the daughter slabs. Magnet and chains were replaced by electro-mechanical grippers. Temperature regulation by computer was installed in the walking beam furnaces. Lower fuel consumption and better furnace performance were thus obtained. Savings were achieved by hot charging at the furnaces, at scarfing, at flame cutting and by using the computers. The total cost of investment to Forges de Clabecq in changing from an all manual to a computer controlled system has been 3M pounds, major costs were in oxycutting (42%), deburring (28%) and furnaces (10%) on the plant side, and management (10%) and handling (10%) to obtain a payback in energy saving of 380,000 pounds p.a. The number of people employed per shift has been reduced from 19 to 9 with an additional manpower saving of 225,000 pounds p.a. (UK).

Tilman, F. (Forges de Clabecq (Belgium))

1989-04-01

36

Making marketing difficult  

DEFF Research Database (Denmark)

A critique of conventional science journalism is offered in this paper. The convention of science journalism as science transmission is claimed to be incapable of coping with challenges emerging from the present commercialization of science - letting science into society by embracing and being embraced by the market-place, while maintaining the old scientific alienation from political life. The case is made that modern science was born ambiguous towards the market-place, and that such ambivalence - relating to different interpretations of the idea of knowledge as a common good - is still to be encountered among scientists. Drawing on series of interviews with scientists from bioscience and biotechnology it is argued that, on the one hand, scientists are into marketing and PR exercises; but, on the other hand, they also voice a demand that journalists should make such marketing difficult. It is the conlusion of the paper that journalists must break with the convention of science transmission in order to fulfilthat demand, and in order to spur a political discussion, among scientists and in public, on how to maintain the idea of knowledge as a common good.

Meyer, Gitte

2005-01-01

37

Management of difficult urticaria.  

UK PubMed Central (United Kingdom)

Chronic urticaria, a major health problem causing patient's distress, induces often physicians' dilemma while dealing with its etiology, investigations and management. Clinical approach of such cases should include apart from clinical history and physical examination laboratory investigations like routine blood test, thyroid profile, etc. as well as sometimes special test like autologous serum skin test. Management includes reassurance, avoidance of precipitating factors, treatment of underlying disorders, and non-pharmacological approach along with pharmacotherapy. First line drug therapy comprises non-sedative and sedative antihistamines, second line doxepin, nifedipine, leukotriene-inhibitors, sulfasalazine, etc. and third line cyclosporine, dapsone, colchicin, etc.

Yadav S; Bajaj AK

2009-07-01

38

Management of difficult urticaria.  

Science.gov (United States)

Chronic urticaria, a major health problem causing patient's distress, induces often physicians' dilemma while dealing with its etiology, investigations and management. Clinical approach of such cases should include apart from clinical history and physical examination laboratory investigations like routine blood test, thyroid profile, etc. as well as sometimes special test like autologous serum skin test. Management includes reassurance, avoidance of precipitating factors, treatment of underlying disorders, and non-pharmacological approach along with pharmacotherapy. First line drug therapy comprises non-sedative and sedative antihistamines, second line doxepin, nifedipine, leukotriene-inhibitors, sulfasalazine, etc. and third line cyclosporine, dapsone, colchicin, etc. PMID:20161863

Yadav, Sudha; Bajaj, A K

2009-07-01

39

Management of difficult urticaria  

Directory of Open Access Journals (Sweden)

Full Text Available Chronic urticaria, a major health problem causing patient?s distress, induces often physicians? dilemma while dealing with its etiology, investigations and management. Clinical approach of such cases should include apart from clinical history and physical examination laboratory investigations like routine blood test, thyroid profile, etc. as well as sometimes special test like autologous serum skin test. Management includes reassurance, avoidance of precipitating factors, treatment of underlying disorders, and non-pharmacological approach along with pharmacotherapy. First line drug therapy comprises non-sedative and sedative antihistamines, second line doxepin, nifedipine, leukotriene-inhibitors, sulfasalazine, etc. and third line cyclosporine, dapsone, colchicin, etc.

Yadav Sudha; Bajaj A

2009-01-01

40

Assisting Difficult Subsea Operations  

Energy Technology Data Exchange (ETDEWEB)

The requirements placed on remotely operated vehicles (ROV) in offshore oil drilling are becoming severe both as these operations extend to deeper waters and in the abandonment of old wells. Oceaneering have developed an integrated ROV system called Minimum to support the company's deep-water Magnum and Millennium ROV systems. Minimum is integrated into the Magnum or Millennium systems and is an inspection ROV designed to operate at a depth of 10 000 feet, operating from a self-contained module beneath the primary ROV cage. The Minimum has been very successfully used in severe deepwater conditions west of Shetland. The article also describes a new dredging tool for use during well abandonment as a contingency when divers encounter sediments inside a well. It was developed by Andrews Genflo.

NONE

2000-07-01

 
 
 
 
41

Hypertension - the difficult decisions.  

UK PubMed Central (United Kingdom)

BACKGROUND: Although management of hypertension is a daily activity of primary care practitioners, it remains one of the most demanding areas of medicine. Reasons for this include the imprecision of blood pressure measurement, the complexity of assessing cardiovascular risk, and the need to use multiple agents to control blood pressure. OBJECTIVE: This article discusses clinical scenarios that force clinicians to make decisions about blood pressure measurement techniques and methods of treatment. DISCUSSION: We consider ambulatory compared to office based blood pressure measurement, the types of clinical scenarios in which ambulatory blood pressure monitoring is likely to be beneficial, what to consider when there is nocturnal elevated blood pressure, and the assessment and management of resistant hypertension.

O'Callaghan CJ; Goh MY; Rong P

2013-06-01

42

Guide for Operational Configuration Management Program including the adjunct programs of design reconstitution and material condition and aging management  

International Nuclear Information System (INIS)

[en] This standard presents program criteria and implementation guidance for an operational configuration management program for DOE nuclear and non-nuclear facilities. This Part 2 includes chapters on implementation guidance for operational configuration management, implementation guidance for design reconstitution, and implementation guidance for material condition and aging management. Appendices are included on design control, examples of design information, conduct of walkdowns, and content of design information summaries

1993-01-01

43

Difficult to control atopic dermatitis  

DEFF Research Database (Denmark)

Difficult to control atopic dermatitis (AD) presents a therapeutic challenge and often requires combinations of topical and systemic treatment. Anti-inflammatory treatment of severe AD most commonly includes topical glucocorticosteroids and topical calcineurin antagonists used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, the topical calcineurin inhibitors tacrolimus and pimecrolimus are preferred in certain locations. Systemic anti-inflammatory treatment is an option for severe refractory cases. Microbial colonization and superinfection contribute to disease exacerbation and thus justify additional antimicrobial / antiseptic treatment. Systemic antihistamines (H1) may relieve pruritus but do not have sufficient effect on eczema. Adjuvant therapy includes UV irradiation preferably of UVA1 wavelength. "Eczema school" educational programs have been proven to be helpful.

Darsow, Ulf; Wollenberg, Andreas

2013-01-01

44

Successful endoscopic strategies for difficult polypectomy.  

UK PubMed Central (United Kingdom)

PURPOSE OF REVIEW: Standard endoscopic polypectomy is a powerful technique to remove most polyps found in the gastrointestinal tract. However, a small percentage of polyps can be classified as difficult, based on size, location, and/or configuration. Traditionally, these difficult polyps were referred for surgical segmental colectomy. Recently, with advancements in endoscopic techniques and accessories, a majority of these difficult polyps are now able to be completely resected using entirely endoscopic techniques. RECENT FINDINGS: Endoscopic techniques and accessories have been evolving during recent years, including increased dissemination of techniques of endoscopic submucosal dissection to the western hemisphere. In addition to refinement of endoscopic techniques, there has been increased interest in developing improved endoscopic accessories, including novel submucosal injectate with auto-dissecting properties, to improve safety and efficiency of endoscopic resection of difficult polyps. SUMMARY: This article will review currently available techniques and strategies for successful endoscopic resection for difficult polyps.

Zhang M; Shin EJ

2013-09-01

45

Self-Consistent Simulation of a Bunched Electron Beam Including Radiation, Space-Charge and Boundary Conditions  

CERN Document Server

High power Free Electron Laser (FEL) designs require high-brightness beams. These beams may suffer beam quality degradation during transport through bending sections from effects that were previously insignificant at low bunch charges. Potential mechanisms include microbunching from longitudinal space-charge and transverse emittance dilution from coherent synchrotron radiation. The effects are not well-understood in the transient state, in the presence of conducting boundaries or when these effects operate together and in conjunction with the beam dynamics. A simulation method applicable under the conditions of a MW-class average power FEL driver has been developed that accounts for radiation, space-charge and boundary conditions in a self-consistent manner. This simulation may be useful in evaluating design concepts under consideration including chicane bunch compressors and energy recovery bending arcs.

Gillingham, D R

2005-01-01

46

Monitoring during difficult airway management.  

UK PubMed Central (United Kingdom)

Monitoring is crucial to assure safety during difficult airway management. Several reports have indicated that the most of the adverse outcomes associated with difficult airway management could have been avoided with the use of necessary monitors, such as a pulse oximeter and a capnometer. Nevertheless, airway complications continue to be major problems during anesthesia, in particular, in patients with difficult airways. In this brief review, I stress the role of monitoring in detecting inadvertent esophageal intubation, during sedation for awake tracheal intubation, during general anesthesia, and during emergence from anesthesia, in patients with difficult airways.

Asai T

2013-07-01

47

DIFFICULT AIRWAY IN THYROID SURGERY  

Directory of Open Access Journals (Sweden)

Full Text Available Background: Thyroid surgery has been considered as a risk factor for the management of difficult airway.Method: We review the relevant literature related to the difficult airway and thyroid surgery.Comments: Endothoracic goiter, deformity of the airway, compression of the airway and thyroid cancer do not appear to have an influence on the difficulty for intubation.Classical parameters have a better predictive value: mouth opening less than 35 mm, Mallampati II-IV, short neck, neck movility less than 80 degrees, thyromental distance less than 60 mm, retrognathia, Cormack index III-IV, macroglossia, inability to protude the teeth and body mass index (BMI) greater than 35 Kg/m2.Conclusions: According to the literature, thyroid disease does not increase the risk for a difficult airway (ventilation / intubation).The risk of an unexpected difficult airway (false negative) cannot be eliminated.All patients must undergo an assessment of the airway

Cuello-Azcárate JJ; Pardal Refoyo JL; Romero-Rapado A; Toro-Pinilla MP

2011-01-01

48

Children with deafblindness : difficult differential diagnostics  

DEFF Research Database (Denmark)

Introduction: The group of children with deafblindness is very heterogeneous. It can be difficult to identify children with deafblindness and to estimate the significance of the sensory loss for the child's development. Material and method: The article presents two cases where it has been difficult to distinguish between deafblindness, autism and mental retardation. Findings: Deafblindness alone may be the cause of conditions similar to autism, mental retardation etc. It is always important to test a hypothesis which states that a serious sensory loss (deafness, blindness or deafblindness) is at the top of a diagnostic hierarchy, and that symptoms from other pervasive developmental disorders come secondary. Conclusion: Differential diagnostics between deafblindness, autism, mental retardation and other serious pervasive developmental disorders are often difficult. Clinical experience is needed, cross-disciplinary cooperation, specialized diagnostic methods together with a long observation and intervention period in order to be able to determine the functioning level of the child in question.

Dammeyer, Jesper Herup

2008-01-01

49

Drastic Measures for Difficult Times  

Science.gov (United States)

This article discusses how colleges and universities are taking drastic measure for difficult times. Hit hard by the global financial crisis, colleges are cutting their budgets in ways that prompt fears about access and retention for minority students. Schools are considering layoffs, unpaid furloughs for faculty and staff, hiring freezes and…

Galuszka, Peter

2008-01-01

50

Techniques for the difficult airway.  

UK PubMed Central (United Kingdom)

PURPOSE OF REVIEW: Management of the difficult airway is associated with significant morbidity and mortality in critically ill patients. An increasing array of advanced airway tools are available, but appropriate selection and application in the ICU remains poorly defined. RECENT FINDINGS: Difficult airway incidence during emergent intubation is 10%, but complications of ICU airway management remain common. Training and equipment in many ICUs remain variable despite data that demonstrate that an 'intubation management bundle' and a systematic approach to teamwork and training can reduce life-threatening airway complications. A protocol employing an extraglottic airway (EGA) early in cases of inadequate ventilation has been associated with no episodes of prolonged hypoxemia in 12 225 consecutive intubations. Direct laryngoscopy with gum elastic bougie is the most commonly employed method to manage emergent difficult airways, and videolaryngoscopes also provide greater glottic visualization and a high rate of intubation success in patients with difficult airway risk factors or a failed airway. SUMMARY: A systematic approach to intubation that emphasizes planning and teamwork can reduce intubation complications. Early use of an EGA or cricothyroidotomy may reduce complications when oxygenation is inadequate. Use of a gum elastic bougie or indirect optical device is also associated with a high rate of intubation success when oxygenation permits.

Niven AS; Doerschug KC

2013-02-01

51

Including Riparian Vegetation in the Definition of Morphologic Reference Conditions for Large Rivers: A Case Study for Europe's Western Plains  

Science.gov (United States)

Methods for defining and retrieving reference conditions for large rivers were explored with emphasis on hydromorphologic and biologic quality indicators. For a set of four large rivers in the European Western Plains ecoregion, i.e., the rivers Meuse, Loire, Allier, and Dordogne, reference reaches were selected based on geomorphologic characteristics. A survey of riparian land use, vegetation, and bed geometry was done for the selected reaches. Responses of the riparian landscape to hydromorphologic conditions were determined with a set of existing and newly developed measures of riparian dynamics and forest development. Strong correlations were observed at the reach and local levels between the ratios of width to depth and embankment and the developed measures of riparian dynamics and forest. Boundary conditions for riparian forest development were determined for the hydromorphologic and biologic indicators of riparian dynamics and vegetation structure. These conditions also proved useful for determining the presence of sustainable populations of Populus nigra and Salix purpurea. From this agreement between abiotic and biotic boundary conditions, a set of useful reference conditions was determined, and a framework for the definition of reference and good status conditions subsequently evolved. Finally, a proposal for assessment and monitoring the proposed indicators is discussed for its applicability.

van Looy, Kris; Meire, Patrick; Wasson, Jean-Gabriel

2008-05-01

52

The difficult patient with constipation.  

UK PubMed Central (United Kingdom)

Difficult patients with constipation mostly suffer for years, have consulted more than one physician and have had some experience with laxatives. The first step should be sorting out what exactly the patient's problem is. For this purpose technical investigations may be helpful, but the most important measures are a detailed history, symptom analysis and proctological examination. Rarely, an underlying and treatable cause of the constipation can be identified. In disordered defaecation this may be a large rectocele or an intussusception of the rectum amenable to proctosurgery. In most cases, however, some form of laxative treatment will be required. For this purpose, a detailed knowledge of their pharmacology is mandatory. The type of laxative and the schedule of administration often have to be determined on an individual basis over a number of weeks. In some patients, combination treatment with macrogol and a stimulant laxative may be the solution. Psychological features must also be taken into account in difficult patients, in particular if they ask for colectomy. Total colectomy with ileorectal anastomosis is an effective (although not universally successful) treatment of constipation, which is, however, hampered by a high rate of both early and late complications.

Müller-Lissner S

2007-01-01

53

How to do it: the difficult thyroid.  

Science.gov (United States)

There is a paucity of publications detailing how to deal with the difficult thyroid cancer. When compared to other cancers, it is relatively rare with several histopathological subtypes which run differing clinical courses and respond to different therapies. It is a condition predominately treated by specifically trained General and now ENT surgeons who already have a thorough knowledge of vocal fold assessment and rehabilitation as well as emergency airways management both to avoid and treat common complications should they occur.Good surgery involves a team effort to produce good results consistently. All members of the team are essential to quality service delivery. Communication with the team and the patient is paramount. We describe our approach to the difficult thyroid. PMID:22196157

Upile, Tahwinder; Jerjes, Waseem; Mahil, Jaspal; Tailor, Hitesh; Balakumar, Ramkishan; Rao, Anuja; Qureshi, Yassar; Bowman, Iain; Mukhopadhyay, Suchana

2011-12-23

54

Guide for Operational Configuration Management Program including the adjunct programs of design reconstitution and material condition and aging management  

International Nuclear Information System (INIS)

[en] This standard presents program criteria and implementation guidance for an operational configuration management program for DOE nuclear and non-nuclear facilities in the operational phase. Portions of this standard are also useful for other DOE processes, activities, and programs. This Part 1 contains foreword, glossary, acronyms, bibliography, and Chapter 1 on operational configuration management program principles. Appendices are included on configuration management program interfaces, and background material and concepts for operational configuration management

1993-01-01

55

Difficult physician-patient relationships.  

Science.gov (United States)

Changes in the delivery of health care services in the United States are proceeding so rapidly that many providers are asking how the working relationships between doctors and patients will be effected. Accelerated by cost containment, quality improvement and the growth of managed care, these changes have caused some critics to feel that shorter visits and gatekeeper systems will promote an adversarial relationship between physicians and patients. However, proponents of the changing system feel that better prevention, follow-up care and the attention to customer service these plans can offer will lead to increased patient satisfaction and improved doctor-patient communication. Dedicated to addressing these concerns, the Bayer Institute for Health Care Communication was established in 1987 as a continuing medical education program (CME) focusing on this topic. A half-day workshop on clinician-patient communication to enhance health outcomes was introduced in 1992 and a second workshop, "Difficult' Clinician-Patient Relationships," was developed two years later. The two courses discussed in this article are offered to all physicians, residents, medical students, mid-level providers and other interested staff within the Carle system. PMID:10186308

Reifsteck, S W

56

Difficult physician-patient relationships.  

UK PubMed Central (United Kingdom)

Changes in the delivery of health care services in the United States are proceeding so rapidly that many providers are asking how the working relationships between doctors and patients will be effected. Accelerated by cost containment, quality improvement and the growth of managed care, these changes have caused some critics to feel that shorter visits and gatekeeper systems will promote an adversarial relationship between physicians and patients. However, proponents of the changing system feel that better prevention, follow-up care and the attention to customer service these plans can offer will lead to increased patient satisfaction and improved doctor-patient communication. Dedicated to addressing these concerns, the Bayer Institute for Health Care Communication was established in 1987 as a continuing medical education program (CME) focusing on this topic. A half-day workshop on clinician-patient communication to enhance health outcomes was introduced in 1992 and a second workshop, "Difficult' Clinician-Patient Relationships," was developed two years later. The two courses discussed in this article are offered to all physicians, residents, medical students, mid-level providers and other interested staff within the Carle system.

Reifsteck SW

1998-09-01

57

Difficult Bond. Derrida and Jewishness  

DEFF Research Database (Denmark)

Watchful insomnia can be a nerve-wracking business especially if there is a question to be, if not resolved, then at least confronted; or a decision called for, not despite the famous undecidablity hypothesis, but precisely because of it. Thus it is that finally, casting off the shadows of the night, Jacques Derrida steps into the daylight, in Paris in December 2000, to address directly the question of his Jewishness. Even if his presentation remains marked by the reservations shown in the past, and in particular the casting of affiliation in the self-cancelling terms of its annulment, Derrida nevertheless here lets down his guard in a way he had not done before. And the outcome is remarkable: for the first time he ascribes the aporetic structure of his thinking to a particular propensity for indeterminacy, which he aligns –not with Judaism in any of its doctrinal forms— but with the haunting event of ‘circumcision’ and with his own, somewhat idiosyncratic, experience of being Jewish. As both theme and strategy, ‘circumcision’ has indeed become a trope of tremendous significance in Derrida’s writing as it articulates itself inside the aporia where affiliation is inevitably determined by its own effacement. It epitomizes a difficult double bond which may well have a direct bearing on Derrida’s construal of what it means to think deconstructively.

Siegumfeldt, Inge Birgitte

2013-01-01

58

Effects of Cd & Ni toxicity to Ceratophyllum demersum under environmentally relevant conditions in soft & hard water including a German lake.  

UK PubMed Central (United Kingdom)

Even essential trace elements are phytotoxic over a certain threshold. In this study, we investigated whether heavy metal concentrations were responsible for the nearly complete lack of submerged macrophytes in an oligotrophic lake in Germany. We cultivated the rootless aquatic model plant Ceratophyllum demersum under environmentally relevant conditions like sinusoidal light and temperature cycles and a low plant biomass to water volume ratio. Experiments lasted for six weeks and were analysed by detailed measurements of photosynthetic biophysics, pigment content and hydrogen peroxide production. We established that individually non-toxic cadmium (3nM) and slightly toxic nickel (300nM) concentrations became highly toxic when applied together in soft water, severely inhibiting photosynthetic light reactions. Toxicity was further enhanced by phosphate limitation (75nM) in soft water as present in many freshwater habitats. In the investigated lake, however, high water hardness limited the toxicity of these metal concentrations, thus the inhibition of macrophytic growth in the lake must have additional reasons. The results showed that synergistic heavy metal toxicity may change ecosystems in many more cases than estimated so far.

Andresen E; Opitz J; Thomas G; Stärk HJ; Dienemann H; Jenemann K; Dickinson BC; Küpper H

2013-09-01

59

Current Trends in the Management of Difficult Urinary Catheterizations  

Directory of Open Access Journals (Sweden)

Full Text Available Routine urinary catheter placement may cause trauma and poses a risk of infection. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands or other potentially obstructive conditions in the lower urinary tract. Solutions to problematic urinary catheterization are not well known and when difficult catheterization occurs, the risk of failed catheterization and concomitant complications increase. Repeated and unsuccessful attempts at urinary catheterization induce stress and pain for the patient, injury to the urethra, potential urethral stricture requiring surgical reconstruction, and problematic subsequent catheterization. Improper insertion of catheters also can significantly increase healthcare costs due to added days of hospitalization, increased interventions, and increased complexity of follow-up evaluations. Improved techniques for catheter placement are essential for all healthcare personnel involved in the management of the patient with acute urinary retention, including attending emergency physicians who often are the first physicians to encounter such patients. Best practice methods for blind catheter placement are summarized in this review. In addition, for progressive clinical practice, an algorithm for the management of difficult urinary catheterizations that incorporates technology enabling direct visualization of the urethra during catheter insertion is presented. This algorithm will aid healthcare personnel in decision making and has the potential to improve quality of care of patients.

Paul A Willette; Scott K Coffield

2012-01-01

60

Difficult airway and difficult intubation in postintubation tracheal stenosis: a case report and literature review  

Directory of Open Access Journals (Sweden)

Full Text Available Paul Zarogoulidis,1 Theodoros Kontakiotis,1 Kosmas Tsakiridis,2 Michael Karanikas,3 Christos Simoglou,4 Konstantinos Porpodis,1 Alexandros Mitrakas,3 Agisilaos Esebidis, 3 Maria Konoglou,5 Nikolaos Katsikogiannis,6 Vasilis Zervas,1 Christina Aggelopoulou,7 Dimitrios Mikroulis,4 Konstantinos Zarogoulidis11Pulmonary Department, "G Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; 2Cardiothoracic Department, Saint Luke Private Hospital, Thessaloniki, Greece; 31st University Surgery Department, 4Cardiothoracic Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; 51st Pulmonary Department, "G Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; 6Surgery Department (NHS), 7Neurology Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GreeceAbstract: Management of a "difficult airway" remains one of the most relevant and challenging tasks for anesthesiologists and pulmonary physicians. Several conditions, such as inflammation, trauma, tumor, and immunologic and metabolic diseases, are considered responsible for the difficult intubation of a critically ill patient. In this case report we present the case of a 46-year-old male with postintubation tracheal stenosis. We will focus on the method of intubation used, since the patient had a "difficult airway" and had to be intubated immediately because he was in a life-threatening situation. Although technology is of utter importance, clinical examination and history-taking remain invaluable for the appropriate evaluation of the critically ill patient in everyday medical life. Every physician who will be required to perform intubation has to be familiar with the evaluation of the difficult airway and, in the event of the unanticipated difficult airway, to be able to use a wide variety of tools and techniques to avoid complications and fatality.Keywords: difficult airway, bronchoscopic intubation, predictive factors, predictive scales

Zarogoulidis P; Kontakiotis T; Tsakiridis K; Karanikas M; Simoglou C; Porpodis K; Mitrakas A; Esebidis A; Konoglou M; Katsikogiannis N; Zervas V; Aggelopoulou C; Mikroulis D; Zarogoulidis K

2012-01-01

 
 
 
 
61

Improvement in Reading Rate under Independent and Difficult Text Levels: Influences on Word and Comprehension Skills  

Science.gov (United States)

Improving reading rate can be difficult for poor readers. In this experiment, we investigated the impact of improvement in reading rate on other aspects of reading, including word recognition, decoding, vocabulary, and comprehension. Poor readers in Grades 2 or 4 (N = 123) were randomly assigned to 1 of 3 conditions: practice reading text at their…

O'Connor, Rollanda E.; Swanson, H. Lee; Geraghty, Cathleen

2010-01-01

62

Dealing with the difficult utility  

International Nuclear Information System (INIS)

STS HydroPower, Ltd. (STS) is an independent hydroelectric power developer involved in the full scope of hydroelectric activities. This includes the permitting, design, financing, turbine design and manufacturing, site construction and operation of small to mid-sized hydroelectric sites across the United States. At the present time, STS owns and operates nine sites in four states with a combined capacity of 20 megawatts. In dealing with the implementation of these sites, STS has dealt with five different utilities. In addition, in pursuing additional development opportunities throughout the United States, STS has had contact with numerous other utilities. During this time it would be fair to conclude that each of these utilities has exhibited its own personality with respect to dealing with independent developers. To the credit of the utility industry, the majority of these utilities have been helpful and supportive of independent projects, but a small number of utilities have approached projects from an initial and continuing adversarial position. The purpose of this paper is to examine those options and procedures available to the developer when a utility is encountered with a negative predisposition.

1991-01-01

63

Review article: Extubation of the difficult airway and extubation failure.  

UK PubMed Central (United Kingdom)

Respiratory complications after tracheal extubation are associated with significant morbidity and mortality, suggesting that process improvements in this clinical area are needed. The decreased rate of respiratory adverse events occurring during tracheal intubation since the implementation of guidelines for difficult airway management supports the value of education and guidelines in advancing clinical practice. Accurate use of terms in defining concepts and describing distinct clinical conditions is paramount to facilitating understanding and fostering education in the treatment of tracheal extubation-related complications. As an example, understanding the distinction between extubation failure and weaning failure allows one to appreciate the need for pre-extubation tests that focus on assessing airway patency in addition to evaluating the ability to breathe spontaneously. Tracheal reintubation after planned extubation is a relatively rare event in the postoperative period of elective surgeries, with reported rates of reintubation in the operating room and postanesthesia care unit between 0.1% and 0.45%, but is a fairly common event in critically ill patients (0.4%-25%). Conditions such as obesity, obstructive sleep apnea, major head/neck and upper airway surgery, and obstetric and cervical spine procedures carry significantly increased risks of extubation failure and are frequently associated with difficult airway management. Extubation failure follows loss of upper airway patency. Edema, soft tissue collapse, and laryngospasm are among the most frequent mechanisms of upper airway obstruction. Planning for tracheal extubation is a critical component of a successful airway management strategy, particularly when dealing with situations at increased risk for extubation failure and in patients with difficult airways. Adequate planning requires identification of patients who have or may develop a difficult airway, recognition of situations at increased risk of postextubation airway compromise, and understanding the causes and underlying mechanisms of extubation failure. An effective strategy to minimize postextubation airway complications should include preemptive optimization of patients' conditions, careful timing of extubation, the presence of experienced personnel trained in advanced airway management, and the availability of the necessary equipment and appropriate postextubation monitoring.

Cavallone LF; Vannucci A

2013-02-01

64

Review article: Extubation of the difficult airway and extubation failure.  

Science.gov (United States)

Respiratory complications after tracheal extubation are associated with significant morbidity and mortality, suggesting that process improvements in this clinical area are needed. The decreased rate of respiratory adverse events occurring during tracheal intubation since the implementation of guidelines for difficult airway management supports the value of education and guidelines in advancing clinical practice. Accurate use of terms in defining concepts and describing distinct clinical conditions is paramount to facilitating understanding and fostering education in the treatment of tracheal extubation-related complications. As an example, understanding the distinction between extubation failure and weaning failure allows one to appreciate the need for pre-extubation tests that focus on assessing airway patency in addition to evaluating the ability to breathe spontaneously. Tracheal reintubation after planned extubation is a relatively rare event in the postoperative period of elective surgeries, with reported rates of reintubation in the operating room and postanesthesia care unit between 0.1% and 0.45%, but is a fairly common event in critically ill patients (0.4%-25%). Conditions such as obesity, obstructive sleep apnea, major head/neck and upper airway surgery, and obstetric and cervical spine procedures carry significantly increased risks of extubation failure and are frequently associated with difficult airway management. Extubation failure follows loss of upper airway patency. Edema, soft tissue collapse, and laryngospasm are among the most frequent mechanisms of upper airway obstruction. Planning for tracheal extubation is a critical component of a successful airway management strategy, particularly when dealing with situations at increased risk for extubation failure and in patients with difficult airways. Adequate planning requires identification of patients who have or may develop a difficult airway, recognition of situations at increased risk of postextubation airway compromise, and understanding the causes and underlying mechanisms of extubation failure. An effective strategy to minimize postextubation airway complications should include preemptive optimization of patients' conditions, careful timing of extubation, the presence of experienced personnel trained in advanced airway management, and the availability of the necessary equipment and appropriate postextubation monitoring. PMID:23302983

Cavallone, Laura F; Vannucci, Andrea

2013-01-09

65

Foreign body aspiration masquerading as difficult asthma  

Directory of Open Access Journals (Sweden)

Full Text Available It is important to assess patients of difficult/therapy resistant asthma carefully in order to identify whether there are any correctable factors that may contribute to their poor control. It is critical to make a diagnosis of asthma and to exclude other airway diseases. A 65-years-old lady presented with repeated acute episodes of dyspnoea and wheezing. She was on regular medication for bronchial asthma for 18 years. There was no history of foreign body aspiration or loss of consciousness. Her chest radiograph was normal. She showed poor response to corticosteroids and bronchodilators. Fibreoptic bronchoscopy (FOB) showed intracordal cyst of the left vocal cord and 1cm size irregular piece of betel nut in right main bronchus, which was removed endoscopically with the help of dormia basket, following which her condition improved and asthma was controlled on inhaled bronchodilators.

Rai S; Kashyap M; Bakshi K

2007-01-01

66

Solving difficult hepatobiliary problems in children  

Scientific Electronic Library Online (English)

Full Text Available Abstract in english Most difficult hepatobiliary (HPB) problems in infancy and childhood result from pathological anatomical/mechanical derangements; therefore, surgery on the liver and bile ducts depends on a detailed understanding of liver structure, function and repair response to injury or disease. The surgeon must be aware of the very diverse range of anatomical variations. Perhaps key to improving the outcome of paediatric HPB surgery is centralised management and associating this with (more) a paediatric liver transplant programme, which adds expertise and, frequently, the added benefit of adult HPB surgical input to paediatric surgical care. In the United Kingdom, this has resulted in excellent measurable benefit, particularly in the management of biliary atresia, but also of choledochal cysts, portal hypertension and liver tumours. These conditions are briefly discussed here, with focus on the technical aspects of operative management.

Millar, A J W

2012-01-01

67

Guide for Operational Configuration Management Program including the adjunct programs of design reconstitution and material condition and aging management. Part 2  

Energy Technology Data Exchange (ETDEWEB)

This standard presents program criteria and implementation guidance for an operational configuration management program for DOE nuclear and non-nuclear facilities. This Part 2 includes chapters on implementation guidance for operational configuration management, implementation guidance for design reconstitution, and implementation guidance for material condition and aging management. Appendices are included on design control, examples of design information, conduct of walkdowns, and content of design information summaries.

1993-11-01

68

Difficult treatment decisions in autoimmune hepatitis  

Directory of Open Access Journals (Sweden)

Full Text Available Treatment decisions in autoimmune hepatitis are complicated by the diversity of its clinical presentations, uncertainties about its natural history, evolving opinions regarding treatment end points, varied nature of refractory disease, and plethora of alternative immunosuppressive agents. The goals of this article are to review the difficult treatment decisions and to provide the bases for making sound therapeutic judgments. The English literature on the treatment problems in autoimmune hepatitis were identified by Medline search up to October 2009 and 32 years of personal experience. Autoimmune hepatitis may have an acute severe presentation, mild inflammatory activity, lack autoantibodies, exhibit atypical histological changes (centrilobular zone 3 necrosis or bile duct injury), or have variant features reminiscent of another disease (overlap syndrome). Corticosteroid therapy must be instituted early, applied despite the absence of symptoms, or modified in an individualized fashion. Pursuit of normal liver tests and tissue is the ideal treatment end point, but this objective must be tempered against the risk of side effects. Relapse after treatment withdrawal requires long-term maintenance therapy, preferably with azathioprine. Treatment failure or an incomplete response warrants salvage therapy that can include conventional medications in modified dose or empirical therapies with calcineurin inhibitors or mycophenolate mofetil. Liver transplantation supersedes empirical drug therapy in decompensated patients. Elderly and pregnant patients warrant treatment modifications. Difficult treatment decisions in autoimmune hepatitis can be simplified by recognizing its diverse manifestations and individualizing treatment, pursuing realistic goals, applying appropriate salvage regimens, and identifying problematic patients early.

Albert J Czaja

2010-01-01

69

Difficult airway communication between anaesthetists and general practitioners.  

UK PubMed Central (United Kingdom)

BACKGROUND AND AIMS: Advance warning of patients who are difficult to intubate may prevent an airway catastrophe but relies on effective communication between specialties. Anaesthetists aim to inform general practitioners whenever a difficult airway is encountered and expect general practitioners to include this information in subsequent referrals. We investigated how anaesthetists communicated with general practitioners, their knowledge of the Read Code (used by general practitioner computer systems) for difficult tracheal intubation, and how likely general practitioners were to pass the information on. METHODS AND RESULTS: We surveyed 631 consultant anaesthetists and 217 general practitioners. We found only 125 (20%) anaesthetists consistently wrote difficult airway letters to general practitioners. Only 20 (3%) knew the Read Code for difficult intubation (SP2y3), although 454 (72%) thought it to be useful. Most general practitioners (212, 98%) thought airway information to be important, but only half receiving a difficult airway communication forwarded it on. General practitioners recommended including the Read Code SP2y3 and labelling it 'high priority', ensuring that 'Difficult Tracheal Intubation' would be listed in the Emergency Care Summary generated for hospital referrals. CONCLUSION: Communication between anaesthetists and general practitioners is currently poor, but could be improved by simplifying difficult airway letters and including the SP2y3 code and a statement of priority.

Wilkes M; Beattie C; Gardner C; McNarry AF

2013-02-01

70

Difficult airway in a patient with Coffin-Siris syndrome.  

Science.gov (United States)

We report on a patient with Coffin-Siris syndrome and consider a potential association between this condition and difficult intubation. Although this inherited condition is extremely rare, anesthesiologists should be aware of its existence and prepare for potential airway management problems whenever it is encountered. PMID:11159267

Dimaculangan, D; Lokhandwala, B; Wlody, D; Gross, R

2001-02-01

71

Difficult airway in a patient with Coffin-Siris syndrome.  

UK PubMed Central (United Kingdom)

We report on a patient with Coffin-Siris syndrome and consider a potential association between this condition and difficult intubation. Although this inherited condition is extremely rare, anesthesiologists should be aware of its existence and prepare for potential airway management problems whenever it is encountered.

Dimaculangan D; Lokhandwala B; Wlody D; Gross R

2001-02-01

72

Nostalgia: retreat or support in difficult times?  

Science.gov (United States)

The relationship between nostalgia and coping during difficult times was explored in 2 empirical studies. In the first, 80 undergraduates, 60 women and 20 men, completed the Nostalgia Inventory, a measure of nostalgia proneness, the COPE Inventory, a dispositional measure of strategies for coping with stressful events, and the Childhood Survey, a survey of impressions of childhood experiences. Nostalgia proneness correlated with use of adaptive coping, including emotional social support, expressing emotions, turning to religion, and suppressing competing activities, and did not correlate with escapist or avoidance strategies, including denial, behavioral disengagement, and substance abuse. Nostalgia proneness was related positively to favorable emotional and behavioral childhood experiences and did not correlate with adverse experiences. Favorable impressions of childhood correlated positively with adaptive coping strategies and inversely with dysfunctional ones, whereas unfavorable childhood experiences correlated positively with dysfunctional coping. Regression analyses suggested that the relationship between nostalgia proneness and certain coping strategies may be mediated in part by childhood experiences. In a second study, 100 undergraduates, 86 women and 14 men, completed the Nostalgia Inventory, recalled autobiographical memories that illustrated how childhood is either special or similar to their present life, and rated their likely use of strategies in dealing with 2 hypothetical problems. Nostalgia proneness correlated with emotional and instrumental social coping and with the goal-directed strategies of planning, taking action, and positive reframing. Further research is recommended to explore the role of childhood memories in coping and to identify mechanisms that mediate the relationship between nostalgia and coping. PMID:24027948

Batcho, Krystine Irene

2013-01-01

73

Living conditions, including life style, in primary-care patients with nonacute, nonspecific spinal pain compared with a population-based sample: a cross-sectional study  

Directory of Open Access Journals (Sweden)

Full Text Available Odd Lindell, Sven-Erik Johansson, Lars-Erik Strender1Center for Family and Community Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, SwedenBackground: Nonspecific spinal pain (NSP), comprising back and/or neck pain, is one of the leading disorders behind long-term sick-listing, including disability pensions. Early interventions to prevent long-term sick-listing require the identification of patients at risk. The aim of this study was to compare living conditions associated with long-term sick-listing for NSP in patients with nonacute NSP, with a nonpatient population-based sample. Nonacute NSP is pain that leads to full-time sick-listing>3 weeks.Methods: One hundred and twenty-five patients with nonacute NSP, 2000–2004, were included in a randomized controlled trial in Stockholm County with the objective of comparing cognitive–behavioral rehabilitation with traditional primary care. For these patients, a cross-sectional study was carried out with baseline data. Living conditions were compared between the patients and 338 nonpatients by logistic regression. The conditions from univariate analyses were included in a multivariate analysis. The nonsignificant variables were excluded sequentially to yield a model comprising only the significant factors (P <0.05). The results are shown as odds ratios (OR) with 95% confidence intervals.Results: In the univariate analyses, 13 of the 18 living conditions had higher odds for the patients with a dominance of physical work strains and Indication of alcohol over-consumption, odds ratio (OR) 14.8 (95% confidence interval [CI] 3.2–67.6). Five conditions qualified for the multivariate model: High physical workload, OR 13.7 (CI 5.9–32.2); Hectic work tempo, OR 8.4 (CI 2.5–28.3); Blue-collar job, OR 4.5 (CI 1.8–11.4); Obesity, OR 3.5 (CI 1.2–10.2); and Low education, OR 2.7 (CI 1.1–6.8).Conclusions: As most of the living conditions have previously been insufficiently studied, our findings might contribute a wider knowledge of risk factors for long-term sick-listing for NSP. As the cross-sectional design makes causal conclusions impossible, our study should be complemented by prospective research.Keywords: nonspecific spinal pain, back pain, neck pain, long-term sick-listing, population-based sample, cross-sectional study

Odd Lindell; Sven-Erik Johansson; Lars-Erik Strender

2010-01-01

74

Management of a difficult knee problem.  

UK PubMed Central (United Kingdom)

Chronic disabling patellofemoral (PF) pain and instability can have significant effects on patient function and lifestyle. Although the management of PF pain has improved greatly, there is still a category of patient who tends to have recalcitrant symptoms, which are difficult to manage. The patient often bounces from practitioner to practitioner, physiotherapist as well as surgeon, for some relief of symptoms. However, often the underlying source of the pain is not well understood, so treatment can aggravate the symptoms. The following case report demonstrates the effectiveness of physiotherapy in managing a complex clinical case of a 40 year old patient with bilateral PF symptoms of severe right knee pain and a subluxing left patella, as well as left hip pain. Some background is given as to the source of the right knee pain with magnetic resonance imaging (MRI) supporting the diagnosis and treatment progression. The initial MRI demonstrated marked redundancy of the patellar tendon, resulting in patella baja (infera). Two years and ten treatments later, the patient, who originally could barely walk, was playing tennis for the first time in 25 years. Her MRI showed a complete resolution of the patella baja (infera), indirectly implying an improvement in quadriceps tone, as well as, resolution of the subchondral bone marrow oedema at the lateral patellar facet. Physiotherapists should not give up on patients with chronic musculoskeletal conditions as much can be done for them. These patients need clinicians to persevere, because certainly, for both patient and therapist, the rewards are great.

McConnell J

2013-06-01

75

Management of a difficult knee problem.  

Science.gov (United States)

Chronic disabling patellofemoral (PF) pain and instability can have significant effects on patient function and lifestyle. Although the management of PF pain has improved greatly, there is still a category of patient who tends to have recalcitrant symptoms, which are difficult to manage. The patient often bounces from practitioner to practitioner, physiotherapist as well as surgeon, for some relief of symptoms. However, often the underlying source of the pain is not well understood, so treatment can aggravate the symptoms. The following case report demonstrates the effectiveness of physiotherapy in managing a complex clinical case of a 40 year old patient with bilateral PF symptoms of severe right knee pain and a subluxing left patella, as well as left hip pain. Some background is given as to the source of the right knee pain with magnetic resonance imaging (MRI) supporting the diagnosis and treatment progression. The initial MRI demonstrated marked redundancy of the patellar tendon, resulting in patella baja (infera). Two years and ten treatments later, the patient, who originally could barely walk, was playing tennis for the first time in 25 years. Her MRI showed a complete resolution of the patella baja (infera), indirectly implying an improvement in quadriceps tone, as well as, resolution of the subchondral bone marrow oedema at the lateral patellar facet. Physiotherapists should not give up on patients with chronic musculoskeletal conditions as much can be done for them. These patients need clinicians to persevere, because certainly, for both patient and therapist, the rewards are great. PMID:22748203

McConnell, Jenny

2012-06-27

76

Discharge and charge characteristics of amorphous FeOOH including aniline (a{sub an}-FeOOH). Influence of preparation conditions on discharge and charge characteristics  

Energy Technology Data Exchange (ETDEWEB)

The effect of the preparation conditions for amorphous FEOOH including aniline (a{sub an}-FeOOH) on its discharge and charge characteristics as a cathode material for a rechargeable lithium battery was investigated to improve the discharge and charge characteristics. The a{sub an}-FeOOH was prepared in solutions containing different Concentrations of aniline, or in solutions with different pH. From the discharge and charge characteristics of these products, it can be seen that the discharge capacity depends on the pH of the reaction solution rather than the concentration of aniline.

Sakaebe, Hikari; Higuchi, Shunichi [Osaka National Research Inst. (Japan). Dept. for Energy Conversion; Kanamura, Kiyoshi; Fujimoto, Hiroyuki; Takehara, Zenichiro [Kyoto Univ. (Japan)

1995-02-01

77

[Difficult airway intubation with flexible bronchoscope].  

UK PubMed Central (United Kingdom)

BACKGROUND AND OBJECTIVE: To describe the efficacy and safety of a flexible bronchoscopy intubation (FBI) protocol in patients with difficult airway. METHOD: We reviewed the medical records of patients diagnosed with difficult airway who underwent flexible bronchoscopy intubation under spontaneous ventilation and sedation with midazolam and fentanyl from March 2009 to December 2010. RESULTS: The study enrolled 102 patients, 69 (67.7%) men and 33 (32.3%) women, with a mean age of 44 years. FBI was performed in 59 patients (57.8%) with expected difficult airway in the operating room, in 39 patients (38.2%) in the Intensive Care Unit (ICU), and in 4 patients (3.9%) in the emergency room. Cough, decrease in transient oxygen saturation, and difficult progression of the cannula through the larynx were the main complications, but these factors did not prevent intubation. CONCLUSION: FBI according to the conscious sedation protocol with midazolam and fentanyl is effective and safe in the management of patients with difficult airway.

Rodrigues AJ; Scordamaglio PR; Palomino AM; de Oliveira EQ; Jacomelli M; Figueiredo VR

2013-07-01

78

Streamflow and water-quality conditions including geologic sources and processes affecting selenium loading in the Toll Gate Creek watershed, Aurora, Arapahoe County, Colorado, 2007  

Science.gov (United States)

Toll Gate Creek is a perennial stream draining a suburban area in Aurora, Colorado, where selenium concentrations have consistently exceeded the State of Colorado aquatic-life standard for selenium of 4.6 micrograms per liter since the early 2000s. In cooperation with the City of Aurora, Colorado, Utilities Department, a synoptic water-quality study was performed along an 18-kilometer reach of Toll Gate Creek extending from downstream from Quincy Reservoir to the confluence with Sand Creek to develop a detailed understanding of streamflow and concentrations and loads of selenium in Toll Gate Creek. Streamflow and surface-water quality were characterized for summer low-flow conditions (July–August 2007) using four spatially overlapping synoptic-sampling subreaches. Mass-balance methods were applied to the synoptic-sampling and tracer-injection results to estimate streamflow and develop spatial profiles of concentration and load for selenium and other chemical constituents in Toll Gate Creek surface water. Concurrent groundwater sampling determined concentrations of selenium and other chemical constituents in groundwater in areas surrounding the Toll Gate Creek study reaches. Multivariate principal-component analysis was used to group samples and to suggest common sources for dissolved selenium and major ions. Hydrogen and oxygen stable-isotope ratios, groundwater-age interpretations, and chemical analysis of water-soluble paste extractions from core samples are presented, and interpretation of the hydrologic and geochemical data support conclusions regarding geologic sources of selenium and the processes affecting selenium loading in the Toll Gate Creek watershed. Streamflow conditions observed and measured during the synoptic water-quality study represent summer base-flow conditions and rainfall conditions for July 2007. The lack of large tributary inflows and the spatial distribution of small tributary inflows, seeps, and springs indicate that diffuse and discrete groundwater inflow supports streamflow during low-flow conditions along the entire 18-kilometer stream reach. Concentrations of dissolved selenium within all subreaches of Toll Gate Creek exceeded the Colorado aquatic-life standard of 4.6 micrograms per liter in 2007. Concentrations of selenium in the upper portion of the Toll Gate Headwaters subreach (TGH) remained close to the aquatic-life standard at about 5 micrograms per liter. Downstream from a concrete-lined channel section, inflows with selenium concentrations greater than the stream contribute selenium load to surface water. However, stream selenium concentrations were less than 20 micrograms per liter all along Toll Gate Creek. Concentrations of selenium in groundwater were in general substantially greater than the Colorado aquatic-life standard of 4.6 micrograms per liter and at some locations were greater than the U.S. Environmental Protection Agency primary drinking-water standard for selenium of 50 micrograms per liter. The distribution of selenium concentrations in groundwater, springs, and the 11 inflows with the greatest selenium concentrations indicates that shallow groundwater in surficial materials and the Denver Formation bedrock is a source of selenium loading to Toll Gate Creek and that selenium loading is distributed along the entire length of the study reach downstream from the concrete-lined channel. Water-quality and solids-sampling results from this study indicate weathering processes release water-soluble selenium from the underlying Denver Formation claystone bedrock with subsequent cycling of selenium in the aquatic environment of Toll Gate Creek. Exposure of the Denver Formation selenium-bearing bedrock to oxidizing atmospheric conditions, surface water, and groundwater, oxidizes selenide, held as a trace element in pyrite or in complexes with organic matter, to selenite and selenate. Secondary weathering products including iron oxides and selenium-bearing salts have accumulated in the weathered zone in the semiarid climate and also can serve as sources or sinks of selenium. P

Paschke, Suzanne S.; Runkel, Robert L.; Walton-Day, Katherine; Kimball, Briant A.; Schaffrath, Keelin R.

2013-01-01

79

A guide to the pediatric patient with "difficult" asthma.  

UK PubMed Central (United Kingdom)

Patients whose asthma symptoms are poorly controlled with the therapies usually recommended for this disease are considered to have "difficult" asthma. Although such patients represent a small proportion of patients with asthma, children who have difficult asthma are at increased risk for morbidity and mortality. Once the diagnosis of asthma is established, caregivers must appropriately categorize and treat the asthma according to the patient's level of symptom severity. The purpose of this article is to present an approach to the management of patients with difficult asthma by (a) searching for alternative diagnoses or conditions that are often associated with asthma, (b) investigating environmental issues, (c) reviewing inhalation techniques, and (d) determining the patient's level of compliance with the prescribed treatment plan and simplifying it whenever possible.

Mazur LJ; de Ybarrondo L; Miller J

1999-11-01

80

A chemical kinetically based ignition delay correlation for iso-octane covering a wide range of conditions including the NTC region  

Energy Technology Data Exchange (ETDEWEB)

An ignition delay correlation has been developed for iso-octane based on the functional behavior exhibited by a detailed chemical kinetic mechanism. The correlation employs a traditional Arrhenius-based, power law formulation, {tau}=A{phi}{sup {alpha}}p{sup {beta}}{chi}{sub O{sub 2}}{sup {gamma}} x exp ({lambda}), including dependencies for equivalence ratio ({phi}), pressure (p) and oxygen percentage ({chi}{sub O2}). However the exponents for these parameters, {alpha}, {beta}, and {gamma}, respectively, are expressed as third-order polynomials with respect to temperature in order to capture changes in functionality seen across different regimes. At very low temperatures {alpha}, {beta}, and {gamma} are forced to a constant value, as seen within the mechanism. The activation energy term, {lambda}, is written as a combination of two quadratic expressions so that the behavior in the negative temperature coefficient (NTC) region can be captured. A pressure-dependent term is also included in the expression for {lambda} in order to reduce the activation energy at higher pressures in the NTC region due to increased low temperature reactivity, and the appearance of cool flame, or low temperature heat release (LTHR). The resulting expression contains 37 constants. The new correlation is applicable over a wide range of conditions and can be used for data comparisons and mechanism evaluation, as well as systems-level engineering simulations. In this work experimental data from rapid compression machines (RCM) and shock tubes (ST) are compared through normalizing features of the correlation, and the performance of a detailed kinetic mechanism is evaluated based on the functional behavior of the {alpha}, {beta}, {gamma} and {lambda} parameters. Six hundred and sixty-one (661) data points have been used to fit the 37 constants of the expression where the experimental conditions cover {phi}=0.2-2.0, p=1-60atm, {chi}{sub O{sub 2}} and T=650-2000 K. Data normalized through the correlation indicate a standard deviation of {+-}4%. Departures from the correlation can be attributed to an incomplete description of the functional dependencies, some inconsistencies with regard to diluent composition, experimental uncertainties, and facility-influenced phenomena. The experimental points have also been simulated using the LLNL detailed iso-octane mechanism, where the computed ignition delay times have been fit to the new correlation. Agreement and differences between the correlated experimental and simulation {alpha}, {beta}, {gamma} and {lambda} functions are highlighted, where it is noted that there is a substantial discrepancy concerning the increased low temperature chemistry at high pressure. Implications for future engine design are discussed. (author)

Goldsborough, S. Scott [Department of Mechanical Engineering, Marquette University, Milwaukee, WI 53201-1881 (United States)

2009-06-15

 
 
 
 
81

Difficult asthma and its treatment in pediatrics  

Directory of Open Access Journals (Sweden)

Full Text Available Difficult asthma which constitutes less than 5% of all childhood asthma cases is defined as presence of daily symptoms, frequent oral corticosteroid requirement and frequent exacerbations for longer than six months, despite the use of inhaled steroid equivalent to 500 mcg fluticasone propionate, long acting beta 2 agonist or theophylline and leukotriene antagonists. Difficult asthma is not expected in childhood due to the absence of remodelling, rapid restoration of the airway, use of efficacious inhaled techniques and steroids and absence of occupational exposures. Therefore, it may be thought that “pediatric difficult asthma” is a differential diagnosis and treatment adherence problem. It has been shown that difficult asthma cases that have been filtered from this aspect have a non-eosinophilic inflammatory phenotype characterized by defective beta 2 receptor responses and high steroid resistance. Increased thickness of the basal membrane supports the view that dysfunctional mechanisms play a more important role than inflammatory mechanisms. Environmental control and elimination of risk factors should be achieved in these cases and proper education for treatment modalities and inhalation techniques need to be provided. (Turk Arch Ped 2010; 45: 80th Year: 1-5)

Hasan Yüksel

2010-01-01

82

Direct puncture cholangiography for clarifying difficult anatomy.  

UK PubMed Central (United Kingdom)

Laparoscopic cholecystectomy is a very frequently performed procedure. Its most dreadful complication is bile duct injury. Difficulty in appreciating the biliary anatomy plays an important role in its causation. Here we describe our technique in clarifying the difficult anatomy by directly injecting the radiologic contrast in the ambiguous area, and thus avoiding a potential injury.

Rabie ME

2013-04-01

83

Why mechanical subsystems are difficult to integrate  

Energy Technology Data Exchange (ETDEWEB)

Though the theme of System Engineering is integration, and it is normal to attempt in integration to ignore the lines between disciplines, there are distinct characteristics of the mechanical design portion of any major system design project that make this difficult. How these characteristics compound the difficulty of integration is discussed and means to minimize the associated obstacles are suggested.

Segalman, D.J.; Ortiz, K. [Sandia National Labs., Albuquerque, NM (United States); Wesner, J.J. [Lucent Technologies, Middletown, NJ (United States)

1996-12-31

84

When Benefits Are Difficult to Measure.  

Science.gov (United States)

It is difficult to apply benefit cost analysis to human service programs. This paper explains "threshold benefit analysis," the derivation of the minimum dollar value which the benefits must attain in order for their value to equal the intervention costs. The method is applied to a mobility training program. (BS)

Birdsall, William C.

1987-01-01

85

PRAISE: Christians Educators and the Difficult Student  

Directory of Open Access Journals (Sweden)

Full Text Available This article defends the role of the Christian educator in reaching the difficult student. It further offers tips for handling the challenging student from a Christian perspective, coupled with tried-and-true research using the acronym PRAISE: being proactive, using reinforcements, assessing and analyzing the intent of misbehavior, being sincere, and empowering students and the Holy Spirit in them.

Beth E. Ackerman

2008-01-01

86

Improving Web Search for Difficult Queries  

Science.gov (United States)

|Search engines have now become essential tools in all aspects of our life. Although a variety of information needs can be served very successfully, there are still a lot of queries that search engines can not answer very effectively and these queries always make users feel frustrated. Since it is quite often that users encounter such "difficult…

Wang, Xuanhui

2009-01-01

87

Recent advances in endoscopic management of difficult bile duct stones.  

UK PubMed Central (United Kingdom)

Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.

Yasuda I; Itoi T

2013-07-01

88

[Management of difficult, severe and recurrent Budd-Chiari syndrome].  

UK PubMed Central (United Kingdom)

OBJECTIVE: To investigate the management of complicated, severe or recurrent Budd-Chiari syndrome. METHODS: From February 2004 to August 2007, 28 patients with complicated, severe or recurrent Budd-Chiari syndrome were treated. In this series, 16 patients relapsed after treated with percutaneous transluminal angioplasty or stent deployment, 2 cases relapsed after surgery; and the other 10 were under severe conditions and hard to treat, including malignancy of the inferior vena cava and right atrium. Meso-cavo-atrial shunt was carried out in 10 cases, meso-cavo-jugular shunt in 6 (capitis medusa was used in one case), cavoatrial shunt in 2 and cavo-jugular shunt in 1, mesocaval shunt in 2, and radical or extended radical correction in 7. RESULTS: One patient (3.6%) died in 24 hours after operation. Graft infection occurred in 1 case. Excellent, good, fair, poor and death rate were 22.2%, 55.5%, 14.8%, 3.7% and 3.7%, respectively, the overall effective rate was 92.5%. CONCLUSION: To select personalized treatment according to the disease status brings hopes to difficult, severe, recurrent Budd-Chiari syndrome.

Wang ZG; Li CM; Gu YQ; Yu HX; Chen B; Guo LR; Li XF; Cui SJ; Li Z

2008-08-01

89

Obstetric Brachial Plexus Palsy Following Routine Versus Difficult Deliveries.  

UK PubMed Central (United Kingdom)

Previous bio-engineering studies showed that intrapartum peak forces applied by the clinician were lower in routine deliveries than difficult deliveries. A total of 751 cases of obstetric brachial plexus palsy were included and divided into two groups: group I (248 patients) were born following routine deliveries and group II (503 patients) were born following difficult deliveries. Both groups were compared regarding the type of palsy and the rate of good/poor spontaneous motor recovery from the palsy. Group I subjects were more likely to have upper Erb palsy whereas those in group II were more likely to develop total palsy (P < .0001). The percentage of newborns with poor functional recovery was significantly higher (P < .05) in group II with regards to shoulder, wrist, and hand function. It was concluded that higher peak forces applied by the clinician in difficult deliveries affect the type of obstetric brachial plexus palsy.

El-Sayed AA

2013-07-01

90

Characterizing mine detector performance over difficult soils  

Science.gov (United States)

A variety of metal detectors are available for the detection of buried metallic targets in general and for humanitarian demining in particular. No one detector is optimal in all environments: variations in soil conductivity, and more importantly, frequency dependent soil magnetic susceptibility can favor one design over another. The use of computer modeling for assessing different designs is straightforward in principle, at least to first order, but still difficult in practice. The Geophysics Lab of the University of Toronto is attempting to address this problem in two ways. The first is by assembling the required computational algorithms to do this into a single simulation code with a straightforward GUI, intended to be public domain as a MATLAB code. The second, the subject of a companion paper in this conference, is by making measurements of the electromagnetic properties of difficult soils, and finding semi-analytic representations of these responses suitable for modeling purposes. The final version of the code, when completed, is to handle single or multiple transmitter and receiver coils of circular or polygonal shape, general transmitter current waveforms, arbitrary transmitter orientations and survey paths, small targets with frequency-dependent anisotropic responses (permitting both magnetic and inductive responses to be calculated), embedded in multi-layered half spaces with both conductivity and frequency-dependent susceptibility (so-called "difficult soils"). The current state of the simulation code and examples of its use will be described in this paper.

Bailey, R. C.; West, G. F.

2006-06-01

91

Difficult laparoscopic cholecystectomy: current evidence and strategies of management.  

UK PubMed Central (United Kingdom)

UNLABELLED: Laparoscopic cholecystectomy is the treatment of choice for gall bladder stone disease. Difficult cholecystectomy is associated with serious complications and a high conversion rate. The aim of this study was to review the current strategies to manage difficult cholecystectomy. METHODS: A Medline search was conducted to review all published English literatures relevant to difficult cholecystectomy through 1993 to 2009. The search words were "laparoscopic cholecystectomy," "difficult cholecystectomy," "difficult laparoscopy," "subtotal laparoscopic cholecystectomy," "fundus first cholecystectomy," and "causes of conversion of laparoscopic cholecystectomy." RESULTS: Ninety-one studies, which included 324,553 patients, were selected for this review. Five major categories of difficulty were identified. Conversion rate and iatrogenic injuries during laparoscopic cholecystectomy are still high despite significant improvement over the last 10 years. Depending on the technique of cholecystectomy, the degree of gall bladder inflammation, patient comorbidities, and surgical experience, the conversion rate was reported between 0.18% and 30%, whereas the incidence of iatrogenic injuries was from 0% to 0.6%. Subtotal cholecystectomy, antegrade and fundus first techniques, and peroperative cholangiogram were associated with lower complications and conversion rate. Risk factors for difficulty were male sex, increased age, acute and thick wall chronic cholecystitis, wide and short cystic duct, cholecystodigestive fistula, previous upper abdominal surgery, obesity, liver cirrhosis, anatomic variation, cholangiocarcinoma, and low surgeon's caseload. CONCLUSIONS: No consensus is found among surgeons on how to manage difficult laparoscopic cholecystectomy. Iatrogenic injuries and conversion rate can be reduced depending on the surgeon's experience, special techniques, and intraoperative investigations. Subtotal cholecystectomy, antegrade or fundus first techniques, and peroperative cholangiogram significantly reduced the complications and conversion rate.

Hussain A

2011-08-01

92

Bilobar atelectasis after difficult tracheal intubation.  

Science.gov (United States)

Acute intra-operative collapse of a lobe without apparent cause is rare. We report a case of transient bilobar atelectasis that developed without any apparent cause after a difficult tracheal intubation in a healthy young patient. Intrabronchial obstruction was ruled out by bronchoscopy. The bilobar atelectasis developed acutely and resolved quickly with mechanical ventilation. The characteristics of the lung collapse were atypical, suggesting either its reflex nature or acute reduction of lung volume owing to intubation-induced coughing. We present a review of the mechanisms of atelectasis. PMID:9485978

Sprung, J; Lozada, L J; Zanettin, G; Banoub, M

1997-12-01

93

THE GENERALIZATION OF A CIRCULAR BOUNDARY CONDITION IN THE PROGRAM POISSON TO INCLUDE NO SYMMETRY AND AXIS-SYMMETRY OF REVOLUTION  

Energy Technology Data Exchange (ETDEWEB)

We have previously reported on the incorporation of a circular boundary condition into the program POISSON for two-dimensional problems (Incorporation of a Circular Boundary Condition into the Program POISSON, S. Caspi, M. Helm, and L.J. Laslett, LBID-887, SSC MAG Note-S, February 13, 1984). The least square method has now been generalized to accept any suitable set of orthogonal functions which can describe the vector potential function outside a circular boundary so located that no external sources are present. We have proceeded to incorporate the boundary condition into cartesian problems which involve no symmetry, and into axis-symmetry cylindrical problems that may have left-right symmetry, antisymmetry or no symmetry.

Caspi, S.; Helm, M.; Laslett, L.J.

1984-07-01

94

The effect of including a series of isometric conditioning contractions to the rowing warm-up on 1,000-m rowing ergometer time trial performance.  

UK PubMed Central (United Kingdom)

Rowing requires strength, power, and strength-endurance for optimal performance. A rowing-based warm-up could be enhanced by exploiting the postactivation potentiation (PAP) phenomenon, acutely enhancing power output at the beginning of a race where it is needed most. Minimal research has investigated the effects of PAP on events of longer duration (i.e. 1,000-m rowing). The purpose of this research was to investigate the effects of PAP on 1,000-m rowing ergometer performance through the use of 2 different warm-up procedures: (a) a rowing warm-up combined with a series of isometric conditioning contractions, known as the potentiated warm-up (PW), and (b) a rowing warm-up only (NW). The isometric conditioning contractions in the PW were performed by "pulling" an immovable handle on the rowing ergometer, consisting of 5 sets of 5 seconds (2 seconds at submaximal intensity, and 3 seconds at maximal intensity), with a 15-second recovery between sets. The 1,000-m rowing ergometer time trial was performed after each warm-up condition, whereby mean power output, mean stroke rate, and split time were assessed every 100 m. Ten Australian national level rowers served as the subjects and performed both conditions in a counterbalanced order on separate days. The PW reduced 1,000-m time by 0.8% (p > 0.05). The PW improved mean power output by 6.6% (p < 0.01) and mean stroke rate by 5.2% (p < 0.01) over the first 500 m; resulting in a reduction of 500-m time by 1.9% (p < 0.01), compared with the NW. It appears that the inclusion of isometric conditioning contractions to the rowing warm-up enhance short-term rowing ergometer performance (especially at the start of a race) to a greater extent than a rowing warm-up alone.

Feros SA; Young WB; Rice AJ; Talpey SW

2012-12-01

95

Difficult weaning in delayed onset diaphragmatic hernia  

Directory of Open Access Journals (Sweden)

Full Text Available Diaphragmatic injuries are relatively rare and result from either blunt or penetrating trauma. Regardless of the mechanism, diagnosis is often missed and high index of suspicion is vital. The clinical signs associated with a diaphragmatic hernia can range from no outward signs to immediately life-threatening respiratory compromise. Establishing the clinical diagnosis of diaphragmatic injuries (DI) can be challenging as it is often clinically occult. Accurate diagnosis is critical since missed DI may result in grave sequelae due to herniation and strangulation of displaced intra-abdominal organs. We present a case of polytrauma with rib fracture and delayed appearance of diaphragmatic hernia manifesting as difficult weaning from ventilatory support.

Ahmed Syed; Nadeem Abu; Pal Jyotishka; Gupta Rahul; Chauhan Sunil

2009-01-01

96

Why Is Image Quality Assessment So Difficult?  

UK PubMed Central (United Kingdom)

Image quality assessment plays an important role in various imageprocessing applications. A great deal of effort has been made in recentyears to develop objective image quality metrics that correlatewith perceived quality measurement. Unfortunately, only limitedsuccess has been achieved. In this paper, we provide some insightson why image quality assessment is so difficult by pointing out theweaknesses of the error sensitivity based framework, which hasbeen used by most image quality assessment approaches in the literature.Furthermore, we propose a new philosophy in designing imagequality metrics: The main function of the human eyes is toextract structural information from the viewing field, and the humanvisual system is highly adapted for this purpose. Therefore, ameasurement of structural distortion should be a good approximationof perceived image distortion. Based on the new philosophy,we implemented a simple but effective image quality indexing algorithm,which is very promising as shown by our current results.1.

Zhou Wang; Alan C. Bovik; Ligang Lu

97

The effect of including a series of isometric conditioning contractions to the rowing warm-up on 1,000-m rowing ergometer time trial performance.  

Science.gov (United States)

Rowing requires strength, power, and strength-endurance for optimal performance. A rowing-based warm-up could be enhanced by exploiting the postactivation potentiation (PAP) phenomenon, acutely enhancing power output at the beginning of a race where it is needed most. Minimal research has investigated the effects of PAP on events of longer duration (i.e. 1,000-m rowing). The purpose of this research was to investigate the effects of PAP on 1,000-m rowing ergometer performance through the use of 2 different warm-up procedures: (a) a rowing warm-up combined with a series of isometric conditioning contractions, known as the potentiated warm-up (PW), and (b) a rowing warm-up only (NW). The isometric conditioning contractions in the PW were performed by "pulling" an immovable handle on the rowing ergometer, consisting of 5 sets of 5 seconds (2 seconds at submaximal intensity, and 3 seconds at maximal intensity), with a 15-second recovery between sets. The 1,000-m rowing ergometer time trial was performed after each warm-up condition, whereby mean power output, mean stroke rate, and split time were assessed every 100 m. Ten Australian national level rowers served as the subjects and performed both conditions in a counterbalanced order on separate days. The PW reduced 1,000-m time by 0.8% (p > 0.05). The PW improved mean power output by 6.6% (p rowing warm-up enhance short-term rowing ergometer performance (especially at the start of a race) to a greater extent than a rowing warm-up alone. PMID:22266645

Feros, Simon A; Young, Warren B; Rice, Anthony J; Talpey, Scott W

2012-12-01

98

Rigid fibrescope Bonfils: use in simulated difficult airway by novices  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Background The Bonfils intubation fibrescope is a promising alternative device for securing the airway. We examined the success rate of intubation and the ease of use in standardized simulated difficult airway scenarios by physicians. We compared the Bonfils to a classical laryngoscope with Macintosh blade. Methods 30 physicians untrained in the use of rigid fibrescopes but experienced in airway management performed endotracheal intubation in an airway manikin (SimMan, Laerdal, Kent, UK) with three different airway conditions. We evaluated the success rate using the Bonfils (Karl Storz, Tuttlingen, Germany) or the Macintosh laryngoscope, the time needed for securing the airway, and subjective rating of both techniques. Results In normal airway all intubations were successful using laryngoscope (100%) vs. 82% using the Bonfils (p Conclusion The Bonfils can be successfully used by physicians unfamiliar with this technique in an airway manikin. The airway could be secured with at least the same success rate as using a Macintosh laryngoscope in difficult airway scenarios. Use of the Bonfils did not delay intubation in the presence of a difficult airway. These results indicate that intensive special training is advised to use the Bonfils effectively in airway management.

Piepho Tim; Noppens Rüdiger R; Heid Florian; Werner Christian; Thierbach Andreas R

2009-01-01

99

Guide for Operational Configuration Management Program including the adjunct programs of design reconstitution and material condition and aging management. Part 1  

Energy Technology Data Exchange (ETDEWEB)

This standard presents program criteria and implementation guidance for an operational configuration management program for DOE nuclear and non-nuclear facilities in the operational phase. Portions of this standard are also useful for other DOE processes, activities, and programs. This Part 1 contains foreword, glossary, acronyms, bibliography, and Chapter 1 on operational configuration management program principles. Appendices are included on configuration management program interfaces, and background material and concepts for operational configuration management.

1993-11-01

100

Difficult to treat spontaneous bacterial peritonitis.  

UK PubMed Central (United Kingdom)

Spontaneous bacterial peritonitis (SBP) is the most frequent infection in patients with cirrhosis. It is associated with high mortality at admission and its occurrence alters the natural course with a high 1 year mortality. Presence of > 250 polymorphonuclear cell (PMN)/mm3 in the India ascitic fluid is diagnostic of SBP. SBP is usually treated with IV antibiotics using third generation cephalosporins and fluoroquinolones. However, despite effective initial treatment subsequent recurrence of SBP with its accompanying mortality has resulted in use of long term antibiotic prophylaxis and such patients are recommended for liver transplant. An increased frequency of multidrug resistant bacterial SBP has recently been recognised with use of prophylaxis and is associated with enhanced mortality. Further, cirrhotics get repeated hospitalisation and ICU care leading to nosocomial infection causing SBP. Therefore, frequency of multidrug resistant bacteria induced SBP among the above settings has increased and the relative risk (RR) of mortality with bacterial resistance has been estimated to be 4 times higher than in patients with SBP without bacterial resistance. Therapeutic approach in such patients at present is a clinical challenge and they are difficult to treat patients. Therefore, SBP can be categorized into community acquired and nosocomial! multidrug resistant SBP.

Shalimar; Acharya SK

2013-01-01

 
 
 
 
101

Difficult elbow fractures: pearls and pitfalls.  

Science.gov (United States)

Complex elbow fractures are exceedingly challenging to treat. Treatment of severe distal humeral fractures fails because of either displacement or nonunion at the supracondylar level or stiffness resulting from prolonged immobilization. Coronal shear fractures of the capitellum and trochlea are difficult to repair and may require extensile exposure. Olecranon fracture-dislocations are complex fractures of the olecranon associated with subluxation or dislocation of the radial head and/or the coronoid process. The radioulnar relationship usually is preserved in anterior but disrupted in posterior fracture-dislocations. A skeletal distractor can be useful in facilitating reduction. Coronoid fractures can be classified according to whether the fracture involves the tip, the anteromedial facet, or the base (body) of the coronoid. Anteromedial coronoid fractures are actually varus posteromedial rotatory fracture subluxations and are often serious injuries. These patterns of injury predict associated injuries and instability as well as surgical approach and treatment. The radial head is the bone most commonly fractured in the adult elbow. If the coronoid is fractured, the radial head becomes a critical factor in elbow stability. Its role becomes increasingly important as other soft-tissue and bony constraints are compromised. Articular injury to the radial head is commonly more severe than noted on plain radiographs. Fracture fragments are often anterior. Implants applied to the surface of the radial head must be placed in a safe zone. PMID:12690844

O'Driscoll, Shawn W; Jupiter, Jesse B; Cohen, Mark S; Ring, David; McKee, Michael D

2003-01-01

102

Difficult elbow fractures: pearls and pitfalls.  

UK PubMed Central (United Kingdom)

Complex elbow fractures are exceedingly challenging to treat. Treatment of severe distal humeral fractures fails because of either displacement or nonunion at the supracondylar level or stiffness resulting from prolonged immobilization. Coronal shear fractures of the capitellum and trochlea are difficult to repair and may require extensile exposure. Olecranon fracture-dislocations are complex fractures of the olecranon associated with subluxation or dislocation of the radial head and/or the coronoid process. The radioulnar relationship usually is preserved in anterior but disrupted in posterior fracture-dislocations. A skeletal distractor can be useful in facilitating reduction. Coronoid fractures can be classified according to whether the fracture involves the tip, the anteromedial facet, or the base (body) of the coronoid. Anteromedial coronoid fractures are actually varus posteromedial rotatory fracture subluxations and are often serious injuries. These patterns of injury predict associated injuries and instability as well as surgical approach and treatment. The radial head is the bone most commonly fractured in the adult elbow. If the coronoid is fractured, the radial head becomes a critical factor in elbow stability. Its role becomes increasingly important as other soft-tissue and bony constraints are compromised. Articular injury to the radial head is commonly more severe than noted on plain radiographs. Fracture fragments are often anterior. Implants applied to the surface of the radial head must be placed in a safe zone.

O'Driscoll SW; Jupiter JB; Cohen MS; Ring D; McKee MD

2003-01-01

103

Difficult-to-treat asthma in childhood.  

UK PubMed Central (United Kingdom)

Asthma continues to be one of the greatest burdens to healthcare resources throughout the developed world. In most cases, good symptom control can be achieved with low-dose inhaled corticosteroids, and can be cared for in the primary and secondary healthcare systems. However, there is a group in whom control is not achieved despite high-dose inhaled corticosteroids and maximal add-on therapies; these are children with problematic severe asthma that should be referred to a specialist team for further investigation and management. In this review we aimed to provide an evidence-based guide for pediatricians providing care for children with asthma in secondary healthcare settings. The review focuses on a proposed investigation and management strategy for children aged between 6 and 16 years with problematic severe asthma, and is supported as far as possible by evidence from the literature. We first address recent advances in nomenclature and then discuss our proposed course of investigation and management of these children. Distinction of children with true, severe, therapy-resistant asthma from those with asthma that is difficult to treat because of unaddressed underlying modifiable factors is critical and is discussed in detail.

Adams A; Saglani S

2013-06-01

104

A pacemaker powered by an implantable biofuel cell operating under conditions mimicking the human blood circulatory system--battery not included.  

UK PubMed Central (United Kingdom)

Biocatalytic electrodes made of buckypaper were modified with PQQ-dependent glucose dehydrogenase on the anode and with laccase on the cathode and were assembled in a flow biofuel cell filled with serum solution mimicking the human blood circulatory system. The biofuel cell generated an open circuitry voltage, Voc, of ca. 470 mV and a short circuitry current, Isc, of ca. 5 mA (a current density of 0.83 mA cm(-2)). The power generated by the implantable biofuel cell was used to activate a pacemaker connected to the cell via a charge pump and a DC-DC converter interface circuit to adjust the voltage produced by the biofuel cell to the value required by the pacemaker. The voltage-current dependencies were analyzed for the biofuel cell connected to an Ohmic load and to the electronic loads composed of the interface circuit, or the power converter, and the pacemaker to study their operation. The correct pacemaker operation was confirmed using a medical device - an implantable loop recorder. Sustainable operation of the pacemaker was achieved with the system closely mimicking human physiological conditions using a single biofuel cell. This first demonstration of the pacemaker activated by the physiologically produced electrical energy shows promise for future electronic implantable medical devices powered by electricity harvested from the human body.

Southcott M; MacVittie K; Halámek J; Halámková L; Jemison WD; Lobel R; Katz E

2013-05-01

105

A pacemaker powered by an implantable biofuel cell operating under conditions mimicking the human blood circulatory system--battery not included.  

Science.gov (United States)

Biocatalytic electrodes made of buckypaper were modified with PQQ-dependent glucose dehydrogenase on the anode and with laccase on the cathode and were assembled in a flow biofuel cell filled with serum solution mimicking the human blood circulatory system. The biofuel cell generated an open circuitry voltage, Voc, of ca. 470 mV and a short circuitry current, Isc, of ca. 5 mA (a current density of 0.83 mA cm(-2)). The power generated by the implantable biofuel cell was used to activate a pacemaker connected to the cell via a charge pump and a DC-DC converter interface circuit to adjust the voltage produced by the biofuel cell to the value required by the pacemaker. The voltage-current dependencies were analyzed for the biofuel cell connected to an Ohmic load and to the electronic loads composed of the interface circuit, or the power converter, and the pacemaker to study their operation. The correct pacemaker operation was confirmed using a medical device - an implantable loop recorder. Sustainable operation of the pacemaker was achieved with the system closely mimicking human physiological conditions using a single biofuel cell. This first demonstration of the pacemaker activated by the physiologically produced electrical energy shows promise for future electronic implantable medical devices powered by electricity harvested from the human body. PMID:23519144

Southcott, Mark; MacVittie, Kevin; Halámek, Jan; Halámková, Lenka; Jemison, William D; Lobel, Robert; Katz, Evgeny

2013-05-01

106

Making light of a difficult phase  

International Nuclear Information System (INIS)

Physicists are always striving to gain control over matter at the quantum level, and ultrafast lasers are just about the best way of achieving this. By precisely controlling the intensity, wavelength and duration of extremely short pulses of light, we can manipulate electronic processes at the atomic level. If these pulses can be shortened to the scale of attoseconds, then the electromagnetic fields within them will be changing on the same timescale as the motion of the electron. This means that physicists can use the pulses to steer electrons with astonishing precision, and control processes such as the emission of light and chemical reactions. Until now, however, there has been a fundamental obstacle to the production of such short pulses. At the sub-femtosecond level, a laser pulse contains only a few cycles of the carrier electromagnetic wave. As the pulse evolves the carrier wave can therefore become out of phase with the amplitude envelope, which can lead to a variety of different electric-field waveforms. This makes it difficult to put the pulse to any constructive use. The difference in phase between the carrier and envelope waves is called the carrier-envelope phase (CEP), and controlling it precisely is essential for a new generation of experiments that will probe and manipulate processes that occur on a sub-femtosecond timescale. Now physicists in Vienna and Germany have managed to do just that, allowing the carrier-envelope phase of a high-power ultrashort pulsed laser to be altered at will. With this set-up they were able to control electrons at the scale of 250 as (250x 018s), and they claim that their technique is limited only by the most fundamental barrier we know - quantum-mechanical uncertainty. (U.K.)

2003-01-01

107

Temperature and moisture conditions for life in the extreme arid region of the Atacama desert: four years of observations including the El Nino of 1997-1998.  

UK PubMed Central (United Kingdom)

The Atacama along the Pacific Coast of Chile and Peru is one of the driest and possibly oldest deserts in the world. It represents an extreme habitat for life on Earth and is an analog for life in dry conditions on Mars. We report on four years (September 1994-October 1998) of climate and moisture data from the extreme arid region of the Atacama. Our data are focused on understanding moisture sources and their role in creating suitable environments for photosynthetic microorganisms in the desert surface. The average air temperature was 16.5 degrees C and 16.6 degrees C in 1995 and 1996, respectively. The maximum air temperature recorded was 37.9 degrees C, and the minimum was -5.7 degrees C. Annual average sunlight was 336 and 335 W m(-2) in 1995 and 1996, respectively. Winds averaged a few meters per second, with strong föhn winds coming from the west exceeding 12 m s(-1). During our 4 years of observation there was only one significant rain event of 2.3 mm, which occurred near midnight local time. We suggest that this event was a rainout of a heavy fog. It is of interest that the strong El Niño of 1997-1998 brought heavy rainfall to the deserts of Peru, but did not bring significant rain to the central Atacama in Chile. Dew occurred at our station frequently following high nighttime relative humidity, but is not a significant source of moisture in the soil or under stones. Groundwater also does not contribute to surface moisture. Only the one rain event of 2.3 mm resulted in liquid water in the soil and beneath stones for a total of only 65-85 h over 4 years. The paucity of liquid water under stones is consistent with the apparent absence of hypolithic (under-stone) cyanobacteria, the only known primary producers in such extreme deserts.

McKay CP; Friedmann EI; Gómez-Silva B; Cáceres-Villanueva L; Andersen DT; Landheim R

2003-01-01

108

Behavior and failure of uniformly hydrided Zircaloy-4 fuel claddings between 25 C and 480 C under various stress states, including RIA loading conditions  

International Nuclear Information System (INIS)

[en] The anisotropic plastic behavior and the fracture of as-received and hydrided Cold-Worked Stress Relieved Zircaloy-4 cladding tubes are investigated under thermal-mechanical loading conditions representative of Pellet-Clad Mechanical Interaction during Reactivity Initiated Accidents in Pressurized Water Reactors. In order to study the combined effects of temperature, hydrogen content, loading direction and stress state, Axial Tensile, Hoop Tensile, Expansion Due to Compression and hoop Plane Strain Tensile tests are performed at room temperature, 350 C and 480 C on the material containing various hydrogen contents up to 1200 wt. ppm (hydrides are circumferential and homogeneously distributed). These tests are combined with digital image correlation and metallographic and fractographic observations at different scales. The flow stress of the material decreases with increasing temperature. The material is either strengthened or softened by hydrogen depending on temperature and hydrogen content. Plastic anisotropy depends on temperature but not on hydrogen content. The ductility of the material decreases with increasing hydrogen content at room temperature due to damage nucleation by hydride cracking. The plastic strain that leads to hydride fracture at room temperature decreases with increasing hydrogen content. The influence of stress triaxiality on hydride cracking is negligible in the studied range. The influence of hydrogen on material ductility is negligible at 350 C and 480 C since hydrides do not crack at these temperatures. The ductility of the material increases with increasing temperature. The evolution of material ductility is associated with a change in both the macroscopic fracture mode of the specimens and the microscopic failure mechanisms. (authors)

2010-01-01

109

A difficult industrial environment. [South Wales  

Energy Technology Data Exchange (ETDEWEB)

There is a coal basin in South Wales which must be one of the greatest agglomerations of natural or man-made hazards in the world. Natural hazards include glaciation, rainfall and geological structure. Man-made hazards which result from undermining include land subsidence, damage to the rocks so that they become very permeable and transmissive of the heavy rainfalls, and massive fissuring on top of the hills due to reactivation of geological faults.

Cochrane, N.J.

1984-01-01

110

HRT in difficult circumstances: are there any absolute contraindications?  

UK PubMed Central (United Kingdom)

Many traditional contraindications to hormone replacement therapy (HRT) are based on the theoretical potential for these hormones to worsen a disease process and are rarely based on supporting data. This review addresses the available data and lack of data that make the prescription of HRT difficult in a variety of common morbidities. In each circumstance, it is assumed that conservative evidence-based therapies have been tried and that menopausal symptoms remain debilitating and are reducing quality of life. Tailoring of the product, dose, route and regimen may avoid some of the theoretical risks of HRT in particular women or conditions and guidelines are given for each co-morbidity. Specifically, it is discussed that tailored HRT may be used without strong evidence of a deleterious effect after ovarian cancer, endometrial cancer, most other gynecological cancers, bowel cancer, melanoma, a family history of breast cancer, benign breast disease, in carriers of BRACA mutations, after breast cancer if adjuvant therapy is not being used, past thromboembolism, varicose veins, fibroids and past endometriosis. Relative contraindications are existing cardiovascular and cerebrovascular disease and breast cancer being treated with adjuvant therapies. Consultation with other carers and written consent are recommended in all these difficult circumstances, but no condition is an absolute contraindication to HRT if potential risk is understood, if HRT is effective in symptom control and if quality of remaining life is paramount.

MacLennan AH

2011-08-01

111

Phlebosclerotic colitis that was difficult to distinguish from collagenous colitis.  

UK PubMed Central (United Kingdom)

Phlebosclerotic colitis is a rare and recently known disease entity and its etiology is still to be elucidated. Some phlebosclerotic colitis cases are difficult to distinguish from collagenous colitis because of the similarity of pathological findings. In all Japanese case reports of phlebosclerotic colitis in which an association with the use of Chinese herbal medicine is suspected, sansisi (gardenia fruit) was included, suggesting pathogenesis of this disease. We report a case of phlebosclerotic colitis that wasdifficult to be distinguished from collagenous colitis, and an association with the use of Chinese herbal medicine was suspected as the cause of the disease.

Hozumi H; Hokari R; Shimizu M; Maruta K; Narimatsu K; Sato H; Sato S; Ueda T; Higashiyama M; Watanabe C; Komoto S; Tomita K; Kawaguchi A; Nagao S; Miura S

2013-07-01

112

Managing the difficult penile prosthesis patient.  

UK PubMed Central (United Kingdom)

INTRODUCTION: Inflatable penile prostheses (IPPs) are associated with excellent long-term outcomes and patient/partner satisfaction. A small percentage of patients remain dissatisfied, despite acceptable surgical results. AIMS: This study aims to evaluate factors associated with patient satisfaction and dissatisfaction, define patient characteristics, which may identify elevated risk of postoperative dissatisfaction, and describe management strategies to optimize functional and psychological patient outcomes. METHODS: A review of urologic and non-urologic cosmetic surgery literature was performed to identify factors associated with patient satisfaction/dissatisfaction. Emphasis was placed on articles defining "high risk" or psychologically challenging patients. MAIN OUTCOME MEASURES: Preoperative factors associated with patient satisfaction/dissatisfaction and character traits, which may identify elevated risk of postoperative dissatisfaction or otherwise indicate a psychologically challenging patient. RESULTS: Contemporary patient and partner satisfaction rates following IPP are 92-100% and 91-95%, respectively. Factors associated with satisfaction include decreased preoperative expectations, favorable female partner sexual function, body mass index ?30, and absence of Peyronie's disease or prior prostatectomy. Determinants of dissatisfaction include perceived/actual loss of penile length, decreased glanular engorgement, altered erectile/ejaculatory sensation, pain, diminished cosmetic outcome, difficulty with device function, partner dissatisfaction and perception of unnatural sensation, complications, and extent of alternative treatments offered. Personality characteristics which may indicate psychologically challenging IPP patients include obsessive/compulsive tendencies, unrealistic expectations, patients undergoing revision surgery, those seeking multiple surgical opinions, feeling of entitlement, patients in denial of their prior erectile/sexual function and current disease status, or those with other psychiatric disorders. The mnemonic CURSED Patient is presented: "Compulsive/obsessive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric." CONCLUSIONS: Although the majority of IPP patients experience excellent, durable satisfaction and outcomes, a challenging subset of patients may be at increased risk of postoperative dissatisfaction. Appropriate recognition/prevention and management of this cohort may help to establish and strengthen relationships, reduce physical, emotional, and legal risk, and ultimately enhance patient satisfaction.

Trost LW; Baum N; Hellstrom WJ

2013-04-01

113

Maxillofacial trauma patient: coping with the difficult airway  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.

Krausz Amir A; el-Naaj Imad; Barak Michal

2009-01-01

114

Processing a difficult urethane elastomer system  

International Nuclear Information System (INIS)

A detailed study of an adiprene/butanediol/trimethylolpropane elastomer system and the associated production process was performed to assess the importance of various processing factors on the physical properties of the system. Results indicated that control of the curing cycle, material ratio, moisture in the curing agent and elastomer, mixing, and vacuum level was necessary. Sufficient control of the manual process could not be obtained to eliminate significant physical property variability. An automatic metering, mixing and dispensing machine was purchased for laboratory evaluation. After modification, including the addition of a high shear vacuum type mixer, and with close vacuum and temperature control, material property variability was still at an unacceptable level. A tracer agent was introduced into the curing agent system to assess the distribution of the curing agent in the elastomer. Machine evaluation using the tracer agent indicated that distribution of the curing agent in the elastomer was very poor is spite of the high shear mixing configuration. The addition of an oscillating motion to the mixing configuration. The addition of an oscillating motion to the mixing system significantly improved curing agent distribution and eliminated material property variability problems. 16 figures, 3 tables

1977-01-01

115

Implications of the KONVERGENCE Model for Difficult Cleanup Decisions  

Energy Technology Data Exchange (ETDEWEB)

Abstract—Some cleanup decisions, such as cleanup of intractable contaminated sites or disposal of spent nuclear fuel, have proven difficult to make. Such decisions face high resistance to agreement from stakeholders possibly because they do not trust the decision makers, view the consequences of being wrong as too high, etc. Our project’s goal is to improve sciencebased cleanup decision-making. This includes diagnosing intractable situations, as a step to identifying a path toward sustainable solutions. Companion papers describe the underlying philosophy of the KONVERGENCE Model for Sustainable Decisions,1 and the overall framework and process steps.2 Where knowledge, values, and resources converge (the K, V, and R in KONVERGENCE), you will find a sustainable decision – a decision that works over time. For intractable cases, serious consideration of the adaptable class of alternatives is warranted – if properly implemented and packaged.

Piet, Steven James; Dakins, Maxine Ellen; Gibson, Patrick Lavern; Joe, Jeffrey Clark; Kerr, Thomas A; Nitschke, Robert Leon

2002-08-04

116

Penile Corporeal Reconstruction during Difficult Placement of a Penile Prosthesis  

Directory of Open Access Journals (Sweden)

Full Text Available For some patients with impotence and concomitant severe tunical/corporeal tissue fibrosis, insertion of a penile prosthesis is the only option to restore erectile function. Closing the tunica over an inflatable penile prosthesis in these patients can be challenging. We review our previous study which included 15 patients with severe corporeal or tunical fibrosis who underwent corporeal reconstruction with autologous rectus fascia to allow placement of an inflatable penile prosthesis. At a mean follow-up of 18 months (range 12 to 64), all patients had a prosthesis that was functioning properly without evidence of separation, herniation, or erosion of the graft. Sexual activity resumed at a mean time of 9 weeks (range 8 to 10). There were no adverse events related to the graft or its harvest. Use of rectus fascia graft for coverage of a tunical defect during a difficult penile prosthesis placement is surgically feasible, safe, and efficacious.

Viet Q. Tran; Timothy F. Lesser; Dennis H. Kim; Sherif R. Aboseif

2008-01-01

117

Pipeline developments 1998 and beyond : more choices, more difficult decisions  

Energy Technology Data Exchange (ETDEWEB)

Some of the basic economic principles that drive gas prices and gas flows across North America, and the pressures these have placed on the pipeline sector, are reviewed. Of pressing importance to the natural gas industry in Western Canada is the prospect that in the near future industrial gas users in eastern Canada will have a wider array of pipeline choices available to them than ever before. This will mean that the users will face more offerings from more pipeline providers, forcing pipeline owners to make more difficult decisions regarding new pipeline capacity. Variables such as price, terms and conditions will become increasingly negotiable. Market power concerns also remain an important issue. As a result, there is increasing call for market-based financial regulation of pipelines. `Market gaming` a condition where a firm manipulates the market to its own market advantage is also receiving considerable attention. The latter is of particular concern in the United States. Against this background, the nature of competition (or the lack of it) in natural gas transport, the influence of short-term service revenues for pipelines, pipeline commitments through subsidiaries, and concerns over short term pipeline valuations skewing investment decisions, are issues that will continue to invite much attention. Regarding market outlook, it was noted that significantly increased export capacity from Alberta could raise the costs of Alberta supplies to eastern Canadian end-users relative to other supply/transport options which may now be viable economic alternatives. figs.

VanderSchee, K. [EnergyERA (Canada)

1998-12-31

118

ECO2M: A TOUGH2 Fluid Property Module for Mixtures of Water, NaCl, and CO2, Including Super- and Sub-Critical Conditions, and Phase Change Between Liquid and Gaseous CO2  

Energy Technology Data Exchange (ETDEWEB)

ECO2M is a fluid property module for the TOUGH2 simulator (Version 2.0) that was designed for applications to geologic storage of CO{sub 2} in saline aquifers. It includes a comprehensive description of the thermodynamics and thermophysical properties of H{sub 2}O - NaCl - CO{sub 2} mixtures, that reproduces fluid properties largely within experimental error for temperature, pressure and salinity conditions in the range of 10 C {le} T {le} 110 C, P {le} 600 bar, and salinity from zero up to full halite saturation. The fluid property correlations used in ECO2M are identical to the earlier ECO2N fluid property package, but whereas ECO2N could represent only a single CO{sub 2}-rich phase, ECO2M can describe all possible phase conditions for brine-CO{sub 2} mixtures, including transitions between super- and sub-critical conditions, and phase change between liquid and gaseous CO{sub 2}. This allows for seamless modeling of CO{sub 2} storage and leakage. Flow processes can be modeled isothermally or non-isothermally, and phase conditions represented may include a single (aqueous or CO{sub 2}-rich) phase, as well as two-and three-phase mixtures of aqueous, liquid CO{sub 2} and gaseous CO{sub 2} phases. Fluid phases may appear or disappear in the course of a simulation, and solid salt may precipitate or dissolve. TOUGH2/ECO2M is upwardly compatible with ECO2N and accepts ECO2N-style inputs. This report gives technical specifications of ECO2M and includes instructions for preparing input data. Code applications are illustrated by means of several sample problems, including problems that had been previously solved with TOUGH2/ECO2N.

Pruess, K.

2011-04-01

119

Incidence, Predictors, and Outcome of Difficult Mask Ventilation Combined with Difficult Laryngoscopy: A Report from the Multicenter Perioperative Outcomes Group.  

UK PubMed Central (United Kingdom)

BACKGROUND:: Research regarding difficult mask ventilation (DMV) combined with difficult laryngoscopy (DL) is extremely limited even though each technique serves as a rescue for one another. METHODS:: Four tertiary care centers participating in the Multicenter Perioperative Outcomes Group used a consistent structured patient history and airway examination and airway outcome definition. DMV was defined as grade 3 or 4 mask ventilation, and DL was defined as grade 3 or 4 laryngoscopic view or four or more intubation attempts. The primary outcome was DMV combined with DL. Patients with the primary outcome were compared to those without the primary outcome to identify predictors of DMV combined with DL using a non-parsimonious logistic regression. RESULTS:: Of 492,239 cases performed at four institutions among adult patients, 176,679 included a documented face mask ventilation and laryngoscopy attempt. Six hundred ninety-eight patients experienced the primary outcome, an overall incidence of 0.40%. One patient required an emergent cricothyrotomy, 177 were intubated using direct laryngoscopy, 284 using direct laryngoscopy with bougie introducer, 163 using videolaryngoscopy, and 73 using other techniques. Independent predictors of the primary outcome included age 46 yr or more, body mass index 30 or more, male sex, Mallampati III or IV, neck mass or radiation, limited thyromental distance, sleep apnea, presence of teeth, beard, thick neck, limited cervical spine mobility, and limited jaw protrusion (c-statistic 0.84 [95% CI, 0.82-0.87]). CONCLUSION:: DMV combined with DL is an infrequent but not rare phenomenon. Most patients can be managed with the use of direct or videolaryngoscopy. An easy to use unweighted risk scale has robust discriminating capacity.

Kheterpal S; Healy D; Aziz MF; Shanks AM; Freundlich RE; Linton F; Martin LD; Linton J; Epps JL; Fernandez-Bustamante A; Jameson LC; Tremper T; Tremper KK

2013-09-01

120

Validation of a scoring system to predict difficult laparoscopic cholecystectomy.  

UK PubMed Central (United Kingdom)

INTRODUCTION: Laparoscopic cholecystectomy (LC) is one of the most common laparoscopic procedures being performed by general surgeons all over the world. Preoperative prediction of the risk of conversion or difficulty of operation is an important aspect of planning laparoscopic surgery. The purpose of our prospective study was to analyze various risk factors and to predict difficulty and degree of difficulty preoperatively by the use of a scoring system. MATERIALS: This prospective study was conducted in the department of surgery, Lady Hardinge Medical College and associated Dr Ram Manohar Lohia Hospital, Delhi, India. The parameters considered in the preoperative scoring method were old age, male sex, history of hospitalization, obesity, previous abdominal surgery scar, palpable gall bladder, wall thickness of gall bladder, pericholecystic collection and impacted stone. A total of 210 patients were included in the study. RESULTS: We found that history of hospitalization, palpable gall bladder, impacted stone and gall bladder wall thickness were statistically significant factors for prediction of difficult laparoscopic cholecystectomy. Sensitivity and specificity of this preoperative scoring method were found to be 95.74% and 73.68% respectively. Positive predictive values of this scoring method were 90% and 88% for easy and difficult cases respectively. Area under ROC curve was 0.86. Conversion rate from laparoscopic to open cholecystectomy was found to be 4.28%. CONCLUSION: With the help of accurate prediction, high risk patient may be informed before hand regarding the probability of conversion and hence they may have a chance to make arrangements accordingly. On the other hand, surgeons also may have to schedule the time and team for the operation appropriately. Surgeons can also be aware about the possible complications that may arise in high risk patients.

Gupta N; Ranjan G; Arora MP; Goswami B; Chaudhary P; Kapur A; Kumar R; Chand T

2013-06-01

 
 
 
 
121

A retrospective review of difficult intubations: is obstructive sleep apnea a predictor?  

UK PubMed Central (United Kingdom)

OBJECTIVE: The purpose of this study was to examine the association of obstructive sleep apnea (OSA) with difficult intubation in patients undergoing general anesthesia requiring tracheal intubation. METHODS: Using a retrospective, case-control study design, 90 adults with difficult tracheal intubation were compared with 81 gender-matched controls, between 2007 and 2010. Analyses included descriptive and inferential statistics, and multivariate regression was used to estimate predictors of difficult intubation while adjusting for patient demographics. RESULTS: In the univariate analysis, OSA was not associated with difficult intubation. After patient factors were controlled for in the multivariate logistic regression, patients without OSA were more likely to have difficult intubation (odds ratio, 0.36; 95% confidence interval, 0.13-0.99; P = .048). Other predictors of difficult intubation were lower body mass index and higher Mallampati score. DISCUSSION: In adult subjects, OSA history was not a predictor of difficult intubation. Other patient or anesthesiologist factors should be assessed for their association with difficult intubation.

Vest D; Lee D; Newcome K; Stamper H

2013-05-01

122

When the end is really the end? The extubation in the difficult airway patient.  

UK PubMed Central (United Kingdom)

Difficult airway management remains one of the most important sources of anesthesia related accidents; recent reviews and dedicated guidelines suggest that not only intubation, but extubation too is a critical phase in terms of potential accidents and serious complications. This paper will highlight some fundamental concepts regarding extubation related problems, focusing particularly on epidemiology, risk factors and time course of difficult extubation, suggesting some conceptual points to plan and manage patients in which a difficult extubation might be expected, including parameters and test to be performed to assess and predict such a situation.

Sorbello M; Frova G

2013-02-01

123

[Decubitus ulcer in the calcaneus region: rapid development, difficult recovery  

UK PubMed Central (United Kingdom)

Heel pressure sores frequently arise in patients kept in bed for a long time independently of their primary disease. In account of this event the authors completed a study concerning possible mutual relations between heel pressure sores and primary disease of the patients; to validate the pharmacological treatment in less severe sores and the surgical resolution in more serious cutaneous lesions. In the last 3 years (1992-1995) at the Rehabilitation Centre of Montescano the authors have treated 39 patients suffering from 63 different severe cutaneous lesions: from phlycten to deep necrosis. The therapeutic plane utilized pharmacological treatment for 1st, 2nd, 3rd degree pressure sores, and surgical treatment for 4th degree. Pharmacological treatment included: enzymatic drugs, bactericidal and bacteriostatic medicines and cicatrizing substances. Different healing times were related to different pressure sore severity. Surgical treatment consisted of transposition of flap into wound defect. This system caused considerable reduction in resolution times. The authors noticed how easily pressure sores arise in the heel region, and how difficultly they heal. This is probably connected with particular anatomical and vascular characteristics of this region.

Fugazza G; Bona F

1996-03-01

124

Does a higher frequency of difficult patient encounters lead to lower quality care?  

UK PubMed Central (United Kingdom)

BACKGROUND: Difficult patient encounters in the primary care office are frequent and are associated with physician burnout. However, their relationship to patient care outcomes is not known. OBJECTIVE: To determine the effect of difficult encounters on patient health outcomes and the role of physician dissatisfaction and burnout as mediators of this effect. DESIGN: A total of 422 physicians were sorted into 3 clusters based on perceived frequency of difficult patient encounters in their practices. Patient charts were audited to assess the quality of hypertension and diabetes management and preventive care based on national guidelines. Summary measures of quality and errors were compared among the 3 physician clusters. RESULTS: Of the 1384 patients, 359 were cared for by high-cluster physicians (those who had a high frequency of difficult encounters), 871 by medium-cluster physicians, and 154 by low-cluster physicians. Dissatisfaction and burnout were higher among physicians reporting higher frequencies of difficult encounters. However, quality of patient care and management errors were similar across all 3 groups. CONCLUSIONS: Physician perception of frequent difficult encounters was not associated with worse patient care quality or more medical errors. Future studies should investigate whether other patient outcomes, including acute care and patient satisfaction, are affected by difficult encounters.

An PG; Manwell LB; Williams ES; Laiteerapong N; Brown RL; Rabatin JS; Schwartz MD; Lally PJ; Linzer M

2013-01-01

125

[Hematuria of papillary or medullar origin: a difficult diagnosis entity].  

UK PubMed Central (United Kingdom)

OBJECTIVES: Renal haemangiomas of renal papillary or medullar origin are a difficult diagnosis entity, being one of the most frequent processes of chronic episodes of hematuria, secondary to benign disease, mainly in young patients. The objective of this paper is to show the difficulty of this diagnosis and the need to suspect it in cases with clinical history similar to the ones described in these cases. METHODS: We report 4 cases of spontaneous hematuria of renal origin, with clinical presentation as renal colic, from the historical case series of the Fundacion Jimenez Díaz-Capio, the last two from the years 2005-6. We present the diagnostic and therapeutic methodology employed, including angio-CT and flexible ureterorenoscopy (URS) as well as various treatment options. RESULTS: Hematuria was identified as "essential" when any relation with tumor or lithiasic pathologies was ruled out, and of renal origin when the source was clearly pointed. We interpreted it was related to angiomas or microangiomas of papillary or medullar origin. In one case, the vascular malformation was interpreted as an arterial venous fistula (AVF) at that level. Hematuria stopped spontaneously in two cases after exploratory URS. The eldest historical case required surgical expiration of the caliceal structures. CONCLUSION: Years ago, following the professional development of Urology as speciality, conventional surgery was carried out in all these cases, of very difficult diagnosis, with a very small number of cases undergoing a conservative approach based on the examination of renal cavities trying to observe and find the bleeding point. Most cases underwent complete or partial nephrectomy. Currently, the possibility of exploration of all renal cavities with the flexible ureterorenoscope enables a better diagnosis of the lesions and a more conservative treatment. The ultimate diagnosis of renal papillary angioma is the pathologic diagnosis, without pathognomonic data in the imaging tests. This pathology is thought of at the end of the diagnostic workup, and when the papillary area is identified as the source of bleeding. The historical case series, with the pathologic findings from nephrectomy specimens, permits us to point out this entity as papillary angioma, in patients with similar clinical presentation.

González Enguita C; Gómez Muñoz J; Martín Vivas C; López Martín L; Susanibar Napuri LF; Alexandro S; Caramelo Díaz C; Vela Navarrete R

2008-06-01

126

Management of difficult airway by retrograde tracheal intubation  

International Nuclear Information System (INIS)

A case of difficult intubation is presented in a patient of adenoid carcinoma with a large right-sided facial defect. She was managed with radiotherapy and a myocutaneous flap reconstruction was done with retrograde tracheal intubation. (author)

2003-01-01

127

Species delimitation in taxonomically difficult fungi: the case of Hymenogaster.  

UK PubMed Central (United Kingdom)

BACKGROUND: False truffles are ecologically important as mycorrhizal partners of trees and evolutionarily highly interesting as the result of a shift from epigeous mushroom-like to underground fruiting bodies. Since its first description by Vittadini in 1831, inappropriate species concepts in the highly diverse false truffle genus Hymenogaster has led to continued confusion, caused by a large variety of prevailing taxonomical opinions. METHODOLOGY: In this study, we reconsidered the species delimitations in Hymenogaster based on a comprehensive collection of Central European taxa comprising more than 140 fruiting bodies from 20 years of field work. The ITS rDNA sequence dataset was subjected to phylogenetic analysis as well as clustering optimization using OPTSIL software. CONCLUSIONS: Among distinct species concepts from the literature used to create reference partitions for clustering optimization, the broadest concept resulted in the highest agreement with the ITS data. Our results indicate a highly variable morphology of H. citrinus and H. griseus, most likely linked to environmental influences on the phenology (maturity, habitat, soil type and growing season). In particular, taxa described in the 19(th) century frequently appear as conspecific. Conversely, H. niveus appears as species complex comprising seven cryptic species with almost identical macro- and micromorphology. H. intermedius and H. huthii are described as novel species, each of which with a distinct morphology intermediate between two species complexes. A revised taxonomy for one of the most taxonomically difficult genera of Basidiomycetes is proposed, including an updated identification key. The (semi-)automated selection among species concepts used here is of importance for the revision of taxonomically problematic organism groups in general.

Stielow B; Bratek Z; Orczán AK; Rudnoy S; Hensel G; Hoffmann P; Klenk HP; Göker M

2011-01-01

128

Move difficult solids-bearing fluids with submersible pumps  

Energy Technology Data Exchange (ETDEWEB)

This article describes how, alone or combined with versatile horizontal mixers, the submersible pump has significant advantages when the worst powerplant slurries have to be moved. The ever-growing need to deal with slurries and other solids-bearing liquids has directed attention to the pumping systems necessary to deal with the high diversity and large volumes of what are often wastes. Many powerplant services and locations, including coalpiles, sumps, and ash handling, call for pumping of solids-bearing liquids. In nearly every case, the wastes are not directly connected with the plant's economic function of power generation but nevertheless consume power and call for heavy capital and maintenance sums. For this reason, powerplants benefit from improved handling of these materials. There are basic differences between pumping of the two-phase slurries and wastes, especially when open reservoirs are part of the flowpaths, and pumping of the traditional, comparatively clean, single-phase liquids of the powerplant. Supply of liquid to the pump is one significant differences. Placement of conventional pumps for slurry service is another problem. Pumping from a closed system, such as a tank, can call for extra space, with a dry pit to hold a lineshaft pump. A conventional pump motor at a low level in a pit is in danger of flooding. An alternative solution to the problem of pump and drive type for the powerplant's difficult solids-bearing liquids is the submersible pump. This type has an entirely sealed motor and can be easily moved and reset advantageously for pumping at any time. Designed to operate with pump and motor fully submerged for long periods, the submersible pump can nevertheless also be mounted in a dry well next to a tank. The pump's ability to run submerged protects the system if the dry well should become flooded.

Pastore, P.R.

1993-09-01

129

Clustering is difficult only when it does not matter  

CERN Document Server

Numerous papers ask how difficult it is to cluster data. We suggest that the more relevant and interesting question is how difficult it is to cluster data sets {\\em that can be clustered well}. More generally, despite the ubiquity and the great importance of clustering, we still do not have a satisfactory mathematical theory of clustering. In order to properly understand clustering, it is clearly necessary to develop a solid theoretical basis for the area. For example, from the perspective of computational complexity theory the clustering problem seems very hard. Numerous papers introduce various criteria and numerical measures to quantify the quality of a given clustering. The resulting conclusions are pessimistic, since it is computationally difficult to find an optimal clustering of a given data set, if we go by any of these popular criteria. In contrast, the practitioners' perspective is much more optimistic. Our explanation for this disparity of opinions is that complexity theory concentrates on the wors...

Daniely, Amit; Saks, Michael

2012-01-01

130

Management of difficult bile duct cannulation in ERCP  

Directory of Open Access Journals (Sweden)

Full Text Available In Encoscopic Retrograde Cholangiopancreatography (ERCP), the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis. Difficult cannulation is defined as a situation where the endoscopist, using his/her regularly used cannulation technique, fails within a certain time limit or after a certain number of unsuccessful attempts. Different methods have been developed to manage difficult cannulation. The most common solution is to perform a precut papillotomy either with a needle knife or with a sphincterotome with or without a guide wire. This review describes different methods to overcome cases of difficult cannulation. We will discuss the success rate and complication rates associated with different methods of reaching the biliary tract.

Marianne Udd; Leena Kylänpää; Jorma Halttunen

2010-01-01

131

In difficult economic times, cities ask nonprofits for voluntary contributions  

Science.gov (United States)

City to ask more from nonprofitshttp://www.boston.com/news/local/massachusetts/articles/2010/12/22/city_to_ask_more_from_nonprofits/?rss_id=Boston.com+--+Local+newsPrinceton: University will provide township a $500K gifthttp://www.centraljersey.com/articles/2011/01/03/the_princeton_packet/news/doc4d2270475d056711196808.txtNonprofits shouldn't be a revenue sourcehttp://www.journaltimes.com/news/opinion/editorial/article_b52dc2e6-1793-11e0-859c-001cc4c03286.htmlBalancing Budgetshttp://www.watertowndailytimes.com/article/20101228/OPINION01/312289981Commentary: The Burden of Tax-Exempt Propertyhttp://www.njpp.org/com_dkoped.htmlOver the holidays, cheer and goodwill reigned supreme in most quarters. In the New Year, it is back to business, and for many nonprofit organizations this could mean another difficult challenge. A movement has been afoot to garner property tax payments from a wide range of nonprofits across the United States as of late, and a number of nonprofits have voiced strong concerns about such a trend. Nonprofits, such as universities and churches, are largely exempt from property taxes, and cash-strapped local governments are seeking a wide range of voluntary contributions from these institutions. In Princeton, New Jersey, the well-endowed Princeton University recently made a voluntary payment to the township of Princeton, but such an offering is much more difficult for other organizations. Tim Delaney, the chief executive of the National Council of Nonprofits, recently remarked, "Governments are taking their public burdens and putting them on the backs of nonprofits, at a time when the demand for our services is skyrocketing." Other taxes instituted as of late on nonprofits include drainage feeds, street-light fees, and a catchall type of voluntary offering known as "payment in lieu of taxes", or PILOT.The first link will take visitors to a recent piece from the Wall Street Journal which talks about this recent trend. The second link leads to a piece from the Boston Globe which describes how the city of Boston is revamping its formula for determining how much nonprofits should contribute to the city coffers. Moving along, the third link leads to a piece from this Monday's Princeton Packet about the voluntary payment given by Princeton University to Princeton Township. The fourth piece leads to an editorial from the Racine Journal Times on this controversial issue. The fifth link leads to another editorial, this time from the Watertown Daily Times which remarks, "Rather than reach into the pockets of schools, churches and community groups, municipalities need to bring their costs under control." Finally, the last link leads to a thoughtful piece from Donald A. Krueckeberg of the Bloustein School of Rutgers University-New Brunswick on the potential burden of tax-exempt property.

Grinnell, Max

2010-01-07

132

Part I: the difficult patient: medical and legal approaches.  

UK PubMed Central (United Kingdom)

Difficult patients are defined as those who elicit strong negative emotions from their physicians. If not acknowledged and managed correctly, these feelings can lead to diagnostic errors, unpleasant confrontations, and troublesome complaints or legal claims. The author reviews common personalities and situations that are associated with difficult encounters in emergency departments and describes an approach stressing flexibility in communication and the early establishment of rapport. He discusses diagnostic possibilities in the agitated or confused, unco-operative patient, reviews relevant laws governing restraint and competence to consent, and outlines techniques to reduce medicolegal risks.

Ovens H

1989-09-01

133

Management of difficult airway in penetrating cervical spine injury.  

UK PubMed Central (United Kingdom)

Management of airway in trauma victim with penetrating cervical/thoracic spine injury has always been a challenge to the anaesthesiologist. Stabilisation of spine during airway manipulation, to prevent any further neural damage, is of obvious concern to the anaesthesiologist. Most anaesthesiologists are not exposed to direct laryngoscopy and intubation in lateral position during their training period. Tracheal intubation in the lateral position may be unavoidable in some circumstances. Difficult airway in an uncooperative patient compounds the problem to secure airway in lateral position. We present a 46-year-old alcoholic, hypertensive, morbidly obese person who suffered a sharp instrument (screwdriver) spinal injury with anticipated difficult intubation; the case was managed successfully.

Prasad MK; Sinha AK; Bhadani UK; Chabra B; Rani K; Srivastava B

2010-01-01

134

GlideScope and Frova Introducer for Difficult Airway Management  

Science.gov (United States)

The introduction into clinical practice of new tools for intubation as videolaringoscopia has dramatically improved the success rate of intubation and the work of anesthesiologists in what is considered the most delicate maneuver. Nevertheless intubation difficulties may also be encountered with good anatomical visualization of glottic structures in videolaringoscopia. To overcome the obstacles that may occur both in a difficult provided intubation such as those unexpected, associated endotracheal introducer able to facilitate the passage of the endotracheal tube through the vocal cords into the trachea may be useful. We report 4 cases of difficult intubation planned and unplanned and completed successfully using the GlideScope videolaryngoscope associated with endotracheal Frova introducer.

Ciccozzi, Alessandra; Guetti, Cristiana; Papola, Roberta; Paladini, Antonella; Varrassi, Giustino; Marinangeli, Franco

2013-01-01

135

This is the tricky part: When directions become difficult  

Directory of Open Access Journals (Sweden)

Full Text Available Automated route guidance systems, both web-based systems and en-route systems, have become commonplace in recent years. These systems often replace human-generated directions, which are often incomplete, vague, or in error. However, human-generated directions have the ability to differentiate between easy and complex steps through language in a way that is more difficult in automated systems. This article examines a set of human-generated verbal directions to better understand why some parts of directions are perceived as being more difficult than the remaining steps. Insights from this analysis will lead to recommendations to improve the next generation of automated route guidance systems.

Stephen Hirtle; Kai-Florian Richter; Samvith Srinivas; Robert Firth

2010-01-01

136

A technique to prevent duodenal blowout after difficult gastrectomies.  

UK PubMed Central (United Kingdom)

A simple technique of decompressing the duodenum following difficult gastrectomies is described which can be applied across the country to reduce the incidence of this serious complication. The procedure has been used in 120 patients with no instance of duodenal blowout.

Raman RS; Kate V; Ananthakrishnan N

2013-01-01

137

Myth 5: Creativity Is Too Difficult to Measure  

Science.gov (United States)

|In his 1982 response to the myth that "creativity is too difficult to measure," Dr. Joe Khatena (a long-time contributor to the literature on creativity), characterized creativity as the "most exciting dimension of mental functioning." Building on a three-dimensional view of creativity (emphasizing the "individual," the "environment," and the…

Treffinger, Donald J.

2009-01-01

138

Transparent-cap-fitted colonoscopy shows higher performance with cecal intubation time in difficult cases.  

UK PubMed Central (United Kingdom)

AIM: To investigate the efficacy of cap-fitted colonoscopy (CFC) with regard to cecal intubation time. METHODS: Two hundred and ninety-five patients undergoing screening colonoscopy at Gospel Hospital, Kosin University College of Medicine were enrolled in this randomized controlled trial between January and December 2010. Colonoscopies were conducted by a single endoscopist. Patient characteristics including age, sex, body mass index, history of abdominal surgery, quality of preparation, and the presence of diverticulosis were recorded. RESULTS: One hundred and fifty patients were allocated into a CFC group and 145 into a non-CFC (NCF) group. Cecal intubations were achieved in all patients. Cecal intubation time in the CFC group was significantly shorter than in the NCF group for specific conditions: age ? 60 years, prior abdominal surgery, and poor bowel preparation. The number of detected adenomas was higher in the CFC group than in the NCF group (P = 0.040). CONCLUSION: CFC facilitated shortening of the cecal intubation time in difficult cases, and was more sensitive for detecting adenomas than was NCF.

Kim HH; Park SJ; Park MI; Moon W; Kim SE

2012-04-01

139

Difficult leg wounds successfully closed with decortication, bioresorbable ECM and NPWT.  

Science.gov (United States)

Complications of a missed compartment syndrome are severe. This case demonstrates the difficulty in dealing with such complications, including the difficult situation of being faced with limb salvage when amputation is the best option. Through a short case description and several images, it is demonstrated how even the most difficult wounds in cases like this can be dealt with and achieve a non-painful limb salvage. In particular, an extreme technique of decorticating the bone and applying bioresorbable extracellular matrix with negative pressure wound therapy was applied in order to achieve final wound closure and pain relief. This case demonstrates integration of multiple modalities for complex wound closure. PMID:24049815

Heiney, J; Redfern, R

2013-06-01

140

Difficult leg wounds successfully closed with decortication, bioresorbable ECM and NPWT.  

UK PubMed Central (United Kingdom)

Complications of a missed compartment syndrome are severe. This case demonstrates the difficulty in dealing with such complications, including the difficult situation of being faced with limb salvage when amputation is the best option. Through a short case description and several images, it is demonstrated how even the most difficult wounds in cases like this can be dealt with and achieve a non-painful limb salvage. In particular, an extreme technique of decorticating the bone and applying bioresorbable extracellular matrix with negative pressure wound therapy was applied in order to achieve final wound closure and pain relief. This case demonstrates integration of multiple modalities for complex wound closure.

Heiney J; Redfern R

2013-06-01

 
 
 
 
141

Geo mining conditions - the need for the study of rocks and deposits including rock mechanics in the science of mining; Geo-Bergbaubedingungen - Zur Notwendigkeit einer bergbaukundlichen Gebirgs- und Lagerstaettenlehre einschliesslich Gebirgsmechanik  

Energy Technology Data Exchange (ETDEWEB)

As already pointed out by the author in a publication in honour of his colleague Professor Wilke and in agreement with the latter he is pleading for re-inclusion of the study of rocks and deposits in the science of mining. Until fifty years ago each textbook in the discipline contained a corresponding chapter. However, the subjects now recommended should concentrate more on mining operations and mining economics than in the past and also include rock mechanics. Hence and for to delimitation from the geosciences it should be called ''geo mining conditions''. The author justifies his concerns not only by his own experience and knowledge, but also by that acquired together with Professor Wilke in various expert reports. In a prepared further article the procedure adopted by the author in his seminars in Leoben and relationship between the recommended subjects in the science of mining and the geosciences and in this context also the differences between the mining industry and construction industry will be examined. (orig.)

Fettweis, G.B.L. [Montanuniversitaet Leoben (Austria). Inst. fuer Bergbaukunde, Bergtechnik und Bergwirtschaft

2004-02-12

142

Cirugía maxilofacial ambulatoria: una estrategia en difíciles condiciones/ Ambulatory maxillofacial surgery: a strategy under difficult conditions  

Scientific Electronic Library Online (English)

Full Text Available Abstract in spanish Se exponen los resultados alcanzados en la cirugía mayor ambulatoria del Servicio de Cirugía Maxilofacial del Hospital Universitario "Dr. Miguel Enríquez" en el año 2003, con el objetivo de evaluar el comportamiento de esta actividad y su repercusión institucional y económica. Se realizó un análisis prospectivo de observación considerando las variables edad, sexo, tipo de anestesia, intervención quirúrgica realizada y complicaciones, las cuales fueron organizad (more) as, analizadas y tabuladas por el método simple de los palotes. El 61 % de los pacientes fue operado por este proceder, todos con anestesia local. Los indicadores hospitalarios mejoraron al reportarse por esta vía el 58,32 % del total de intervenciones quirúrgicas. El sexo femenino (63,38 %) y los grupos de edades de 15-24 y 35-44 años, fueron predominantes en nuestra serie. Las extracciones múltiples con alveoloplastias y la exéresis de los dientes retenidos, fueron las intervenciones quirúrgicas de mayor frecuencia, con el 48,02 y 38,60 %, respectivamente. No hubo complicaciones significativas. Se comparan los resultados con el de otros autores, que son muy similares en el orden cuantitativo. Se evalúa el impacto económico-social por el importante ahorro de recursos que representa este método, fundamentalmente al no haber gastos por hospitalización, y en la familia, que solo deja de trabajar el día de la operación, además de preferir este método por tener mayor acercamiento con el paciente. Abstract in english The results attained in the ambulatory major surgery of the Maxillofacial Surgery Service of “Dr. Miguel Enríquez” Teaching Hospital in 2003 are exposed aimed at evaluating the behavior of this activity and its institutional and economic impact. The method consisted in an observational prospective analysis, considering variables such as age, sex, type of anesthesia, surgery performed and complications, which were organized, analyzed and tabulated by the downs (more) troke method. It was observed that 61 % underwent this surgical procedure with local anesthesia. The hospital indicators improved on being reported by this way 58.32 % of the total of operations. Females (63.38 %) and the age groups 15-24 and 35-44 predominated in our series. Multiple extractions with alveoloplasties and the exeresis of the retained tooth were the most frequent operations, with 48.02 and 38.60 %, respectively. There were no significant complications. The results are compared with those obtained by other authors that were very similar in the quantitative sense. The economic-social impact is evaluated due to the significant saving of resources this method represents., since there are no hospitalization costs and the relatives only have to be absent from work the day of the operation. They also prefer this method because they are closer to the patient.

Hernández Pedroso, Luis; Ducasse Olivera, Pedro A.

2006-04-01

143

[A woman with restless genital syndrome: a difficult-to-treat condition].  

UK PubMed Central (United Kingdom)

BACKGROUND: Restless Genital Syndrome (RGS) refers to the uncommon experience of excessive and persistent sensations of genital and clitoral arousal, with either restless legs or symptoms of an overactive bladder, in the absence of conscious feelings of sexual desire. RGS is caused by a small fiber sensory neuropathy of the dorsal nerve of the clitoris. To date, there is no consensus on the treatment for RGS. CASE DESCRIPTION: A 58-year-old woman presented with persistent and unwanted genital arousal in her clitoris and labia minora. The arousal symptoms were accompanied by restless legs. Despite the pre-orgasmic feelings, orgasm was not achieved. Sexual activity did not resolve the symptoms. Two months prior to the onset of RGS symptoms a presacral abscess had been drained. CONCLUSION: Lidocaine, oxazepam, clonazepam, tramadol and transcutaneous electrical nerve stimulation, combined with psychotherapeutic counseling, have been described as the most appropriate treatment modalities for RGS based on the experiences to date.

Spoelstra SK; Waldinger M; Nijhuis ER; Weijmar Schultz WC

2013-01-01

144

Success Nonetheless: Making public utilities work in small-scale democracies despite difficult social capital conditions  

Digital Repository Infrastructure Vision for European Research (DRIVER)

INTRODUCTION: The fate of societies and their governments intertwined. Academics and policy makers have long sought to understand how the attributes of a people translate to the form of government that arises and survives. In particular, they have explored which key social levers can increase the su...

Douglas, S.

145

[Cytomegalovirus and systemic lupus: severe infection and difficult diagnosis].  

UK PubMed Central (United Kingdom)

INTRODUCTION: There are a few reports only on cytomegalovirus (CMV) reactivation in lupus. Diagnosis of this infection is difficult and can be associated with of a poor outcome. We report three cases of infection with CMV that occurred in patients with lupus and review the literature. CASE REPORTS: The three reported patients presented with fever, polyarthritis, myocarditis and enteritis. Lupus was longstanding and the patients were receiving corticosteroids or cyclophosphamide. There was no major CD4 lymphopenia. The diagnosis was obtained with the presence of antigenemia pp65. The outcome was favorable with antiviral therapy in two patients, while the remaining patient died. In the English literature, pulmonary and intestinal involvement seem frequent, and associated with poor prognosis. CONCLUSION: In systemic lupus CMV infection is often serious and difficult to diagnose. Risk factors, treatment and prophylaxis remain to be evaluated in this population. The incidence of this infection could increase among patients receiving a biotherapy.

Declerck L; Queyrel V; Morell-Dubois S; Dewilde A; Charlanne H; Launay D; Lambert M; Hachulla E; Hatron PY

2009-09-01

146

Interesting cases which were difficult to diagnose by CT  

Energy Technology Data Exchange (ETDEWEB)

Computed tomography (CT) clinically provides us with much more useful diagnostic information regarding the localization, size, shape, extent and inner structure of the lesions and in some cases the specific diagnosis can be also obtained by CT alone. However, it is usually difficult to define the longitudinal extent of the lesions, their relation to adjacent tissues, the originated site in enormous lesion and histological type also. At CT examination, it is essential to recognize these drawbacks and limitations on CT. From these points of view, six interesting cases (i.e. pericardial diverticulum, hepatoma with retroperitoneal metastasis, cholangiohepatoma, afferent loop syndrome, invagination and retroperitoneal malignant schwannoma) which were difficult to diagnose by CT and proved ultimately with operation or autopsy were illustrated with some reviews.

Ueki, K.; Okubo, K.; Shinohara, S. (Kagoshima Univ. (Japan). Faculty of Medicine)

1981-06-01

147

Weathering the storm: persevering through a difficult time.  

UK PubMed Central (United Kingdom)

Parse's human becoming theory of nursing and research methodology were used to uncover the structure of the lived experience of persevering through a difficult time for eight women with ovarian cancer. Three core concepts surfaced: deliberately persisting, significant engagements, and shifting life patterns. Through conceptual integration these emerged as powering valuing in the connecting-separating of originating. Deliberately persisting, an active forging onward, was supported in the perseverance literature. The concept significant engagements, a variety of encounters uniquely important to an individual, was further clarified. Shifting life patterns, the changing ways of living as the difficult time emerged, was not addressed in the perseverance literature and represents new knowledge to the discipline of nursing.

Allchin-Petardi L

1998-01-01

148

Management of difficult airway in penetrating cervical spine injury.  

Science.gov (United States)

Management of airway in trauma victim with penetrating cervical/thoracic spine injury has always been a challenge to the anaesthesiologist. Stabilisation of spine during airway manipulation, to prevent any further neural damage, is of obvious concern to the anaesthesiologist. Most anaesthesiologists are not exposed to direct laryngoscopy and intubation in lateral position during their training period. Tracheal intubation in the lateral position may be unavoidable in some circumstances. Difficult airway in an uncooperative patient compounds the problem to secure airway in lateral position. We present a 46-year-old alcoholic, hypertensive, morbidly obese person who suffered a sharp instrument (screwdriver) spinal injury with anticipated difficult intubation; the case was managed successfully. PMID:20532076

Prasad, Mukesh Kumar; Sinha, Ajay Kumar; Bhadani, Umesh Kumar; Chabra, Balbir; Rani, Kanchan; Srivastava, Bhavana

2010-01-01

149

Difficult intubation due to chronic hiccup: a case report  

Directory of Open Access Journals (Sweden)

Full Text Available Hiccup is described as a spasm of the diaphragm that causes a sudden inhalation followed by rapid closure of the glottis that produces a sound. Hiccup cause difficulties for medical procedures such as surgery, endoscopy or magnetic resonance imaging. In the literature, hiccup is presented as a situation that is seen due to anesthesia and most studies describe to manage anesthesia-related hiccup. The data about difficult intubation because of hiccup is lacking. Hereby, we present a case of difficult intubation due to chronic hiccup. The patient had a chronic hiccup associated with grade 3 esophagitis and hiatal hernia. Laparoscopic Nissen fundoplication and thoracoscopic phrenic nerve ablation was performed. Our patient was hiccupping during surgery. However, the severity and the frequency of the hiccup attacks were decreased after surgery.

Erman Aytac; Ziya Salihoglu; Ahmet Demirkaya; Bilgi Baca; Kamil Kaynak; Tayfun Karahasanoglu; Ismail Hakki Hamzaoglu

2011-01-01

150

Dexmedetomidine for conscious sedation in difficult awake fiberoptic intubation cases.  

Science.gov (United States)

Currently used methods of sedation for fiberoptic intubation such as benzodiazepines, propofol, or opioids have their limitations. Dexmedetomidine (DEX) is a selective alpha-2 adrenergic agonist that has been used clinically for its sympatholytic, analgesic, and sedative properties. We report on 4 patients with particularly difficult airways who underwent successful awake fiberoptic intubation with DEX. Dexmedetomidine was used to provide a moderate level of conscious sedation without causing respiratory distress or hemodynamic instability during fiberoptic intubation. PMID:17379129

Bergese, Sergio D; Khabiri, Babak; Roberts, William D; Howie, Michael B; McSweeney, Thomas D; Gerhardt, Mark A

2007-03-01

151

Dexmedetomidine for conscious sedation in difficult awake fiberoptic intubation cases.  

UK PubMed Central (United Kingdom)

Currently used methods of sedation for fiberoptic intubation such as benzodiazepines, propofol, or opioids have their limitations. Dexmedetomidine (DEX) is a selective alpha-2 adrenergic agonist that has been used clinically for its sympatholytic, analgesic, and sedative properties. We report on 4 patients with particularly difficult airways who underwent successful awake fiberoptic intubation with DEX. Dexmedetomidine was used to provide a moderate level of conscious sedation without causing respiratory distress or hemodynamic instability during fiberoptic intubation.

Bergese SD; Khabiri B; Roberts WD; Howie MB; McSweeney TD; Gerhardt MA

2007-03-01

152

Incidence and predictors of difficult mask ventilation and intubation.  

UK PubMed Central (United Kingdom)

BACKGROUND: This study is aimed to determine the incidence and predictors of difficult and impossible mask ventilation. MATERIALS AND METHODS: Information like age, snoring history, obstructive sleep apnea, dental and mandibular abnormalities, macroglossia, grading like SLUX, Mallampatti, Cormack Lehanne, atlantooccipital extension, presence of beard or moustache, mouth opening were collected. During mask ventilation, the information related to the ventilation and intubation was collected. All variables found to be significant in univariate analysis were subjected to the multivariate logistic regression model to identify independent predictors of measured outcome. RESULTS: Difficult mask ventilation (DMV) was observed in 30 male patients and 9 female patients. Of the 40 patients who had difficult intubation (DI), 7 patients had both DMV and intubation and 1 patient was of impossible mask ventilation/ intubation. Snoring was the lone significant risk factor for DMV. The risk factors identified for DI were snoring, retrognathia, micrognathia, macroglossia, short thick neck, Mallampatti grade [III/IV], abnormal SLUX grade, Cormack Lehanne grade [II,III/IV], abnormal atlantooccipital extension grading, flexion/extension deformity of neck, protuberant teeth, cervical spine abnormality, mouth opening < 3 cm, and BMI > 26 kg/m(2). BMI > 26 kg/m(2) and atlantooccipital extension grade > 3 were independent risk factors for DI and the presence of two of the variables made the sensitivity and specificity of 43% and 99% respectively with a positive predictive value of 74%. CONCLUSIONS: The predictive score may lead to a better anticipation of difficult airway management, potentially deceasing the morbidity and mortality resulting from hypoxia or anoxia with failed ventilation.

Shah PN; Sundaram V

2012-10-01

153

Hemorrhagic herpes encephalitis: A difficult diagnosis in computed tomography  

Energy Technology Data Exchange (ETDEWEB)

Herpes simplex encephalitis (HSE) is the most common sporadically appearing encephalitis in Central Europe. Differential diagnosis to brain tumors or spontaneous intercerebral hemorrhage is difficult. There are CT scan findings which are characteristic of HSE but there are no pathognomonic patterns. These characteristic findings are helpful in differential diagnosis to neoplastic or vascular processes. Thus, other diagnostic procedures (i.e. brain biopsy) to confirm diagnosis of HSE and effective therapy may be carried out in time. The difficulties in differential diagnosis are shown by the presented case.

Neumann, N.U.; von Albert, H.H.

1982-02-04

154

Hemorrhagic herpes encephalitis: A difficult diagnosis in computed tomography  

International Nuclear Information System (INIS)

Herpes simplex encephalitis (HSE) is the most common sporadically appearing encephalitis in Central Europe. Differential diagnosis to brain tumors or spontaneous intercerebral hemorrhage is difficult. There are CT scan findings which are characteristic of HSE but there are no pathognomonic patterns. These characteristic findings are helpful in differential diagnosis to neoplastic or vascular processes. Thus, other diagnostic procedures (i.e. brain biopsy) to confirm diagnosis of HSE and effective therapy may be carried out in time. The difficulties in differential diagnosis are shown by the presented case. (orig.)

1982-02-04

155

The Minister Council decree about conditions for to bring into the Polish customs area, to take away from the Polish customs area, and to transit through this area nuclear materials, radioactive sources and device including such sources  

International Nuclear Information System (INIS)

The decree refers to conditions for to bring into the Polish customs area, to take away from the Polish customs area, and to transit through this area nuclear materials, radioactive sources and devices containing such sources.

2002-12-11

156

Development of the Schedule for Multiple Parallel "Difficult" Peptide Synthesis on Pins  

Science.gov (United States)

Unified schedule for multiple parallel solid-phase synthesis of so-called “difficult” peptides on polypropylene pins was developed. Increase in the efficiency of 9-fluorenyl(methoxycarbonyl) N-terminal amino-protecting group removal was shown to have a greater influence on the accuracy of the “difficult” peptide synthesis than the use of more efficient amino acid coupling reagents such as aminium salts. Hence the unified schedule for multiple parallel solid-phase synthesis of “difficult” peptides included the procedure for N-terminal amino group deprotection modified by applying a more efficient reagent for the deprotection and the standard procedure of amino acid coupling by carbodiimide method with an additional coupling using aminium salts, if necessary. Amino acid coupling with the help of carbodiimide allows to follow the completeness of the coupling via the bromophenol blue indication, thus providing the accuracy of the synthesis and preventing an overexpenditure of expensive reagents. About 100 biotinylated hepatitis C virus envelope protein fragments, most of which represented “difficult” peptides, were successfully obtained by synthesis on pins with the help of the developed unified schedule.

Kolesanova, Ekaterina F.; Sanzhakov, Maxim A.; Kharybin, Oleg N.

2013-01-01

157

How can schools build learning organisations in difficult education contexts?  

Directory of Open Access Journals (Sweden)

Full Text Available There is paucity in the study of learning organisations within the education sector and particularly in schools working in difficult socio-economic contexts, such as those studied in this investigation. In this qualitative study I therefore sought evidence from teachers, in one of the districts of Gauteng province, through in-depth, semi-structured focus group interviews to establish what a learning organisation is. Using data obtained through two in-depth, semi-structured focus group interviews with 16 teachers, themes were constructed to theorise their experiences on what a learning organisation is. The results showed that teacher commitment to personal learning enhanced student achievement. This study contributes to the understanding of theories on learning organisations from the experiences of these teachers working in disadvantaged townships schools.

Kholeka Constance Moloi

2010-01-01

158

How can schools build learning organisations in difficult education contexts?  

Scientific Electronic Library Online (English)

Full Text Available Abstract in english There is paucity in the study of learning organisations within the education sector and particularly in schools working in difficult socio-economic contexts, such as those studied in this investigation. In this qualitative study I therefore sought evidence from teachers, in one of the districts of Gauteng province, through in-depth, semi-structured focus group interviews to establish what a learning organisation is. Using data obtained through two in-depth, semi-structure (more) d focus group interviews with 16 teachers, themes were constructed to theorise their experiences on what a learning organisation is. The results showed that teacher commitment to personal learning enhanced student achievement. This study contributes to the understanding of theories on learning organisations from the experiences of these teachers working in disadvantaged townships schools.

Moloi, Kholeka Constance

2010-01-01

159

Radon mitigation experience in difficult-to-mitigate schools  

International Nuclear Information System (INIS)

Initial radon mitigation experience in schools has shown sub-slab depressurization (SSD) to be generally effective in reducing elevated levels of radon in schools that have a continuous layer of clean, coarse aggregate underneath the slab. However, mitigation experience is limited in schools without sub-slab aggregate and in schools with characteristics such as return-air ductwork underneath the slab or unducted return-air plenums in the drop ceiling that are open to the sub-slab area (via open tops of block walls). Mitigation of schools with utility tunnels and of schools constructed over crawl spaces is also limited. Three Maryland schools exhibiting some of the above characteristics are being researched to help understand the mechanisms that control radon entry and mitigation in schools where standard SSD systems are not effective. This paper discusses specific characteristics of potentially difficult-to-mitigate schools and, where applicable, details examples from the three Maryland schools.

1990-01-01

160

Structural health monitoring systems in difficult environments. Offshore wind turbines  

Energy Technology Data Exchange (ETDEWEB)

The paper discusses the design and capability of Structural Health Monitoring Systems (SHMS) deployed on Offshore Wind Turbines together with the management of the tasks and risks in the offshore environment. The application of SHMS in difficult environments is a particularly challenging task, where ease of installation, ruggedness and reliability of equipment is essential in providing the key information of the structural integrity of Offshore Wind Turbine Towers. This information is required to evaluate the structural response, status and remaining operational life of the structure. The installation and commissioning of such systems have a significant focus on safety and access to the structures where onsite retrofitting of sensors and instrumentation are carried out in the field. Experience has been gained during the installation and commissioning of over 30 systems that have been deployed in the field in the UK offshore sector over the last two year period. (orig.)

Faulkner, P.; Cutter, P.; Owens, A. [Strainstall Monitoring, Midsomer Norton (United Kingdom)

2012-07-01

 
 
 
 
161

Sampling in difficult to access refugee and immigrant communities.  

UK PubMed Central (United Kingdom)

We evaluated sampling strategies and trust-building activities in a large multiphase epidemiologic study of torture prevalence in populations that were difficult to locate and enroll. Refugee groups under study were Somalis from Somalia and Oromos from Ethiopia who were living in Minneapolis and St. Paul, Minnesota, in 1999-2002. Without a complete sampling frame from which to randomly recruit participants, we employed purposive sampling methods. Through comparative and statistical analyses, we found no apparent differences between our sample and the underlying population and discovered no effects of recruiting methods on study outcomes, suggesting that the sample could be analyzed with confidence. Ethnographic trust and rapport-building activities among investigators, field staff, and immigrant communities made it possible to obtain the sample and gather sensitive data. Maintaining a culture of trust was crucial in recovering from damaging environmental events that threatened data collection.

Spring M; Westermeyer J; Halcon L; Savik K; Robertson C; Johnson DR; Butcher JN; Jaranson J

2003-12-01

162

[Anesthetic management of Menkes disease infant with difficult vascular access].  

UK PubMed Central (United Kingdom)

We report anesthetic management of a 6-month-old boy with Menkes disease who underwent three surgeries for vesicoureteral reflux, rupture of the bladder diverticulum, inguinal hernia, and gastroesophageal reflux. Menkes disease is a rare sex-linked disorder of copper absorption and metabolism. Anesthetic management of such patients is rather challenging because of high incidence of seizures, gastroesophageal reflux with the risk of aspiration, hypothermia, airway and vascular complications. In our patient general anesthesia was uneventfully maintained by sevoflurane combined with intravenous remifentanil and fentanyl. We experienced no major complications except some difficulties with intravenous and arterial cannulation. It was especially difficult to establish intravenous and invasive blood pressure lines because of tortuous blood vessels in this patient. We conclude that in patients with Menkes disease scheduled for surgery intravenous access should be established before the induction of general anesthesia. The necessity of invasive blood pressure monitoring should be also carefully considered beforehand.

Yoshida T; Furutani K; Hashimoto T; Taneoka M; Tobita T; Baba H

2010-10-01

163

Hydraulically actuated fuel injector including a pilot operated spool valve assembly and hydraulic system using same  

Science.gov (United States)

The present invention relates to hydraulic systems including hydraulically actuated fuel injectors that have a pilot operated spool valve assembly. One class of hydraulically actuated fuel injectors includes a solenoid driven pilot valve that controls the initiation of the injection event. However, during cold start conditions, hydraulic fluid, typically engine lubricating oil, is particularly viscous and is often difficult to displace through the relatively small drain path that is defined past the pilot valve member. Because the spool valve typically responds slower than expected during cold start due to the difficulty in displacing the relatively viscous oil, accurate start of injection timing can be difficult to achieve. There also exists a greater difficulty in reaching the higher end of the cold operating speed range. Therefore, the present invention utilizes a fluid evacuation valve to aid in displacement of the relatively viscous oil during cold start conditions.

Shafer, Scott F. (Morton, IL)

2002-01-01

164

Usefulness of percutaneous transhepatic cholangioscopic lithotomy for removal of difficult common bile duct stones.  

UK PubMed Central (United Kingdom)

BACKGROUND/AIMS: Approximately 5% to 10% of common bile duct (CBD) stones are difficult to remove by conventional endoscopic methods. Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) can be an alternative method for this condition, but is not well established yet. The aim of this study was to evaluate the clinical efficacy and safety of PTCSL for removal of difficult CBD stones. METHODS: This study is a retrospective review of 34 consecutive patients who underwent unsuccessful removal of CBD stones using conventional endoscopic methods between December 2008 and July 2010 and were subsequently treated using PTCSL. RESULTS: Among 443 patients with CBD stones, 34 patients (7.8%) failed to achieve stone removal using conventional endoscopic methods. Of these 34 patients, 33 were treated using PTCSL. In all 33 cases (100%), complete stone removal was achieved using PTCSL. Most complications (15/17, 88.2%) were mild and transient. Major complications occurred in two patients (6.1%) who experienced hemobilia, and percutaneous transhepatic biliary drainage tract disruption, respectively; which were fully recovered without mortality. CONCLUSIONS: Despite prolonged hospital stay and temporary decline of quality of life, PTCSL is an effective and safe method in the management of difficult CBD stones, especially in patients with difficulty in approaching the affected bile duct.

Lee JH; Kim HW; Kang DH; Choi CW; Park SB; Kim SH; Jeon UB

2013-01-01

165

Treatment of inguinal hernia in a difficult environment: feasibility and efficacy of ilioinguinal and iliohypogastric blocks.  

UK PubMed Central (United Kingdom)

Hernia repair is a very frequent surgical procedure; nonetheless, it is estimated that in Africa, only one patient in five undergoes this procedure. Patients and methods. We evaluated the feasibility of this surgery under ilioinguinal and iliohypogastric nerve blocks in difficult environments. The medical-surgical group supporting Operation Unicorn has treated 48 inguinal hernias as free medical aid, including 34 with these nerve blocks. Results. The block did not fail in any case. The mean time until discharge was 6.85 h, which meant that outpatient surgery was possible. Discussion and conclusion. This type of anesthesia is interesting in difficult environments. It is a safe, inexpensive, and easy to learn technique. These qualities should promote its use in countries with a low GNP.

Goutorbe P; Lacroix G; Pauleau G; Daranda E; Goin G; Bordes J; Meaudre E; Balandraud P

2013-06-01

166

[Difficult respiratory management in a patient with bilateral giant bullae].  

Science.gov (United States)

We report a case of bilateral giant bullae in a patient with multiple traumas. He had his arm amputated at the shoulder because of a machine accident and admitted to our hospital. Chest X-ray showed right-sided pneumothorax with bilateral giant bullae. Trimming of the stump was performed immediately after the placement of a right chest tube. He gradually developed hypoxia and hypercapnia with acidemia during the operation because of atelectasis due to sputum. Postoperatively, enlargement of right giant bulla led to frequent respiratory failure and he received a bilateral bullectomy through a median sternotomy 3 weeks after the accident. It was difficult to ventilate him due to air leak from the bilateral bulla and SpO2 dropped to below 70% with 100% oxygen. We continued the operation with standby extracorporeal membrane oxygenator (ECMO). Although the operation was finished without ECMO finally, ECMO had better been kept ready during anethesia with giant bullae when life threatening complication may occur at any point. PMID:19860232

Fujita, Ayaka; Hashiba, Eiji; Takahira, Yoko; Kitayama, Masatou; Tubo, Toshihito; Hirota, Kazuyoshi

2009-10-01

167

[Difficult respiratory management in a patient with bilateral giant bullae].  

UK PubMed Central (United Kingdom)

We report a case of bilateral giant bullae in a patient with multiple traumas. He had his arm amputated at the shoulder because of a machine accident and admitted to our hospital. Chest X-ray showed right-sided pneumothorax with bilateral giant bullae. Trimming of the stump was performed immediately after the placement of a right chest tube. He gradually developed hypoxia and hypercapnia with acidemia during the operation because of atelectasis due to sputum. Postoperatively, enlargement of right giant bulla led to frequent respiratory failure and he received a bilateral bullectomy through a median sternotomy 3 weeks after the accident. It was difficult to ventilate him due to air leak from the bilateral bulla and SpO2 dropped to below 70% with 100% oxygen. We continued the operation with standby extracorporeal membrane oxygenator (ECMO). Although the operation was finished without ECMO finally, ECMO had better been kept ready during anethesia with giant bullae when life threatening complication may occur at any point.

Fujita A; Hashiba E; Takahira Y; Kitayama M; Tubo T; Hirota K

2009-10-01

168

The Barnes case: taking difficult futility cases public.  

UK PubMed Central (United Kingdom)

Futility disputes are increasing and courts are slowly abandoning their historical reluctance to engage these contentious issues, particularly when confronted with inappropriate surrogate demands for aggressive treatment. Use of the judicial system to resolve futility disputes inevitably brings media attention and requires clinicians, hospitals, and families to debate these deep moral conflicts in the public eye. A recent case in Minnesota, In re Emergency Guardianship of Albert Barnes, explores this emerging trend and the complex responsibilities of clinicians and hospital administrators seeking to replace an unfaithful surrogate demanding aggressive therapy. Use of the courts requires the coordinated commitment of significant institutional resources, management of intense media scrutiny and individual and organizational courage to enter the unpredictable world of litigation. Given the dearth of legislative guidance on medical futility, individual clinicians and institutions will continue to bear the difficult responsibility for resolution of individual futility disputes. The Barnes case illustrates how one institution successfully used the judicial system to replace an unfaithful surrogate, cease the provision of inappropriate aggressive care, and stimulate a community dialogue about appropriate care at the end of life.

Mickelsen RA; Bernstein DS; Marshall MF; Miles SH

2013-01-01

169

Bronchogenic Cyst in a Patient with Difficult Asthma  

Directory of Open Access Journals (Sweden)

Full Text Available Difficult to treat asthma is an asthma syndrome that brings in our mind other differentials. Mediastinal masses are not common findings, but are important variables. Bronchogenic cyst is a congenital anomaly of the foregut that is typically found in the mediastinum and diagnosed accidentally. We present a 4-year-old girl with allergic asthma that began at 8-months of age and finally a bronchogenic cyst was detected in this patient. The patient had history of asthma since she was eight months old. She had a history of several asthma attacks which had partly responded to asthma management. During the last episodes of asthma attacks, she was hospitalized in Pediatric Intensive Care Unit. Imaging studies showed a 4×3 cm mass in the posterior part of the thoracic cavity that had led to tracheal narrowing was found for which the patient underwent thoracotomy and in surgical exploration a cyst that had compressed the thoracic trachea. Pathological examination of the cyst revealed a bronchogenic cyst. Bronchogenic cyst is an uncommon developmental abnormality but in a patient with obstructive pattern of airways it should be considered in differential diagnosis of asthma, especially if the asthma management is not successful.

Soheil Ben Razavi; Mohammad Hassan Bemanian; Shokooh Taghipoor; Reza Nafisi Moghadam; Zahra Behnamfar

2010-01-01

170

The Difficult Empowerment in Danish Hospital: Power to the nurses!?  

DEFF Research Database (Denmark)

The employee empowerment literature promises better organizational performance as well as more motivated and satisfied employees. However, this literature often neglects the specific context of public services in general, or the health care sector, hospitals, and nursing in particular. Nurses in Danish public hospitals work in a unique situation that makes the uncritical transfer of empowerment interventions intended to redesign their work difficult or even unfeasible. Analysis from an institutional perspective of the ongoing power struggle between agens of change at several levels in the Danish health care field indicates how norms originating from the public bureaucracy and medical comminities constrain such micro-level change initiatives. According to an organizational change perspective, narrow interventions would likely be inadequate, since conflict is likely given the particular characteristics of public organizations, and the specific attitudes of physicians and politicians and their desire to control the hospital sector. At the same time, this paper also emphasizes that the empowerment concept is likely to appeal to hospital managers and nurses in the Danish public hospital sector, since it builds on the nursing professions's self-conceptualization and is associated with better organizational performance. Our analysis starts by clarifying the concept of "nursing empowerment", and then applies a field perspective on Danish hospitals in order to identify the forces that may limit the possibility of empowering nurses and nursing. Based on this analysis, we discuss how to bring about successful nursing empowerment interventions.

Witt, Flemming; Nielsen, JØrn Flohr

2005-01-01

171

Radionuclides difficult to measure in waste packages. Final report  

Energy Technology Data Exchange (ETDEWEB)

In this study nuclide specific correlation analyses between key nuclides that can be easily measured and nuclides that are difficult to measure are presented. Data are taken from studies and data compilations from various countries. The results of this study can serve to perform assays of the nuclide specific radionuclide contents in waste packages by gamma measurements of {sup 60}Co and {sup 137}Cs and calculation of the contents of other nuclides via the correlation analyses, sometimes referred to as `scaling factor method`. It can thus be avoided to have to take samples from the waste for separate analysis. An attempt is made to also investigate the physical and chemical backgrounds behind the proposed correlations. For example, a formation pathway common to the two nuclides to be correlated can be regarded as an explanation, if a good correlation is found. On the other hand, if the observed correlation is of poor quality, reasons may possibly lie in different behaviour of the two nuclides in the water system of the nuclear plant. This implies not only chemical solubility, transfer constants etc. in the water system, which would not only affect the proportionality between the two nuclides, but a different behavior in different parts of the water system must be assumed (e.g. different filter efficiencies etc). 47 refs, 57 figs, 40 tabs.

Thierfeldt, S.; Deckert, A. [Brenk Systemplanung, Aachen (Germany)

1995-11-01

172

Precut sphincterotomy: a reliable salvage for difficult biliary cannulation.  

UK PubMed Central (United Kingdom)

Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and precut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% successful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when administered to the proper patient. Although precut sphincterotomy ensures over 90% success of biliary cannulation, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also reported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilatation of their biliary tract. Nevertheless, precut sphincterotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, efficacy and potential complications of precut sphincterotomy.

Saritas U; Ustundag Y; Harmandar F

2013-01-01

173

Precut sphincterotomy: a reliable salvage for difficult biliary cannulation.  

Science.gov (United States)

Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and precut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% successful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when administered to the proper patient. Although precut sphincterotomy ensures over 90% success of biliary cannulation, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also reported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilatation of their biliary tract. Nevertheless, precut sphincterotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, efficacy and potential complications of precut sphincterotomy. PMID:23326155

Saritas, Ulku; Ustundag, Yucel; Harmandar, Ferda

2013-01-01

174

Radionuclides difficult to measure in waste packages. Final report  

International Nuclear Information System (INIS)

In this study nuclide specific correlation analyses between key nuclides that can be easily measured and nuclides that are difficult to measure are presented. Data are taken from studies and data compilations from various countries. The results of this study can serve to perform assays of the nuclide specific radionuclide contents in waste packages by gamma measurements of 60Co and 137Cs and calculation of the contents of other nuclides via the correlation analyses, sometimes referred to as 'scaling factor method'. It can thus be avoided to have to take samples from the waste for separate analysis. An attempt is made to also investigate the physical and chemical backgrounds behind the proposed correlations. For example, a formation pathway common to the two nuclides to be correlated can be regarded as an explanation, if a good correlation is found. On the other hand, if the observed correlation is of poor quality, reasons may possibly lie in different behaviour of the two nuclides in the water system of the nuclear plant. This implies not only chemical solubility, transfer constants etc. in the water system, which would not only affect the proportionality between the two nuclides, but a different behavior in different parts of the water system must be assumed (e.g. different filter efficiencies etc). 47 refs, 57 figs, 40 tabs.

1995-01-01

175

Validating the difficult intravenous access clinical prediction rule.  

UK PubMed Central (United Kingdom)

OBJECTIVE: This study aimed to evaluate the difficult intravenous access (DIVA) score, a clinical prediction rule, which states that children with a score of 4 or more will have a 50% higher rate of a failed intravenous placement on the first attempt compared with the mean failure rate. METHODS: This was a prospective cohort study in children 0 to 14 years, undergoing peripheral intravenous placement by doctors in the emergency department of a medium-sized general hospital. Before intravenous placement attempts, demographic data inclusive of age and DIVA score were recorded. A maximum of 3 attempts per doctor were allowed, after which a more senior doctor undertook subsequent attempts. The site of successful placement was recorded. RESULTS: Five hundred children were enrolled. The male-female ratio was 1.3:1. One hundred thirty-three (26.6%) were less than 1 year, 103 (20.6%) were aged 1 to 2 years, and 264 (52.8%) were 3 years or older. One hundred ten children (22%) had a failed intravenous placement on the first attempt. Of the 151 children with a DIVA score of 4 or more, 57 (37.7%) had a failed intravenous placement, validating the clinical prediction rule. Only 5 subjects (1%) did not have intravenous placement after 6 attempts. CONCLUSIONS: This study validates DIVA score and provides a simple tool that can enhance the accuracy of the information offered to parents as it relates to the success rates of intravenous placement in children.

O'Neill MB; Dillane M; Hanipah NF

2012-12-01

176

[The surgical treatment of stomach ulcers difficult to remove  

UK PubMed Central (United Kingdom)

Experience in surgical treatment of 154 patients with large gastric ulcers and ulcers of the cardiac part of the stomach is discussed. All the patients underwent resection of the stomach in various modifications with a 2.6% mortality rate. Penetration was encountered in 62.4% of patients with large ulcers and in 69.2% of those with ulcers of the cardia. In 13.6% of patients with "difficult" gastric ulcers ligation of the main trunk of the left gastric artery becomes necessary, which may be the cause of incompetence of the gastrointestinal anastomosis in performance of tubular resection. Intraoperative angiotensiometry showed that in ligation of the trunk of the left gastric artery the intramural blood flow in the distal segment of the tubular gastric stump was reduced by one third. Preservation of the gastroepiploic arteries in mobilization of the stomach in this situation prevents ischemia of the gastric stump. The method of tubular resection makes it possible to avoid subtotal removal of the organ in most patients with gastric ulcers which are hardly removable and allows the Billroth I operation to be carried out.

Chernyshev VN; Aleksandrov IK

1992-02-01

177

Radioactivity [includes radioactivity levels  

International Nuclear Information System (INIS)

The Environmental Digest for Wales is prepared on a regular basis by the Welsh Office and brings together data on the Welsh environment from a number of sources. Most of the information contained in the tables is collected as part of continuous monitoring programmes and will be updated in future editions. Some tables contain information collected only once as part of a survey or study, and will not be included in future volumes of the series. The section on Radioactivity includes tables of concentration in air, rainwater, milk, fish and gives details of the liquid radioactive wastes discharged from Welsh nuclear power stations (at Wylfa and Trawsfynydd) and the gamma dose rates around Welsh nuclear power stations. An appendix includes a glossary of terms used, the units of radioactivity and a list of radionuclides present in the environment. (author).

1988-01-01

178

Radioactivity (includes radioactivity levels)  

Energy Technology Data Exchange (ETDEWEB)

The Environmental Digest for Wales is prepared on a regular basis by the Welsh Office and brings together data on the Welsh environment from a number of sources. Most of the information contained in the tables is collected as part of continuous monitoring programmes and will be updated in future editions. Some tables contain information collected only once as part of a survey or study, and will not be included in future volumes of the series. The section on Radioactivity includes tables of concentration in air, rainwater, milk, fish and gives details of the liquid radioactive wastes discharged from Welsh nuclear power stations (at Wylfa and Trawsfynydd) and the gamma dose rates around Welsh nuclear power stations. An appendix includes a glossary of terms used, the units of radioactivity and a list of radionuclides present in the environment. (author).

1989-01-01

179

Busulfan 12 mg/kg plus melphalan 140 mg/m2 versus melphalan 200 mg/m2 as conditioning regimens for autologous transplantation in newly diagnosed multiple myeloma patients included in the PETHEMA/GEM2000 study  

Science.gov (United States)

Background The aim of this study was to compare the long-term safety and efficacy of oral busulfan 12 mg/kg plus melphalan 140 mg/m2 and melphalan 200 mg/m2 as conditioning regimens for autologous stem cell transplantation in newly diagnosed patients with multiple myeloma in the GEM2000 study. Design and Methods The first 225 patients received oral busulfan 12 mg/kg plus melphalan 140 mg/m2; because of a high frequency of veno-occlusive disease, the protocol was amended and a further 542 patients received melphalan 200 mg/m2. Results Engraftment and hospitalization times were similar in both groups. Oral busulfan 12 mg/kg plus melphalan 140 mg/m2 resulted in higher transplant-related mortality (8.4% versus 3.5%; P=0.002) due to the increased frequency of veno-occlusive disease in this group. Response rates were similar in both arms. With respective median follow-ups of 72 and 47 months, the median progression-free survival was significantly longer with busulfan plus melphalan (41 versus 31 months; P=0.009), although survival was similar to that in the melphalan 200 mg/m2 group. However, access to novel agents as salvage therapy after relapse/progression was significantly lower for patients receiving busulfan plus melphalan (43%) than for those receiving melphalan 200 mg/m2 (58%; P=0.01). Conclusions Conditioning with oral busulfan 12 mg/kg plus melphalan 140 mg/m2 was associated with longer progression-free survival but equivalent survival to that achieved with melphalan 200 mg/m2 but this should be counterbalanced against the higher frequency of veno-occlusive disease-related deaths. This latter fact together with the limited access to novel salvage therapies in patients conditioned with oral busulfan 12 mg/kg plus melphalan 140 mg/m2 may explain the absence of a survival difference. Oral busulfan was used in the present study; use of the intravenous formulation may reduce toxicity and result in greater efficacy, and warrants further investigation in myeloma patients. (Clinicaltrials.gov identifier: NCT00560053).

Lahuerta, Juan Jose; Mateos, Maria Victoria; Martinez-Lopez, Joaquin; Grande, Carlos; de la Rubia, Javier; Rosinol, Laura; Sureda, Anna; Garcia-Larana, Jose; Diaz-Mediavilla, Joaquin; Hernandez-Garcia, Miguel T.; Carrera, Dolores; Besalduch, Joan; de Arriba, Felipe; Oriol, Albert; Escoda, Lourdes; Garcia-Frade, Javier; Rivas-Gonzalez, Concepcion; Alegre, Adrian; Blade, Joan; San Miguel, Jesus F.

2010-01-01

180

In tight : defining tight gas as difficult as producing it  

Energy Technology Data Exchange (ETDEWEB)

Tight gas is considered to be natural gas contained in difficult to produce rock formations that require special completion, stimulation, and production techniques to achieve economic production. Tight gas reservoirs are low-permeability sands or carbonate reservoirs that typically occur in basin-centred or deep-basin settings. For Canadian producers, tight gas plays have grown increasingly more attractive in recent years because of the price environment as well as improved exploration and exploitation technologies. There has been a direct relationship between gas prices and the development of unconventional resources in Canada. The differences between Canadian basins and basins in the United States were discussed in relation to various drilling strategies. In Canada, the strategy has been to map and drill stratigraphic sweet spots, relatively small bodies of rock with conventional reservoir quality within larger tight-gas trends or fairways. It was suggested that 3 major technological advances have stimulated tight gas production in Western Canada: directional and horizontal drilling; under-balanced drilling and advanced fracture stimulation. In tight gas reservoirs, the key to production is to intersect the natural fracture system present within the rock to provide more pathways in which the hydrocarbons can flow to the wellbore. Details of EnCana Corporation's drilling strategies and activities was presented, with specific reference to their recent focus on tight gas opportunities. It was suggested that the key component of any large-scale resource play is to have a sufficient land base so the ongoing development of the resource will encounter enough prolific wells to offset under-producing wells. It was concluded that tight gas production is becoming increasingly important in Canada. 2 figs.

Ball, C.

2005-08-01

 
 
 
 
181

Optimization of difficult cycles of ship gas-turbine installations  

Directory of Open Access Journals (Sweden)

Full Text Available Possibilities to increase in specific work and effective efficiency of a complex thermodynamic cycle of ship gas-turbine installations with one-stage intermediate cooling and regeneration of heat of exhausted gases are considered in the paper. Necessary conditions for this purpose are described: additional intermediate heating, achievement of an optimum degree of pressure increase and optimum degree of regeneration.

Ivanov Vadim Aleksandrovich

2011-01-01

182

Neuroprotection (including hypothermia).  

UK PubMed Central (United Kingdom)

There have been over 2000 publications in the last year addressing the topic of neuroprotection. Novel and emerging therapeutic targets that have been explored include cerebral inflammation, hypothermia, neural transplantation and repair and gene therapy. Unfortunately, with few exceptions, the successes of experimental neuroprotection have not been translated into clinical practice. The possible reasons for the discrepancy between experimental success and clinical benefit are explored.

Menon DK; Summors AC

1998-10-01

183

Management of difficult multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis: update 2012.  

UK PubMed Central (United Kingdom)

Multidrug-resistant (MDR) tuberculosis (TB) denotes bacillary resistance to at least isoniazid and rifampicin. Extensively drug-resistant (XDR) TB is MDR-TB with additional bacillary resistance to any fluoroquinolone and at least one second-line injectable drugs. Rooted in inadequate TB treatment and compounded by a vicious circle of diagnostic delay and improper treatment, MDR-TB/XDR-TB has become a global epidemic that is fuelled by poverty, human immunodeficiency virus (HIV) and neglect of airborne infection control. The majority of MDR-TB cases in some settings with high prevalence of MDR-TB are due to transmission of drug-resistant bacillary strains to previously untreated patients. Global efforts in controlling MDR-TB/XDR-TB can no longer focus solely on high-risk patients. It is difficult and costly to treat MDR-TB/XDR-TB. Without timely implementation of preventive and management strategies, difficult MDR-TB/XDR-TB can cripple global TB control efforts. Preventive strategies include prompt diagnosis with adequate TB treatment using the directly observed therapy, short-course (DOTS) strategy and drug-resistance programmes, airborne infection control, preventive treatment of TB/HIV, and optimal use of antiretroviral therapy. Management strategies for established cases of difficult MDR-TB/XDR-TB rely on harnessing existing drugs (notably newer generation fluoroquinolones, high-dose isoniazid, linezolid and pyrazinamide with in vitro activity) in the best combinations and dosing schedules, together with adjunctive surgery in carefully selected cases. Immunotherapy may also have a role in the future. New diagnostics, drugs and vaccines are required to meet the challenge, but science alone is insufficient. Difficult MDR-TB/XDR-TB cannot be tackled without achieving high cure rates with quality DOTS and beyond, and concurrently addressing poverty and HIV.

Chang KC; Yew WW

2013-01-01

184

The incidence of difficult intubation in 2 000 patients undergoing thyroid surgery: A single center experience  

Directory of Open Access Journals (Sweden)

Full Text Available Background/Aim. The incidence of difficult intubation (DI) is 1-10%, and DI leading to inability to intubate occurs in 0.04% of the population. The aim of this study was to evaluate the incidence of DI in thyroid surgery and to assess possible correlation of difficult tracheal intubation with sex and primary diagnosis. Methods. We studied 2 000 consecutive patients (1 705 females) scheduled for thyroid surgery who were assessed for DI prior to general anesthesia, with respect to primary disease diagnosis and sex. Patients were divided into four groups: patients with nodal goiter (group A), polynodal goiter (group B), hyperthyroidism (group C) and thyroid carcinoma (group D). Difficult intubation was predicted using the scoring system which included 13 parameters ranged from 0 to 2. Additive score > 5 was accepted as a predictor of DI. True DI was defined as impossible visualization of glottis with direct laryngoscopy (grade III and IV). Results. Difficult intubation was observed in 110/2 000 patients (5.5%). The incidence of DI was higher in males (26/295, 8.8%) then females (84/1 705, 4.9%) (p < 0.01). The incidence of DI was highest in the group B (6.2%). Extremely DI occurred in 15/2000 patients (0.75%), the most of them in the group C (1.1%). Sensitivity of used scoring system was 91.8% and specificity 86.5%. Conclusions. The incidence of DI was highest in patients with polynodal goiter but extremely DI was present mostly in patients with hyperthiroidism. Men seem to be at higher risk for DI than women. Scoring system used in this study for prediction of DI may be useful in this patient population.

Kalezi? Nevena; Milosavljevi? Radoje; Paunovi? Ivan; Živaljevi? Vladan; Dikli? Aleksandar; Mati? Danica; Ivanovi? Branislava; Neškovi? Vojislava

2009-01-01

185

Prospective model-based comparison of different laryngoscopes for difficult intubation in infants.  

UK PubMed Central (United Kingdom)

BACKGROUND: Difficult intubation in infants is uncommon but may be a challenge for the anesthesiologist. Many optical-assisted techniques are available to ease endotracheal placement of tube but have not been systemically evaluated for pediatric practice. AIM: The study was performed to compare conventional pediatric Macintosh - with different optical laryngoscopes in difficult endotracheal intubation in infants. We hypothesized that inexperienced anesthetists would perform more successful with optical devices and that differences between the devices would be found. METHODS/MATERIALS: In this randomized controlled study, 30 anesthesia residents performed endotracheal intubation in an infant model of difficult airway presenting with airway obstruction and neck immobilization. Primary endpoints were intubation success rate and intubation time. Beyond that glottis view, dental trauma and difficulty of technique were evaluated and measured by a study observer. Macintosh, Airtraq(®), Storz DCI(®) -, and Gyrus Infant Bullard(®) laryngoscopes were used in random order. After standardized briefing every resident had three attempts of at most 120 s with every device to place a 3-mm tube into the trachea. Glottis view and difficulty of technique were rated by the residents using classification of Cormack/Lehane and Visual Analogue Scale (VAS; 0 = easy to 10 = very difficult). RESULTS: Success rate was 41% with conventional Macintosh, 43% with Airtraq(®), 62% with Storz DCI(®), and 100% with Bullard(®) laryngoscopes. Median time from passing the lips to first ventilation was 67 s (Storz DCI(®) laryngoscope), 54 s (Macintosh laryngoscope), 45 s (Airtraq(®) laryngoscope), and 21 s (Bullard(®) laryngoscope), respectively. Dental trauma did not occur with Bullard(®) laryngoscope and was frequent with Storz DCI(®) laryngoscope (39%) and Macintosh laryngoscope (42%). Glottis view was best with Bullard(®) laryngoscope (Grade 1 in 100%) and worst with Macintosh laryngoscope (Grade 1 in 2%). Difficulty of technique was rated with a VAS score of 2 (Bullard(®) laryngoscope), 4.5 (Storz DCI(®) laryngoscope) and 6 (Airtraq(®) - and Macintosh laryngoscopes). CONCLUSIONS: Inexperienced anesthetists have higher success rates and shorter intubation times with optical-assisted laryngoscopes compared with conventional Macintosh laryngoscope. Gyrus Infant Bullard(®) laryngoscope significantly undertakes best success rate and shortest intubation time with mildest impact to maxillary dents and easiest technique. Our findings support the hypothesis that optical laryngoscopes can be used successfully by inexperienced anesthetists in simulated difficult pediatric airway conditions.

Kalbhenn J; Boelke AK; Steinmann D

2012-08-01

186

[Difficult treatment of amiodarone-induced thyrotoxicosis: a case report  

UK PubMed Central (United Kingdom)

Amiodarone causes changes in thyroid function tests in about 15-20% of patients, inducing either hypothyroidism or thyrotoxicosis. The iodine load and the destructive thyroiditis caused by amiodarone produce thyrotoxicosis. We report a case of amiodarone-induced thyrotoxicosis diagnosed when investigating the reason for worsening of cardiac function. Prognosis and treatment of cardiac disorder were determined by thyrotoxicosis. The management needed a closed monitoring of thyroid function. Treatment was based on high doses of propylthiouracil and dexamethasone, but they couldn t control cardiac condition and surgery was warranted. When amiodarone-induced thyrotoxicosis is refractory to medical treatment, we believe surgery should be considered earlier.

Pedro T; Martínez-Hervás S; Lorente R; Catalá M; Ortega J; Real JT; Carmena R

2007-11-01

187

Vía respiratoria difícil en paciente obstétrica acondroplásica/ A difficult airway in an obstetrics patient presenting with achondroplasia  

Scientific Electronic Library Online (English)

Full Text Available Abstract in spanish Introducción: La acondroplasia es la condición más común asociada a una estatura baja con grave desproporción anatómica. Las complicaciones de la vía respiratoria difícil constituyen una de las causas más frecuente de su morbilidad y mortalidad, entre las que se pueden citar: macroglosia, escasa apertura bucal, presencia de una tráquea estrecha, limitación en la movilidad cervical, problemas pulmonares crónicos, mandíbula pequeña con aglomeración de la dent (more) adura y mentón prominente. Objetivo: Describir la conducta anestésica de una paciente obstétrica acondroplásica con vía respiratoria difícil. Caso Clínico: Paciente del sexo femenino, de 20 años de edad, con diagnóstico de acondroplasia y asma bronquial. Embarazo gemelar de 34 semanas el cual le imposibilitaba la deambulación, la sostenibilidad, dificultad respiratoria y no tolerancia del decúbito supino. Se le practicó cesárea, abordaje de vía respiratoria difícil, intubación con máscara laríngea Fastrach colocación de tubo endotraqueal # 6.0, ventilación controlada adecuada, utilización de relajantes musculares no despolarizantes, estabilización hemodinámica intraoperatoria, recuperación. Se trasladó a Sala Recuperación Anestésica sin complicaciones. Alta médica a los 10 días de hospitalización. Conclusiones: El abordaje de la vía respiratoria de las pacientes con Acondroplasia constituye un enigma para los anestesiólogos, pero la discusión multidisciplinaria y la ejecución de un plan de actuación favoreció el buen resultado del binomio madre-feto. Abstract in english Introduction: The achondroplasia is the commonest condition associated with a low height with a severe anatomical disproportion. The complications of the difficult airway are one of the more frequent cause of morbility and mortality including: macroglossia, an scarce buccal aperture, presence of a narrow trachea, limitation of cervical mobility, chronic pulmonary problems, small mandible with teeth crowding and a prominent chin. Objective: To describe the anesthetic behav (more) ior of an obstetrics patient with achondroplasia and a difficult airway. Clinical case: A female patient aged 20 diagnosed with achondroplasia and bronchial asthma. A twin pregnancy of 34 weeks avoiding her to walk, to stand up, respiratory difficulty and no tolerance of supine decubitus. She undergoes a cesarean section, approach of the difficult airway, intubation with a Fastrach laryngeal mask, placement of the #6.0 endotracheal tube, appropriate controlled ventilation, use of non-depolarizing muscle relaxants, intraoperative hemodynamic stabilization, recovery. She was transferred to Anesthesia Recovery Ward with complications, was discharged at 10 days of hospitalization. Conclusions: The approach of the airway of patients with achondroplasia is an enigma for anesthesiologists, but the multidisciplinary discussion and the performance of action plan favored the good result of mother-fetus duo.

Llanos Palmira, Lisette Elena; López Rabasa, Sahily Irene; Fonseca León, Alejandro; González Rodríguez, Gonzalo Santos; Díaz Rodríguez, Jorge Humberto

2012-08-01

188

Mental Connection at Distance: Useful for Solving Difficult Tasks?  

Directory of Open Access Journals (Sweden)

Full Text Available Aim of this study is to provide a demonstration of the non-local property of the human mind to connect at distance, that is, without the classical means of communication. In the first experiment, 40 participants were requested to identify in two separate sessions, 10 real and 10 false Chinese ideograms presented randomly, trying to connect mentally with the research assistant sending correct suggestions at distance that is without any possibility to communicate with them by conventional means. As control condition, in one of these two sessions the helper did not send any suggestion although the receiver believed the contrary. In the session without suggestion, the hits’ mean score was 10.55; conversely, in the condition where a research assistant tried to suggest the correct identification at distance, the hits’ mean score was 11.33. Both a frequentist and a Bayesian statistical analysis approach, allows to reject the Null Hypothesis supporting the alternative one, that is, the possibility of mental connection at distance exploiting the non-local properties of the human mind. A second experiment aimed at increasing the efficiency of this mental connection taking into account task complexity and the level of Absorption of participants as a personality trait deemed favorable to non-local communication. However the results were similar to the first experiment. Although mental connection at distance seems feasible, variables which positively moderate this kind of communication are still to be identified.

Patrizio E. Tressoldi; Stefano Massaccesi; Massimiliano Martinelli; Sara Cappato

2011-01-01

189

[Double lumen tube insertion in awake patients through the AirTraq laryngoscope in 2 cases of expected difficult airway].  

UK PubMed Central (United Kingdom)

The likelihood of difficult airway in thoracic surgery increases in the presence of associated cancer of the pharynx or larynx. The difficulty is greater when a double lumen tube must be inserted in these conditions, and various newly developed optical devices offer solutions for managing such cases. We report on 2 patients with expected difficult airway who were scheduled for lung resection. In both cases, intubation was accomplished through the AirTraq laryngoscope while the patient remained awake. Awake patient tolerance is facilitated by this laryngoscope, because the tube can be inserted without changing the position of the tongue or placing pressure on the vallecula.

Salazar Herbozo E; Planas B; Ramasco F; Gómez Rice A; Catalán P

2011-05-01

190

Newer trends in the management of psoriasis at difficult to treat locations: Scalp, palmoplantar disease and nails  

Directory of Open Access Journals (Sweden)

Full Text Available Psoriasis is a common, chronic, inflammatory disease with a wide range of clinical presentations. The disease severity ranges from mild to severe. Plaque type of psoriasis is the most common. A number of factors like previous treatment history and comorbid conditions influence the treatment of psoriasis in an individual patient. Location of the lesions is also an important consideration. Psoriasis localized to certain areas of the body like scalp, nails, palms and soles remains difficult to treat. These sites have been referred to as the difficult locations in literature. This article covers the management of psoriasis limited to these special areas.

Handa Sanjeev

2010-01-01

191

Asthma of difficult handling, not all that hiss is asthma  

International Nuclear Information System (INIS)

The paper tries about a patient of masculine sex 13 years old who consults initially for square that begins in February of 1999, consistent in cough, breathlessness and difficulty to breathe, he consults to one hospital where it is managed with beta two micronebulized, corticoids endovenous and oxygen being obtained improvement, reason why they give exit. Three days later he consults again for similar square; receiving the same treatment; a week later he presents cough and severe breathing difficulty, for that again consult and he is remitted to the Hospital San Rafael (Bogota) for no-improvement of the square. The paper includes the antecedents, exams, clinical evolution and paraclinics

2000-01-01

192

Difficult clinical management of anti-tuberculosis DRESS syndrome.  

UK PubMed Central (United Kingdom)

We describe 11 cases of anti-tuberculosis DRESS (drug-related rash with eosinophilia and systemic symptoms) syndrome, a potentially serious complication of treatment that led to interruption of treatment for prolonged periods, systemic corticosteroid use and the resumption of treatment with less effective regimens. All patients had rash and toxic hepatitis, one died of multi-organ failure and, contrary to expectations, the evolution of tuberculosis (advanced in most cases) did not progress under corticosteroid treatment. The drug most frequently involved was rifampicin, while retreatment schemes included, in most cases, levofloxacin, ethambutol, streptomycin and cycloserine.

Palmero D; Castagnino J; Musella RM; Mosca C; González Montaner P; de Casado GC

2013-01-01

193

Stereoelectroencephalography following subdural grid placement for difficult to localize epilepsy.  

UK PubMed Central (United Kingdom)

BACKGROUND: Despite the use of invasive subdural recording, failure to localize or resect the epileptogenic zone (EZ) occurs. Potential causes for this include EZ originating outside of the subdural grid coverage area, involvement of eloquent cortex, or complications requiring removal of electrodes without seizure localization. No study has examined the safety and efficacy of stereoelectroencephalography (SEEG) after subdural grid placement. OBJECTIVE: To determine the efficacy of SEEG in patients who have previously undergone subdural grid placement. METHODS: A prospective analysis was performed on 14 patients who had subdural grid evaluation and underwent subsequent SEEG monitoring. The follow-up period after the SEEG-guided resections ranged from 11 months to 34 months with an average follow-up of 20.1 months. Magnetic resonance imaging findings, EZ localization, outcomes, type of surgery, and perioperative complications were evaluated. RESULTS: Ten patients (71%) underwent a resection after SEEG reimplantation. Of the 4 patients (29%) not undergoing resection, 2 had seizures arising from eloquent cortex, 1 had bitemporal epilepsy, and 1 had a previous temporal lobectomy contralateral to the EZ. An estimate of the EZ was achieved in all patients based on interictal and ictal recordings. In patients undergoing resection, 60% were seizure-free at 11 months. Perioperative complications were minimal and included 1 abscess, which required burr-hole drainage and antibiotics. CONCLUSION: SEEG is a safe and effective method after subdural grid placement is inconclusive, providing an additional opportunity for seizure freedom in this highly challenging group of patients.

Vadera S; Mullin J; Bulacio J; Najm I; Bingaman W; Gonzalez-Martinez J

2013-05-01

194

Externally used drug for treating difficult and complicated pain like tumour and preparation method thereof  

UK PubMed Central (United Kingdom)

The present invention discloses an external application medicine for treating tumor and other difficult pains and a preparation method thereof. The external application medicine for treating tumor and other difficult pains is characterized in that the medicine contains raw materials and auxiliary materials with the following weight portions: the raw materials include 5 to 7 portions of dog tibia, 4 to 6 portions of bauhinia purpurea, 3 to 5 portions of Chinese silkvine root-bark, 5 to 6 portions of red lucid ganoderma, 3 to 4 portions of medicinal evodia fruit, 4 to 5 portions of myrrh and 90 to 150 portions of ethanol solvent the auxiliary materials added include: 9 to 14 portions of menthol (enhancing transdermal agent), 7 to 10 portions of borneol and 7 to 10 portions of wintergreen oil, 1.6 to 3.0 portions of highly replaced hydroxypropyl cellulose (thickening film forming agent) and 4 to 6 portions of glycerol (moisturizing agent). The preparation of the present invention has the advantages of rapid effect, wide application, strong pain ease, reliable curing effect and convenient use.

XINGTANG GAO

195

Management of difficult-to-treat patients with ulcerative colitis: focus on adalimumab.  

UK PubMed Central (United Kingdom)

The treatment of ulcerative colitis has changed over the last decade, with the introduction of biological drugs. This article reviews the currently available therapies for ulcerative colitis and the specific use of these therapies in the management of patients in different settings, particularly the difficult-to-treat patients. The focus of this review is on adalimumab, which has recently obtained approval by the European Medicines Agency and the US Food and Drug Administration, for use in treating adult patients with moderate-to-severe, active ulcerative colitis, who are refractory, intolerant, or who have contraindications to conventional therapy, including corticosteroids and thiopurines. Since the results emerging from the pivotal trials have been subject to some debate, the aim of this review was to summarize all available data on the use of adalimumab in ulcerative colitis, focusing also on a retrospective series of real-life experiences. Taken together, the current evidence indicates that adalimumab is effective for the treatment of patients with different types of ulcerative colitis, including biologically naïve and difficult-to-treat patients.

Armuzzi A; Pugliese D; Nardone OM; Guidi L

2013-01-01

196

Management of difficult-to-treat patients with ulcerative colitis: focus on adalimumab  

Directory of Open Access Journals (Sweden)

Full Text Available Alessandro Armuzzi, Daniela Pugliese, Olga Maria Nardone, Luisa Guidi IBD Unit, Complesso Integrato Columbus, Catholic University, Rome, Italy Abstract: The treatment of ulcerative colitis has changed over the last decade, with the introduction of biological drugs. This article reviews the currently available therapies for ulcerative colitis and the specific use of these therapies in the management of patients in different settings, particularly the difficult-to-treat patients. The focus of this review is on adalimumab, which has recently obtained approval by the European Medicines Agency and the US Food and Drug Administration, for use in treating adult patients with moderate-to-severe, active ulcerative colitis, who are refractory, intolerant, or who have contraindications to conventional therapy, including corticosteroids and thiopurines. Since the results emerging from the pivotal trials have been subject to some debate, the aim of this review was to summarize all available data on the use of adalimumab in ulcerative colitis, focusing also on a retrospective series of real-life experiences. Taken together, the current evidence indicates that adalimumab is effective for the treatment of patients with different types of ulcerative colitis, including biologically naïve and difficult-to-treat patients. Keywords: randomized controlled trials, real-life experiences

Armuzzi A; Pugliese D; Nardone OM; Guidi L

2013-01-01

197

Submucous fibrosis secondary to chewing of quids: another cause of unanticipated difficult intubation.  

UK PubMed Central (United Kingdom)

PURPOSE: To report a case of unusual difficult intubation secondary to oral submucosal fibrosis (SMF) associated with malignancy of the hypopharynx. CLINICAL FEATURES: A 57-yr-old male, ASA-I physical status presented for percutaneous nephrolithotripsy. The patient was a known alcoholic and smoker with a habit of chewing quids for the past 36 years. Airway assessment revealed oral SMF and slight difficulty in opening the mouth fully. Mentohyoid and mentothyroid distances were normal. However, during intubation, unanticipated difficulty was encountered. On direct laryngoscopy, the tip of the epiglottis could barely be visualized. Intubation was possible after passing a gum elastic bougie blindly under the epiglottis and negotiating a 7.0 internal diameter tracheal tube over it. Postoperatively, indirect laryngoscopy (IDL) showed severe SMF involving the oral cavity, epiglottis and pyriform fossae and an ulcerative malignancy of the hypopharynx with fixation of the left hemilarynx. CONCLUSION: SMF is a premalignant condition of the oral cavity associated with fibrosis of involved structures that can be associated with malignancy of the aerodigestive tract. Distortion of the airway anatomy may render intubation difficult. IDL maybe useful in the preoperative evaluation of these patients.

Mahajan R; Jain K; Batra YK

2002-03-01

198

Hybrid methodology for the detection, tracking, and classification of humans in difficult infrared video  

Science.gov (United States)

The detection, tracking, and classification of humans in video imagery is of obvious military and civilian importance. The problem is difficult under the best of circumstances. In infrared (IR) imagery, or any grayscale imagery, the problem is compounded by the lack of color cues. Sometimes, human detection in IR imagery can take advantage of the thermal difference between humans and background-but this difference is not robust. Varying environmental conditions regularly degrade the thermal contrast between humans and background. In difficult data, humans can be effectively camouflaged by their environment and standard feature detectors are unreliable. The research described here uses a hybrid approach toward human detection, tracking, and classification. The first is a feature-based correlated body parts detector. The second is a pseudo-Hough transform applied to the edge images of the video sequence. The third relies on an optical flow-based vector field transformation of the video sequence. This vector field permits a multidimensional application of the feature detectors initiated in the previous two methods. Then a multi-dimensional oriented Haar transform is applied to the vector field to further characterize potential detections. This transform also shows potential for distinguishing human behavior.

Bonick, James R.

2012-05-01

199

A difficult parent: when parent-child attachment is fragile.  

UK PubMed Central (United Kingdom)

CASE: Mrs. Forrest brought Jackie, her 11-year-old adopted daughter, to her pediatrician with a range of concerns, including problems with attention, school performance, anxiety, and frequent oppositional behaviors. Jackie was removed from school because of her mother's concern that the "school was not doing enough" to help Jackie. School reports were not available at this visit. Her mother reported going to great lengths to seek help for Jackie, including individual and family therapy, a psychological evaluation, academic tutoring, and a variety of home-school curricula. She planned to enroll Jackie in a residential treatment program. Little is known about Jackie's early childhood experience. She may have been exposed to alcohol and drugs during the pregnancy. Jackie lived with her biological mother until age 3 years, at which time she was placed in foster care because of allegations of abuse and neglect. She was in multiple foster homes until she was adopted by Mr. and Mrs. Forrest at 6 years of age. Mrs. Forrest's description of Jackie's oppositional behaviors was vague, and when asked to cite specific examples of these behaviors, Mrs. Forrest replied, "Unless you live with her you will have no idea how she really is." With Jackie present in the room, Mrs. Forrest stated that Jackie "is wrecking our family," and that she and Jackie "have never been attached to each another."When interviewed alone, Jackie was noticeably upset by what her mother had said; she displayed a sad affect. She expressed remorse for "being bad" and a desire "to get along with my family" and "to go back to school." She drew a picture of herself and her adoptive mother smiling and eating ice cream together.Over the next several months, Jackie's mother insisted that the pediatrician prescribe medication to manage Jackie's behaviors; she became upset when he expressed reluctance. She was resistant to a recommendation for family therapy, although she did place Jackie in individual therapy. At this point, Jackie's pediatrician became aware of his feelings of anger and resentment directed toward Mrs. Forrest.

Brown S; Bertuol C; Kuhn NN; Stein MT

2013-01-01

200

Difficult OptEase Filter Retrievals After Prolonged Indwelling Times  

International Nuclear Information System (INIS)

PurposeThe OptEase vena cave filter (Cordis, Piscataway, NJ) is commercially available as a retrievable or permanent filter with short recommended indwelling time, presumably due to extensive contact of the filter side struts with the inferior vena cava wall and subsequent neointimal hyperplasia leading to incorporation. Our purpose was to evaluate OptEase filter retrievals with a long indwelling time period that required unconventional retrieval techniques.Materials and MethodsWe retrospectively reviewed patients who underwent OptEase filter retrieval with long undwelling times requiring additional maneuvers for retrieval. Techniques used included rigid endobronchial forceps dissection and wire-through-loop snare. Each patient underwent postretrieval venogram to evaluate for possible complications. In addition, patients had clinical follow-up 2 weeks after the retrieval procedure.ResultsThere were three patients (2 women, 1 man; average age 64 years) who underwent OptEase filter retrieval. The mean indwelling time was 6.4 months. The indwelling filters were successfully retrieved. There were no complications. Postprocedural follow-up showed no clinical pathology.ConclusionUnconventional techniques aided in the retrieval of OptEase filters with long indwelling times

2013-01-01

 
 
 
 
201

Meeting the challenge of constructing a uniquely difficult barrier wall  

International Nuclear Information System (INIS)

A soil-bentonite vertical barrier wall with intersecting and round corners was constructed in complex geology and steep terrain to enclose and dewater a 1.4 hectare (3.5 acre) area once used for hazardous waste lagoons and landfills at the Queen City Farms (QCF) Superfund site in Maple Valley, Washington. The barrier system, including cap and barrier wall, was designed to contain light non-aqueous phase liquid (LNAPL), in addition to subsurface soil and ground water contaminated with chromium, polychlorinated biphenyls, polyaromatic hydrocarbons, trichloroethylene, dichloroethylene and vinyl chloride in the dissolved-phase. These contaminants threaten a drinking water aquifer beneath the site. Constructing the vertical barrier was a challenge due to steep slopes of 20 percent along the alignment (19.2 meter elevation change in the top of the wall), a 22.5 meter (75 foot) design wall depth, heavily consolidated clays and silts, open works gravels (gravel without finer soils), and geologic discontinuity. The barrier wall is keyed into either a glacial till or thin clayey-silt aquitard. Extensive earth moving, stepped walls and many construction techniques were used to enable construction of this barrier wall. Commonly accepted constructability criteria would have discouraged the construction of this wall.

1997-01-01

202

Prediction is Difficult, Especially the Future: A Progress Report  

Directory of Open Access Journals (Sweden)

Full Text Available Objective This paper reviews developments in the consolidation and diversification of the evidence based library and information practice (EBLIP) paradigm since publication of the authors’ book Evidence Based Practice for Information Professionals: a Handbook in 2004.Methods The authors provide an updated narrative review of key themes in the development of evidence based librarianship within the context of the new consensual term ‘EBLIP.’ Sources for this thematic framework included professional literature, Internet searches, and the authors’ personal experiences.Results ? While considerable achievements have been realized within a three?year period, most notably the instigation of the journal known as EBLIP, a broadening of the paradigm to other library sectors, and increased availability of implementation studies, many challenges remain. Of particular concern is the lack of international strategic foresight in determining rotation of the biennial international conferences and distribution of influential EBLIP infrastructures and initiatives.Conclusion ? While the enthusiasms and energies of individual practitioners and work teams have made considerable progress in meeting short?term objectives, uncertainty remains concerning how longer?term objectives requiring infrastructure and resources might be realized. From its faltering steps as a toddler EBLIP has developed to a ‘prepubescent’ stage with the promise of ‘growth spurts’ and ‘emotional crises.’ The next three years should prove both challenging and demanding.

Andrew Booth; Anne Brice

2007-01-01

203

Controlling difficult pelvic bleeding with argon beam coagulator during laparoscopic ultra low anterior resection.  

UK PubMed Central (United Kingdom)

In recent years, the standard of care for lower rectal tumors has developed to include a total mesorectal excision, which provides optimal long-term results. There has been debate with regard to the best approach for lower rectal tumors, conventional open versus less invasive procedures. As the trend toward less invasive surgical procedures progresses, similar complications, which are seen in open cases, are being encountered, such as the notorious presacral fascia bleed. These are small vessels, which are difficult to locate and control. Surgical literature suggests different methods during laparoscopic procedures. These include: placing lap pads and holding pressure, placing saline bag, placing tacks, using bone wax, and electrocautry at different settings. We present a case of a 57-year-old male, positive for lymph node disease, who underwent laparoscopic ultra low anterior resection with total mesorectal excision and protective loop ileostomy.

Kandeel A; Meguid A; Hawasli A

2011-02-01

204

Controlling difficult pelvic bleeding with argon beam coagulator during laparoscopic ultra low anterior resection.  

Science.gov (United States)

In recent years, the standard of care for lower rectal tumors has developed to include a total mesorectal excision, which provides optimal long-term results. There has been debate with regard to the best approach for lower rectal tumors, conventional open versus less invasive procedures. As the trend toward less invasive surgical procedures progresses, similar complications, which are seen in open cases, are being encountered, such as the notorious presacral fascia bleed. These are small vessels, which are difficult to locate and control. Surgical literature suggests different methods during laparoscopic procedures. These include: placing lap pads and holding pressure, placing saline bag, placing tacks, using bone wax, and electrocautry at different settings. We present a case of a 57-year-old male, positive for lymph node disease, who underwent laparoscopic ultra low anterior resection with total mesorectal excision and protective loop ileostomy. PMID:21304367

Kandeel, Ahmed; Meguid, Ahmed; Hawasli, Abdelkader

2011-02-01

205

THE EFFECTS OF SONIC ENVIRONMENT OF INDIVIDUALIZED INSTRUCTION IN LEARNING DIFFICULT AND EASY TASKS BY HIGH ACHIEVERS.  

Science.gov (United States)

THE SIXTH-GRADE STUDENTS OBTAINING THE 80 HIGHEST MEAN SCORES ON THE METROPOLITAN ACHIEVEMENT TEST FORM D WERE RANDOMLY ASSIGNED TO GROUPS OF EASY OR DIFFICULT TASKS WITHIN EACH OF FIVE DECIBEL LEVEL GROUPS. THE LEARNING TASKS WERE TAKEN FROM THE MEANINGFULNESS OF ALL POSSIBLE CVC TRIGRAMS (ARCHER, 1960). THE APPARATUS INCLUDED A TAPE RECORDING OF…

MCCARTHY, EDWARD H.

206

Initial clinical assessment of a novel multifunctional topical ointment for difficult-to-heal wounds: a case series.  

UK PubMed Central (United Kingdom)

Chronic wounds are characterized by prolonged inflammation, bacterial bioburden, and ischemia. These factors represent the barriers to wound healing that need to be addressed in order to achieve wound closure. The authors performed the initial clinical testing of WinVivo Wound Ointment ("WinVivo"), a novel topical ointment containing several botanicals that have been previously shown to promote favorable wound environment and advance wound healing. In this series of 13 patients with difficult-to-heal lower-extremity wounds, WinVivo was well tolerated and demonstrated the ability to simultaneously support granulation tissue formation; decrease the amount of exudate, edema, and malodor; and reduce pain. The ulcers included in this study have been present for a minimum of 3 weeks and a maximum of 5 years prior to the start of treatment with WinVivo. Eight of 13 wounds have previously been treated with at least 1 type of advanced wound healing modality, such as dermal substitutes or negative-pressure wound therapy. Treatment with WinVivo lasted for 3 to 12 weeks and resulted in a mean 88% wound closure, with 4 wounds healing completely. In addition to significant reduction in wound size, all patients have exhibited other clinical benefits, suggesting overall improvement in wound conditions. Future studies in a larger population, as well as case-control studies comparing WinVivo with a standard of care, are therefore warranted to further evaluate the efficacy of this new treatment.

Reyzelman AM; Bazarov I

2012-12-01

207

Initial clinical assessment of a novel multifunctional topical ointment for difficult-to-heal wounds: a case series.  

Science.gov (United States)

Chronic wounds are characterized by prolonged inflammation, bacterial bioburden, and ischemia. These factors represent the barriers to wound healing that need to be addressed in order to achieve wound closure. The authors performed the initial clinical testing of WinVivo Wound Ointment ("WinVivo"), a novel topical ointment containing several botanicals that have been previously shown to promote favorable wound environment and advance wound healing. In this series of 13 patients with difficult-to-heal lower-extremity wounds, WinVivo was well tolerated and demonstrated the ability to simultaneously support granulation tissue formation; decrease the amount of exudate, edema, and malodor; and reduce pain. The ulcers included in this study have been present for a minimum of 3 weeks and a maximum of 5 years prior to the start of treatment with WinVivo. Eight of 13 wounds have previously been treated with at least 1 type of advanced wound healing modality, such as dermal substitutes or negative-pressure wound therapy. Treatment with WinVivo lasted for 3 to 12 weeks and resulted in a mean 88% wound closure, with 4 wounds healing completely. In addition to significant reduction in wound size, all patients have exhibited other clinical benefits, suggesting overall improvement in wound conditions. Future studies in a larger population, as well as case-control studies comparing WinVivo with a standard of care, are therefore warranted to further evaluate the efficacy of this new treatment. PMID:23151766

Reyzelman, Alexander M; Bazarov, Irina

2012-12-01

208

Combustion-assisted laser cutting of a difficult-to-machine superalloy  

International Nuclear Information System (INIS)

[en] In laser cutting, the largest single application of lasers in manufacturing, the assist gas plays an important role in affecting the cutting performance. The assist gas is usually oxygen or an inert gas. In this paper acetylene and oxygen was employed to create combustion reactions during CO2 laser cutting that enabled an improvement in the cutting speed, and cut quality of a difficult-to-machine superalloy. A comparison with laser cutting of a plain carbon steel under identical conditions was also made to determine the usefulness of combustion energy. Results indicate that both cutting speed and quality are enhanced by the reduction in the viscosity of slag formed during cutting (which assisted in ejection of the slag through the bottom of the kerf) due to the heat released by the acetylene burning inside the kerf. Correlations of experimental data with a theoretical model provided the influence of combustion power and gas-flow power on the cutting phenomena

1992-01-01

209

Combustion-assisted laser cutting of a difficult-to-machine superalloy  

Energy Technology Data Exchange (ETDEWEB)

In laser cutting, the largest single application of lasers in manufacturing, the assist gas plays an important role in affecting the cutting performance. The assist gas is usually oxygen or an inert gas. In this paper acetylene and oxygen was employed to create combustion reactions during CO[sub 2] laser cutting that enabled an improvement in the cutting speed, and cut quality of a difficult-to-machine superalloy. A comparison with laser cutting of a plain carbon steel under identical conditions was also made to determine the usefulness of combustion energy. Results indicate that both cutting speed and quality are enhanced by the reduction in the viscosity of slag formed during cutting (which assisted in ejection of the slag through the bottom of the kerf) due to the heat released by the acetylene burning inside the kerf. Correlations of experimental data with a theoretical model provided the influence of combustion power and gas-flow power on the cutting phenomena.

Molian, P.A. (Iowa State Univ. of Science and Technology, Ames, IA (United States). Dept. of Mechanical Engineering); Baldwin, M. (Iowa Laser Technolgy, Inc., Cedar Falls, IA (United States))

1992-01-01

210

Diversity of life. Effects of power generation and transmission on biodiversity difficult to assess  

Energy Technology Data Exchange (ETDEWEB)

Scientific theories do not necessarily enable us to forecast the consequences of our actions on wildlife. Presumably, nature is able to adapt to environmental changes through variations on the genetic, species and ecosystem level; i.e. by means of biodiversity. The first studies conducted within the electricity sector show that the effects of emissions form an individual power plant on biodiversity are extremely difficult to assess because of long-range dispersion of the emission and many other factors simultaneously acting on the environment. Some concrete information about the impact of power transmission lines on biodiversity was obtained. These effects were primarily reversible. Some transmission line zones may even have favourable effects on biodiversity and on the living conditions of certain endangered species. (orig.)

Hongisto, M.; Nikula, A.

1996-11-01

211

Clinical usefulness of double-guidewire technique for difficult biliary cannulation in endoscopic retrograde cholangiopancreatography.  

UK PubMed Central (United Kingdom)

BACKGROUND AND AIM: Although biliary cannulation with pancreatic guidewire placement (P-GW) is useful for difficult cases in endoscopic retrograde cholangiopancreatography (ERCP), the clinical significance of wire-guided cannulation with P-GW (double-guidewire technique: DGT) has not been clarified. The aim of the present study was to evaluate the usefulness of DGT for difficult biliary cannulation after unsuccessful biliary cannulation using a cannula/sphincterotome under guidance of injected contrast with P-GW (single-guidewire technique: SGT). METHODS: One-hundred and forty-six patients with difficult biliary cannulation who underwent SGT were included in this retrospective study. DGT was carried out if SGT was unsuccessful. Pancreatic duct (PD) stenting was attempted to prevent post-ERCP pancreatitis (PEP) in all patients. The success rate of cannulation and the risk factors for PEP were investigated. RESULTS: Biliary cannulation with SGT was achieved in 70%. DGT was carried out in 25 patients with unsuccessful SGT, biliarycannulation being successful in 72%. Of the 13 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 46%. The incidence of PEP in patients who had undergone SGT, DGT, and precut sphincterotomy was 8% (12: mild, 8; moderate, 3; severe, 1), 4% (mild, 1), and 0%, respectively. PD stenting was successfully carried out in 86%. Multivariate analysis revealed unsuccessful PD stenting to be the only risk factor for PEP (OR 8.3, 95% CI 2.3-30). CONCLUSIONS: DGT may replace SGT or become the salvage procedure in cases of unsuccessful SGT as a result of its high success rate with an acceptable incidence of PEP. Failed pancreatic duct stenting in these techniques was frequently associated with PEP.

Ito K; Horaguchi J; Fujita N; Noda Y; Kobayashi G; Koshita S; Kanno Y; Ogawa T; Masu K; Hashimoto S

2013-08-01

212

Ultrasound is the optimal choice for guidance in difficult hysteroscopy.  

UK PubMed Central (United Kingdom)

OBJECTIVES: To compare costs and complications associated with ultrasound-guided hysteroscopy vs laparoscopy-guided hysteroscopy vs hysteroscopy alone for the surgical repair of intrauterine septa and synechiae. METHODS: This was a retrospective cohort study. Charts of all patients undergoing reparative surgery for intrauterine synechiae or uterine septa at our academic institution between 2000 and 2008 were reviewed. A total of 159 procedures were included in the study, categorized into concurrent laparoscopic guidance (n = 69), ultrasound guidance (n = 52) or no guidance (n = 38). Data regarding billing, surgical case logs and complications were collected for these procedures. Using these data, complication rates and inflation-adjusted charges were compared between the groups. Statistical analysis was performed using Fisher's exact test and Student's t-test, as appropriate. RESULTS: A uterine perforation rate of 8.7% was observed with laparoscopic guidance vs 1.9% with ultrasound guidance (P = 0.12) and 5.3% with no guidance (P = 0.41). Analysis of billing data showed that average total costs were significantly less for ultrasound guidance than for laparoscopic guidance ($9124 vs $11 895, P < 0.001). Ultrasound guidance did not increase costs over hysteroscopy alone ($9124 vs $8242, P = 0.54). CONCLUSION: Real-time transabdominal ultrasound guidance during the resection of intrauterine synechiae or septa resulted in a trend towards reduced uterine perforation. Moreover, ultrasound guidance is less costly than laparoscopic guidance and adds no additional cost over hysteroscopy alone. Taken together, transabdominal ultrasound guidance is the optimal means of intraoperative guidance for the resection of uterine synechiae and septa.

Kresowik JD; Syrop CH; Van Voorhis BJ; Ryan GL

2012-06-01

213

A Qualitative Study of the Types and Characteristics of Difficult Patrons in University Libraries  

Directory of Open Access Journals (Sweden)

Full Text Available The phrase “difficult patron” is often associated with troubles and habitually abnormal behavior from patrons. From the viewpoint of organization, the existence of difficult patrons might signal dissatisfaction with services, collections, facilities, or with specific individual librarians. But difficult patron’s complaints may also be regarded as valuable opportunities to improve customer service and satisfaction. Hence, for the circulation librarians, learning how to interact with difficult patrons is quite important. This article reports findings from a qualitative study which investigated types and behavioral characteristics of difficult patrons in university libraries in Taiwan. Semi-structured interviewing method was used to investigate 23 circulation librarians’ experiences with difficult patrons. Based on the findings, this article discusses why some patrons are difficult as well as service strategies for dealing with difficult patrons in university libraries.

Chen Su-may Sheih

2009-01-01

214

The new bits: Expertise included  

Energy Technology Data Exchange (ETDEWEB)

This supplement contains seven short articles on new drill bit technology. Articles describe the evolution of bit technology, the performance of PDC and diamond-impregnated drill bits, advanced designs in roller cone bits, advanced computational fluid dynamics software used to evaluate drill bits, difficult drilling demands, and optimization of rock and well drilling by selection of the right bit.

NONE

2000-06-01

215

Development and evaluation of a score to predict difficult epidural placement during labor.  

UK PubMed Central (United Kingdom)

BACKGROUND AND OBJECTIVES: Difficult epidural placement (DEP) during labor may be distressing for the patient and may increase the risk of dural puncture. A score predicting DEP based on the combination of individual risk factors could identify high-risk patients. This study aimed to identify risk factors for DEP and build a prediction score. METHODS: Three hundred thirty patients were prospectively included. Difficult epidural placement was defined as more than 1 skin puncture with a Tuohy needle. Dura puncture occurrence was recorded. The population was randomly split into a training set and a validation set. In the training set, risk factors were identified with logistic regression and used to build a score defining 3 risk groups. Model and score discrimination was assessed with the C-index and clinical usefulness of the score with decision curves. RESULTS: Difficult epidural placement frequency was 30% (95% confidence interval [95% CI], 25%-35%). Dural puncture was more frequent in DEP patients (4% vs 0%, P = 0.007). Three independent risk factors for DEP were identified: difficult interspinous space palpation (odds ratio [OR], 6.1; 95% CI, 2.8-13.9), spinal deformity (OR, 2.4; 95% CI, 1.1-5.3), and inability to flex the back (OR, 3.0; 95% CI, 1.2-7.8). The C-index of the model was 0.81 (95% CI, 0.74-0.88) in the training set and 0.78 (95% CI, 0.70-0.86) in the validation set. A 5-point score was created to define groups with low risk (score 0), intermediate risk (score 1-2), and high risk (score 3-4), with predicted rates of DEP of 9.7%, 30.3%, and 68.9%, respectively. The C-index of the score was 0.79 (95% CI, 0.72-0.86) in the training set and 0.76 (95% CI, 0.69-0.84) in the validation set. Decision curves support the clinical usefulness of the score. CONCLUSIONS: This study confirms risk factors for DEP and proposes a score to predict DEP. The score identifies high-risk patients who may benefit from an intervention to decrease DEP. This hypothesis should be evaluated in an impact study.

Guglielminotti J; Mentré F; Bedairia E; Montravers P; Longrois D

2013-05-01

216

The neural bases of difficult speech comprehension and speech production: Two Activation Likelihood Estimation (ALE) meta-analyses.  

UK PubMed Central (United Kingdom)

The role of speech production mechanisms in difficult speech comprehension is the subject of on-going debate in speech science. Two Activation Likelihood Estimation (ALE) analyses were conducted on neuroimaging studies investigating difficult speech comprehension or speech production. Meta-analysis 1 included 10 studies contrasting comprehension of less intelligible/distorted speech with more intelligible speech. Meta-analysis 2 (21 studies) identified areas associated with speech production. The results indicate that difficult comprehension involves increased reliance of cortical regions in which comprehension and production overlapped (bilateral anterior Superior Temporal Sulcus (STS) and anterior Supplementary Motor Area (pre-SMA)) and in an area associated with intelligibility processing (left posterior MTG), and second involves increased reliance on cortical areas associated with general executive processes (bilateral anterior insulae). Comprehension of distorted speech may be supported by a hybrid neural mechanism combining increased involvement of areas associated with general executive processing and areas shared between comprehension and production.

Adank P

2012-07-01

217

Simulation of a new 3D imaging sensor for identifying difficult military targets  

Science.gov (United States)

This paper reports the successful application of automatic target recognition and identification (ATR/I) algorithms to simulated 3D imagery of 'difficult' military targets. QinetiQ and Selex S&AS are engaged in a joint programme to build a new 3D laser imaging sensor for UK MOD. The sensor is a 3D flash system giving an image containing range and intensity information suitable for targeting operations from fast jet platforms, and is currently being integrated with an ATR/I suite for demonstration and testing. The sensor has been extensively modelled and a set of high fidelity simulated imagery has been generated using the CAMEO-SIM scene generation software tool. These include a variety of different scenarios (varying range, platform altitude, target orientation and environments), and some 'difficult' targets such as concealed military vehicles. The ATR/I algorithms have been tested on this image set and their performance compared to 2D passive imagery from the airborne trials using a Wescam MX-15 infrared sensor and real-time ATR/I suite. This paper outlines the principles behind the sensor model and the methodology of 3D scene simulation. An overview of the 3D ATR/I programme and algorithms is presented, and the relative performance of the ATR/I against the simulated image set is reported. Comparisons are made to the performance of typical 2D sensors, confirming the benefits of 3D imaging for targeting applications.

Harvey, Christophe; Wood, Jonathan; Randall, Peter; Watson, Graham; Smith, Gordon

2008-05-01

218

Directed Forgetting of Negative Self-Referential Information Is Difficult: An fMRI Study  

Science.gov (United States)

A large body of evidence suggested that both emotion and self-referential processing can enhance memory. However, it remains unclear how these two factors influence directed forgetting. This study speculates that directed forgetting of negative self-referential memory is more difficult than forgetting of other-referential memory. To verify this speculation, we combined the directed forgetting paradigm with the self-reference task. The behavioral result suggested that although both self-referential and other-referential information can be directly forgotten, less self-referential information can be forgotten than other-referential information. At the neural level, the forget instruction strongly activated the frontal cortex, suggesting that directed forgetting is not memory decay but an active process. In addition, compared with the negative other-referential information, forgetting of the negative self-referential information were associated with a more widespread activation, including the orbital frontal gyrus (BA47), the inferior frontal gyrus (BA45, BA44), and the middle frontal gyrus. Our results suggest that forgetting of the self-referential information seems to be a more demanding and difficult process.

Cui, Qian; Wei, Dongtao; Li, Wenfu; Qiu, Jiang; Zhang, Qinglin

2013-01-01

219

Difficult removal of an epidural catheter in the anterior epidural space.  

UK PubMed Central (United Kingdom)

When administering postoperative acute pain services, particularly regarding patient- controlled epidural analgesia, difficulties may occasionally be encountered during removal of the epidural catheter. In this report, we present an instance of difficult removal of epidural catheter in a female patient undergoing open reduction and internal fixation of the femoral neck with patient-controlled epidural analgesia as the means of postoperative pain control. The patient had satisfactory analgesia for 3 days; however, during the removal of the epidural catheter, difficulties were encountered and epidurogram revealed that the epidural catheter had become anchored in the anterior epidural space without kinking or knotting. Subsequently, the patient was requested to lie prone on the surgical table with a pillow placed beneath her lower abdomen and catheter removal was tried again. Fortunately, the epidural catheter was removed easily without the need for a guided stylet. We believe that the cause of the difficult removal of the epidural catheter in this case might have resulted from an unusual and unwanted deeper anchorage of the catheter along the anterior epidural space during placement. We also include some discussion on the management of problematic removal.

Chen JL; Cherng CH; Chan SM; Lin CS; Wong CS; Juan CJ; Yeh CC

2010-03-01

220

Difficult removal of an epidural catheter in the anterior epidural space.  

Science.gov (United States)

When administering postoperative acute pain services, particularly regarding patient- controlled epidural analgesia, difficulties may occasionally be encountered during removal of the epidural catheter. In this report, we present an instance of difficult removal of epidural catheter in a female patient undergoing open reduction and internal fixation of the femoral neck with patient-controlled epidural analgesia as the means of postoperative pain control. The patient had satisfactory analgesia for 3 days; however, during the removal of the epidural catheter, difficulties were encountered and epidurogram revealed that the epidural catheter had become anchored in the anterior epidural space without kinking or knotting. Subsequently, the patient was requested to lie prone on the surgical table with a pillow placed beneath her lower abdomen and catheter removal was tried again. Fortunately, the epidural catheter was removed easily without the need for a guided stylet. We believe that the cause of the difficult removal of the epidural catheter in this case might have resulted from an unusual and unwanted deeper anchorage of the catheter along the anterior epidural space during placement. We also include some discussion on the management of problematic removal. PMID:20434115

Chen, Jia-Lin; Cherng, Chen-Hwan; Chan, Shun-Ming; Lin, Chia-Shiang; Wong, Chih-Shung; Juan, Chun-Jung; Yeh, Chun-Chang

2010-03-01

 
 
 
 
221

The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Background Literature on difficult doctor-patient relationships has focused on the "difficult patient." Our objective was to determine physician and practice characteristics associated with greater physician-reported frustration with patients. Methods We conducted a secondary analysis of the Physicians Worklife Survey, which surveyed a random national sample of physicians. Participants were 1391 family medicine, general internal medicine, and medicine subspecialty physicians. The survey assessed physician and practice characteristics, including stress, depression and anxiety symptoms, practice setting, work hours, case-mix, and control over administrative and clinical practice. Physicians estimated the percentage of their patients who were "generally frustrating to deal with." We categorized physicians by quartile of reported frustrating patients and compared characteristics of physicians in the top quartile to those in the other three quartiles. We used logistic regression to model physician characteristics associated with greater frustration. Results In unadjusted analyses, physicians who reported high frustration with patients were younger (p 55 per week, higher stress, practice in a medicine subspeciality, and greater number of patients with psychosocial problems or substance abuse. Conclusion Personal and practice characteristics of physicians who report high frustration with patients differ from those of other physicians. Understanding factors contributing to physician frustration with patients may allow us to improve the quality of patient-physician relationships.

Krebs Erin E; Garrett Joanne M; Konrad Thomas R

2006-01-01

222

Difficult-to-treat gouty arthritis: a disease warranting better management.  

Science.gov (United States)

Gouty arthritis is the most common inflammatory arthritis in adults and is characterized by very painful flares. Gouty arthritis results from an elevated body uric acid pool, which leads to deposition of monosodium urate crystals, mainly in the joints. These crystals trigger the release of proinflammatory cytokines, in particular interleukin (IL)-1?, which stimulates inflammation. Gouty arthritis can progress to a chronic, deforming and physically disabling disease through the development of disfiguring tophi, joint destruction and persistent pain. Standard treatments are effective in most patients. Acutely, anti-inflammatory therapies provide rapid pain relief and resolution of flares. Chronically, urate-lowering therapies reduce serum urate levels and, in combination with anti-inflammatory prophylaxis, reduce the risk of flares. However, for a growing number of patients, current standard treatments are ineffective or are contraindicated, largely due to the presence of co-morbidities. Indeed, metabolic syndrome, hypertension, dyslipidaemia, cardiovascular disease, diabetes mellitus and renal impairment are all highly prevalent in individuals with gouty arthritis, and may lead to standard treatments being ineffective or inappropriate. Such patients with difficult-to-treat disease require alternative therapies. Gouty arthritis can have a major impact on health-related quality of life (HR-QOL), especially in patients with difficult-to-treat disease, as revealed by recent studies comparing HR-QOL for patients with gouty arthritis with that of the general population. All studies revealed clinically significant reductions in physical functioning for individuals with gouty arthritis compared with the general population. The difference was particularly marked for patients with difficult-to-treat disease. Gouty arthritis also constitutes an important economic burden through absence from work and medical costs. Again, the burden is greater in patients with difficult-to-treat disease. The development of difficult-to-treat disease reflects the short-comings of current standard treatments in a growing number of gouty arthritis patients. This has been recognized by the pharmaceutical industry and has promoted the development of innovative therapies. An appreciation of the key role of IL-1? in inflammation in gouty arthritis has led to the development of a new class of anti-inflammatory agents that block IL-1? signal transduction. The current IL-1? blockers in trials are rilonacept and canakinumab. Canakinumab, a fully human anti-IL-1? monoclonal antibody, has been shown to produce rapid and sustained pain relief from acute flares in patients with difficult-to-treat disease, and both rilonacept and canakinumab have been shown to reduce the risk of recurrent flares. Promising new therapies for reducing serum urate levels are also being developed. These include the recently approved therapies pegloticase (a pegylated form of the enzyme uricase that converts urate to allantoin), inhibitors of renal urate transporter proteins, and inhibitors of purine nucleotide phosphorylase, an enzyme involved in purine metabolism. Further studies are warranted to establish the value and role of these new therapies in the management of gouty arthritis. These new options should help reduce the growing human burden associated with gouty arthritis, lowering the tophaceous burden, minimizing the risk of flares, and enabling patients to achieve rapid and effective pain relief when flares do occur. PMID:21812506

Schlesinger, Naomi

2011-07-30

223

Difficult-to-treat gouty arthritis: a disease warranting better management.  

UK PubMed Central (United Kingdom)

Gouty arthritis is the most common inflammatory arthritis in adults and is characterized by very painful flares. Gouty arthritis results from an elevated body uric acid pool, which leads to deposition of monosodium urate crystals, mainly in the joints. These crystals trigger the release of proinflammatory cytokines, in particular interleukin (IL)-1?, which stimulates inflammation. Gouty arthritis can progress to a chronic, deforming and physically disabling disease through the development of disfiguring tophi, joint destruction and persistent pain. Standard treatments are effective in most patients. Acutely, anti-inflammatory therapies provide rapid pain relief and resolution of flares. Chronically, urate-lowering therapies reduce serum urate levels and, in combination with anti-inflammatory prophylaxis, reduce the risk of flares. However, for a growing number of patients, current standard treatments are ineffective or are contraindicated, largely due to the presence of co-morbidities. Indeed, metabolic syndrome, hypertension, dyslipidaemia, cardiovascular disease, diabetes mellitus and renal impairment are all highly prevalent in individuals with gouty arthritis, and may lead to standard treatments being ineffective or inappropriate. Such patients with difficult-to-treat disease require alternative therapies. Gouty arthritis can have a major impact on health-related quality of life (HR-QOL), especially in patients with difficult-to-treat disease, as revealed by recent studies comparing HR-QOL for patients with gouty arthritis with that of the general population. All studies revealed clinically significant reductions in physical functioning for individuals with gouty arthritis compared with the general population. The difference was particularly marked for patients with difficult-to-treat disease. Gouty arthritis also constitutes an important economic burden through absence from work and medical costs. Again, the burden is greater in patients with difficult-to-treat disease. The development of difficult-to-treat disease reflects the short-comings of current standard treatments in a growing number of gouty arthritis patients. This has been recognized by the pharmaceutical industry and has promoted the development of innovative therapies. An appreciation of the key role of IL-1? in inflammation in gouty arthritis has led to the development of a new class of anti-inflammatory agents that block IL-1? signal transduction. The current IL-1? blockers in trials are rilonacept and canakinumab. Canakinumab, a fully human anti-IL-1? monoclonal antibody, has been shown to produce rapid and sustained pain relief from acute flares in patients with difficult-to-treat disease, and both rilonacept and canakinumab have been shown to reduce the risk of recurrent flares. Promising new therapies for reducing serum urate levels are also being developed. These include the recently approved therapies pegloticase (a pegylated form of the enzyme uricase that converts urate to allantoin), inhibitors of renal urate transporter proteins, and inhibitors of purine nucleotide phosphorylase, an enzyme involved in purine metabolism. Further studies are warranted to establish the value and role of these new therapies in the management of gouty arthritis. These new options should help reduce the growing human burden associated with gouty arthritis, lowering the tophaceous burden, minimizing the risk of flares, and enabling patients to achieve rapid and effective pain relief when flares do occur.

Schlesinger N

2011-07-01

224

A guide to performing difficult bimanual coordination tasks: just follow the yellow brick road.  

Science.gov (United States)

Both discrete and continuous bimanual coordination patterns are difficult to effectively perform when the two limbs are required to perform different movements patterns, move at different velocities and/or move different amplitudes unless some form of integrated feedback is provided. The purpose of the present experiment was to determine the degree to which a complex bimanual coordination pattern could be performed when integrated feedback and movement template are provided. The complex bimanual coordination pattern involved reciprocal movements of the two limbs under different difficulty requirements. As defined by Fitts' index of difficulty (ID), the left arm (ID = 3, A = 16°, W = 4°) task was of lower difficulty than the right arm task (ID = 5, A = 32°, W = 2°). Note that the left and right limb movements are also different in terms of movement time, movement velocity, accuracy requirements and amplitude as well as one movement was continuous and the other intermittent. Participants were provided 2 blocks of 9 trials in the bimanual condition (30 s/trial). Following the bimanual phase, participants performed two unimanual test trials-one with each limb. The results demonstrated that the performance for each limb in the bimanual condition was similar to the performance for the same limb and conditions in the unimanual control conditions. The similarity was indicated by the same movement speed, movement structure, endpoint variability and hit rates for the bimanual and unimanual conditions. The results support our hypothesis that people can overcome the intrinsic difficulties associated with performing complex bimanual coordination patterns when provided appropriate perceptual information feedback that allows them to detect and correct coordination errors. PMID:23811738

Wang, Chaoyi; Kennedy, Deanna M; Boyle, Jason B; Shea, Charles H

2013-06-28

225

Difficult choices.  

UK PubMed Central (United Kingdom)

Different circumstances bring different levels of complexity to end-of-life care decisions. Physicians must act in the best interest of the patient, but with the ethical responsibility of not doing any intentional harm. As end-of-life issues heat up again in Capitol debates, protecting physicians' ability to carry out that duty under the 1999 Texas Advance Directives Act is a key feature of legislation the Texas Medical Association developed in collaboration with the Texas Hospital Association, the Texas Catholic Conference, the Texas Alliance for Life, and other faith-based groups. The groups are also pushing for reforms they believe will improve transparency and communication for all parties affected by these decisions.

Sorrel AL

2013-01-01

226

Engineering classification of karst ground conditions  

Directory of Open Access Journals (Sweden)

Full Text Available On a world scale, the dissolution of limestone and gypsum by natural waters creates extensive karst landforms that can be very difficult ground for civil engineers. Caves threaten foundation integrity, notably where their width is greater than their roof thickness. Sinkholes pose many problems, and are classified into six types, including subsidence sinkholes formed in soil cover within karst terrains. Rockhead morphology varies from uniform to pinnacled, also creating difficult ground to excavate or found upon. A proposed engineering classification of karst defines various complexities of ground conditions by the geohazards that they provide, mainly the caves, sinkholes and rockhead relief. Ground investigation techniques and foundation design philosophies are considered so that they are appropriate to the ground conditions provided by the different classes of karst.

Waltham,A.C.; Fookes,P.G.

2005-01-01

227

Statistical optimization of gold recovery from difficult leachable sulphide minerals using bacteria  

Energy Technology Data Exchange (ETDEWEB)

Some of refractory gold ores represent one of the difficult processable ores due to fine dissemination and interlocking of the gold grains with the associated sulphide minerals. This makes it impossible to recover precious metals from sulphide matrices by direct cyanide leaching even at high consumption of cyanide solution. Research to solve this problem is numerous. Application of bacteria shows that, some types of bacteria have great affect on sulphides bio-oxidation and consequently facilitate the leaching process. In this paper, leaching of Saudi gold ore, from Alhura area, containing sulphides before cyanidation is studied to recover gold from such ores applying bacteria. The process is investigated using stirred reactor bio-leaching rather than heap bio-leaching. Using statistical analysis the main affecting variables under studied conditions were identified. The design results indicated that the dose of bacteria, retention time and nutrition K{sub 2}SO{sub 4} are the most significant parameters. The higher the bacterial dose and the bacterial nutrition, the better is the concentrate grade. Results show that the method is technically effective in gold recovery. A gold concentrate containing > 100 g/t gold was obtained at optimum conditions, from an ore containing < 2 g/t gold i.e., 10 ml bacterial dose, 6 days retention time, and 6.5 kg/t K{sub 2}SO{sub 4}as bacteria nutrition. (orig.)

Ahmed, Hussin A.M. [King Abdulaziz Univ., Jeddah (Saudi Arabia). Mining Engineering Dept.; El-Midany, Ayman A. [King Saud Univ., Riyadh (Saudi Arabia)

2012-07-01

228

Difficult embryo transfers or blood on catheter and assisted reproductive outcomes: a systematic review and meta-analysis.  

UK PubMed Central (United Kingdom)

We performed a systematic review and meta-analysis to examine whether a difficult embryo transfer or the presence of blood on the transfer catheter affects assisted reproduction outcomes. We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). We aimed to determine the risk ratio (RR) associated with difficult embryo transfer or the presence of blood on the transfer catheter for the following outcomes: live birth, clinical pregnancy, and miscarriage. We identified 3066 papers, of which 194 were reviewed and nine were included. The outcome of live birth was not reported in any of the included studies and the effect on miscarriage was too imprecise for any conclusions. Pooled analysis of five studies demonstrated lower clinical pregnancy rates following a non-easy embryo transfer (RR=0.75; 95% CI=0.66-0.86). This included three studies showing subjectively difficult transfers reducing clinical pregnancies (RR=0.67; 95% CI=0.51-0.87) and two studies in which the need for additional manoeuvers reduced clinical pregnancies (RR=0.78; 95% CI=0.67-0.91). The presence of blood on the transfer catheter did not affect clinical pregnancy rates (RR=0.96; 95% CI=0.82-1.14) in five studies. We concluded that low quality evidence suggests that a difficult embryo transfer but not a bloody catheter reduces the chance of achieving a clinical pregnancy. More good quality studies are needed to evaluate the effect of difficult embryo transfer and the presence of blood on the catheter on the main outcomes of assisted reproduction.

Phillips JA; Martins WP; Nastri CO; Raine-Fenning NJ

2013-06-01

229

Difficult embryo transfers or blood on catheter and assisted reproductive outcomes: a systematic review and meta-analysis.  

Science.gov (United States)

We performed a systematic review and meta-analysis to examine whether a difficult embryo transfer or the presence of blood on the transfer catheter affects assisted reproduction outcomes. We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). We aimed to determine the risk ratio (RR) associated with difficult embryo transfer or the presence of blood on the transfer catheter for the following outcomes: live birth, clinical pregnancy, and miscarriage. We identified 3066 papers, of which 194 were reviewed and nine were included. The outcome of live birth was not reported in any of the included studies and the effect on miscarriage was too imprecise for any conclusions. Pooled analysis of five studies demonstrated lower clinical pregnancy rates following a non-easy embryo transfer (RR=0.75; 95% CI=0.66-0.86). This included three studies showing subjectively difficult transfers reducing clinical pregnancies (RR=0.67; 95% CI=0.51-0.87) and two studies in which the need for additional manoeuvers reduced clinical pregnancies (RR=0.78; 95% CI=0.67-0.91). The presence of blood on the transfer catheter did not affect clinical pregnancy rates (RR=0.96; 95% CI=0.82-1.14) in five studies. We concluded that low quality evidence suggests that a difficult embryo transfer but not a bloody catheter reduces the chance of achieving a clinical pregnancy. More good quality studies are needed to evaluate the effect of difficult embryo transfer and the presence of blood on the catheter on the main outcomes of assisted reproduction. PMID:23347607

Phillips, James A S; Martins, Wellington P; Nastri, Carolina O; Raine-Fenning, Nicholas J

2013-01-22

230

Cases of difficult suture removal following the McDonald procedure.  

UK PubMed Central (United Kingdom)

Abstract We examined the clinical significance of difficult suture removal following the McDonald procedure. We examined 117 patients following the McDonald procedure with a singleton pregnancy who delivered at ? 34 weeks of gestation. Difficult suture removal was defined as when spinal anesthesia was required for suture removal. Seven patients (6.0%) were defined as involving difficult suture removal. The cervical length in the difficult-removal-group was significantly shorter than that in the easy-removal-group at suture removal (p = 0.04). If the cervical length was shorter than 20 mm, the odds ratio for difficult suture removal was 9.0 (95% CI 1.6-49, p = 0.01). The progression of cervical ripening following the McDonald suture may be associated with an increased risk of difficult suture removal.

Suzuki S

2013-10-01

231

Use of simple clinical predictors on preoperative diagnosis of difficult endotracheal intubation in obese patients.  

UK PubMed Central (United Kingdom)

BACKGROUND AND OBJECTIVES: Although the incidence of difficult laryngoscopy is similar in obese and non-obese patients, there are more reports of difficult intubation in obese individuals. Alternatives for the diagnosis and prediction of difficult intubation in the preoperative period may help reduce anesthetic complications in obese patients. The aim of this study was to identify predictors for the diagnosis of difficult airway in obese patients, correlating with the clinical methods of pre-anesthetic evaluation and polysomnography. We also compared the incidence of difficult facemask ventilation and difficult laryngoscopy between obese and non-obese patients, identifying the most prevalent predictors. METHODS: Observational, prospective and comparative study, with 88 adult patients undergoing general anesthesia. In the preoperative period, we evaluated a questionnaire on the clinical predictors of the obstructive sleep apnea syndrome (OSAS) and anatomical parameters. During anesthesia, we evaluated difficult facemask ventilation and laryngoscopy. Descriptive statistics and correlation test were used for analysis. RESULTS: Patients were allocated into two groups: obese group (n=43) and non-obese group (n=45). Physical status, prevalence of snoring, hypertension, diabetes mellitus, neck circumference, and Mallampati index were higher in the obese group. Obese patients had a higher incidence of difficult facemask ventilation and laryngoscopy. There was no correlation between anatomical or clinical variable and difficult facemask ventilation in both groups. In obese patients, the diagnosis of OSAS showed strong correlation with difficult laryngoscopy. CONCLUSIONS: The clinical and polysomnographic diagnosis of OSA proved useful in the preoperative diagnosis of difficult laryngoscopy. Obese patients are more prone to difficult facemask ventilation and laryngoscopy.

Magalhães E; Oliveira Marques F; Sousa Govêia C; Araújo Ladeira LC; Lagares J

2013-05-01

232

Celecoxib reduces symptoms in men with difficult chronic pelvic pain syndrome (Category IIIA)  

Directory of Open Access Journals (Sweden)

Full Text Available We investigated the effectiveness of celecoxib in reducing symptoms in patients with difficult chronic pelvic pain syndrome (CPPS), NIH category IIIA. Sixty-four patients with category IIIA CPPS were randomized into two groups of 32 subjects each. One group was treated with celecoxib (200 mg daily) and the other with placebo. All patients underwent treatment for 6 weeks and were evaluated clinically before (baseline) and after 1, 2, 4, 6, and 8 weeks of treatment. The evaluation included the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) and a subjective global assessment (SGA). Repeated measures analysis of variance was used to evaluate treatment and time effects and their interaction. A decrease (means ± SD) in total NIH-CPSI score from 23.91 ± 5.27 to 15.88 ± 2.51 in the celecoxib group and from 24.25 ± 5.09 to 19.50 ± 2.50 in the placebo group was observed during treatment (0 to 6 weeks). A statistically significant decrease was observed in pain subscore (P < 0.006), quality of life subscore (P < 0.032) and total NIH-CPSI score (P < 0.015) after 2, 4 and 6 weeks, but not in urinary subscore. In addition, 38% of the celecoxib and 13% of the placebo subjects had at least a moderate improvement in SGA. The trend was similar for the NIH-CPSI scores. However, the response to treatment in terms of total NIH-CPSI score or subscore was not significantly different from placebo after interruption of treatment for 2 weeks. Our results show that celecoxib provides significant symptomatic improvement limited to the duration of the therapy in patients with difficult category IIIA CPPS compared to placebo.

W.P. Zhao; Z.G. Zhang; X.D. Li; D. Yu; X.F. Rui; G.H. Li; G.Q. Ding

2009-01-01

233

The Bonfils fiberscope: a clinical evaluation of its learning curve and efficacy in difficult airway management.  

UK PubMed Central (United Kingdom)

BACKGROUND: This study evaluated the use of the Bonfils fiberscope by analyzing its learning curve, efficacy and safety during airway management. METHODS: This was a prospective observational study where five anesthetists, with differing levels of experience, were asked to use the Bonfils rigid fiberscope (Karl Storz) for a six-month period. They used the scope when performing endotracheal intubations in patients undergoing general anesthesia. The patients were excluded if various clinical indicators predicted that they might be difficult to intubate. The patient's head was kept in the neutral position to simulate the intubation of a trauma patient. Direct laryngoscopy with a Macintosh blade was performed to assign a Cormack and Lehane grade prior to attempting laryngoscopy with the Bonfils fiberscope. After intubating the patient with the Bonfils fiberscope, intubation time and any complications or failures noted after the procedure were recorded. RESULTS: The study included 216 patients, three of which were failed intubations. No complications occurred during the study period. The median intubation time was 21.4 s. The learning curve improved significantly after 20 intubations (P<0.05) and was affected by the operator's experience and aptitude with endoscopic viewing. Seventeen patients were deemed to have "unpredicted" difficult airways: 15 subjects with a Cormack grade 3 (6.9%) and two subjects with a Cormack 4 (0.9%). Median time to intubation in subjects with a Cormack <3 was 16 s (95% CI=10-29 s), and in subjects with a Cormack ?3, it was 15 s (CI 95%=15-18 s) with P=0.703. CONCLUSION: The Bonfils fiberscope is an efficient, easy to use and safe device for endotracheal intubation.

Falcetta S; Pecora L; Orsetti G; Gentili P; Rossi A; Gabbanelli V; Adrario E; Donati A; Pelaia P

2012-02-01

234

'Difficult to diagnose' desmoid tumours: a potential role for CTNNB1 mutational analysis.  

UK PubMed Central (United Kingdom)

AIMS: The utility of CTNNB1 (encoding ?-catenin) genotyping for diagnosing sporadic desmoid tumours (DT) when traditional clinicopathological parameters were inconclusive was evaluated. METHODS AND RESULTS: Cases included were: (i) new primary lesions where initial DT diagnosis was inconclusive; and (ii) possible recurrent DT versus scar. Formalin-fixed paraffin-embedded (FFPE) tissues were obtained via needle biopsy or a surgical excision (57 specimens) as part of initial assessment. DNA extraction, CTNNB1 exon 3 amplification and sequencing were conducted in a Clinical Laboratory Improvement Amendments of 1988 (CLIA)-approved molecular diagnostics laboratory. For patients with no previous DT history (n =?47) sequencing identified mutations in 30 (64%), substantiating DT diagnosis. In biopsies with non-mutated (NM) CTNNB1 (n?=?17) the test was inconclusive; in seven of these, a diagnosis of DT was strongly favoured in the subsequent surgical resection specimen. Ten patients with previously resected DT were evaluated; mutation was identified in six cases (60%), indicating DT over scar. In two (20%) with primary tumours harbouring CTNNB1 mutation no mutation was found, favouring scar over DT; the other two NM-CTNNB1 cases (20%) were inconclusive. CONCLUSIONS: CTNNB1 genotyping can be very useful in 'difficult to diagnose' lesions when the differential diagnosis includes DT. Recognizing inherent test limitations, the presence of CTNNB1 mutation can inform the therapeutic approach.

Colombo C; Bolshakov S; Hajibashi S; Lopez-Terrada L; Wang WL; Rao P; Benjamin RS; Lazar AJ; Lev D

2011-08-01

235

To shape or not to shape...simulated bougie-assisted difficult intubation in a manikin.  

UK PubMed Central (United Kingdom)

Thirty anaesthetists attempted to place a derived 'optimal' curve bougie or a straight bougie in the trachea of a manikin, in a randomised cross-over study. A Grade 3 Cormack and Lehane laryngoscopic view was simulated. The anaesthetists were blinded to success (tracheal placement) or failure (oesophageal placement). The success rates with the curved and straight bougies were 83 and 7%, respectively, giving a difference (95% confidence interval) of 77% (54-87%) between the two bougies (p < 0.0001). On a separate occasion, under identical laboratory conditions, 30 anaesthetists attempted to place a straight coudé (angled)-tipped bougie or a straight straight-tipped bougie in the trachea of a manikin. The success rates with the coudé- and straight-tipped bougies were 43 and 0%, respectively, giving a difference (95% confidence interval) of 43% (21-61%) between the two bougies (p < 0.001). These results suggest that bougies used to facilitate difficult intubation should be curved and have a coudé tip.

Hodzovic I; Wilkes AR; Latto IP

2003-08-01

236

3D seismology Ruehlermoor: Highly dissolved seismology under difficult conditions; 3D Seismik Ruehlermoor: Hochaufloesende Seismik unter schwierigen Bedingungen  

Energy Technology Data Exchange (ETDEWEB)

The previous structural plan of the petroleum deposit Ruehlermoor in Emsland (Federal Republic of Germany) only was based on the results of a multiplicity of drillings. In order to optimize the production and the EOR measures (EOR = Enhanced Oil Recovery), a highly soluble three-dimensional seismological measurement is accomplished. The goal of this measurement is the dissolution of disturbance displacements in an order of magnitude of five meters. The substantial problem is the fact that the oil field completely lies under a moorland which is dismounted industrially. The three-dimensional seismological measurements only can be accomplished in the winter months with mobile Sonic drilling equipment.

Koerbe, M.; Bartz, V. [Gaz de France Produktion Exploration Deutschland GmbH, Lingen (Germany)

2008-10-23

237

CONDITIONING SHAMPOO  

UK PubMed Central (United Kingdom)

An improved stable conditioning shampoo imparts improved physical and cosmetic properties to the hair such as wet and dry comb, wet and dry feel, gloss, static control and manageability, yet does not cause build-up and does not contain any polyhydric compounds. The shampoo includes an anionic surfactant, a water-soluble cationic surfactant, a water-insoluble conditioning agent, and a suspending agent where the suspending agent is a mixture of a cellulose derivative and a PVM/MA Decadiene crosspolymer. The conditioning shampoo is stable for extended periods.

DUVEL Lane A.

238

Conditioning shampoo  

UK PubMed Central (United Kingdom)

An improved stable conditioning shampoo imparts improved physical and cosmetic properties to the hair such as wet and dry comb, wet and dry feel, gloss, static control and manageability, yet does not cause build-up and does not contain any polyhydric compounds. The shampoo includes an anionic surfactant, a water soluble cationic surfactant, a water-insoluble conditioning agent, and a suspending agent where the suspending agent is a mixture of a cellulose derivative and a PVM/MA Decadiene crosspolymer. The conditioning shampoo is stable for extended periods.

DUVEL LANE A

239

Musculoskeletal ultrasound including definitions for ultrasonographic pathology  

DEFF Research Database (Denmark)

Ultrasound (US) has great potential as an outcome in rheumatoid arthritis trials for detecting bone erosions, synovitis, tendon disease, and enthesopathy. It has a number of distinct advantages over magnetic resonance imaging, including good patient tolerability and ability to scan multiple joints in a short period of time. However, there are scarce data regarding its validity, reproducibility, and responsiveness to change, making interpretation and comparison of studies difficult. In particular, there are limited data describing standardized scanning methodology and standardized definitions of US pathologies. This article presents the first report from the OMERACT ultrasound special interest group, which has compared US against the criteria of the OMERACT filter. Also proposed for the first time are consensus US definitions for common pathological lesions seen in patients with inflammatory arthritis.

Wakefield, RJ; Balint, PV

2005-01-01

240

Utility of single and double balloon endoscopy in patients with difficult colonoscopy: a randomized controlled trial.  

UK PubMed Central (United Kingdom)

AIM: To compare the utility of single-balloon colonoscopy (SBC) or double-balloon colonoscopy (DBC) for difficult colonoscopies. METHODS: Between August 2008 and June 2010, patients in whom total colonoscopy failed within 30 min of insertion were assigned randomly to undergo either SBC or DBC. No sedatives were used. After the endoscopy, all patients were asked to evaluate pain during the procedure on a 10-point analog scale (1 = no pain; 10 = worst imaginable pain) with a questionnaire. The study outcomes were the cecal intubation rate and time, endoscopic findings, complications, and pain score. RESULTS: The SBC and DBC groups included 11 and 10 patients, respectively. All but one SBC patient achieved total colonoscopy successfully. The cecal intubation times were 18 min (range: 10-85 min) and 12.8 min (range: 9.5-42 min) in the SBC and DBC groups, respectively (P = 0.17). No difference was observed in the prevalence of colon polyps between the SBC and DBC groups (45% vs 30%, P = 0.66). SBC showed advanced colon cancer in the ascending colon, which was inaccessible using conventional colonoscopy. The respective pain scores were 5 (1-10) [median (range)] and 5 (1-6) in the SBC and DBC groups (P = 0.64). No complications were noted in any patient. CONCLUSION: The utility of single- and double-balloon endoscopy for colonoscopy seems comparable in patients with incomplete colonoscopy using a conventional colonoscope.

Yamada A; Watabe H; Takano N; Togo G; Yamaji Y; Yoshida H; Kawabe T; Omata M; Koike K

2013-08-01

 
 
 
 
241

Celecoxib reduces symptoms in men with difficult chronic pelvic pain syndrome (Category IIIA)  

Scientific Electronic Library Online (English)

Full Text Available Abstract in english We investigated the effectiveness of celecoxib in reducing symptoms in patients with difficult chronic pelvic pain syndrome (CPPS), NIH category IIIA. Sixty-four patients with category IIIA CPPS were randomized into two groups of 32 subjects each. One group was treated with celecoxib (200 mg daily) and the other with placebo. All patients underwent treatment for 6 weeks and were evaluated clinically before (baseline) and after 1, 2, 4, 6, and 8 weeks of treatment. The eva (more) luation included the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) and a subjective global assessment (SGA). Repeated measures analysis of variance was used to evaluate treatment and time effects and their interaction. A decrease (means ± SD) in total NIH-CPSI score from 23.91 ± 5.27 to 15.88 ± 2.51 in the celecoxib group and from 24.25 ± 5.09 to 19.50 ± 2.50 in the placebo group was observed during treatment (0 to 6 weeks). A statistically significant decrease was observed in pain subscore (P

Zhao, W.P.; Zhang, Z.G.; Li, X.D.; Yu, D.; Rui, X.F.; Li, G.H.; Ding, G.Q.

2009-10-01

242

Needle Knife Precut Papillotomy and Fistulotomy for Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography.  

UK PubMed Central (United Kingdom)

Background: Although needle knife precut papillotomy and needle knife fistulotomy have been considered useful alternatives for achieving selective biliary cannulation, controversies remain regarding the technical proficiency for performing this procedure and safety concerns. Aim: This retrospective study evaluates the feasibility and safety of combining needle knife precut papillotomy and fistulotomy (NKPPF) to assist endoscopic retrograde cholangiopancreatography (ERCP) for difficult biliary cannulation. Methods: Data were collected and analyzed for 48 patients who underwent NKPPF between January 2008 and September 2012 at our center. The operation success rate, mean procedure time, and post-ERCP complications were investigated and compared with those of standard cannulation. Results: The success rate for NKPPF was 96% (46/48) and the mean procedure time was 4.5 ± 1.6 min based on our data set. The major complications included pancreatitis, which occurred in 2 of the 48 patients (4%), and acute cholangitis, which was observed in 1 patient (2%). There was no significant difference between the complication rate of NKPPF (6%) and standard cannulation therapeutic ERCP (4%). Conclusion: NKPPF is an effective method for accessing the biliary system after failed standard cannulation and is not associated with an increased risk of complications. © 2013 S. Karger AG, Basel.

Zhang QS; Han B; Xu JH; Bao WM; Tao JL; Zhang Y

2013-01-01

243

Needle Knife Precut Papillotomy and Fistulotomy for Difficult Biliary Cannulation during Endoscopic Retrograde Cholangiopancreatography.  

UK PubMed Central (United Kingdom)

Background: Although needle knife precut papillotomy and needle knife fistulotomy have been considered useful alternatives for achieving selective biliary cannulation, controversies remain regarding the technical proficiency for performing this procedure and safety concerns. Aim: This retrospective study evaluates the feasibility and safety of combining needle knife precut papillotomy and fistulotomy (NKPPF) to assist endoscopic retrograde cholangiopancreatography (ERCP) for difficult biliary cannulation. Methods: Data were collected and analyzed for 48 patients who underwent NKPPF between January 2008 and September 2012 at our center. The operation success rate, mean procedure time, and post-ERCP complications were investigated and compared with those of standard cannulation. Results: The success rate for NKPPF was 96% (46/48) and the mean procedure time was 4.5 ± 1.6 min based on our data set. The major complications included pancreatitis, which occurred in 2 of the 48 patients (4%), and acute cholangitis, which was observed in 1 patient (2%). There was no significant difference between the complication rate of NKPPF (6%) and standard cannulation therapeutic ERCP (4%). Conclusion: NKPPF is an effective method for accessing the biliary system after failed standard cannulation and is not associated with an increased risk of complications. © 2013 S. Karger AG, Basel.

Zhang QS; Han B; Xu JH; Bao WM; Tao JL; Zhang Y

2013-08-01

244

Diagnostic utility of immunohistochemistry in morphologically difficult prostate cancer: review of current literature.  

UK PubMed Central (United Kingdom)

Varma M & Jasani B (2005) Histopathology47, 1-16 Diagnostic utility of immunohistochemistry in morphologically difficult prostate cancer: review of current literatureImmunohistochemistry is widely used to distinguish prostate cancer from benign mimics and to establish the prostatic origin of poorly differentiated carcinoma. We critically review the recent advances in prostate cancer immunohistochemistry, including the introduction of newer basal cell markers such as p63 and the discovery of the overexpression of alpha-methylacyl coenzyme A racemase (AMACR) in prostate cancer. The description of newer urothelial markers to aid the distinction of prostate cancer from urothelial carcinoma is also presented together with refinements in the quality control of PSA and PSAP immunostaining. Although AMACR is a useful immunohistochemical marker for prostate cancer, it has significant limitations. These limitations are discussed and the need for interpreting AMACR immunoreactivity in the appropriate morphological context and in conjunction with basal call markers is emphasized. We also describe the utility of an immunohistochemical panel composed of PSA, PSAP and high molecular weight cytokeratin for distinguishing poorly differentiated prostate cancer from high-grade urothelial carcinoma. A morphological differential diagnosis based selection of immunohistochemical markers is highlighted as a novel approach in the diagnosis of prostate cancer in routine surgical pathology practice.

Varma M; Jasani B

2005-07-01

245

Utility of single and double balloon endoscopy in patients with difficult colonoscopy: A randomized controlled trial  

Directory of Open Access Journals (Sweden)

Full Text Available AIM: To compare the utility of single-balloon colonoscopy (SBC) or double-balloon colonoscopy (DBC) for difficult colonoscopies. METHODS: Between August 2008 and June 2010, patients in whom total colonoscopy failed within 30 min of insertion were assigned randomly to undergo either SBC or DBC. No sedatives were used. After the endoscopy, all patients were asked to evaluate pain during the procedure on a 10-point analog scale (1 = no pain; 10 = worst imaginable pain) with a questionnaire. The study outcomes were the cecal intubation rate and time, endoscopic findings, complications, and pain score. RESULTS: The SBC and DBC groups included 11 and 10 patients, respectively. All but one SBC patient achieved total colonoscopy successfully. The cecal intubation times were 18 min (range: 10-85 min) and 12.8 min (range: 9.5-42 min) in the SBC and DBC groups, respectively (P = 0.17). No difference was observed in the prevalence of colon polyps between the SBC and DBC groups (45% vs 30%, P = 0.66). SBC showed advanced colon cancer in the ascending colon, which was inaccessible using conventional colonoscopy. The respective pain scores were 5 (1-10) [median (range)] and 5 (1-6) in the SBC and DBC groups (P = 0.64). No complications were noted in any patient. CONCLUSION: The utility of single- and double-balloon endoscopy for colonoscopy seems comparable in patients with incomplete colonoscopy using a conventional colonoscope.

Atsuo Yamada; Hirotsugu Watabe; Noriyuki Takano; Goichi Togo; Yutaka Yamaji; Haruhiko Yoshida; Takao Kawabe; Masao Omata; Kazuhiko Koike

2013-01-01

246

Behavioral problems in children and adolescents with difficult-to-treat asthma.  

UK PubMed Central (United Kingdom)

BACKGROUND: The aim of this study was to quantify behavioral problems in clinically treated children and adolescents with asthma and to examine the association of these problems and quality of life with difficult-to-treat asthma. METHODS: Clinical patients with difficult-to-treat asthma (n = 31) and patients with asthma who were not classified as difficult-to-treat asthma (n = 52) completed the Pediatric Asthma Quality of Life Questionnaire [PAQLQ(S)]. Their parents completed the Child Behavior Checklist (CBCL) to assess behavioral problems. Behavioral problem scores were compared to norms of population reference groups and both behavioral problems and quality of life were compared between children and adolescents with and without difficult-to-treat asthma. RESULTS: Especially internalizing behavioral problems such as being withdrawn/depressed and somatic complaints were more severe in the asthmatic groups compared to the healthy reference groups. The behavioral problems 'somatic complaints' and 'thought problems' as well as a lower quality of life were more severe in children and adolescents with difficult-to-treat asthma than in asthma patients who did not fulfill the criteria of difficult-to-treat asthma. CONCLUSIONS: Behavioral problems and a lower quality of life are suggested to be more pronounced in clinically treated children and adolescents with difficult-to-treat asthma than in asthma patients who are not classified as difficult-to-treat asthma. With respect to practical implications, our data suggest that health-care professionals should - especially in children and adolescents with difficult-to-treat asthma - assess and, if necessary, treat behavioral problems.

Verkleij M; van de Griendt EJ; Kaptein AA; van Essen-Zandvliet L; Duiverman E; Geenen R

2011-02-01

247

Sensitivity and noise in GC-MS: Achieving low limits of detection for difficult analytes  

Science.gov (United States)

Gas chromatography-mass spectrometry (GC-MS) instrument limit of detection (LOD) is typically listed by major vendors as that of octafluoronaphthalene (OFN). Most current GC-MS instruments can achieve LODs in the low femtogram range. However, GC-MS LODs for realistic analytes in actual samples are often a few orders of magnitude higher than OFN's. Users seldom encounter 1 pg LOD in the single ion monitoring mode in their applications. We define this detectability difference as the "OFN gap." In this paper, we demonstrate and discuss how the OFN gap can be significantly reduced by the use of GC-MS with supersonic molecular beams (SMB). Experimental results were obtained with a recently developed GC-MS with SMB named 1200-SMB, that is based on the conversion of the Varian 1200 system into a GC-MS-MS with SMB. With this 1200-SMB system, the LOD of all types of analytes, including OFN, in real samples is significantly improved through the combination of: (a) enhanced molecular ion; (b) elimination of vacuum background noise; (c) elimination of mass independent noise; (d) elimination of ion source peak tailing and degradation; (e) significantly increased range of thermally labile and low volatility compounds that are amenable for analysis through lower sample elution temperatures; (f) reduced column bleed and ghost peaks through sample elution at lower temperatures; (g) improved compatibility with large volume injections; and (h) reduced matrix interferences through the combination of enhanced molecular ion and MS-MS. As a result, the 1200-SMB LODs of common and/or difficult compounds are much closer to its OFN LOD, even in complex matrices. We crossed the dimethoate, 30 for methylstearate, 50 for cholesterol, 50 for permethrin, >400 for methomyl, and >2000 for C32H66. In general, the harder the compound analysis, the greater is the gain in sample detectability using the 1200-SMB versus traditional GC-MS. Thus, the 1200-SMB lowers LOD, particularly for difficult analytes that are normally sacrificed in methods, and the detectability gains can amount to a few orders of magnitude over traditional GC-MS in real-world applications.

Fialkov, Alexander B.; Steiner, Urs; Lehotay, Steven J.; Amirav, Aviv

2007-01-01

248

Prediction of difficult intubations using conventional indicators; Does rapid sequence intubation ease difficult intubations? A prospective randomised study in a tertiary care teaching hospital  

Directory of Open Access Journals (Sweden)

Full Text Available Background : Endotracheal intubations performed in the Emergency Department. Aims : To assess whether conventional indicators of difficult airway can predict a difficult intubation in the Emergency Setting and to investigate the effect of rapid sequence intubation (RSI) on ease of intubation. Settings and Design : A prospective randomized study was designed involving 60 patients requiring intubation, over a period of 4 months. Materials and Methods : Demographic profile, details of methods used, airway assessment, ease of intubation, and Cormack and Lehane score were recorded. Airway assessment score and ease of intubation criteria were devised and assessed. Statistical Analysis : Descriptive statistical analysis was carried out. Chi-square/2 × 2, 2 × 3, 3 × 3, Fisher Exact test have been used to find the significance of study parameters on categorical scale between two or more groups. Results : Patients with a Mallampatti score of three or four were found to have worse laryngoscopic views (Cormack-Lehane score, 3 or 4). Of all airway indicators assessed, an increased Mallampatti score was found to have significant correlation with increased difficulty in intubation. The use of RSI was associated with better laryngoscopic views, and easier intubations. Conclusions : An airway assessment using the Mallampatti score is invaluable as a tool to predict a difficult airway and should be performed routinely if possible. RSI aids intubation ease. If not otherwise contraindicated, it should be performed routinely for all intubations in the ED.

Gangadharan Lakshmi; Sreekanth C; Vasnaik Mabel

2011-01-01

249

[Neurophysiological and functional assessment of patients with difficult-to-control asthma].  

UK PubMed Central (United Kingdom)

INTRODUCTION: Due to the inadequate response to inhaled corticoids, patients with difficult-to-control asthma (DCA) are submitted to oral corticoids or use of Omalizumab. Although it is necessary to treat these patients, a significant relationship between steroid usage and both peripheral and respiratory weakness muscle, results in implications such as loss of quality of life and compromised lung function. Nonetheless, it is not known whether these patients suffer neurophysiological changes due to drug effect. OBJECTIVE: To investigate the neurophysiological and functional characteristics of patients with DCA in order to gain a better understanding of the condition. METHOD: A cross-sectional study was carried out involving three groups of patients: DCA-C (use of oral corticosteroids), DCA-O (use of omalizumab) and CG (healthy controls matched for age). The assessment involved the six-minute walk test, sit-to-stand test, static balance on a pressure platform, patellar and Achilles reflexes and quadriceps strength in the dominant leg. RESULTS: The results revealed no statistically significant differences between the control group and DCA groups in relation to neurophysiological aspects. However, the DCA groups exhibited a significant reduction in functional capacity [decreased muscle strength (p < 0.05), shorter distance covered on walk test (p < 0.05) and lesser number of repetitions on sit-to-stand test (p < 0.05)] in comparison to the control group. CONCLUSION: Individuals with DCA exhibited a reduction in functional capacity. The DCA-C group also demonstrated a reduction in muscle strength when compared with control group, likely caused by the continual use of corticoids. However, no neurophysiological alterations were found in the studied population.

Freitas Canuto F; Silva SM; Malosá Sampaio LM; Stirbulov R; Ferrari Corrêa JC

2012-07-01

250

'SIMPLES': a structured primary care approach to adults with difficult asthma.  

UK PubMed Central (United Kingdom)

The substantial majority of patients with asthma can expect minimal breakthrough symptoms on standard doses of inhaled corticosteroids with or without additional add-on therapies. SIMPLES is a structured primary care approach to the review of a person with uncontrolled asthma which encompasses patient education monitoring, lifestyle and pharmacological management and addressing support needs which will achieve control in most patients. The small group of patients presenting with persistent asthma symptoms despite being prescribed high levels of treatment are often referred to as having 'difficult asthma'. Some will have difficult, 'therapy resistant' asthma, some will have psychosocial problems which make it difficult for them to achieve asthma control and some may prove to have an alternative diagnosis driving their symptoms. A few patients will benefit from referral to a 'difficult asthma' clinic. The SIMPLES approach, aligned with close co-operation between primary and specialist care, can identify this patient group, avoid inappropriate escalation of treatment, and streamline clinical assessment and management.

Ryan D; Murphy A; Ställberg B; Baxter N; Heaney LG

2013-09-01

251

Two cases of low grade astrocytoma difficult to distinguish by computed tomography (CT)  

Energy Technology Data Exchange (ETDEWEB)

In two cases of low grade astrocytoma, preoperative diagnosis was difficult by CT alone. The cases are presented with other examinations. Clinical and CT features of low grade astrocytoma are discussed in contrast to cerebral infarction.

Saito, H.; Yoneya, M.; Kamisato, N.; Sakamoto, T.; Kowada, M. (Akita Univ. (Japan))

1981-09-01

252

77 FR 59629 - Statutorily Mandated Designation of Difficult Development Areas for 2013  

Science.gov (United States)

...DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT [Docket No. FR-5652-N-01] Statutorily Mandated Designation of Difficult Development Areas for 2013 AGENCY: Office of the...Secretary, Department of Housing and Urban Development. ACTION:...

2012-09-28

253

The difficult nosology of blepharophimosis-mental retardation syndromes: report on two siblings.  

Science.gov (United States)

Blepharophimosis-mental retardation syndromes (BMRS) include a group of clinically and etiologically heterogeneous conditions, which can occur as isolated features or as part of distinct disorders displaying multiple congenital anomalies. We report on two siblings, a 6-year-old girl and an 18-month-old male, presenting with overlapping clinical findings. Major characteristics included facial dysmorphisms with upward slanted palpebral fissures, blepharophimosis, telecanthus, hypertelorism, posteriorly rotated and abnormal ears, and micrognathia. Ectodermal abnormalities consisted of fine hair, sparse eyebrows, and thin skin. Both patients had feeding difficulties with gastro-esophageal reflux and growth retardation. Psychomotor skills were severely delayed with no verbal capacity. The male sib also displayed low growth hormone (GH) levels, while the older sister had low cholesterol and mildly elevated TSH levels. Numerous metabolic/genetic investigations, including cholesterol precursors, dosage, and high-resolution array-CGH, were negative. BMR syndromes, including Dubowitz syndrome, Marden-Walker syndrome, Ohdo/Ohdo-like syndromes, and the cholesterol storage disorders were considered. We concluded that these two patients are affected by a possible autosomal recessive condition within the heterogeneous clinical spectrum of BMRS, fitting with the Young-Simpson syndrome subtype. PMID:21567902

Dentici, Maria Lisa; Mingarelli, Rita; Dallapiccola, Bruno

2011-02-22

254

The difficult nosology of blepharophimosis-mental retardation syndromes: report on two siblings.  

UK PubMed Central (United Kingdom)

Blepharophimosis-mental retardation syndromes (BMRS) include a group of clinically and etiologically heterogeneous conditions, which can occur as isolated features or as part of distinct disorders displaying multiple congenital anomalies. We report on two siblings, a 6-year-old girl and an 18-month-old male, presenting with overlapping clinical findings. Major characteristics included facial dysmorphisms with upward slanted palpebral fissures, blepharophimosis, telecanthus, hypertelorism, posteriorly rotated and abnormal ears, and micrognathia. Ectodermal abnormalities consisted of fine hair, sparse eyebrows, and thin skin. Both patients had feeding difficulties with gastro-esophageal reflux and growth retardation. Psychomotor skills were severely delayed with no verbal capacity. The male sib also displayed low growth hormone (GH) levels, while the older sister had low cholesterol and mildly elevated TSH levels. Numerous metabolic/genetic investigations, including cholesterol precursors, dosage, and high-resolution array-CGH, were negative. BMR syndromes, including Dubowitz syndrome, Marden-Walker syndrome, Ohdo/Ohdo-like syndromes, and the cholesterol storage disorders were considered. We concluded that these two patients are affected by a possible autosomal recessive condition within the heterogeneous clinical spectrum of BMRS, fitting with the Young-Simpson syndrome subtype.

Dentici ML; Mingarelli R; Dallapiccola B

2011-03-01

255

Predictive value of lung function trend and FeNO for difficult asthma in children.  

UK PubMed Central (United Kingdom)

OBJECTIVE: The aim of this study was to evaluate the predictive value of lung function and fraction of exhaled nitric oxide (FeNO) for difficult asthma in children. PATIENTS AND METHODS: Children with asthma referred to an asthma clinic for uncontrolled persistent asthma on inhaled corticosteroids (ICSs) alone or in combination with a long-acting beta2-agonist and/or a leukotriene receptor antagonist were followed in a prospective 1-year study to identify difficult asthma. At the end of the study period, difficult asthma was considered for children with persistent asthma symptoms and/or frequent moderate/severe asthma exacerbations despite regular intake of ICSs (beclomethasone or equivalent) > 800 microg/d for at least 3 months, after correcting for adherence to treatment, inhalation technique, and comorbidities and after implementing an individualized treatment plan. The difficult asthma phenotype was characterized using a multidimensional approach combining clinical features and pathophysiologic features (lung function and inflammation). Unfavorable lung function trend (persistent airway obstruction and fluctuations in forced expiratory volume in the first second of alpha > 0.5) and persistently high FeNO levels (> 45 ppb despite increasing ICS doses) were analyzed as risk factors for difficult asthma in the logistic regression analysis together with male sex, atopy, concurrent severe rhinitis, obesity, psychopathology, exposure to tobacco smoke, low socioeconomic status, lack of adherence to treatment, and persistent bronchodilator response. RESULTS: Forty-six asthmatic children (34 males, 74%) with a mean (SEM) age of 7.55 (3.04) years were enrolled. After 1 year, 24 children (52%) were labeled as having difficult asthma. Independent risk factors for difficult asthma were persistently high FeNO (P = .04), obesity (P = .04), and severe rhinitis (P = .03). CONCLUSIONS: Persistently high FeNO predicts difficult asthma in children, while unfavorable lung function trend does not.

Agache I; Ciobanu C

2012-01-01

256

The prediction of difficult intubation in obese patients using mirror indirect laryngoscopy: A prospective pilot study  

Science.gov (United States)

Background: The incidence of difficult laryngoscopy and intubation in obese patients is higher than in the general population. Classical predictors of difficult laryngoscopy and intubation have been shown to be unreliable. We prospectively evaluated indirect mirror laryngoscopy as a predictor of difficult laryngoscopy in obese patients. Materials and Methods: 60 patients with a body mass index (BMI) greater than 30, scheduled to undergo general anesthesia, were enrolled. Indirect mirror laryngoscopy was performed and was graded 1-4 according to Cormack and Lehane. A view of grade 3-4 was classified as predicting difficult laryngoscopy. Additional assessments for comparison were the Samsoon and Young modification of the Mallampati airway classification, Wilson Risk Sum Score, neck circumference, and BMI. The view obtained upon direct laryngoscopy after induction of general anesthesia was classified according to Cormack and Lehane as grade 1-4. Results: Sixty patients met the inclusion criteria; however, 8 (13.3%) patients had an excessive gag reflex, and examination of the larynx was not possible. 15.4% of patients who underwent direct laryngoscopy had a Cormack and Lehane grade 3 or 4 view and were classified as difficult. Mirror laryngoscopy had a tendency toward statistical significance in predicting difficult laryngoscopy in these patients. Conclusions: This study is consistent with previous studies, which have demonstrated that no one individual traditional test has proven to be adequate in predicting difficult airways in the obese population. However, the new application of an old test - indirect mirror laryngoscopy - could be a useful additional test to predict difficult laryngoscopy in obese patients.

Budde, Arne O; Desciak, Matthew; Reddy, Venugopal; Falcucci, Octavio A; Vaida, Sonia J; Pott, Leonard M

2013-01-01

257

Comparison of Easy and Difficult Embryo Transfer Outcomes in In Vitro Fertilization Cycles  

Directory of Open Access Journals (Sweden)

Full Text Available Background: The aim of this study was to compare the effects of easy and difficult embryotransfers (ET) on implantation and pregnancy rates.Materials and Methods: In this prospective study, we analyzed the results of 706 ET proceduresover a 12-month period. An easy ET was defined as a transfer that occurred without the useof force or other instrumentation. A difficult ET was defined as the use of force for catheterplacement, and/or the use of additional instruments, and/or manipulation. Pregnancy rate wascompared between patients with easy or difficult ETs.Results: There was a significantly higher implantation rate in the easy group (21.7%) comparedto the difficult group (12.1%, p<0.05).The easy group had a higher pregnancy rate (38.1%)compared to patients who had difficult ETs (21.4%; p<0.05).Conclusion: Any uterine manipulation during ET adversely affects in vitro fertilization (IVF).Precaution should be taken to identify possibly difficult ET cases in advance.

Firouzeh Ghaffari; Kiandokht Kiani; Akram Bahmanabadi; Mohammadreza Akhoond

2013-01-01

258

The difficult patients in pain therapy: how to recognize and manage them  

Directory of Open Access Journals (Sweden)

Full Text Available When physicians experience negative reactions to patients, they often perceive the patients as "difficult". Such patients make up 15% to 30% of primary care practice populations. They are those whom most physicians dread. The dependency of difficult patients heavily influences the doctor-patient relationship and the outcome of the treatment. These patients often present with physical symptoms that could not be medically explained. Pain is the most frequent complaint, though unrecognized psychopatological disorders are more prevalent among these patients.Conversely, difficult patients are rather common in chronic pain syndromes, particularly in back pain, failed back syndrome and atypical facial pain. Diagnosis can be achieved on phenomenological, psychopathological and psychodynamic grounds. The management of difficult patients can prove to be a tough task for both physicians and nurses, as they are time-consuming, draining the emotional resources of the therapist, and evoke feelings of aversion and frustration.Appropriate use of patient-doctor communication skills and an effort to improve relations with the patient through empathy, tolerance and non-judgemental listening are suggested as ways of transform a difficult encounter into a workable patient doctor relationship.

G. De Benedittis

2005-01-01

259

Interobserver variability for non-invasive prediction of difficult intubation in different years of anesthesiology residency.  

UK PubMed Central (United Kingdom)

BACKGROUND: The incidence of a difficult laryngoscopy/intubation, which could lead to failed intubation is in the range of 1.5%-13%. Failed intubation may lead to hypoxia, brain damage or death. Preoperative evaluation of the airway can be accomplished by non-invasive bedside clinical tests during physical examination. We studied interobserver variability for non-invasive prediction of difficult intubation in different anesthesiology residency years. METHODS: Three hundred eighty four adult patients undergoing elective surgery with general anesthesia and endotracheal intubation were enrolled this study. The investigators were divided in to two groups: three of them were in 4th (Group 1) and the other three were in 1st (Group 2) year of their anesthesiology residency. The variables evaluated were age, weight, height, submental-cervical angle, measurements of mandibular space, deviation of trachea, jaw-hyomental distance, swelling or scar tissue at neck, limited mouth opening, small mouth cavity, macroglossia, cleft lip-palate, long teeth and modified Mallampati score. RESULTS: The incidence of difficult intubation is 4.9%. Group 1 is more successful than Group 2 in predicting difficult intubation. CONCLUSIONS: Regarding Mallampati score, measurements of mandibular space, jaw-hyomental distance, mouth opening and mouth cavity; interobserver variability is detected in predicting difficult intubation among different years of anesthesiology residency. In means of submental-cervical angle, tracheal deviation, swelling or scar tissue at neck and macroglossia, similar results which are statistically significant, are obtained.

Celebi N; Canbay O; Cil H; Disli ZK; Karagoz AH

2012-10-01

260

Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study.  

UK PubMed Central (United Kingdom)

RATIONALE: Difficult intubation in the intensive care unit (ICU) is a challenging issue. OBJECTIVES: To develop and validate a simplified score for identifying patients with difficult intubation in the ICU and to report related complications. METHODS: Data collected in a prospective multicenter study from 1,000 consecutive intubations from 42 ICUs were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICUs and internally by bootstrap on 1,000 iterations. MEASUREMENTS AND MAIN RESULTS: In multivariate analysis, the main predictors of difficult intubation (incidence = 11.3%) were related to patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening); pathology (severe hypoxia, coma); and operator (nonanesthesiologist). From the ? parameter, a seven-item simplified score (MACOCHA score) was built, with an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.85-0.94). In the validation cohort (prevalence of difficult intubation = 8%), the AUC was 0.86 (95% CI, 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98%, and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was 0.89 (95% CI, 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest, or death) occurred in 38% of the 1,000 cases. Patients with difficult intubation (n = 113) had significantly higher severe life-threatening complications than those who had a nondifficult intubation (51% vs. 36%; P < 0.0001). CONCLUSIONS: Difficult intubation in the ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items discriminates difficult and nondifficult intubation in the ICU. Clinical trial registered with www.clinicaltrials.gov (NCT 01532063).

De Jong A; Molinari N; Terzi N; Mongardon N; Arnal JM; Guitton C; Allaouchiche B; Paugam-Burtz C; Constantin JM; Lefrant JY; Leone M; Papazian L; Asehnoune K; Maziers N; Azoulay E; Pradel G; Jung B; Jaber S

2013-04-01

 
 
 
 
261

The snare technique: a novel atraumatic method for the removal of difficult nasal foreign bodies.  

UK PubMed Central (United Kingdom)

BACKGROUND: Nasal foreign bodies (NFBs) are a common occurrence, particularly in children between 2 and 4 years old. Many techniques have been developed to remove NFBs, though intranasal batteries, in particular, possess characteristics such as round shape, smooth surface, and limited visibility that make attempts at removal significantly more difficult. In the context of intranasal batteries, a considerable local soft tissue reaction and potential necrosis may exist to further complicate removal. OBJECTIVE: To present a technique for removal of difficult intranasal foreign bodies that may be utilized by health care practitioners, particularly in the Emergency Department setting. CASE REPORT: We present a case of a 4-year-old child presenting with intranasal battery with mucosal necrosis. After conventional techniques failed, we utilized a novel wire snare technique to dissect the NFB free from the nasal mucosa safely and in an atraumatic fashion. CONCLUSION: This technique is noted to be a rapid, atraumatic, and effective means for the removal of difficult NFBs.

Fundakowski CE; Moon S; Torres L

2013-01-01

262

COATING COMPOSITION INCLUDING MARKED POLYMERS  

UK PubMed Central (United Kingdom)

The invention relates to a coating composition (C) including, with regard to 100 wt % thereof: 0.01 to 30 wt % of a polymer (P) including at least 50 mol % of at least one monomer selected from the group consisting of acrylic acid, methacrylic acid, itaconic acid or maleic acid, 15 to 70 wt % of at least one auxiliary coating agent, if required, the remainder being an agent or a mixture of agents selected from at least a plasticizing agent, a coloring agent, a flow-enhancing agent or an inert filler characterized in that hapten markers are grafted onto a proportion of the weight of said polymer (P) other than zero.

DUCCINI YVES; LEFEBVRE SANDRA; TROUVE GERARD

263

A no-go related prefrontal negativity larger to irrelevant stimuli that are difficult to suppress  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Background There is a wide debate in the literature about whether N2/P3 effects in no-go trials reflect the inhibition of an intended action, or the absence of a negative movement-related potential typical of go trials. The aim of this study was to provide an objective measure of the suppression of irrelevant information (in a conjoined selective visual attention task) under conditions that were perfectly comparable from the viewpoint of the motoric processes involved. Methods Twenty-nine right-handed students took part in the study. Their EEGs were recorded from 128 scalp sites while they viewed gratings of four different spatial frequencies (from 0.75 to 6 c/deg) randomly flashed in the four upper and lower quadrants of the visual field. The tasks consisted of attending and responding to a conjunction of spatial frequency and space location. Intermediate frequencies (1.5 and 3 c/deg) acted as distracters or lures. Analysis of the ERPs elicited by the same physical stimulus, close in spatial frequency to the actual target and falling within the attended quadrant (pseudo-target) vs. a non-target location, allowed us to identify the time course and neural bases of brain activation during the suppression of irrelevant information. Results FAs were on average 9% for pseudo-targets and 0.2% for other types of lures, indicating that the former were more difficult to suppress. Target-related ERP components (occipito/temporal selection negativity, posterior P3b and precentral motor N2) were greater to pseudo-targets than other distracters. A large prefrontal negativity (370–430 ms) was also identified, much larger to pseudo-targets than non-targets (and absent in response to real targets), thus reflecting response inhibition and top-down cognitive control processes. Conclusion A LORETA inverse solution identified the neural generators of this effect in the left dorsolateral prefrontal cortex (DLPF), left and right fusiform gyri and bilateral superior temporal cortices. The tentative hypothesis is advanced that these activations might reflect the modulatory effects exerted by the fronto/temporal circuit for the suppression of irrelevant information.

Proverbio Alice M; Del Zotto Marzia; Crotti Nicola; Zani Alberto

2009-01-01

264

Colecistectomía laparoscópica difícil, estrategias de manejo/ Difficult laparoscopic cholecystectomy, management strategies  

Scientific Electronic Library Online (English)

Full Text Available Abstract in spanish La colecistectomía laparoscópica es uno de los procedimientos quirúrgicos practicados más frecuentemente por el cirujano general y en un importante número de casos se efectúa en pacientes mayores con gran inflamación vesicular, lo que pone a prueba los conocimientos y habilidades del cirujano. Es perfectamente posible reconocer, antes del acto quirúrgico, en cuáles pacientes este resultará difícil en mayor o menor grado, para así diseñar estrategias de manejo (more) intraoperatorio que nos permitan resolver favorablemente estos casos. En este artículo, el cual se presenta acompañado de videos de casos clínicos publicados en la página electrónica de la Asociación Colombiana de Cirugía (http://www.ascolcirugia.org), se pretende mostrar cuáles son las opciones de manejo en aquellos pacientes cuyas colecistectomías son muy difíciles por el grado de inflamación o por las enfermedades subyacentes y que constituyen alternativas de manejo viables para la colecistectomía laparoscópica clásica o para evitar la conversión a cirugía abierta; aunque también, se llama fuertemente la atención sobre la necesidad de una conversión temprana y oportuna antes de tener complicaciones o alteraciones iatrogénicas de la vía biliar u otro órgano vecino. Abstract in english Laparoscopic cholecystectomy is one of the most commonly performed procedures by the general surgeon and an important number of cases occur in elderly patients with major inflammation of the gallbladder, a condition that challenges the knowledge and ability of the surgeon. It is perfectible possible to recognize, prior to surgery, which patients will present major or minor difficulties so as to design intraoperative strategies in order to favorably resolve such situations (more) . This article is complemented wit uploaded YouTube videos in the web page of the Asociación Colombiana de Cirugía, http://www.ascolcirugia.org. It intends to show the different management options in those patients with very difficult cholecystectomies because of the degree of inflammation or the underlying pathology that constitute viable alternatives to the classic laparoscopic cholecystectomy or to avoid conversion open surgery; however, it also strongly calls attention to the need of early and timely conversion so as to avoid complications or iatrogenic lesion of the bile duct or neighbor organs.

Álvarez, Luis Fernando; Rivera, Diego; Esmeral, Miguel Evaristo; García, Marta Cecilia; Toro, Diego Fernando; Rojas, Olga Lucía

2013-07-01

265

New developmnts in flow measurement technology provide solutions to difficult process applications  

Energy Technology Data Exchange (ETDEWEB)

This paper describes some new methods developed in the last few years that allow solutions to historically difficult flow measurement applications. Some of these applications are: measuring the flow from a piston pump, long term reliable operation on a process that tends to coat out on the pipeline, monitoring flow in partially-filled lines, and the measurement of fluids with solids in high speed batching applications. The new methods adapt basic electromagnetic flowmeter (magmeter) technology, with new approaches in sensor and electronics design, allowing these difficult applications to succeed. Applicable industries are Chemical, Food & Beverage, Water & Waste, and allied process industries. Successful applications will be cited regarding this topic.

Rose, C.; Vass, G. [Bailey-Fischer & Porter, Warminster, PA (United States)

1995-12-31

266

The Bonds and Burdens of Family Life: Using Narrative Analysis to Understand Difficult Relationships  

Directory of Open Access Journals (Sweden)

Full Text Available Attempts to understand difficult family relationships have ignored the inextricable links between positive and negative relationships. Narrative analysis provides insight into complex relationships within social context. We analysed interviews with older people in New Zealand using levels of narrativity to reveal the negotiations required to manage personal identity at the intersection of competing public narratives. Participants and interviewers used public narratives of family life that reinforce family roles while simultaneously drawing upon alternative narratives of identity and morality. Investigating narratives of difficult family relationships reveals the influence of dominant social norms on the negotiation of social identities through personal stories.

Mary Breheny; Christine Stephens

2011-01-01

267

Energy, entropy, environment: Why is protection of the environment objectively difficult?  

Energy Technology Data Exchange (ETDEWEB)

Evolution and man`s history indicate that the winners are the species and societies that act faster and consume more high-quality energy and materials: in other words, those which cause more pollution and faster growth of entropy. This could be the reason why protection of the environment is objectively difficult and, in particular, why it is almost impossible to considerably reduce man`s consumption of energy and materials in a world of competition. To escape this fatal evolutionary outcome, fundamentally new thinking is needed, thinking which takes the survival of mankind as the primary value. The role of religion in solving this tremendously difficult task should not be neglected

Rebane, Karl K. [Institute of Physics, Tartu (Estonia)

1995-05-01

268

Malignant lymphomas (including myeloproliferative disorders)  

International Nuclear Information System (INIS)

This chapter deals with the radiotherapy and cytotoxic chemotherapy of the malignant lymphomas. Included within this group are Hodgkin's disease, non-Hodgkin's lymphoma, mycosis fungoides, and chronic lymphatic leukaemia. A further section deals with the myeloproliferative disorders, including granulocytic leukaemia, polycythaemia vera, and primary thrombocythaemia. Excluded are myeloma and reticulum cell sarcoma of bone and acute leukaemia. With regard to Hodgkin's disease, the past 25 years have seen general recognition of the curative potential of radiotherapy, at least in the local stages, and, more recently, awareness of the ability to achieve long-term survival after combination chemotherapy in generalised or in recurrent disease. At the same time the importance of staging has become appreciated and the introduction of procedures such as lymphography, staging laparotomy, and computer tomography (CT) has enormously increased its reliability. Advances have not been so dramatic in the complex group of non-Hodgkins's lymphomas, but are still very real.

1985-01-01

269

PESTICIDE COMPOSITIONS INCLUDING POLYMERIC ADJUVANTS  

UK PubMed Central (United Kingdom)

Pesticidal compositions of improved effectiveness are provided, including a pesticide (e.g., an insecticide or herbicide) together with a copolymer adjuvant or additive selected from the group consisting of acid or salt copolymers containing individual quantities of maleic and itaconic moieties. The compositions of the invention provide multiple-fold increases in effectiveness, as compared with an equal amount of the pesticide in the absence of the copolymer.

SANDERS JOHN LARRY

270

Perinatal risk factors including malformation  

International Nuclear Information System (INIS)

The study gives a survey of the factors most frequently mentioned in the literature as factors likely to adversely affect a pregnancy. One essential aspect is the discussion of those factors that can be counted among the causes of malformations, as among others, prenatal radiation exposure. The study prepared within the framework of the research project 'Radiobiological environmental monitoring in Bavaria' is intended to serve as a basis for a retrospective and prospective evaluation of infant mortality, perinatal conditions and occurrence of malformations in Bavaria, with the principal idea of drawing up an environment - related health survey. The study therefore, in addition to ionizing radiation also takes into account other detectable risks within the ecologic context, as e.g. industrial installations, refuse incineration plants or waste dumps, or urbanity. (orig./MG).

1991-01-01

271

Power generation method including membrane separation  

Energy Technology Data Exchange (ETDEWEB)

A method for generating electric power, such as at, or close to, natural gas fields. The method includes conditioning natural gas containing C.sub.3+ hydrocarbons and/or acid gas by means of a membrane separation step. This step creates a leaner, sweeter, drier gas, which is then used as combustion fuel to run a turbine, which is in turn used for power generation.

Lokhandwala, Kaaeid A. (Union City, CA)

2000-01-01

272

Aortic valve endocarditis with splenic and brain abscesses: difficult management issues.  

UK PubMed Central (United Kingdom)

Staphylococcus aureus endocarditis is associated with a high incidence of complications, a poor prognosis, and high operative mortality. We present a complex case of aortic valve endocarditis in a critically ill patient, highlight the difficult management issues, and report a good outcome.

Attaran S; Wragg A; Awad WI

2011-04-01

273

Aortic valve endocarditis with splenic and brain abscesses: difficult management issues.  

Science.gov (United States)

Staphylococcus aureus endocarditis is associated with a high incidence of complications, a poor prognosis, and high operative mortality. We present a complex case of aortic valve endocarditis in a critically ill patient, highlight the difficult management issues, and report a good outcome. PMID:21521679

Attaran, Saina; Wragg, Andrew; Awad, Wael Ibrahim

2011-04-01

274

Tracheobronchopathia osteochondroplastica and difficult intubation: case report and perioperative recommendations for anesthesiologists.  

UK PubMed Central (United Kingdom)

Tracheobronchopathia osteochondroplastica is a rare disorder characterized by cartilaginous or ossified submucosal nodules that project into the tracheobronchial lumen. It is typically discovered in the evaluation of chronic upper respiratory symptoms. A case of a completely asymptomatic man diagnosed with extensive disease throughout his upper airway after unanticipated difficult endotracheal intubation for elective surgery, is presented.

Warner MA; Chestnut DH; Thompson G; Bottcher M; Tobert D; Nofftz M

2013-08-01

275

?????? ????????? ????????????-???????? ??????? ????????????? ???????????? ???????? ????????? ?????? INFORMATION-CONTROLLING SYSTEM STRUCTURE SYNTHESIS OF OPERATION SUPPORT OF DIFFICULT TECHNICAL SYSTEMS ?????? ????????? ?????????????-??????????? ??????? ????????????? ???????????? ??????? ??????????? ??????  

Directory of Open Access Journals (Sweden)

Full Text Available  ????????????? ????????? ?????? ?? ?????????? ?????????????-???????????? ????? ????????????-???????? ??????, ??????????? ??? ????????????? ???????????? ???????? ????????? ?????? ?? ??????????? ????????? ???????????????? ????? ??????? ????????? ?????. The system approach to formation of a functional-structural level of the information-controlling systems intended for support of operation of difficult technical systems on the expanded interval of an operational stage of their life cycle is offered. ????????? ????????? ?????? ? ???????????? ?????????????-???????????? ?????? ?????????????-??????????? ??????, ??????????????? ??? ????????????? ???????????? ??????? ??????????? ?????? ?? ??????????? ????????? ????????????????? ????? ?? ?????????? ?????.

Valeriy I. Chepizhenko

2009-01-01

276

'SIMPLES': a structured primary care approach to adults with difficult asthma.  

Science.gov (United States)

The substantial majority of patients with asthma can expect minimal breakthrough symptoms on standard doses of inhaled corticosteroids with or without additional add-on therapies. SIMPLES is a structured primary care approach to the review of a person with uncontrolled asthma which encompasses patient education monitoring, lifestyle and pharmacological management and addressing support needs which will achieve control in most patients. The small group of patients presenting with persistent asthma symptoms despite being prescribed high levels of treatment are often referred to as having 'difficult asthma'. Some will have difficult, 'therapy resistant' asthma, some will have psychosocial problems which make it difficult for them to achieve asthma control and some may prove to have an alternative diagnosis driving their symptoms. A few patients will benefit from referral to a 'difficult asthma' clinic. The SIMPLES approach, aligned with close co-operation between primary and specialist care, can identify this patient group, avoid inappropriate escalation of treatment, and streamline clinical assessment and management. PMID:23974674

Ryan, Dermot; Murphy, Anna; Ställberg, Björn; Baxter, Noel; Heaney, Liam G

2013-09-01

277

Gliomatosis cerebri: a brain tumour which is too difficult to treat?  

Digital Repository Infrastructure Vision for European Research (DRIVER)

Gliomatosis cerebri is a rare form of primary diffuse brain tumour first described by Nevin in 1938. It was originally considered to be a post-mortem diagnosis before Troost et al reported a clinically diagnosed case in 1987. However antemortem diagnosis remains difficult due to vague clinical sympt...

Choi, D; Schulz, U; Seex, K

278

Cardiorespiratory coupling during sleep in difficult-to-control asthmatic patients.  

UK PubMed Central (United Kingdom)

Heart rate variability (HRV) and respiration recorded during sleep from 8 patients suffering from difficult-to-control asthma were studied to investigate autonomic nervous system control of cardiac and respiratory activities, and of cardio-respiratory coupling during different sleep stages.

Cabiddu R; Aletti F; Duarte Souza V; Peres Costa I; Stirbulov R; Borghi Silva A; Bianchi AM; de Oliveira LV; Cerutti S; Malosa Sampaio L

2012-01-01

279

[Planning and performing surgical stage of dental implantation in difficult clinical cases based on computer modeling].  

UK PubMed Central (United Kingdom)

Clinical experience of preoperative computer modeling of dental implant intervention is described. By studying the ergonomics and the accuracy a proper stereolithography guide is selected. This method allows performing a complex preoperative virtual study of dental implants placement depending on future prosthodontics restoration in difficult clinical cases. Requires collaboration at the planning stage of prosthodontist, surgeon, radiologist, 3D-modeling specialists.

Kulakov AA; Butsan SB; Sukharski? II; Khokhlachev SB; Perfil'ev SA; Chernen'ki? MM

2011-01-01

280

[Planning and performing surgical stage of dental implantation in difficult clinical cases based on computer modeling].  

Science.gov (United States)

Clinical experience of preoperative computer modeling of dental implant intervention is described. By studying the ergonomics and the accuracy a proper stereolithography guide is selected. This method allows performing a complex preoperative virtual study of dental implants placement depending on future prosthodontics restoration in difficult clinical cases. Requires collaboration at the planning stage of prosthodontist, surgeon, radiologist, 3D-modeling specialists. PMID:21512464

Kulakov, A A; Butsan, S B; Sukharski?, I I; Khokhlachev, S B; Perfil'ev, S A; Chernen'ki?, M M

2011-01-01

 
 
 
 
281

"Those were difficult years...": Oral accounts of Vlachophones from their captivity in Požarevac, Serbia  

Digital Repository Infrastructure Vision for European Research (DRIVER)

Considering that the oral accounts of the people who experienced the events at a difficult period in time is the most important of all the other research material, I am attempting, with this article, to present a few phases of the captivity of the Vlachophones in Požarevac in 1916. The main objectiv...

Panopoulou Kalliopi

282

On the Improvement of Multi-Legged Locomotion over Difficult Terrains using a Balance Stabilization Method  

Digital Repository Infrastructure Vision for European Research (DRIVER)

This paper deals with the real?time walking of a multi-legged robot over difficult terrains using a balance stabilization method in order to achieve a fast speed and robust locomotion with minimal tracking errors. The stabilization method is described through a ZMP?based online pattern&#...

Umar Asif; Javaid Iqbal

283

Entry on difficult export markets by Chinese domestic firms: the role of foreign export spillovers  

Digital Repository Infrastructure Vision for European Research (DRIVER)

In this study, we explore how the intensity of foreign export spillovers in China varies depending on the difficulty of entry on export markets. We rely on different proxies to define what a "difficult" country is and we find that the presence of surrounding foreign exporting firms helps domestic on...

Mayneris, Florian; Poncet, Sandra

284

Role of locking plates in treatment of difficult ununited fractures: a clinical study.  

UK PubMed Central (United Kingdom)

Objective: To present our experience in treatment of difficult ununited long bone fractures with locking plate. Methods: Retrospective evaluation of locking plate fixation in 10 difficult nonunions of long bone fractures was done. Fixation was done with locking plate for femoral shaft fracture (3 patients), supracondylar fracture of femur (gap nonunion), fracture of clavicle, fracture of both forearm bones (radius and ulna) fracture of ulna, fracture of shaft of humerus, fracture of tibial diaphysis and supracondylar fracture of humerus (one patient each). Five fractures had more than one previous failed internal fixation. One patient had infected nonunion which was managed by debridement with cast immobilization followed by fixation with locking plate at six weeks. Seven fractures were atrophic, two were oligotrophic, and one was hypertrophic. Fibular autograft was used in 2 cases and iliac crest cancellous bone graft used in all the patients. Results: Minimum follow-up was 6 months (range, 6 months to 2.5 years). Average time for union was 3.4 months (range 2.5 to 6 months). None of the patients had plate-related complications or postoperative wound infections. Conclusion: Along with achieving stability with locking compression plate, meticulous soft tissue dissection, acceptable reduction, good fixation technique and bone grafting can help achieve union in difficult nonunion cases. Though locking plate does not by itself ensure bony union, we have found it to be another useful addition to our armamentarium for treating difficult fracture nonunions.

Kumar A; Gupta H; Yadav CS; Khan SA; Rastogi S

2013-02-01

285

Providing Dental Services for People with Disabilities: Why Is It So Difficult?  

Science.gov (United States)

|This article examines why it is difficult for individuals with disabilities to obtain dental services. It discusses inadequate preparation of dentists, cultural norms that create social, attitudinal, economic, and environmental barriers, and limited participation in the Medicaid dental program. The need for changes in dental school curricula is…

Waldman, H. Barry; Perlman, Steven P.

2002-01-01

286

2010 ASCO Annual Meeting: progress in difficult-to-treat cancers  

Directory of Open Access Journals (Sweden)

Full Text Available The 46th Annual Meeting of the American Society of Clinical Oncology took place in June 2010 in Chicago, USA. More than 30,000 specialists discussed the latest innovations in research, quality, practice and technology in cancer. Here we highlight the most significant advances in difficult-to-treat cancers [2].

Günther J Wiedemann; Wolfgang Wagner

2010-01-01

287

Difficult diagnosis of celiac disease: diagnostic accuracy and utility of chromo-zoom endoscopy.  

UK PubMed Central (United Kingdom)

BACKGROUND: Chromo-zoom endoscopy has been demonstrated to be valuable in assessing the degree of intestinal villous atrophy in patients with suspected celiac disease. OBJECTIVE: To evaluate the diagnostic accuracy of chromo-zoom endoscopy in patients with difficult diagnosis because of nonconcordant test results and/or the confounding of a gluten-free diet initiated before an appropriate diagnosis of celiac disease and to compare the findings to a recent reference standard, the in vitro gliadin challenge test. DESIGN: Prospective, case-control study. SETTING: Tertiary-care referral hospital. PATIENTS: Patients without celiac disease (negative control group, n = 9), patients with celiac disease (positive control group, n = 41), and patients with difficult diagnosis (n = 27). INTERVENTION: Chromo-endoscopy with indigo carmine and endoscopic zoom-magnification were performed. Duodenal fragments were collected for the in vitro gliadin challenge test. The area under the receiver operating characteristic curve (ROC) was used for statistical analyses on accuracy. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy of chromo-zoom endoscopy for detection of mucosal abnormalities in patients with difficult diagnosis. RESULTS: Chromo-zoom endoscopy had a high accuracy for celiac disease diagnosis in analyses on negative controls and positive controls (area under roc = 0.99). In the difficult diagnosis group, the accuracy of chromo-zoom endoscopy was lower (area under roc = 0.83), but it increased after exclusion of patients with celiac disease on gluten-free diet (area under roc = 0.88). LIMITATIONS: There was a 4% failure rate in the ability to cultivate biopsies. Also, the study was done at an academic medical center. CONCLUSION: Chromo-zoom endoscopy has high accuracy for cases of difficult diagnosis of celiac disease but only in untreated patients with celiac disease.

Iovino P; Pascariello A; Russo I; Galloro G; Pellegrini L; Ciacci C

2013-02-01

288

Methods of corrosion diagnosis for purposes of combustion of difficult fuels; Methoden der Korrosionsdiagnose bei der Verbrennung schwieriger Brennstoffe  

Energy Technology Data Exchange (ETDEWEB)

Biomasses and substitute fuels classify as difficult fuels on account of their high scale formation and corrosion potential. The methods used for assessing this damage potential can be divided into three categories: diagnosis based on the fuel itself; diagnosis during operation of the energy production plant; and diagnosis by regular monitoring during downtimes. For the final assessment it is important to give due consideration to the characteristics of both the fuel and the firing process. Study of the fuel alone would not give a sufficiently accurate picture of the real situation. Setting the assessment on a broader basis provides greater leeway in decisions of fuel selection, conditioning and mix, selection and combination of protective measures, firing control and selection of parameters used to steer plant output and thus ultimately contributes to optimising energy efficiency.

Beckmann, Michael; Krueger, Sascha; Gebauer, Kathrin; Pohl, Martin [Technische Univ. Dresden (Germany). Fakultaet Maschinenwesen; Spiegel, Wolfgang; Mueller, Wolfgang [CheMin GmbH Chemische und Mineralogische Untersuchungen, Augsburg (Germany)

2009-07-01

289

Avoiding toxins including spermatotoxic medications.  

UK PubMed Central (United Kingdom)

Global rates of infertility are significant, especially in many developing countries. In developed countries, infertility affects up to 15% of the reproductive-age population, with male factors involved in 50% of cases. During medical evaluation, a review of current and past medications and social habits is essential, as they may adversely affect fertility. In addition, knowledge of exposure is important for counseling regarding future fertility, as many such toxic exposures have reversible effects. We reviewed the English literature over the past 35 years for all types of studies that have examined drug, medication, and other exposures that have been linked to altered semen quality and male fertility. Both human and animal studies were included in this analysis. The goal of this review is to delineate the medication and habitual risk factors that have been associated with male infertility.

Stearns G; Turek PJ

2013-07-01

290

Avoiding toxins including spermatotoxic medications.  

Science.gov (United States)

Global rates of infertility are significant, especially in many developing countries. In developed countries, infertility affects up to 15% of the reproductive-age population, with male factors involved in 50% of cases. During medical evaluation, a review of current and past medications and social habits is essential, as they may adversely affect fertility. In addition, knowledge of exposure is important for counseling regarding future fertility, as many such toxic exposures have reversible effects. We reviewed the English literature over the past 35 years for all types of studies that have examined drug, medication, and other exposures that have been linked to altered semen quality and male fertility. Both human and animal studies were included in this analysis. The goal of this review is to delineate the medication and habitual risk factors that have been associated with male infertility. PMID:23775384

Stearns, Gillian; Turek, Paul J

2013-06-17

291

CM training includes education, preceptor.  

UK PubMed Central (United Kingdom)

At UPMC, new case managers initially spend one to four weeks on the floor, following a case manager, then go through intensive training before spending an additional six week with a preceptor in the hospital to which they are assigned. Initial time in the hospital gives new case managers an idea about what the job entails, making it easier for them to understand the information they are taught during the training, which includes classroom instruction and demonstrating what they have learned. UPMC has a full-time training department staffed by former case managers who are certified in InterQual criteria and also keep the entire case management staff in the health system up to date on compliance issues and new regulations. After the new candidates have completed six weeks of working with a preceptor, a trainer spends a day with them to make sure they understand the job and answer any questions.

2013-07-01

292

Suitability of optical techniques for investigating complex flows in difficult environments  

Science.gov (United States)

In recent years, laser based optical techniques have been extensively used in industry to investigate flow. The main application areas vary from complex flow fields in rotating turbo machines to complicated two-phase gas/liquid and liquid/liquid flows. Several measuring systems, based on optical techniques, are commercially available which include laser doppler system, phase doppler system, laser diffraction system and scanning laser microscope. The choice of the measuring system mainly depends on the information required and the nature of flow involved. This paper describes the limitations and the general problems of some of these measuring techniques. Results from several experimental rigs have been presented and in some cases measurements from two different optical systems have been compared for identical flow conditions. The discrepancy in results have been explained to justify the use of these techniques.

Zaidi, Sohail H.

1997-11-01

293

Defense Waste Management Plan for buried transuranic-contaminated waste, transuranic-contaminated soil, and difficult-to-certify transuranic waste  

Energy Technology Data Exchange (ETDEWEB)

GAO recommended that DOE provide specific plans for permanent disposal of buried TRU-contaminated waste, TRU-contaminated soil, and difficult-to-certify TRU waste; cost estimates for permanent disposal of all TRU waste, including the options for the buried TRU-contaminated waste, TRU-contaminated soil, and difficult-to-certify TRU waste; and specific discussions of environmental and safety issues for the permanent disposal of TRU waste. Purpose of this document is to respond to the GAO recommendations by providing plans and cost estimates for the long-term isolation of the buried TRU-contaminated waste, TRU-contaminated soil, and difficult-to-certify TRU waste. This report also provides cost estimates for processing and certifying stored and newly generated TRU waste, decontaminating and decommissioning TRU waste processing facilities, and interim operations.

1987-06-01

294

The opinions of health care staff about the management of difficult airway in the emergency department: a questionnaire survey  

Directory of Open Access Journals (Sweden)

Full Text Available Objectives: The aim of this study was to assess the airway management and difficult airway procedures with nine multiple choice questions directed to seventy emergency department staff. Materials and Methods: Nine multiple choice questions were used for the questionnaire. The first five questions were used to define the airway management and the current practices in managing difficult airway and the remaining four were used to define the opinion of participants in particular situations. Results: Seventy participants composed of physicians and allied health care personnel were included in the study. The results showed that emergency physicians were responsible for airway management in 70% of the emergency departments. However, there was no standard algorithm established in 40% of the sites. 27% of participants reported that the bag valve mask ventilation was not safe enough due to the risk of aspiration. 95.7% of the participants reported that they occasionally need alternative airway devices, however 31.4% of them did not have these devices in use. All of the participants agreed that alternative airway devices should be available in emergency departments and 91.4% stated that they should also be available for use in the prehospital environment. Conclusion: It is important to take the opinions of emergency department staff into consideration for determining the needs of emergency medical practice.

Murat DURUSU; Selahattin ÖZYÜREK; Gül PAMUKÇU; Kerem PEKBÜYÜK; Betül AKBU?A; Ahmet DEM?RCAN; Murat ERO?LU; Mehmet ERYILMAZ

2008-01-01

295

An Exploratory Study on Coping Strategies of Confronting Difficult Patrons: The Case of University Circulation Librarians  

Directory of Open Access Journals (Sweden)

Full Text Available The coping strategies utilized by front-line serving circulation librarians might positively or negatively affect the image of a certain library organization. And every tactic adopted is in fact integrated with the manipulation and modification of the circulation librarian’s emotional labor. Therefore, from the perspective on “emotional labor”, this study attempts to employ semi-structured in-depth interviews with 23 university circulation librarians in Taiwan, thereby analyzing their coping strategies when encountering different types of difficult patrons. In doing so, this study aims to better university library administrators’ understanding of circulation librarians’ circumstance of dealing with difficult patrons and of their emotional labor, thus enhancing appropriate organizational strategies for emotional management and overall quality of library service.

Chen Su-may Sheih

2012-01-01

296

The relationship between clinical outcomes and medication adherence in difficult-to-control asthma.  

UK PubMed Central (United Kingdom)

Medication non-adherence and the clinical implications in difficult-to-control asthma were audited. Prescription issue data from 115 patients identified sub-optimal adherence (<80%) in 65% of patients on inhaled corticosteroids (ICS) or combined ICS/long-acting ?2 agonist (LABA). In those using separate ICS and LABA, adherence to LABA (50%) was significantly better than to ICS (14.3%). Patients with sub-optimal ICS adherence had reduced FEV(1) and higher sputum eosinophil counts. Adherence ratio was an independent predictor of previous ventilation for acute severe asthma (p=0.008). The majority of patients with difficult-to-control asthma are non-adherent with their asthma medication. Non-adherence is correlated with poor clinical outcomes.

Murphy AC; Proeschal A; Brightling CE; Wardlaw AJ; Pavord I; Bradding P; Green RH

2012-08-01

297

Solid-phase peptide synthesis: from standard procedures to the synthesis of difficult sequences.  

UK PubMed Central (United Kingdom)

This protocol for solid-phase peptide synthesis (SPPS) is based on the widely used Fmoc/tBu strategy, activation of the carboxyl groups by aminium-derived coupling reagents and use of PEG-modified polystyrene resins. A standard protocol is described, which was successfully applied in our lab for the synthesis of the corticotropin-releasing factor (CRF), >400 CRF analogs and a countless number of other peptides. The 41-mer peptide CRF is obtained within approximately 80 working hours. To achieve the so-called difficult sequences, special techniques have to be applied in order to reduce aggregation of the growing peptide chain, which is the main cause of failure for peptide chemosynthesis. Exemplary application of depsipeptide and pseudoproline units is shown for synthesizing an extremely difficult sequence, the Asn(15) analog of the WW domain FBP28, which is impossible to obtain using the standard protocol.

Coin I; Beyermann M; Bienert M

2007-01-01

298

Solid-phase peptide synthesis: from standard procedures to the synthesis of difficult sequences.  

Science.gov (United States)

This protocol for solid-phase peptide synthesis (SPPS) is based on the widely used Fmoc/tBu strategy, activation of the carboxyl groups by aminium-derived coupling reagents and use of PEG-modified polystyrene resins. A standard protocol is described, which was successfully applied in our lab for the synthesis of the corticotropin-releasing factor (CRF), >400 CRF analogs and a countless number of other peptides. The 41-mer peptide CRF is obtained within approximately 80 working hours. To achieve the so-called difficult sequences, special techniques have to be applied in order to reduce aggregation of the growing peptide chain, which is the main cause of failure for peptide chemosynthesis. Exemplary application of depsipeptide and pseudoproline units is shown for synthesizing an extremely difficult sequence, the Asn(15) analog of the WW domain FBP28, which is impossible to obtain using the standard protocol. PMID:18079725

Coin, Irene; Beyermann, Michael; Bienert, Michael

2007-01-01

299

Microwave-assisted synthesis of difficult sequence-containing peptides using the isopeptide method.  

UK PubMed Central (United Kingdom)

Microwave-assisted Fmoc solid phase peptide synthesis (SPPS) was applied in combination with the isopeptide strategy to establish a new method for the rapid synthesis of difficult sequence-containing peptide. A model peptide (8Q(Ser)) was produced in one day using the method developed, in contrast with two weeks using the isopeptide method. Both methods produced the desired peptide in high yield and purity, while classical SPPS did not result in the desired product.

Hussein WM; Liu TY; Toth I; Skwarczynski M

2013-04-01

300

GlideScope Videolaryngoscopy in the Simulated Difficult Airway: Bougie vs a Standard Stylet  

Directory of Open Access Journals (Sweden)

Full Text Available Objective: GlideScope® videolaryngoscopy (GVL) has been shown to improve visualization of the glottis compared to direct laryngoscopy (DL). However, due to the angle of approach to the glottis, intubation can still be challenging. We hypothesized that novice GVL users would be able to intubate faster and easier using an airway introducer (frequently known as a bougie) than with a standard intubating stylet. Methods: Intubations were performed on a human airway simulator with settings for easy and difficult airways. Participants were emergency medicine (EM) residents or faculty (n=21) who were novice GVL users. Participants were intubated a total of eight times (four GVL, four DL) using either a bougie or an intubating stylet. We recorded time to intubate (TTI) and difficulty rating using a visual analog scale (VAS) and non-parametric statistical methods for analysis. We reported medians with interquartile range (IQR). Results: The median TTI with difficult airway settings and the bougie-GVL was 76 seconds (IQR 50, 102) versus 64 seconds (IQR 50.5, 125), p=0.76 for the stylet-GVL combination. The median VAS difficulty score, on difficult airway settings, for the bougie-GVL was 5 cm (IQR 3.3, 8.0) versus 6.2cm (IQR 5.0, 7.5) with the stylet-GVL, p=0.53. Conclusion: Among novices using GVL for simulated difficult airway management, there was no benefit, in terms of speed or ease of intubation, by using the bougie over the standard stylet. [West J Emerg Med. 2010; 11(5):426-431.

Nielsen, Alison A; Hope, Charity B; Bair, Aaron E

2010-01-01

 
 
 
 
301

Treatment resistant depression in primary care: Co-constructing difficult encounters.  

UK PubMed Central (United Kingdom)

Many patients with depression do not recover despite medication or therapy. Individuals with treatment resistant depression often have co-morbid anxiety, personality difficulties and drug or alcohol misuse and have been characterised as difficult, heartsink or problem personalities by general practitioners. Yet critical studies of interaction in medical settings suggest that the context may have a role in constructing the patient. A total of 12 audio-recorded routine consultations were analysed following guidelines for qualitative analysis of medical discourse. The interpretation focused on ways in which the context and structure of primary care consultations in a UK setting construct difficult encounters, which may lead to patients with treatment resistant depression being seen as difficult to manage in various ways. Three overarching observations were that presentation of multiple problems in multiple domains clash with the consultation format; that patients' atypically high level of activity in a time-limited setting prevents patient-centred work; that the question and answer format restricts multifaceted discussions of social and emotional problems, preventing shared understandings emerging. However, although interactions appear uneasy, they are repaired and may be moderately palliative. Suggestions are made for re-orienting general practitioner work with treatment resistant depression towards long-term goal setting outside of the traditional consultation structure in order to develop shared understandings.

McPherson S; Byng R; Oxley D

2013-08-01

302

Use of ultrasound to facilitate difficult lumbar puncture in the pediatric oncology population  

Science.gov (United States)

In the pediatric hematology-oncology population, lumbar punctures (LP’s) are commonly performed to administer intrathecal chemotherapy and obtain CSF samples. Difficult LP’s can arise due to obesity, fibrous tissue formation due to repeated LP procedures, or spinal abnormalities. For difficult LP’s that require imaging-guidance, fluoroscopy is generally?? Fluoroscopy, however, subjects the patient and healthcare providers to radiation while also potentially increasing procedure cost and time. We retrospectively studied the utility of ultrasound-guidance to facilitate LP in 4 pediatric hematology-oncology patients. All 4 patients had a history of difficult LP and 3 of 4 had previously required use of fluoroscopy. With the use of ultrasound, the LP was successfully performed in all 4 patients with one attempt (number of attempts not recorded in one patient). Procedure time was less than 20 minutes in all 4 patients. Our preliminary data suggests that ultrasound may be an efficacious alternative to fluoroscopy. By using ultrasound to identify the landmarks in the lumbar region, the appropriate puncture point can be determined allowing access to the intrathecal space with relative ease. This would decrease the need for fluoroscopy-guidance, the incidence of multiple punctures as well as reducing the procedure time and costs.

Warhadpande, Shantanu; Martin, David; Bhalla, Tarun; Rehman, Saif; Rose, Melissa; Guinipero, Terri; Tobias, Joseph D

2013-01-01

303

Endoscopic papillary large balloon dilatation alone is safe and effective for the treatment of difficult choledocholithiasis in cases of Billroth II gastrectomy: a single center experience.  

UK PubMed Central (United Kingdom)

BACKGROUND: Endoscopic treatment of difficult common bile duct (CBD) stones (diameter ? 10 mm, or four or more) is difficult in patients who have undergone Billroth II (B-II) gastrectomy. Endoscopic sphincterotomy (EST) can be particularly troublesome due to anatomical changes effected by the gastrectomy. AIM: We evaluated the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with large-diameter dilation balloons in the treatment of difficult CBD stones in patients who have undergone B-II gastrectomy. MATERIALS AND METHODS: From June 2006 to April 2011, patients with difficult CBD stones and who had undergone B-II gastrectomy previously were included in this study. EPLBD was performed with a 10-18 mm balloon catheter. When selective cannulation through the sphincter was possible, EPLBD was performed without EST. EPLBD was otherwise performed after fistulotomy with needle knife. RESULTS: A total of 40 patients (32 male) underwent EPLBD for the retrieval of CBD stones, and concurrent fistulotomy was performed in seven patients. The median diameter of CBD was 13 mm (range 10-20 mm) and the balloon was 12 mm (range 10-17 mm). CBD stones were successfully removed in all patients. In only three patients, repeated sessions of ERCP were required for complete removal of CBD stones. Mechanical lithotripsy was required in only one case. Acute complications from EPLBD included mild pancreatitis in two patients (5.0 %). Severe complications, including perforation and bleeding, were not observed. Late complications included stone recurrence in one patient (2.5 %) and cholecystitis in four patients (10.0 %). CONCLUSIONS: In cases of B-II gastrectomy, EPLBD without EST is a safe and highly effective technique for the retrieval of difficult CBD stones. EPLBD should be considered as an alternative tool to conventional EST.

Jang HW; Lee KJ; Jung MJ; Jung JW; Park JY; Park SW; Song SY; Chung JB; Bang S

2013-06-01

304

COSMETIC AND DERMATOLOGICAL FORMULATIONS INCLUDING ISONONYL BENZOATE  

UK PubMed Central (United Kingdom)

A method for the preparation of a formulation including adding at least one substance of the general formula (I) wherein R1 is an unbranched or branched C9-alkyl radical to at least one component selected from the group of an emollient, emulsifier, surfactant, thickener, viscosity regulator, stabilizer, UV light protection filter, antioxidant, hydrotropic agent, filler, film-forming agent, pearlescent additive, deodorant active compound, antiperspirant active compound, insect repellent, self-tanning agent, preservative, conditioning agent, perfume, dyestuff, biogenic active compound, care additive, super-oiling agent, and solvent.

SPRINGER OLIVER; THUM OLIVER; MEYER JURGEN; JENNI KLAUS

305

Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem  

Energy Technology Data Exchange (ETDEWEB)

Painful skeletal metastases are a common problem in cancer patients. Although external beam radiation therapy is the current standard of care for cancer patients who present with localized bone pain, 20-30% of patients treated with this modality do not experience pain relief, and few further options exist for these patients. For many patients with painful metastatic skeletal disease, analgesics remain the only alternative treatment option. Recently, image-guided percutaneous methods of tumor destruction have proven effective for treatment of this difficult problem. This review describes the application, limitations, and effectiveness of percutaneous ablative methods including ethanol, methyl methacrylate, laser-induced interstitial thermotherapy (LITT), cryoablation, and percutaneous radiofrequency ablation (RFA) for palliation of painful skeletal metastases. (orig.)

Callstrom, Matthew R.; Charboneau, J. William; Atwell, Thomas D.; Farrell, Michael A.; Welch, Timothy J.; Maus, Timothy P. [Mayo Clinic, Department of Radiology, Rochester, MN (United States); Goetz, Matthew P.; Rubin, Joseph [Mayo Clinic, Department of Oncology, Rochester, MN (United States)

2006-01-01

306

Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem.  

UK PubMed Central (United Kingdom)

Painful skeletal metastases are a common problem in cancer patients. Although external beam radiation therapy is the current standard of care for cancer patients who present with localized bone pain, 20-30% of patients treated with this modality do not experience pain relief, and few further options exist for these patients. For many patients with painful metastatic skeletal disease, analgesics remain the only alternative treatment option. Recently, image-guided percutaneous methods of tumor destruction have proven effective for treatment of this difficult problem. This review describes the application, limitations, and effectiveness of percutaneous ablative methods including ethanol, methyl methacrylate, laser-induced interstitial thermotherapy (LITT), cryoablation, and percutaneous radiofrequency ablation (RFA) for palliation of painful skeletal metastases.

Callstrom MR; Charboneau JW; Goetz MP; Rubin J; Atwell TD; Farrell MA; Welch TJ; Maus TP

2006-01-01

307

Notícias difíceis e o posicionamento dos oncopediatras: revisão bibliográfica/ Difficult news and the standpoint of pediatric oncologists: a bibliographical review  

Scientific Electronic Library Online (English)

Full Text Available Abstract in portuguese Com objetivo de discutir e compreender as experiências de oncopediatras diante da tarefa de comunicar notícias difíceis (ND) a pacientes e familiares procedeu-se uma revisão bibliográfica a partir das bases de dados da Biblioteca Virtual em Saúde (BVS) que contém artigos divulgados por PubMed, Lilacs, Scielo, Scopus e SciVerse, buscando a produção sobre o tema. Os artigos disponíveis, avaliados pela análise temática, evidenciam as seguintes questões: carênci (more) a de estudos focando a percepção dos profissionais sobre as notícias difíceis; a comunicação como estratégia pela qual, aspectos psicossociais, culturais, bioéticos, legais e emocionais são tratados; expectativa de habilidades médicas para as quais esses profissionais não foram treinados. Observou-se também que informações e treinamento dos profissionais sobre estratégias a cerca dos modos de lidar com a comunicação de ND são insuficientes para acompanhar o dinamismo das ocorrências e das relações pessoais na área de oncologia onde o paciente costuma estar ou sentir-se em constante ameaça de vida. Abstract in english In order to discuss and understand the experiences of oncologists faced with the task of communicating difficult news to children and their close family members, a bibliographical review was conducted in the Virtual Health Library databases containing the literature published by PubMed, Lilacs, Scielo, Scopus and SciVerse with input on the theme. The articles available evaluated by thematic analysis reveal the following aspects: the lack of studies focusing on the percept (more) ion of professionals about imparting difficult news; communication as a strategy by which psychosocial, cultural, bioethical, legal and emotional aspects are handled; that more is expected from physicians than they were trained for. It was also seen that the information and training of professionals in strategies regarding how to handle the communication of difficult news needs to be ongoing in order to keep up with the dynamism of the occurrences and the physician-patient relations in the oncological field in which patients tend to be or feel under constant life-threatening conditions.

Afonso, Selene Beviláqua Chaves; Minayo, Maria Cecília de Souza

2013-09-01

308

Label free fragment screening using surface plasmon resonance as a tool for fragment finding - analyzing parkin, a difficult CNS target.  

UK PubMed Central (United Kingdom)

Surface Plasmon Resonance (SPR) is rarely used as a primary High-throughput Screening (HTS) tool in fragment-based approaches. With SPR instruments becoming increasingly high-throughput it is now possible to use SPR as a primary tool for fragment finding. SPR becomes, therefore, a valuable tool in the screening of difficult targets such as the ubiquitin E3 ligase Parkin. As a prerequisite for the screen, a large number of SPR tests were performed to characterize and validate the active form of Parkin. A set of compounds was designed and used to define optimal SPR assay conditions for this fragment screen. Using these conditions, more than 5000 pre-selected fragments from our in-house library were screened for binding to Parkin. Additionally, all fragments were simultaneously screened for binding to two off target proteins to exclude promiscuous binding compounds. A low hit rate was observed that is in line with hit rates usually obtained by other HTS screening assays. All hits were further tested in dose responses on the target protein by SPR for confirmation before channeling the hits into Nuclear Magnetic Resonance (NMR) and other hit-confirmation assays.

Regnström K; Yan J; Nguyen L; Callaway K; Yang Y; Diep L; Xing W; Adhikari A; Beroza P; Hom RK; Riley B; Rudolph D; Jobling MF; Baker J; Johnston J; Konradi A; Bova MP; Artis RD

2013-01-01

309

A survey of anaesthetic practice in predicting difficult intubation in UK and Europe.  

UK PubMed Central (United Kingdom)

CONTEXT: Unexpected difficulty in tracheal intubation is an intermittent and often terrifying problem for all practising anaesthetists. There are many preoperative assessment tests to predict a difficult laryngeal view or a difficult intubation, but we found no published evidence of how frequently these predictive tests are used or how useful they are perceived to be by anaesthetists. OBJECTIVE: We decided to ask UK and non-UK anaesthetists attending the Annual Scientific Meeting of the European Society of Anaesthesiology about their practice in predicting difficult intubation. DESIGN: The study was conceived as a survey. SETTING: The airway tests were compiled into a questionnaire, hand distributed among anaesthetists at Euroanaesthesia - the European group (after excluding UK attendees) - and posted to randomly selected anaesthetists in the UK - the UK group. PARTICIPANTS: Overall, 888 of 1230 (72%) questionnaires were completed. The response rate from the UK group of anaesthetists was 69% (481 of 700) and from the European group was 77% (407 of 530). RESULTS: On a scale 1 (never) to 5 (always), the mean score for frequency of use was similar for both groups of anaesthetists and ranged from about 4 for mouth opening to about 1 for Nodding Donkey. The mean score for usefulness (1 = useless, 5 = extremely useful) ranged from about 3.7 to 2 for the same two tests. The UK group found most tests slightly less useful than did the European group. With regard to the frequency of assessing the airway, 9% of the European group, but 16% of the UK group, failed always (score 5) or regularly (score 4) to assess the airway before general anaesthesia. Furthermore, 21 and 36% of the UK and European groups, respectively, failed to do so before regional anaesthesia. CONCLUSION: These results are a cause for concern with regard to both airway management training and patient safety.

McPherson D; Vaughan RS; Wilkes AR; Mapleson WW; Hodzovic I

2012-05-01

310

Cyanoacrylate spray for treatment of difficult-to-control GI bleeding.  

UK PubMed Central (United Kingdom)

BACKGROUND: Although endoscopic therapy is highly effective for control of GI bleeding, a small proportion of patients experience persistent bleeding and may require radiologic or surgical intervention. Experience with cyanoacrylate spray for treatment of difficult-to-control GI bleeding is limited. OBJECTIVE: To evaluate the efficacy and safety of an endoscopic cyanoacrylate spray technique for treatment of difficult-to-control GI bleeding. DESIGN: Case series. SETTING: Two tertiary-care centers. PATIENTS: This study involved consecutive patients with overt GI bleeding who were treated with n-butyl-2-cyanoacrylate spray during endoscopy for persistent bleeding despite conventional hemostatic therapies. INTERVENTION: Cyanoacrylate spray. MAIN OUTCOME MEASUREMENTS: Hemostasis, rebleeding, adverse events, and technical failure associated with cyanoacrylate spray. RESULTS: Five patients were treated with cyanoacrylate spray during endoscopy for persistent bleeding (duodenal ulcer in 3, gastric vascular ectasia in 1, rectal postpolypectomy bleeding in 1) after failed conventional therapies. Immediate hemostasis and technical success were achieved in all patients. At a median follow-up of 42 days (range 38-120 days), 2 patients developed recurrent bleeding. One patient experienced rebleeding 2 days after the procedure, subsequently requiring radiographic intervention and surgery. Another patient had recurrent bleeding from a different bleeding source 18 days after the procedure. No adverse events attributed to the cyanoacrylate spray were observed. LIMITATIONS: Small number of patients. CONCLUSION: In patients with difficult-to-control GI bleeding failing conventional endoscopic therapies, cyanoacrylate spray was effective in achieving immediate hemostasis. Prospective studies with a larger number of patients to evaluate the role of the cyanoacrylate spray technique during endoscopy for GI bleeding are needed.

Walia SS; Sachdeva A; Kim JJ; Portocarrero DJ; Lewis TD; Zhao YS

2013-09-01

311

The potential for noncaring when dealing with difficult patients: strategies for moral decision making.  

UK PubMed Central (United Kingdom)

The potential for noncaring when dealing with difficult patients is a very real concern in nursing. Noncaring, manifested by distancing and withdrawal or punitive behaviors, exacts a high toll on the nurse-patient relationship. Noncaring may result in missed diagnoses and interventions, social isolation, and minimal or negative contact with the nurse. The purpose of this article is to share strategies for moral decision making that support the patient, family, and nurse in all care settings. Decisions to care must be based on professional, ethical, and moral principles rather than personal preferences. Scrutinizing one's personal biases and actions with application of ethical principles provides the framework for these strategies.

Maupin CR

1995-04-01

312

The potential for noncaring when dealing with difficult patients: strategies for moral decision making.  

Science.gov (United States)

The potential for noncaring when dealing with difficult patients is a very real concern in nursing. Noncaring, manifested by distancing and withdrawal or punitive behaviors, exacts a high toll on the nurse-patient relationship. Noncaring may result in missed diagnoses and interventions, social isolation, and minimal or negative contact with the nurse. The purpose of this article is to share strategies for moral decision making that support the patient, family, and nurse in all care settings. Decisions to care must be based on professional, ethical, and moral principles rather than personal preferences. Scrutinizing one's personal biases and actions with application of ethical principles provides the framework for these strategies. PMID:7782811

Maupin, C R

1995-04-01

313

[Between care and punishment: the difficult coexistence of nursing care and prison culture].  

UK PubMed Central (United Kingdom)

INTRODUCTION/BACKGROUND: Recent research results have shown that nursing practice in correctional psychiatric settings is difficult since institutional functionning and correctional culture threaten fundamental socioprofessional standards of care. OBJECTIVES: The aim of this paper is to present the results of a research conducted in a Canadian correctional facility between 2006 and 2009 with nurses providing psychiatric care. RESULTS: This research highlights the challenges faced by the nursing staff who see their professional practice constrained by correctional prerogatives. DISCUSSION/CONCLUSION: we believe that the results of our research are paramount if we wish to understand the specificities of this complex field of nursing.

Holmes D; Jacob JD

2012-12-01

314

Vocational education students: a difficult-to-reach population at risk for smoking-related cancer.  

UK PubMed Central (United Kingdom)

Vocational education high school students comprise a significant proportion of the school-based population. Recent studies indicate vocational education students are at greater risk for cigarette smoking behavior than their non-vocational education counterparts. Vocational students have higher prevalence rates of smoking than do non-vocational students and are more likely to report that they expect to be smoking in the future. Characteristics of adolescents who participate in vocational education and their cigarette smoking behavior are reviewed, as well as the need to develop, implement, and evaluate new educational approaches designed to prevent cigarette smoking and the use of other tobacco products in this difficult-to-reach population.

Corcoran RD; Allegrante JP

1989-05-01

315

Rhabdomyolysis: rare complications with a difficult prognosis in the course of anticancer treatment.  

UK PubMed Central (United Kingdom)

Rhabdomyolysis refers to a number of clinical and biochemical symptoms, which result from the destruction of skeletal muscles. The following triad of symptoms is considered typical: myalgia, muscle weakness, and dark urine. The most common reasons for rhabdomyolysis in children are infections. It has also been reported that rhabdomyolysis may be caused by chemotherapy drugs. The most difficult complication of rhabdomyolysis is renal failure. The authors present a 17-year-old boy diagnosed with Ewing sarcoma and a 16-year-old boy suffering from acute leukemia, both with rhabdomyolysis developed in the course of infection caused by Clostridium difficile, and drug-induced neutropenia.

Sobol G; Musio? K; Mizia-Malarz A; Stolpa W; Krupa M; Wo? H

2012-05-01

316

The approach to large left ventricular aneurysms. A report of three difficult cases.  

Science.gov (United States)

We report the management and evaluation of three difficult left ventricular aneurysms from a series of 246 cases treated between 1970 and 1985. These three cases reflect our present approach to left ventricular aneurysms after previous aortocoronary bypass (case 1), aneurysms with distorted ventricular geometry and severe mitral regurgitation (case 2), and large, minimally symptomatic left ventricular aneurysms (case 3). All three cases had very little or no coronary artery disease, and the main purpose of surgery in them was primarily to correct ventricular pathology. PMID:3209608

Berry, D W; Vauthey, J N; Snyder, D; Mills, N L; Ochsner, J L

317

The approach to large left ventricular aneurysms. A report of three difficult cases.  

UK PubMed Central (United Kingdom)

We report the management and evaluation of three difficult left ventricular aneurysms from a series of 246 cases treated between 1970 and 1985. These three cases reflect our present approach to left ventricular aneurysms after previous aortocoronary bypass (case 1), aneurysms with distorted ventricular geometry and severe mitral regurgitation (case 2), and large, minimally symptomatic left ventricular aneurysms (case 3). All three cases had very little or no coronary artery disease, and the main purpose of surgery in them was primarily to correct ventricular pathology.

Berry DW; Vauthey JN; Snyder D; Mills NL; Ochsner JL

1988-11-01

318

VIRTUAL EINSTEINIAN FORCE FIELDS IN THE SYNERGY OF NAVIGATING SPACE OF DIFFICULT ERGATIC SYSTEMS ??????????? ?????????????? ??????? ???? ? ???????? ?????????????? ???????????? ??????? ???????????? ?????? ?????????? ?????????????? ?????? ???? ? ???????? ????????????? ???????? ???????? ?????????? ??????  

Directory of Open Access Journals (Sweden)

Full Text Available  In the article the analysis of modern directions of navigating spaces development of complex ergatic systems has been carried out, their transformation tendencies of structural and functional levels have been shown. Limitations of modern methods of the conflicts resolution of difficult dynamic systems have been exposed. For the conflicts resolution in environments of type CNS/ATM it has been offered to use the natural-scientific system approach. This approach contains full group virtual of navigating space symmetries, ergatic systems organization laws (functional and technological homeostasis), and also operation laws of complex technical systems. Control levels of conflicting dynamic objects have been formalized. ?????????? ????????????? ??????? ?????????????? ??????? ????? ??? ?????????? ?????????????? ???????????? ?????? ? ???????????? ????????????? ?????????????. ???????????? ???????????? ???????????? ???????????? ??????? ????? ??? ????’?????? ?????????????? ?????????? ?????? ? ????????? ???????????? ?????????.

?.?. ?????????; ?.?. ??????; ?.?. ???????

2012-01-01

319

[The community health agent and working as a team: the easy and difficult aspects].  

UK PubMed Central (United Kingdom)

The objective of this study is to analyze the easy and difficult aspects of teamwork according to community health agents. Qualitative analysis was carried out from the hermeneutical and dialectic perspective; the reference point was the senses interpretation method. The strengths and weaknesses they pointed out revealed that working as a team requires emotional relationships, with emphasis on communication, respect and cooperation, and that team meetings is an important strategy to achieve this. In conclusion, there is a need for continuous investments in team member relationships.

Peres CR; Caldas Júnior AL; da Silva RF; Marin MJ

2011-08-01

320

Evaluation Of Treatment Modalities For Vitiligo At Sites Difficult To Treat-A Preliminary Report  

Directory of Open Access Journals (Sweden)

Full Text Available The treatment of vitiligo involving the mucosae, acral areas, palms and soles is an arduous challenge. No definite treatment guideline exists for these patients. The preliminary results of evaluation of four different treatment regimens in these patients are presented. Forty patients were alternatively assigned to 4 regimens comprising of PUVASOL: PUVASOL with levamisole: topical corticosteroids and topical corticosteroids with levamisole. All the four regimens gave comparable results. PUVASOL and topical corticosteroids used alone or in combination with levamisole are all equally effective in treating the so called â€?difficult to treat or resistant” sites in vitiligo with cosmetically acceptable results (25.50% pigmentation) after 6 months of therapy.

Nagrath Naresh; Handa Sanjeev; Dogra Sunil; Kaur Inderjeet

2003-01-01

 
 
 
 
321

Gastric Tube Placement in Difficult Cases: An Extensive review of the Aternative Methods  

Directory of Open Access Journals (Sweden)

Full Text Available Gastric tube placement for enteral feeding and gastric drainage is very commonly performed procedure in the ICU. The placement may sometimes be difficult or impossible in intubated and paralyzed patients due to impaction and/or coiling in the mouth. The recognition of the site/s of impaction and methods to overcome them have been described variously in literature with different degrees of success. Knowledge and practice of these alternative methods can be sometimes of great help particularly while facing difficulty

Prashant Kumar; Sumit Ray; Prakash Shastri; B K Rao

2008-01-01

322

Conditioning shampoo  

UK PubMed Central (United Kingdom)

The present invention relates to an improved conditioning shampoo composition which is stable, thoroughly cleanses the hair, and imparts improved physical and cosmetic properties to hair such as wet and dry comb, wet and dry feel, gloss, static control and manageability, yet does not cause build-up on human hair as is common with many conditioning shampoos. The shampoo composition comprises by weight 8%-20% of an anionic surfactant, 0.1%-5% of a water soluble cationic surfactant, 0.1%-8% of an insoluble, dispersed or emulsified, non-volatile silicone, and 0.5%-5% of a suspending or emulsifying nonionic surfactant such as an N-alkylated-2-pyrrolidone having a structure: (III) wherein R is an alkyl moiety, straight chain or branched chain, including from about 8 to about 16 carbon atoms, and water. Preferred embodiments additonally may contain from about 0.5% to about 1% by weight of a non-volatile amine-functional siloxane.

ZHOU JINGSHI; FOCHTMAN DAVID J

323

Structural biology and drug discovery of difficult targets: the limits of ligandability.  

UK PubMed Central (United Kingdom)

Over the past decade, researchers in the pharmaceutical industry and academia have made retrospective analyses of successful drug campaigns in order to establish "rules" to guide the selection of new target proteins. They have identified features that are considered undesirable and some that make targets "unligandable." This review focuses on the factors that make targets difficult: featureless binding sites, the lack of hydrogen-bond donors and acceptors, the presence of metal ions, the need for adaptive changes in conformation, and the lipophilicity of residues at the protein-ligand interface. Protein-protein interfaces of multiprotein assemblies share many of these undesirable features, although those that involve concerted binding and folding in their assembly have better defined pockets or grooves, and these can provide opportunities for identifying hits and for lead optimization. In some protein-protein interfaces conformational changes-often involving rearrangement of large side chains such as those of tyrosine, tryptophan, or arginine-are required to configure an appropriate binding site, and this may require tethering of the ligands until higher affinity is achieved. In many enzymes, larger conformational rearrangements are required to form the binding site, and these can make fragment-based approaches particularly difficult.

Surade S; Blundell TL

2012-01-01

324

Exhaled nitric oxide predicts control in patients with difficult-to-treat asthma.  

Science.gov (United States)

We aimed to evaluate the accuracy of baseline exhaled nitric oxide fraction (F(eNO)) to recognise individuals with difficult-to-treat asthma who have the potential to achieve control with a guideline-based stepwise strategy. 102 consecutive patients with suboptimal asthma control underwent stepwise increase in the treatment with maximal fluticasone/salmeterol combination dose for 1 month. Then, those who remained uncontrolled received oral corticosteroids for an additional month. With this approach, 53 patients (52%) gained control. Those who achieved control were more likely to have positive skin results (60.4% versus 34%; p = 0.01), positive bronchodilator test (57.1% versus 35.8%; p = 0.02) and peak expiratory flow variability > or =20% (71.1% versus 49.1%; p = 0.04). Conversely, depression was more frequent in those who remained uncontrolled (18.4 % versus 43.4 %; p = 0.01). An F(eNO) value > or =30 ppb demonstrated a sensitivity of 87.5% (95% CI 73.9-94.5%) and a specificity of 90.6% (95% CI 79.7-95.9%) for the identification of responsive asthmatics. The current results suggest that F(eNO) can identify patients with difficult-to-treat asthma and the potential to respond to high doses of inhaled corticosteroids or systemic steroids. PMID:19996191

Pérez-de-Llano, L A; Carballada, F; Castro Añón, O; Pizarro, M; Golpe, R; Baloira, A; Vázquez Caruncho, M; Boquete, M

2009-12-08

325

Is it that difficult to find a good preference order for the incremental algorithm?  

UK PubMed Central (United Kingdom)

In a recent article published in this journal (van Deemter, Gatt, van der Sluis, & Power, 2012), the authors criticize the Incremental Algorithm (a well-known algorithm for the generation of referring expressions due to Dale & Reiter, 1995, also in this journal) because of its strong reliance on a pre-determined, domain-dependent Preference Order. The authors argue that there are potentially many different Preference Orders that could be considered, while often no evidence is available to determine which is a good one. In this brief note, however, we suggest (based on a learning curve experiment) that finding a Preference Order for a new domain may not be so difficult after all, as long as one has access to a handful of human-produced descriptions collected in a semantically transparent way. We argue that this is due to the fact that it is both more important and less difficult to get a good ordering of the head than of the tail of a Preference Order.

Krahmer E; Koolen R; Theune M

2012-07-01

326

On the Improvement of Multi-Legged Locomotion over Difficult Terrains using a Balance Stabilization Method  

Directory of Open Access Journals (Sweden)

Full Text Available This paper deals with the real?time walking of a multi-legged robot over difficult terrains using a balance stabilization method in order to achieve a fast speed and robust locomotion with minimal tracking errors. The stabilization method is described through a ZMP?based online pattern?generation scheme inspired by bio?mimetic stepping leg transferences with an active balance control so as to reduce the propagation of instability while performing rapid stepping actions for a fast walking gait in the presence of external disturbances. The proposed control system uses a force?position controller [14] which takes impact dynamics into consideration to compensate for the effect of external perturbations during walking by estimating impulsive forces in real?time. Using the proposed stabilization method, the robot plans appropriate footholds on the ground in order to achieve a reasonable average walking speed over difficult terrains in a natural environment. The success and performance of the proposed method is realized through dynamic simulations and real?world experiments using a six?legged hexapod robot.

Umar Asif; Javaid Iqbal

2012-01-01

327

Factor analysis in difficult tracheal intubation: laryngoscopy-induced airway obstruction.  

UK PubMed Central (United Kingdom)

We have studied eight patients with a history of difficult tracheal intubation, using x-ray laryngoscopy and local anaesthesia, a curved Macintosh blade and a standard intubating position. The view obtained was better than recorded previously during general anaesthesia in two patients, and in a third the x-ray showed that positioning the blade tip beneath the epiglottis would have improved vision, suggesting that reproducibility of the assessment may not be consistent. The "ease of intubation" and "complementary" angles may be helpful in the assessment of such patients. A "peardrop" effect is described whereby during laryngoscopy, the epiglottis became pressed against the posterior pharyngeal wall as a result of tongue compression. In the absence of muscle paralysis, removal of the blade caused immediate correction. However, during anaesthesia with neuromuscular block it is suggested that this not only occurs more readily but, may not correct when the blade is removed. Iatrogenic airway obstruction during moderately difficult tracheal intubation may be common and should be anticipated.

Horton WA; Fahy L; Charters P

1990-12-01

328

Treatment of difficult-to-control blood pressure in a multidisciplinary clinic at a public hospital.  

UK PubMed Central (United Kingdom)

Cardiovascular morbidity and mortality in disadvantaged populations remains high. Few innovative strategies or services to treat chronic diseases have been critically analyzed in these patients. We evaluated our initial experiences with a newly established multidisciplinary clinic For the treatment of difficult-to-control hypertension and describe reasons for poor blood pressure control as well as treatment strategies. Patients with blood pressures greater than 140/90 despite concurrent treatment with three or more medications for at least three months were referred to our clinic. Data regarding sociodemographic characteristics, health beliefs and behaviors were collected. Two physicians jointly proposed an explanation for lack of blood pressure control. A multidisciplinary team of physicians, nurses, pharmacists, and nutritionists aggressively assessed and reinforced educational objectives tailored to individual needs. 58% of patients achieved target blood pressure at six months, but 22% were lost to follow-up. The most common reasons for previous treatment failure were volume overload and poor medication adherence. We conclude that a multidisciplinary clinic for difficult-to-control blood pressure can be successful in a large, urban hospital serving a disadvantaged minority population. However, more study is needed to delineate the specific reasons for success and further refine treatment strategies.

Tao LS; Hart P; Edwards E; Evans AT; Whitaker E; Smith P

2003-04-01

329

Operative reduction and fixation of a difficult supracondylar extension fracture of the humerus.  

UK PubMed Central (United Kingdom)

We evaluated the results of the operative treatment of a difficult supracondylar fracture of the elbow. A series of 45 consecutive children, the majority presenting initially with a complete dislocation of the humerus, was reexamined. Thirty-two of the patients had undergone an early operation applying the anterior cubital approach and 13 patients had been treated by traction. The lengths of the follow-up periods were 3.1 +/- 1.5 and 8.8 +/- 2.6 years, respectively. Normal range of extension-flexion and rotation movements was preserved almost invariably by either modality of therapy, whereas the carrying angle of the elbow was reduced significantly more often in the group treated by traction. None of the patients presented with permanent nerve dysfunction, keloid formation, or myositis ossificans. The two preventable early complications, slipping of the osteosynthesis and entrapment of the ulnar nerve, were related to the fixation of the fracture. There were no early or late infectious complications. When the anterior approach was used, operative reduction and fixation of a difficult supracondylar fracture of the humerus proved to be both safe and timesaving. Anatomical results of operation were superior to those attained by traction therapy in our series.

Kekomäki M; Luoma R; Rikalainen H; Vilkki P

1984-01-01

330

Probe angioplasty through an intracoronary probing catheter in lesions which are difficult to cross.  

UK PubMed Central (United Kingdom)

The clinical records of the first 17 consecutive patients (20 lesions) in whom percutaneous transluminal coronary angioplasty was done using the ultra-low profile "balloon-on-wire probe" passed through an intracoronary probing catheter were reviewed. All patients had high-grade "difficult" lesions. In 15 lesions (12 patients) other balloon systems (over-the-wire low profile balloons (n = 9), and balloon-on-wire used alone, (n = 6)) had failed to cross the lesion. Acute ischemia due to complete occlusion at the site of the lesion during attempts to cross was seen in 3 of these patients. The intracoronary probing catheter was used to deliver the probe across the lesion in all these cases. Successful dilatation was achieved in 14 lesions (93%). In 5 lesions (5 patients) this combination was used as the initial strategy. Three of these had chronic total occlusions. Successful dilatation was achieved in 3 lesions (60%) using this combination and in 1 lesion over-the-wire balloon finally succeeded. There was 1 failure. The intracoronary probing catheter in combination with probe balloon wire offers a promising method to increase the success rate in patients with high grade "difficult" lesions. This combination is especially useful in situations where other balloon systems fail to cross the lesion.

Kumar K; Kaul U; Dev V; Rajani M; Sharma S

1991-02-01

331

Probe angioplasty through an intracoronary probing catheter in lesions which are difficult to cross.  

Science.gov (United States)

The clinical records of the first 17 consecutive patients (20 lesions) in whom percutaneous transluminal coronary angioplasty was done using the ultra-low profile "balloon-on-wire probe" passed through an intracoronary probing catheter were reviewed. All patients had high-grade "difficult" lesions. In 15 lesions (12 patients) other balloon systems (over-the-wire low profile balloons (n = 9), and balloon-on-wire used alone, (n = 6)) had failed to cross the lesion. Acute ischemia due to complete occlusion at the site of the lesion during attempts to cross was seen in 3 of these patients. The intracoronary probing catheter was used to deliver the probe across the lesion in all these cases. Successful dilatation was achieved in 14 lesions (93%). In 5 lesions (5 patients) this combination was used as the initial strategy. Three of these had chronic total occlusions. Successful dilatation was achieved in 3 lesions (60%) using this combination and in 1 lesion over-the-wire balloon finally succeeded. There was 1 failure. The intracoronary probing catheter in combination with probe balloon wire offers a promising method to increase the success rate in patients with high grade "difficult" lesions. This combination is especially useful in situations where other balloon systems fail to cross the lesion. PMID:2010238

Kumar, K; Kaul, U; Dev, V; Rajani, M; Sharma, S

1991-02-01

332

The difficult hepaticojejunostomy after pancreatic head resection: reconstruction with a T tube.  

UK PubMed Central (United Kingdom)

BACKGROUND: After pancreatic head resection, bile leaks from a difficult hepaticojejunostomy secondary to a small or fragile common hepatic duct may be reduced by a T tube at the side of the anastomosis. METHODS: A retrospective analysis of patients who underwent a difficult hepaticojejunostomy without or with a T tube was performed. RESULTS: In 48% (55/114) of patients, a T tube was placed at the side of the hepaticojejunostomy; 52% (59/114) did not have a T tube. Bile leaks occurred in 12% (14/114) (9% [5/55] in patients with a T tube vs 15% [9/59] without a T tube, P = .316). Bile leaks were associated with mortality, abscess formation, hemorrhage, and sepsis. Seven percent (8/114) of patients required revisional laparotomy (2% [1/55] with a T tube vs 12% [7/59] without a T tube, P = .036). Mortality was not different between the groups. Minor T-tube-associated complications occurred in 15% (8/55) without major complications. CONCLUSIONS: Augmentation of anastomosis with a T tube cannot prevent biliary leakage but does reduce the severity of bile leaks, resulting in less reoperations.

Herzog T; Belyaev O; Bakowski P; Chromik AM; Janot M; Suelberg D; Uhl W; Seelig MH

2013-07-01

333

Agreement of dermatopathologists in the evaluation of clinically difficult melanocytic lesions: how golden is the 'gold standard'?  

UK PubMed Central (United Kingdom)

BACKGROUND: The 'gold standard' for the diagnosis of melanocytic lesions is dermatopathology. Although most of the diagnostic criteria are clearly defined, the interpretation of histopathology slides may be subject to interobserver variability. OBJECTIVES: The aim of this study was to determine the variability among dermatopathologists in the interpretation of clinically difficult melanocytic lesions. METHODS: This study used the database of MelaFind®, a computer-vision system for the diagnosis of melanoma. All lesions were surgically removed and sent for independent evaluation by four dermatopathologists. Agreement was calculated using kappa statistics. RESULTS: A total of 1,249 pigmented melanocytic lesions were included. There was a substantial agreement among expert dermatopathologists: two-category kappa was 0.80 (melanoma vs. non-melanoma) and three-category kappa was 0.62 (malignant vs. borderline vs. benign melanocytic lesions). The agreement was significantly greater for patients ?40 years (three-category kappa = 0.67) than for younger patients (kappa = 0.49). In addition, the agreement was significantly lower for patients with atypical mole syndrome (AMS) (kappa = 0.31) than for patients without AMS (kappa = 0.76). LIMITATIONS: The data were limited by the inclusion/exclusion criteria of the MelaFind® study. This might represent a selection bias. The agreement was evaluated using kappa statistics. This is a standard method for evaluating agreement among pathologists, but might be considered controversial by some statisticians. CONCLUSIONS: Expert dermatopathologists have a high level of agreement when diagnosing clinically difficult melanocytic lesions. However, even among expert dermatopathologists, the current 'gold standard' is not perfect. Our results indicate that lesions from younger patients and patients with AMS may be more problematic for the dermatopathologists, suggesting that improved diagnostic criteria are needed for such patients.

Braun RP; Gutkowicz-Krusin D; Rabinovitz H; Cognetta A; Hofmann-Wellenhof R; Ahlgrimm-Siess V; Polsky D; Oliviero M; Kolm I; Googe P; King R; Prieto VG; French L; Marghoob A; Mihm M

2012-01-01

334

Precut fistulotomy for difficult biliary cannulation: is it a risky preference in relation to the experience of an endoscopist?  

UK PubMed Central (United Kingdom)

BACKGROUND: Several studies have reported on the correlation between the experience level of an endoscopist and the outcomes of precut procedures. However, there are limited data on the early use of the precut fistulotomy in relation to the experience of an endoscopist. AIM: To evaluate the efficacy and safety of precut fistulotomy in difficult biliary cannulation after ERCP training. METHODS: Two endoscopists, one at each tertiary referral center, performed the precut fistulotomy for difficult biliary cannulation between September 2008 and February 2010. The technical success, complications, and clinical outcomes in three groups were recorded prospectively over time. RESULTS: A total of 159 (23.1%) patients underwent precut fistulotomy. The mean procedure time was decreased as the number of procedures increased (p < 0.01). The success rates of selective biliary cannulation in the three groups were 86.8, 86.8, and 88.7% respectively, for the first attempt (p = 0.77) and 93.7% for the second attempt. Post-ERCP pancreatitis developed in nine (5.7%) patients, which was not statistically significant between the three groups. As the frequency of papillary contacts increased, post-ERCP pancreatitis tended to increase (p = 0.017). In the multivariate analysis, more than 15 attempts at cannulating the major papilla prior to fistulotomy was a risk factor for pancreatitis (odds ratio 4.8, 95% CI 1.178-19.580, p = 0.029). CONCLUSIONS: After therapeutic ERCP training involving at least 100 ERCPs, including at least half that were therapeutic cases and more than ten that were precut papillotomies, a precut fistulotomy can be performed safely and effectively in low-risk patients.

Lee TH; Bang BW; Park SH; Jeong S; Lee DH; Kim SJ

2011-06-01

335

Assets for policy making in health promotion: overcoming political barriers inhibiting women in difficult life situations to access sport facilities.  

UK PubMed Central (United Kingdom)

Although the need for intersectoral policy making in health promotion has been commonplace and a high priority for several decades, there is still a lack of appropriate methods available to assess the inputs, processes, and outcomes associated with the effectiveness of such approaches, particularly in relation to sectors outside of health. This paper demonstrates how asset based models to intersectoral policy making in health promotion can improve the effectiveness of projects aiming to improve health and related outcomes. In particular, it summarises how asset based approaches to the planning and implementation of health promotion programmes can be used to develop our methods for assessing intersectorial actions. The paper is based on the findings from a local neighbourhood project based in Erlangen, Germany, aiming to improve the opportunities for physical activity among women in difficult life situations. The neighbourhood was characterised by high rates of unemployment, social welfare recipients, and migrants. Ethnographic methods enabled us to highlight the range of health related assets available in the neighbourhood which could be activated to improve access to and uptake of physical activity amongst the target population. Results indicate that intersectoral policies seeking to improve health outcomes, are more likely to be successful if they maximise the opportunities for making the most of the assets that exist in individuals, communities and organisations. This study demonstrates how the asset model was used to create the supportive environments which facilitated women from the target population to work with policy makers on an equal footing. Their involvement in project planning and implementation helped to achieve the structural changes required to achieve the aims of the project. These included the establishment of a new job position at the city office for sports and improved access to sport facilities for women in difficult life situations.

Rütten A; Abu-Omar K; Frahsa A; Morgan A

2009-12-01

336

[Roles of Cookgas and Fastrach intubating laryngeal mask airway for anticipated difficult tracheal intubation].  

UK PubMed Central (United Kingdom)

OBJECTIVE: To compare the clinical effectiveness of blind intubation through the Cookgas intubating laryngeal airway(CILA) or Fastrach intubating laryngeal mask airway(FT-LMA) for anticipated difficult tracheal intubation. METHODS: Eighty-six patients with anticipated difficult tracheal intubation who were undergoing elective plastic surgery under general anesthesia were randomly allocated into CILA group(n=43) and FT-LMA group(n=43) . After general anesthesia being induced and CILA or FT-LMA being inserted, the patients were treated with blind intubation through CILA or FT-LMA. In each case, the number and the time of intubating laryngeal airway(ILA) insertion and blind intubation attempts and ILA removal were recorded. The view of glottis under fiberoptic bronchoscope(FOB) via CILA or FT-LMA was recorded. In addition, noninvasive blood pressure and heart rate were recorded before and after intravenous anesthetic induction, at ILA insertion, at intubation, at ILA removal and every minute thereafter for 5 minutes. RESULTS: CILA or FT-LMA was inserted successfully in all 86 patients. The rate of the first successful insertion was not significantly different between two groups(P>0.05) . In CILA group, the first intubation attempt succeeded in 35 patients;5 and 2 cases were intubated blindly at the second and the third attempt, one patient failed who was intubated successfully by FOB via CILA. In FT-LMA group, 32 patients were intubated successfully at the first attempt, 4 at the second attempt, 3 at the third attempt, and 4 cases failed, three of them were intubated smoothly with FOB through FT-LMA, one failed patient was intubated by FOB. The time of FT-LMA insertion(34.2?13.9) s was significantly longer when compared with CILA(22.4?18.9) s (P<0.05) . However, the time of blind intubation through CILA and FT-LMA [(46.0?26.7) s vs.(51.8?41.1) s]and the time of ILA removal[(39.3?11.9) s vs.(35.3?10.4) s] were not significantly different between groups(P>0.05) . Hemodynamic changes during blind intubation in the two groups showed no significant differences(P>0.05) . CONCLUSIONS: Blind intubation via CILA or FT-LMA is safe and effective for anticipated difficult tracheal intubation. Nevertheless, CILA is easier to be inserted, with relatively higher success rate of blind intubation.

Yang D; Deng XM; Tong SY; Tang GZ; Wei LX; Sui JH; Wang L

2013-04-01

337

Case report of clival tuberculoma. Difficult to diagnose by means of a CT scan  

Energy Technology Data Exchange (ETDEWEB)

A patient with tuberculoma at the skull base was reported. Twenty-two years old, she had complained for ten years of amenorrhea, headache, and visual disturbance. On neurological examination, bitemporal hemianopsia, bilateral sixth nerve palsy, and recent right-side facial palsy were demonstrated. On radiological examination, a destructive lesion was found at the clivus. CT and MRI demonstrated, a space-taking lesion expanding to the floor of the third ventricle anteriorly, to the cerebello-pontine angle superiorly, and to the epipharynx inferiorly, and a marked swelling of the cerebellum, though no confirmative diagnosis could be obtained without a biopsy of the epipharyngeal tumor. The histological examination revealed that the tumor was tuberculoma. Medical treatment with INH, RFP, and steroids was effective. Although tuberculoma involving the skull base is very rare and rather difficult to diagnose, the authors would like to stress that early accurate diagnosis is very important because the lesion is curable with appropriate medical treatment.

Ichikawa, F.; Tachibana, S.; Miyasaka, Y.; Suwa, T.; Iida, H.; Kan, S.; Matsuda, Y.

1987-02-01

338

Pulmonary arteriovenous malformations presenting as difficult-to-control asthma: a case report  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Introduction Although pulmonary arteriovenous malformations are relatively rare disorders, they are an important part of the differential diagnosis of common pulmonary problems, such as hypoxemia, dyspnea on exertion and pulmonary nodules. Case presentation An 11-year-old Croatian boy of Mediterranean origin with a history of asthma since childhood was admitted to our hospital for evaluation of difficult-to-control asthma during the previous six months. A chest X-ray showed a homogeneous soft tissue mass in the lingual area. Computed tomography angiography of the thorax showed two pulmonary arteriovenous malformations, one on each side of the lungs. Diagnosis of hereditary hemorrhagic telangiectasia was made clinically by Curaçao criteria. Genetic analysis revealed a mutation in the endoglin gene. The patient was treated with embolotherapy with good clinical outcome. Conclusion We present a case of pulmonary arteriovenous malformations masquerading as refractory asthma.

Navratil Marta; Vidjak Vinko; Rubi? Filip; Erceg Damir; Turkalj Mirjana

2013-01-01

339

[Inflammatory alterations of the greater omentum--a difficult preoperative diagnosis  

UK PubMed Central (United Kingdom)

Isolated inflammatory alterations of the greater omentum are rare diseases. Since the preoperative diagnosis is difficult these changes are usually ascertained upon laparotomy. Between 1999 and 2001 four patients (44-88-years-old, 2 males) underwent laparotomy for an inflammatory tumor mass or an acute abdomen, respectively. C-reactive protein was elevated in all cases. In two cases a primary torsion of the greater omentum was found, in the other two a paracolic pseudotumorous omentitis. Resection of the diseased omental parts led to complete recovery. Torsion of the greater omentum and omentitis cause abdominal symptoms with an inflammatory component that often mimics other more common diseases such as acute appendicitis and urges laparotomy. Partial omentectomy is the therapy of choice.

Knoop M; Vorwerk T

2002-07-01

340

Treatment options for refractory and difficult to treat seizures: focus on vigabatrin  

Directory of Open Access Journals (Sweden)

Full Text Available Justin A Tolman, Michele A FaulknerSchool of Pharmacy and Health Professions, Creighton University, Omaha, Nebraska, NE, USAAbstract: Complex partial seizures are often refractory to current pharmacological therapies. These difficult to treat seizures are typically managed using multiple antiepileptic drugs (AEDs). AEDs as a group are frequently associated with significant adverse drug effects, multiple drug interactions, and numerous potential clinical complications due to their individual pharmacokinetic profiles and unique drug properties. Recently, the approval of vigabatrin by the US Food and Drug Administration has necessitated that clinicians re-evaluate these risk-benefit relationships and determine where the drug fits within the treatment scheme for the management of complex partial seizures. This review will facilitate that re-evaluation through a brief review of AEDs used in the treatment of complex partial seizures, followed by a focused discussion on vigabatrin.Keywords: vigabatrin, complex partial seizures, refractory seizures, risk evaluation and mitigation strategy, epilepsy

Tolman JA; Faulkner MA

2011-01-01

 
 
 
 
341

Use of Laryngeal Mask Airway in the Management of a Difficult Airway: A Case Report  

Directory of Open Access Journals (Sweden)

Full Text Available Background: Difficulty in management of the airway occurs most frequently in patients who have Mallampati grade III and IV, and other unfavourable airway findings like short neck, restriction in range of motion of the temporoman-dibular joints and inadequate neck flexion and extension. Because of unavailability of fibreoptic bronchoscopes or inexperience in their use, laryngeal mask airway (LMA) has become a common and acceptable airway management option. This is a case report of a postmenopausal woman who had her airway managed with LMA following initial failed intubation necessitating a rescheduling of the operation. Result: The patient had a successful surgery and postoperative recovery was uneventful. Conclusion: The LMA is a useful option in the management of an anticipated or unexpected difficult airway, especially in resource-poor settings where fibreoptic bronchoscopes may not be readily available.

Elizabeth Ogboli-Nwasor; Ahmad Tijjani Lawal

2013-01-01

342

A case of sigmoid endometriosis difficult to differentiate from colon cancer  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Background Although endometriosis with sigmoid serosal involvement is not uncommon in women of childbearing age, the mucosal involvement is rare and differential diagnosis from colon cancer may be difficult due to the lack of pathognomonic symptoms and the poor diagnostic yield of colonoscopy and colonic biopsies. Case presentation We present a case of a young woman with sigmoid endometriosis, in which the initial diagnostic workup suggested colon cancer. Histologic evidence, obtained from a second colonoscopy, along with pelvic ultrasound findings led to the final diagnosis of intestinal endometriosis which was confirmed by laparoscopy. Conclusion Colonic endometriosis is often a diagnostic challenge and should be considered in young women with symptoms from the lower gastrointestinal tract.

Dimoulios Philippos; Koutroubakis Ioannis E; Tzardi Maria; Antoniou Pavlos; Matalliotakis Ioannis M; Kouroumalis Elias A

2003-01-01

343

980nm laser for difficult-to-treat basal cell carcinoma  

Science.gov (United States)

Begin basal cell carcinoma (BCC) is most common skin cancer over the world. There are around 20 modalities for BCC treatment. Laser surgery is uncommon option. We demonstrate our long term follow up results. Aim: To evaluate long term efficacy of a 980nm diode laser for the difficult-to-treat basal cell carcinoma. Materials and Methods: 167 patients with 173 basal cell carcinoma on the nose were treated with a 980 nm diode laser from May 1999 till May 2005 at Latvian Oncology center. All tumors were morphologically confirmed. 156 patients were followed for more than 5 years. Results: The lowest recurrence rate was observed in cases of superficial BCC, diameterConclusions: 980 nm diode laser is useful tool in dermatology with high long term efficacy, good acceptance by the patients and good cosmetics results.

Derjabo, A. D.; Cema, I.; Lihacova, I.; Derjabo, L.

2013-06-01

344

Pulmonary arteriovenous malformations presenting as difficult-to-control asthma: a case report.  

UK PubMed Central (United Kingdom)

UNLABELLED: INTRODUCTION: Although pulmonary arteriovenous malformations are relatively rare disorders, they are an important part of the differential diagnosis of common pulmonary problems, such as hypoxemia, dyspnea on exertion and pulmonary nodules. CASE PRESENTATION: An 11-year-old Croatian boy of Mediterranean origin with a history of asthma since childhood was admitted to our hospital for evaluation of difficult-to-control asthma during the previous six months. A chest X-ray showed a homogeneous soft tissue mass in the lingual area. Computed tomography angiography of the thorax showed two pulmonary arteriovenous malformations, one on each side of the lungs. Diagnosis of hereditary hemorrhagic telangiectasia was made clinically by Curaçao criteria. Genetic analysis revealed a mutation in the endoglin gene. The patient was treated with embolotherapy with good clinical outcome. CONCLUSION: We present a case of pulmonary arteriovenous malformations masquerading as refractory asthma.

Navratil M; Vidjak V; Rubi? F; Erceg D; Turkalj M

2013-01-01

345

Endoscopic management of bile duct stones: residual bile duct stones after surgery, cholangitis, and "difficult stones".  

UK PubMed Central (United Kingdom)

Endoscopic treatment has become, according to the latest recommendations, the standard treatment for common bile duct stones (CBDS), although in certain situations, surgical clearance of the common duct at the time of laparoscopic cholecystectomy is still considered a possible alternative. The purpose of this article is not to compare endoscopic with surgical treatment of CBDS, but to describe the various techniques of endoscopic treatment, detailing their preferential indications and the various treatment options that must sometimes be considered when faced with "difficult calculi" of the CBD. The different techniques of lithotripsy and the role of biliary drainage with plastic or metallic stents will be detailed as well as papillary balloon dilatation and particularly the technique of sphincterotomy with macrodilatation of the sphincter of Oddi (SMSO), a recently described approach that has changed the strategy for endoscopic management of CBDS. Finally, the overall strategy for endoscopic management of CBDS, with description of different techniques, will be exposed.

Karsenti D

2013-06-01

346

China in the Copenhagen process: the difficult inclusion of an emerging power  

International Nuclear Information System (INIS)

The authors propose an analysis of the Chinese assets and posture before the Copenhagen Conference. They evoke the environmental consequences of the rapid development of the Chinese economy and demography: urban pollution, acid rains, and desertification. They note that the Chinese government had to acknowledge these environmental concerns by specifying energetic performance objectives in its economic planning, by publishing a National Climate Change Programme and a middle and long term development plan for renewable energies. They outline that the different objectives related to energy performance, renewable energy production or greenhouse gas emissions are still difficult to implement at the local level as Chinese provinces are wishing to preserve their competitiveness. The authors comment China's posture in international negotiations as an emerging country or developing country which sets it free of any constraining objective. They examine the possibilities for changing this situation and involve China in reduction obligations. Then they try to foresee China's attitude in Copenhagen and to identify the possible scenarios

2009-01-01

347

Pulmonary adenocarcinoma associated with SAPHO syndrome difficult to differentiate from multiple bone metastasis.  

UK PubMed Central (United Kingdom)

The patient was a 57-year-old man with a chief complaint of anterior chest pain who was diagnosed with clinical stage IV (c-T2N2M1) non-small-cell lung cancer (adenocarcinoma). Tenderness in the sternoclavicular joint, acne, periodontitis, and palmoplantar pustulosis were evident, and SAPHO syndrome was diagnosed. SAPHO syndrome is a rare disorder that results in synovitis, acne, pustulosis, hyperostosis, and osteomyelitis. Bone scintigraphy showed tracer accumulation in the costal cartilage, sternoclavicular joint, and cervical vertebrae 6-7. Although the bone lesions of SAPHO syndrome were difficult to differentiate from bone metastasis of pulmonary adenocarcinoma, metastatic bone tumors were ruled out by magnetic resonance imaging, computed tomography, and fluorodeoxyglucose positron emission tomography. There have been no previously reported cases of lung cancer with comorbid SAPHO syndrome. We report such a case and discuss the relevant literature, particularly that concerned with the evaluation of bone lesions.

Shibakuki R; Seto T; Uematsu K; Shimizu K; Seki N; Nakano M; Ishii H; Ohta M; Eguchi K

2006-01-01

348

"Those were difficult years...": Oral accounts of Vlachophones from their captivity in Požarevac, Serbia  

Directory of Open Access Journals (Sweden)

Full Text Available Considering that the oral accounts of the people who experienced the events at a difficult period in time is the most important of all the other research material, I am attempting, with this article, to present a few phases of the captivity of the Vlachophones in Požarevac in 1916. The main objective is to depict the climate of the era throughout the time frame from 1916 -- the commencement of their captivity outside Greece - and their return in 1918 through the personal and collective experiences of ordinary people. It is an effort to highlight the value of the oral culture, incorporating the voice of the unseen protagonists into the historical data. It describes the way they reached this specific area, the two years they spent there, and the four phases of their return.

Panopoulou Kalliopi

2006-01-01

349

Comparison of malleable stylet and reusable and disposable bougies by paramedics in a simulated difficult intubation.  

UK PubMed Central (United Kingdom)

In a randomised crossover study, 60 ambulance paramedics attempted tracheal intubation of a manikin model of a Cormack and Lehane grade 3/4 view using a Portex stylet, Portex and Frova single-use bougies, and a Portex reusable bougie. Tracheal intubation within 30 s was achieved by 34/60 (57%) using the stylet, 18/60 (30%) using a Portex single-use bougie, 16/60 (27%) using a Frova single-use bougie and 5/60 (8%) using a Portex reusable bougie. The proportion intubating within 30 s was significantly higher with the stylet compared with any bougie (p < 0.001), but significantly lower with a Portex reusable bougie than any other device (p < 0.004). Participants rated the Portex reusable bougie as significantly more difficult to use than the other devices (p < 0.001). There was no evidence of a relationship between previous experience and success rate for any device.

Gregory P; Woollard M; Lighton D; Munro G; Jenkinson E; Newcombe RG; O'Meara P; Hamilton L

2012-04-01

350

To shape or not to shape...simulated bougie-assisted difficult intubation in a manikin.  

Science.gov (United States)

Thirty anaesthetists attempted to place a derived 'optimal' curve bougie or a straight bougie in the trachea of a manikin, in a randomised cross-over study. A Grade 3 Cormack and Lehane laryngoscopic view was simulated. The anaesthetists were blinded to success (tracheal placement) or failure (oesophageal placement). The success rates with the curved and straight bougies were 83 and 7%, respectively, giving a difference (95% confidence interval) of 77% (54-87%) between the two bougies (p bougies were 43 and 0%, respectively, giving a difference (95% confidence interval) of 43% (21-61%) between the two bougies (p bougies used to facilitate difficult intubation should be curved and have a coudé tip. PMID:12859474

Hodzovic, I; Wilkes, A R; Latto, I P

2003-08-01

351

Comparison of malleable stylet and reusable and disposable bougies by paramedics in a simulated difficult intubation.  

Science.gov (United States)

In a randomised crossover study, 60 ambulance paramedics attempted tracheal intubation of a manikin model of a Cormack and Lehane grade 3/4 view using a Portex stylet, Portex and Frova single-use bougies, and a Portex reusable bougie. Tracheal intubation within 30 s was achieved by 34/60 (57%) using the stylet, 18/60 (30%) using a Portex single-use bougie, 16/60 (27%) using a Frova single-use bougie and 5/60 (8%) using a Portex reusable bougie. The proportion intubating within 30 s was significantly higher with the stylet compared with any bougie (p < 0.001), but significantly lower with a Portex reusable bougie than any other device (p < 0.004). Participants rated the Portex reusable bougie as significantly more difficult to use than the other devices (p < 0.001). There was no evidence of a relationship between previous experience and success rate for any device. PMID:22288931

Gregory, P; Woollard, M; Lighton, D; Munro, G; Jenkinson, E; Newcombe, R G; O'Meara, P; Hamilton, L

2012-01-31

352

[A case of gastrointestinal stromal tumor of rectum, difficult to differentiate from leiomyosarcoma of prostate].  

Science.gov (United States)

A 70 year-old male was seen at the hospital with the chief complaints of frequent miction and incomplete urinary retention. A hen's egg-sized firm mass was palpable in anterior wall of rectum by digital rectal examination. Intravenous urography showed severe bilateral hydronephroureter. Transrectal ultrasound, CT scan and MRI revealed a mass with 5 cm in diameter between prostate and rectum, and the margin of them were unclear. On needle biopsy of the tumor, leiomyosarcoma of the prostate was suspected. We performed radical cytectomy and created continent urinary reserver. Because the tumor and rectum could not be lysed, part of the rectum was resected. Histological examination showed gastrointestinal stromal tumor (GIST) of rectum. GIST of rectum is a rare entity, and in case of contact with the prostate, it is difficult to differentiate from leiomyosarcoma of prostate. PMID:11593705

Kuruma, H; Ao, T; Suyama, K; Okuno, N; Mizoguchi, H; Murayama, M; Koshiba, K; Motoori, T

2001-09-01

353

[A case of gastrointestinal stromal tumor of rectum, difficult to differentiate from leiomyosarcoma of prostate].  

UK PubMed Central (United Kingdom)

A 70 year-old male was seen at the hospital with the chief complaints of frequent miction and incomplete urinary retention. A hen's egg-sized firm mass was palpable in anterior wall of rectum by digital rectal examination. Intravenous urography showed severe bilateral hydronephroureter. Transrectal ultrasound, CT scan and MRI revealed a mass with 5 cm in diameter between prostate and rectum, and the margin of them were unclear. On needle biopsy of the tumor, leiomyosarcoma of the prostate was suspected. We performed radical cytectomy and created continent urinary reserver. Because the tumor and rectum could not be lysed, part of the rectum was resected. Histological examination showed gastrointestinal stromal tumor (GIST) of rectum. GIST of rectum is a rare entity, and in case of contact with the prostate, it is difficult to differentiate from leiomyosarcoma of prostate.

Kuruma H; Ao T; Suyama K; Okuno N; Mizoguchi H; Murayama M; Koshiba K; Motoori T

2001-09-01

354

[Difficult parents? The challenges of responding to the needs of psychiatrically ill parents in pediatric practice].  

UK PubMed Central (United Kingdom)

This article discusses the interactions with so-called "difficult" parents, who often suffer from mental illness that has never been treated. The article offers recommendations to decode the emotional communication of such parents who doubt their own ability to care for their children as well as that of the pediatrician's. A clinical case is presented of a mother who "can't take it anymore" with her three-year-old son, in order to focus in greater depth on improving interactions with the physician. The authors strongly recommend assessment of what parents say about their child as well as of first-hand observations of parent-child interactions. Approaches to help the pediatrician better evaluate parental distress and associated risks to the child, while maintaining the parent-pediatrician alliance, are discussed.

Schechter DS; Rusconi-Serpa S

2013-02-01

355

Neonatal intensive care: an obvious, yet difficult area for cerebral near-infrared spectroscopy  

Science.gov (United States)

The first clinical application of near-infrared spectroscopy (NIRS) 11 years go was on the head of newborn infants under intensive care. Since then much credible and some important data have been accumulated in this area of research. The best data have been obtained using manipulation of arterial oxygen saturation to obtain single or repeated estimates of cerebral blood flow or cerebral blood volume, or interference with cerebral venous return to obtain measures of venous oxygen saturation. It has been more difficult to take advantage of the continuous and noninvasive nature of NIRS. In particular, the value of the cytochrome signal can still be doubted. A role has not yet developed for NIRS in clinical neonatology.

Skov, Lotte; Brun, Nikolai C.; Greisen, Gorm

1997-01-01

356

A case of hepatic angiomyolipoma difficult to distinguish from hepatocellular carcinoma  

Directory of Open Access Journals (Sweden)

Full Text Available We report a case of hepatic angiomyolipoma with uncommon clinical features. A 56-year-old man presented with a hepatic tumor in the caudate lobe. The tumor was hypoechoic on ultrasonography, showed early-phase hyperattenuation on enhanced computed tomography and did not absorb iron on superparamagnetic iron oxide-enhanced magnetic resonance imaging. Hepatocellular carcinoma was highly suspected, and the patient underwent hepatic resection. Histologically, the tumor was mainly composed of smooth muscle cells and contained small amounts of adipose cells and blood vessels. On immunohistochemical staining, the smooth muscle cells were positive for a melanocytic cell-specific monoclonal antibody. In cases with uncommon features of angiomyolipoma, it is quite difficult to distinguish angiomyolipoma from hepatocellular carcinoma.

Masahiro Takahara, Yasuhiro Miyake, Kazuyuki Matsumoto, Daisuke Kawai, Eisuke Kaji, Tatsuya Toyokawa, Morihito Nakatsu, Masaharu Ando, Mamoru Hirohata

2009-01-01

357

Evaluation of Success Rate of Ultrasound-Guided Venous Cannulation in Patients with Difficult Venous Access  

Directory of Open Access Journals (Sweden)

Full Text Available "nBackground/Objective: We evaluated a new ultrasound-guided approach to percutaneous cephalic vein or basilic vein cannulation in patients with difficult intravenous access. "nPatients and Methods: Patients who required intravenous access and were candidates for surgical approach, or central venous catheterization were enrolled into the study. They had at least three unsuccessful attempts at establishing a peripheral intravenous line. By using a 7.5-MHz ultrasound probe, the cephalic or basilic vein was identified and then cannulated with a conventional venous cannula. The time from probe placement to cannulation, the number of attempts and complications were recorded. "nResults: Eighty-eight patients were enrolled; 28 (31.8%) female and 60 (68.2%) male. The intravenous (IV) drug abusers consisted of 29 patients (33%) which were all men (48% of males). The procedure was successful in 94.3% and failed in five cases (5.7%) after three attempts. The mean time of procedure was 175±153 seconds. There was a significant difference between IV drug abusers (231±203) and non IV drug abusers (149±118) regarding access time (p-value=0.012). The procedure was successful after one attempt in 61 patients (73.5%), two attempts in 20 patients (24.1%) and three attempts in two patients (2.4%). The cannula was dislodged in three cases after one hour of follow-up. No other complications happened. Conclusion: Ultrasound-guided cephalic and basilic vein cannulation is safe and time saving, has a high success rate in patients with difficult peripheral intravenous access, and may be used as the first step in these patients before the other more invasive alternatives.  

S Etezazizn; B Tavakoli; A Hekmatnia; N Omidifar; M Moradi

2010-01-01

358

Dangerous or merely difficult? The new population of forensic mental hospitals.  

UK PubMed Central (United Kingdom)

BACKGROUND: During recent decades, there has been a substantial increase in admissions to forensic mental hospitals in several European countries. It is not known if reforms implemented in mental health policies and practices are responsible for this development. OBJECTIVE: Our study examined the development of mental health care in Austria and the incidence and prevalence of mentally disordered offenders judged not guilty by reason of insanity (NGRI). METHODS: We analysed data on service provision and data from criminal statistics between 1970 and 2008 from several national sources. RESULTS: During the first decade when reforms to mental health practice were implemented, the incidence and prevalence of offenders judged NGRI remained unchanged, despite a reduction of mental hospital beds by nearly 50% and little outpatient care. Surprisingly, the enormous increase in admissions to forensic inpatient treatment began in Austria only after community mental health services were rolled out across the country in the 1990s. This increase was primarily due to admissions of patients who had committed less severe offences, while rates of those who had committed homicide remained unchanged. CONCLUSION: Our results cannot be explained by details of the reforms such as the downsizing of mental hospitals or a lack of outpatient facilities, nor by changes to criminal sentencing. Rather, the results provide evidence of an increasingly inadequate provision of comprehensive care for "difficult" but not extremely dangerous psychotic patients living in the community. This may result from the attitudes of mental health professionals who have become less inclined to integrate aggressive behaviour into their understanding of psychosis. As a consequence, increasing numbers of "difficult" patients end up in forensic psychiatric institutions. This development, which can be observed in nearly all European countries, raises concerns with regard to efforts to destigmatize both patients and psychiatry.

Schanda H; Stompe T; Ortwein-Swoboda G

2009-09-01

359

Double guidewire technique vs transpancreatic precut sphincterotomy in difficult biliary cannulation.  

UK PubMed Central (United Kingdom)

AIM: To compare the outcomes between double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) in patients with difficult biliary cannulation. METHODS: This was a prospective, randomized study conducted in single tertiary referral hospital in Korea. Between January 2005 and September 2010. A total of 71 patients, who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved, were randomized into DGT (n = 34) and TPS (n = 37) groups. DGT or TPS was done for selective biliary cannulation. We measured the technical success rates of biliary cannulation, median cannulation time, and procedure related complications. RESULTS: The distribution of patients after randomization was balanced, and both groups were comparable in baseline characteristics, except the higher percentage of endoscopic nasobiliary drainage in the DGT group (55.9% vs 13.5%, P < 0.001). Successful cannulation rate and mean cannulation times in DGT and TPS groups were 91.2% vs 91.9% and 14.1 ± 13.2 min vs 15.4 ± 17.9 min, P = 0.732, respectively. There was no significant difference between the two groups. The overall incidence of post- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis was 38.2% vs 10.8%, P < 0.011 in the DGT group and the TPS group; post-procedure pancreatitis was significantly higher in the DGT group. But the overall incidence of post-ERCP hyperamylasemia was no significant difference between the two groups; DGT group vs TPS group: 14.7% vs 16.2%, P < 1.0. CONCLUSION: When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved, DGT and TPS facilitated biliary cannulation and showed similar success rates. However, post-procedure pancreatitis was significantly higher in the DGT group.

Yoo YW; Cha SW; Lee WC; Kim SH; Kim A; Cho YD

2013-01-01

360

What's conditioned in conditioned place preference?  

UK PubMed Central (United Kingdom)

Conditioned place preference (CPP) is a learned behavior shown in many vertebrates, including humans. CPP occurs when a subject comes to prefer one place more than others because the preferred location has been paired previously with rewarding events. The CPP paradigm is widely used to explore the reinforcing effects of natural and pharmacological stimuli, including drugs of addiction. There is a general assumption that an acquired place preference is based on classical conditioning derived 'incentive motivation'. However, this may be an oversimplification of the multiple learning processes involved. We argue that although CPP may appear as an incentive-driven behavior related to secondary reinforcers, it may also be a result of operant conditioning of behavior prevailing at the conditioning site, as well as a result of conditioned treatment effects. Here, we outline alternative explanations for an observed CPP, which may fundamentally affect the interpretation of results with this paradigm in its use as a screening tool for rewarding properties of treatments.

Huston JP; Silva MA; Topic B; Müller CP

2013-03-01

 
 
 
 
361

Science Teachers’ and Students’ Perceived Difficult Topics in the Integrated Science Curriculum of Lower Secondary Schools in Barbados  

Digital Repository Infrastructure Vision for European Research (DRIVER)

The study was designed to investigate the perception of students and teachers of the difficult topics in the lower secondary school science curriculum of Barbados; if there were statistically significant differences in (a) students’ perception and teacher perception of difficult topics and (b) stude...

Babalola Ogunkola; David Samuel

362

Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management : a randomized clinical trial  

DEFF Research Database (Denmark)

Awake flexible fiberoptic intubation (FFI) is the gold standard for management of anticipated difficult tracheal intubation. The purpose of this study was to compare awake FFI to awake McGrath® video laryngoscope, (MVL), (Aircraft Medical, Edinburgh, Scotland, United Kingdom) intubation in patients with an anticipated difficult intubation. The authors examined the hypothesis that MVL intubation would be faster than FFI.

Rosenstock, Charlotte Vallentin; ThØgersen, Bente

2012-01-01

363

A Novel 'Cheese Wire' Technique for Stent Positioning Following Difficult Iliac Artery Subintimal Dissection and Aortic Re-Entry  

International Nuclear Information System (INIS)

Subintimal wire dissection is a well-established method for traversing difficult vascular occlusions. This technique relies on re-entry of the true lumen distal to the occlusion, which may be difficult in diseased vessels with significant calcification. This case report describes a novel 'cheese wire' technique to allow stent positioning without the use of proprietary re-entry devices.

2009-01-01

364

High fidelity medical simulation in the difficult environment of a helicopter: feasibility, self-efficacy and cost  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Background This study assessed the feasibility, self-efficacy and cost of providing a high fidelity medical simulation experience in the difficult environment of an air ambulance helicopter. Methods Seven of 12 EM residents in their first postgraduate year participated in an EMS flight simulation as the flight physician. The simulation used the Laerdal SimMan™ to present a cardiac and a trauma case in an EMS helicopter while running at flight idle. Before and after the simulation, subjects completed visual analog scales and a semi-structured interview to measure their self-efficacy, i.e. comfort with their ability to treat patients in the helicopter, and recognition of obstacles to care in the helicopter environment. After all 12 residents had completed their first non-simulated flight as the flight physician; they were surveyed about self-assessed comfort and perceived value of the simulation. Continuous data were compared between pre- and post-simulation using a paired samples t-test, and between residents participating in the simulation and those who did not using an independent samples t-test. Categorical data were compared using Fisher's exact test. Cost data for the simulation experience were estimated by the investigators. Results The simulations functioned correctly 5 out of 7 times; suggesting some refinement is necessary. Cost data indicated a monetary cost of $440 and a time cost of 22 hours of skilled instructor time. The simulation and non-simulation groups were similar in their demographics and pre-hospital experiences. The simulation did not improve residents' self-assessed comfort prior to their first flight (p > 0.234), but did improve understanding of the obstacles to patient care in the helicopter (p = 0.029). Every resident undertaking the simulation agreed it was educational and it should be included in their training. Qualitative data suggested residents would benefit from high fidelity simulation in other environments, including ground transport and for running codes in hospital. Conclusion It is feasible to provide a high fidelity medical simulation experience in the difficult environment of the air ambulance helicopter, although further experience is necessary to eliminate practical problems. Simulation improves recognition of the challenges present and provides an important opportunity for training in challenging environments. However, use of simulation technology is expensive both in terms of monetary outlay and of personnel involvement. The benefits of this technology must be weighed against the cost for each institution.

Wright Stewart W; Lindsell Christopher J; Hinckley William R; Williams Annette; Holland Carolyn; Lewis Christopher H; Heimburger Gail

2006-01-01

365

564?Is It Really Difficult-to-treat Asthma? Don't Forget Other Causes of Wheeze.  

UK PubMed Central (United Kingdom)

BackgroundOne in 4 asthma patients may not have their condition adequately controlled and experience persistent symptoms despite treated with high healthcare utilization. But do all of them really have asthma?MethodsHere we present 3 cases; all were diagnosed as asthma, had been treating with multiple bronchodilators, even oral steroids and were not responding to the treatment. And so they were refered to our clinic as having difficult-to-treat asthma as candidates for omelizumab therapy.ResultsCase1: A 44-year-old female presented with 18 years history of dyspnea, wheeze and chronic cough. Her FEV1 was 37% of the predicted (0.93 lt), FVC and FEV1/FVC were subnormal and showed no reversibility. CT scan showed a deformed trachea with a diverticula in the posterior region with cystic bronchiectasis in lung parenchyma, bilaterally. Bronchial endoscopy showed dyskinesia extending almost totally throughout the tracheobronchial tree with complete expiratory collapse. Her diagnosis was changed as Mounier-Kuhn syndrome. Case 2: A 19-year-old female presented with 11 years history of persistent wheezing and dyspnea which were progressively increasing for the last 5 years. Her FEV1 was 85% and the FEV1/FVC % 77 of the predicted, showed no reversibility. Her CT scan was in normal limits. Fiberoptic bronchoscopy revealed a severe airway stenosis like a pinhole at the beginning of the right main bronchus, adjacent to the carina. Excluding her asthma diagnosis she underwent a balloon dilatation procedure, which improved her symptoms. Case 3: A 50-year-old female presented with 16 years history of dyspnea, wheeze, chronic cough. Her FEV1 was 40% of the predicted (0.91 lt), and showed reversibility of 28%. She had an elevated total IgE level of 1126 IU/mL with serum eosinophilia of 5.5%. Her HRCT scan revealed bilateral central bronchiectasis with fleeting pulmonary parenchymal opacities. Her sensitization to Aspergillus fumigatus was shown by positive skin testing. She was diagnosed as having allergic bronchopulmonary aspergillosis and oral itracanosole with steroid were added to her treatment which improved her symptoms.ConclusionsAlthough all patients' symptoms looked like asthma, and all diagnosed as having asthma for many years, the diagnosis should always be confirmed before accepting them as “difficult-to-treat”.

Kalkan IK; Kalpaklioglu AF

2012-02-01

366

Interactive film scenes for tutor training in problem-based learning (PBL): dealing with difficult situations  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Background In problem-based learning (PBL), tutors play an essential role in facilitating and efficiently structuring tutorials to enable students to construct individual cognitive networks, and have a significant impact on students' performance in subsequent assessments. The necessity of elaborate training to fulfil this complex role is undeniable. In the plethora of data on PBL however, little attention has been paid to tutor training which promotes competence in the moderation of specific difficult situations commonly encountered in PBL tutorials. Methods Major interactive obstacles arising in PBL tutorials were identified from prior publications. Potential solutions were defined by an expert group. Video clips were produced addressing the tutor's role and providing exemplary solutions. These clips were embedded in a PBL tutor-training course at our medical faculty combining PBL self-experience with a non-medical case. Trainees provided pre- and post-intervention self-efficacy ratings regarding their PBL-related knowledge, skills, and attitudes, as well as their acceptance and the feasibility of integrating the video clips into PBL tutor-training (all items: 100 = completely agree, 0 = don't agree at all). Results An interactive online tool for PBL tutor training was developed comprising 18 video clips highlighting difficult situations in PBL tutorials to encourage trainees to develop and formulate their own intervention strategies. In subsequent sequences, potential interventions are presented for the specific scenario, with a concluding discussion which addresses unresolved issues. The tool was well accepted and considered worth the time spent on it (81.62 ± 16.91; 62.94 ± 16.76). Tutors considered the videos to prepare them well to respond to specific challenges in future tutorials (75.98 ± 19.46). The entire training, which comprised PBL self-experience and video clips as integral elements, improved tutor's self-efficacy with respect to dealing with problematic situations (pre: 36.47 ± 26.25, post: 66.99 ± 21.01; p Conclusions The interactive tool with instructional video clips is designed to broaden the view of future PBL tutors in terms of recognizing specific obstacles to functional group dynamics and developing individual intervention strategies. We show that this tool is well accepted and can be successfully integrated into PBL tutor-training. Free access is provided to the entire tool at http://www.medizinische-fakultaet-hd.uni-heidelberg.de/fileadmin/PBLTutorTraining/player.swf.

Bosse Hans M; Huwendiek Soeren; Skelin Silvia; Kirschfink Michael; Nikendei Christoph

2010-01-01

367

Vía aérea difícil: interacciones entre ortodoncia y anestesiología/ Difficult airway: relationship between orthodontics and anaesthesiology  

Scientific Electronic Library Online (English)

Full Text Available Abstract in spanish Introducción: La intubación endotraqueal es una técnica bien estandarizada pero sin embargo, dependiendo de la experiencia del operador, alteraciones anatómicas o impuestas por la patología, pueden existir situaciones en las que no se puede ventilar al paciente. Objetivo: Pretendemos identificar la implicación de nuestra disciplina en el control de la via aérea de pacientes que requieren anestesia o reanimación respiratoria o hemodinámica. Metodos: Se han estudia (more) do los hallazgos clínicos denominados «poco tranquilizadores» publicados en la guía clínica de la Sociedad Americana de Anestesiología (ASA) para establecer una via aérea difícil a la intubación. Hemos tratado de ver y traducir estas situaciones clínicas desde el punto de vista ortodóncico-odontológico. Resultados: De los once criterios de riesgo de la ASA, podemos modificar favorablemente, con tratamientos ortodóncicos y ortopédicos convencionales, seis de ellos y parte de las situaciones adscritas al apartado cinco (grados III y IV de la clasificación de Mallampati-Samsoon). Conclusión: Parece adecuado considerar las posibilidades del tratamiento ortodóncico y la ortopedia dentofacial, no sólo como instrumento de tratamiento de maloclusiones habituales, sino como profilaxis de algunas situaciones que pueden desencadenar problemas ante situaciones de urgencia, como es la dificultad de intubación previa a una intervención quirúrgica. Abstract in english Introduction: Endotracheal intubation is a well standardised technique although depending on the experience of the operator, anatomical or pathology-related alterations, there may exist situations in which the patient cannot receive ventilation. Objective: We aim to identify the implication of our speciality in the control of the airway of patients requiring anaesthesia or respiratory or hemodynamic resuscitation. Methods: We have studied the clinical findings termed «no (more) n-reassuring» published in the PRACTICE GUIDELINES FOR MANAGEMENT OF THE DIFFICULT AIRWAY of the American Society of Anaesthesiology (ASA) in order to establish an airway difficult for intubation. We have attempted to view and translate these clinical situations from the orthodontic-odontologic perspective. Results: Of the eleven ASA risk criteria, we can favourably modify, with conventional orthodontic and orthopaedic treatments, six of these and part of the situations ascribed to Section five (degrees III and IV of the Mallampati-Samsoon classification). Conclusion: It seems fitting to consider the possibilities of orthodontic treatment and dentofacial orthopaedics, not only as an instrument for treating habitual malocclusions, but rather as a prophylaxis for some situations that can trigger off problems in emergency situations, such as the difficulty of intubation before a surgical operation.

Carlos-Villafranca, Félix de; Cobo-Plana, Juan; Macías-Escalada, Emilio; Martínez, Juliana

2005-04-01

368

The difficult concussion patient: what is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms?  

UK PubMed Central (United Kingdom)

BACKGROUND: Concussion in sport typically recovers clinically within 10 days of injury. In some cases, however, symptoms may be prolonged or complications may develop. The objectives of the current paper are to review the literature regarding the difficult concussion and to provide recommendations for an approach to the investigation and management of patients with persistent symptoms. METHODS: A qualitative review of the literature on concussion in sport was conducted with a focus on prolonged recovery, long-term complications and management including investigation and treatment strategies. MEDLINE and Sports Discus databases were reviewed. RESULTS: Persistent symptoms (>10 days) are generally reported in 10-15% of concussions. This figure may be higher in certain sports (eg, ice hockey) and populations (eg, children). In general, symptoms are not specific to concussion and it is important to consider and manage coexistent pathologies. Investigations may include formal neuropsychological testing and conventional neuroimaging to exclude structural pathology. Currently, there is insufficient evidence to recommend routine clinical use of advanced neuroimaging techniques or genetics markers. Preliminary studies demonstrate the potential benefit of subsymptom threshold activity as part of a comprehensive rehabilitation programme. Limited research is available on pharmacological interventions. CONCLUSIONS: Cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion. Important components of management, after the initial period of physical and cognitive rest, include associated therapies such as cognitive, vestibular, physical and psychological therapy, assessment for other causes of prolonged symptoms and consideration of a graded exercise programme at a level that does not exacerbate symptoms.

Makdissi M; Cantu RC; Johnston KM; McCrory P; Meeuwisse WH

2013-04-01

369

Thermal Decomposition of HEs Included in Industrial Perforating Systems  

International Science & Technology Center (ISTC)

Predictive Model for Estimating the Effects Produced by Thermal Decomposition of HE Included in Perforating Systems of the Oil and Gas Industry on Their Normal Operation in Boreholes under Various Temperature and Time Conditions

370

Power counting in baryon chiral perturbation theory including vector mesons  

International Nuclear Information System (INIS)

It is demonstrated that using a suitable renormalization condition one obtains a consistent power counting in manifestly Lorentz-invariant baryon chiral perturbation theory including vector mesons as explicit degrees of freedom.

2003-11-20

371

Modeling temperature and moisture fields in conditioned spaces using zonal approach, including sorption phenomena in buildings materials; Modelisation thermo-hydro-aeraulique des locaux climatises selon l'approche zonale (prise en compte des phenomenes de sorption d'humidite)  

Energy Technology Data Exchange (ETDEWEB)

Building simulation models represent in our days an important tool for building conception and performance analysis. Although moisture interacts in many ways with the whole building affecting therefore its behavior, frequently these models neglects the interactions between them. In addition, in most of them, indoor air conditions are considered uniform, which is a non-realistic assumption in conditioned spaces. In this work, a model to predict temperature and moisture fields in conditioned spaces, using zonal approach, is proposed. This method is based in dividing spatially a room in a relative small number of zones, typically on the order of tens to hundreds, where the state variables of air are considered uniform, with the exception of pressure that varies hydrostatically. While not as fine-grained as CFD simulation, zonal models do give useful information about temperature and moisture distributions that is important in comfort analysis. The proposed model was structured in three groups of sub-models representing the three building domains: indoor air, envelope and HVAC system. The indoor air sub-model is related to the indoor air space, where airflow speed can be considered weak. The envelope sub-model is related to the radiation exchanges between envelope and its neighborhood, and to the simultaneous heat and mass transfers across the envelope material. This latest can be represented by four sub-models of different complexity levels, with two of them taking into account moisture adsorption and desorption by building materials. Concerning to the HVAC system model, it refers to the whole system that means equipment, control and specific airflow from equipment. All sub-models were coupled into a modular simulation environment, SPARK, well-adapted to compare different models. The applicability of the proposed model is shown by two examples. The first one shows the importance of considering moisture sorption phenomena in the prediction of indoor air conditions, while the second shows the impact of the external environment in the behavior of a conditioned space and in its HVAC system performance. (author)

Cordeiro Mendoca, K.

2004-05-15

372

[Sporadic adenoma and colitis-associated intraepithelial neoplasia: a difficult differential diagnosis  

UK PubMed Central (United Kingdom)

The differential diagnosis between sporadic adenoma and colitis-associated neoplasia is difficult. Clinical, histological and molecular genetic methods are available to recognise a difference between these two entities. The aim of the present analysis was to check known criteria in a large series of patients and 352 patients with ulcerative colitis and concomitant intraepithelial neoplastic lesions [149 adenomas (A), 123 colitis-associated intraepithelial neoplasias (N), 80 carcinomas (K)] were investigated. Clinical history helped to identify patients with sporadic adenoma since patients with colitis-associated neoplastic lesions presented with different data such as age (A: 61.3+/-13 years, N: 48.4+/-16.4 years, K: 53.9+/-16.9 years), duration of disease (A: 6.9+/-8.1 years, N: 11.9+/-10 years, K: 13.6+/-9.6 years), frequency of pancolitis (A: 28.6%, N: 56.3%, K: 48.3%) and frequency of solitary lesions (A: 83.7%, N: 23.1%, K: 51.9%). The differential diagnosis between adenoma and colitis-associated neoplasia in patients with ulcerative colitis appears to be possible but the diagnosis should only be made in the remission phase. Furthermore the patients need a careful endoscopic and bioptic follow-up. If in doubt one should consider colitis-associated neoplasia especially when there are multiple intraepithelial neoplastic lesions. Long-term follow-up studies are urgently needed.

Vieth M; Behrens H; Stolte M

2003-02-01

373

Novel use of osmotic tissue expanders to treat difficult anterior palatal fistulas.  

UK PubMed Central (United Kingdom)

Objective: Novel use of osmotic tissue expanders to recruit local palatal mucoperiosteum for the treatment of difficult anterior palatal fistulas. Design: This is a retrospective review of our experience with osmotic tissue expanders for closure of secondary palatal fistulas. Setting: The study occurred at Oregon Health and Science University, a tertiary care level academic hospital. Patients, Participants: All patients were treated for combined cleft lip and palate by the Oregon Health and Science University Craniofacial Disorders multidisciplinary team. They were determined to be appropriate candidates due to the anterior location of the fistula and symptomatic nature. Patients complained of significant nasal regurgitation of liquid and solids. Interventions: All patients underwent a two-stage procedure under general anesthesia. The first stage was placement of the expanders. The second stage was 1 week later, with removal of the expanders, palatal revision, and closure of the oronasal fistula. Main Outcome Measure: The primary outcome measures determined before data collection were treatment of symptoms and decreased size of fistula. Results: Seven patients with palatal fistulas were treated with osmotic tissue expanders. Five patients had complete closure of the fistula. Two patients demonstrated slit-like fistulas that were no longer symptomatic and were amenable to closure at time of alveolar bone grafting. No complications were observed. Conclusions: The use of osmotic tissue expanders is a viable alternative for repair of large anterior palatal fistulas, especially in a scarred or previously operated palate. Patients were also no longer symptomatic.

Jenq TF; Hilliard SM; Kuang AA

2011-03-01

374

Vía aérea difícil en pediatría: signos predictores. Artículo de revisión Difficult airway in pediatrics. Predicting signs  

Directory of Open Access Journals (Sweden)

Full Text Available El manejo de la Vía Aérea es la A del ABC de la medicina moderna y representa un reto para el anestesiólogo experto, y aún más para el que se encuentra en entrenamiento. Una intubación difícil no anticipada es una emergencia médica, si no es tratada con rapidez y de forma apropiada, puede condicionar problemas serios y hasta la muerte del paciente. En el presente artículo se hace una revisión del diagnóstico precoz de esta entidad, mediante signos predictores, teniendo en cuenta algunas de las características principales de la vía aérea del niño que la diferencian del adulto.The management of the airway is the A in the ABC of current medicine, and represents a challenge for an expert in anestesiology, and much more for those in the training process. An anticipated difficult intubation is a medical emergency which must be treated rapidly and properly because it can result in serious problems and lead to death. In this article a review of the early diagnosis of this entity through predicting signs , considering some main features at the child airway which are different from the adult's was carried out.

Judith Pérez Lara; Alina Acosta Menoya; Emilio Díaz Gener; Ángel González Martínez

2007-01-01

375

Use of MALDI-TOF mass spectrometry for identification of bacteria that are difficult to culture.  

UK PubMed Central (United Kingdom)

Rapid and reliable detection and identification of bacterial species are necessary for diagnosis and efficient treatment. Until recently, bacterial identification in clinical laboratories has mainly relied on conventional phenotypic and gene sequencing identification techniques. The identification of anaerobic bacteria, fastidious and slow growing bacteria using conventional methods is time consuming, expensive and complicated. Many anaerobes grow poorly or are nonreactive in most diagnostic systems. Unambiguous diagnosis of active tuberculosis is a time-consuming process, requiring as long as 12 weeks for positive identification of the organism. This long time frame presents challenges for case identification. Early identification of pathogenic bacteria is very important for the disease control. Recently, bacteriologists have focused their attention on the use of mass spectrometry (MS) for bacterial identification, especially Matrix Assisted Laser Desorption Ionization Time-Of-Flight (MALDI-TOF). Use of MALDI-TOF-MS is described in this review, with a special emphasis on the successful identification of groups of bacteria, which are difficult to culture. MALDI-TOF-MS is a powerful, rapid, precise, and cost-effective method for identification of intact bacteria, compared to conventional phenotypic techniques or molecular biology. Our review suggests that identification of anaerobes, fastidious bacteria and slow growing bacteria, has been improved by the arrival of MALDI-TOF-MS in clinical laboratories.

Biswas S; Rolain JM

2013-01-01

376

Management of acute clinical presentation of anaplastic thyroid cancer. A difficult choice.  

UK PubMed Central (United Kingdom)

AIM: evaluate emergency treatment of patients presenting with anaplastic thyroid cancer with acute compressive sympthoms. MATERIAL OF STUDY: In the present report, we describe three patients with anaplastic thyroid cancer who presented clinically with acute compressive sympthoms. All patients underwent debulking surgery in order to relieve the sympthoms and perform a potentially curative resection. RESULTS: The first two patients with diagnosis of ATC couldn't undergo to radiotherapy and chemotherapy for the presence of infection of the wound and for the earlier disease relapse in the mediastinum and died after 1 month and 3 months. The third patient (with papillary thyroid cancer with focal areas of anaplastic cancer) after surgical treatment underwent external radiotherapy and is alive over 2 years. DISCUSSION: Compression, deviation, and infiltration of trachea have impeded the achievement of a safe respiratory access with tracheostomy and these three patients underwent debulking surgery to relieve compressive sympthoms. These three cases confirm the importance of acute local compressive symptoms of ATC and their difficult management. CONCLUSIONS: In such cases a debulking surgery can be considered as a valid option in the emergency management. Nevertheless debulking surgery (and even radical excision of the tumor), when performed alone, offer a minimal improved survival. KEY WORDS: Anaplastic thyroid cancer, Debulking surgery, Emergency treatment.

Biffoni M; Garritano S; Scipioni P; Colangelo M; De Meo D; Monti M

2013-03-01

377

Management of difficult airways using a hospital-wide "Alpha Team" approach.  

Science.gov (United States)

Airway management is germane to safe patient care. Keys to management of difficult airways (DAs) are the "Right People, Right Parts, and Right Place" (R3P3). Successful management of DA requires clinicians who have adequate training, experience, and equipment. Policies were implemented to optimize the management of DAs. One identified inpatients with potential DAs, whereas the other addressed creation and deployment of "Alpha Teams" (ATs). In the event of impending respiratory compromise, an AT was called in the same manner as a code blue. Health care providers were educated about these process changes, and ATs were tested using computerized patient simulators and self-paced observations. Testing assessed performance before, immediately after, and 30 days after the seminar. Changes in, and retention of, knowledge about DAs was analyzed. The goal of the R3P3 was to identify DAs and then to bring a well-trained hospital-wide AT to the bedside to decrease response time, rapidly establish a definitive airway, and improve survivability in an airway emergency. PMID:20606209

Long, Lisa; Vanderhoff, Bruce; Smyke, Norman; Shaffer, L E T; Solomon, Joseph; Steuer, Jill D

378

Evaluation of Early Precut with Needle-Knife in Difficult Biliary Cannulation During ERCP.  

UK PubMed Central (United Kingdom)

BACKGROUND: There is scarce information on whether performing the precut procedure early rather than after several cannulation attempts is associated with different success and complication rates. OBJECTIVE: The aim of this retrospective study was is to compare the early precut technique with the standard one in terms of the results and complications. METHODS: The contemporary success rate and postoperative complications in 792 endoscopic retrograde cholangiopancreatography cases were frequently observed during the period from June 2007 to May 2011, and 56 of these cases were carried out with precut biliary sphincterotomy after the standard sphincterotomy had failed. RESULTS: The success rate for standard sphincterotomy was 89.8 %: 51 out of 56 cases were carried out with precut biliary sphincterotomy and succeeded. The total success rate was 96.3 %. The difference was significant (? (2) = 25.62, p < 0.01) compared to the success rate of first cannulation, while the difference in complication rates between precut and standard sphincterotomy was minor (9.9 vs. 12.5 %, p > 0.05). CONCLUSION: Early precut with a needle-knife in a difficult biliary cannulation was safe and effective if performed by experienced endoscopists.

Zhu JH; Liu Q; Zhang DQ; Feng H; Chen WC

2013-08-01

379

Measuring competition in plant communities where it is difficult to distinguish individual plants  

Directory of Open Access Journals (Sweden)

Full Text Available A novel method for measuring plant-plant interactions in undisturbed semi-natural and natural plant communities where it is difficult to distinguish individual plants is discussed. It is assumed that the ecological success of the different plant species in the plant community may be adequately measured by plant cover and vertical density (a measure that is correlated to the 3-dimensional space occupancy and biomass). Both plant cover and vertical density are measured in a standard pin-point analysis in the beginning and at the end of the growing season. In the outlined competition model the vertical density at the end of the growing season is assumed to be a function of the cover of all species at the start of the growing season, and the cover at the start of the growing season is assumed to be a function of the vertical density of all species at the end of the previous growing season. The method allows direct measurements of the competitive effects of neighbouring plants on plant performance and the estimation of parameters that describe the ecological processes of plant-plant interactions during the growing season as well as the process of survival and recruitment between growing seasons. Additionally, the presented method is suited for testing different ecological hypothesis on competitive interactions along environmental gradients, investigating the importance of competition, as well as predicting the likelihood of different ecological scenarios.

Christian Damgaard

2011-01-01

380

Measuring competition in plant communities where it is difficult to distinguish individual plants  

DEFF Research Database (Denmark)

A novel method for measuring plant-plant interactions in undisturbed semi-natural and natural plant communities where it is difficult to distinguish individual plants is discussed. It is assumed that the ecological success of the different plant species in the plant community may be adequately measured by plant cover and vertical density (a measure that is correlated to the 3-dimensional space occupancy and biomass). Both plant cover and vertical density are measured in a standard pin-point analysis in the beginning and at the end of the growing season. In the outlined competition model the vertical density at the end of the growing season is assumed to be a function of the cover of all species at the start of the growing season, and the cover at the start of the growing season is assumed to be a function of the vertical density of all species at the end of the previous growing season. The method allows direct measurements of the competitive effects of neighbouringzplants on plant performance and the estimation of parameters that describe the ecological processes of plantplant interactions during the growing season as well as the process of survival and recruitment between growing seasons. Additionally, the presented method is suited for testing different ecological hypothesis on competitive interactions along environmental gradients, investigating the importance of competition, as well as predicting the likelihood of different ecological scenarios.

Damgaard, Christian

2011-01-01

 
 
 
 
381

[Difficult road to diagnosing dementia with lewy bodies (DLB). case report].  

UK PubMed Central (United Kingdom)

AIM: The main aim of the study was to present the case of a patient with neurological, depressive and psychotic symptoms, most probably connected with progressing dementia with Lewy bodies (DLB). METHOD: The systematic symptom analysis based on the clinical examination and medical documentation. RESULTS: During the first hospitalisation, the presented patient was diagnosed with acute and transient psychotic disorders (F23). After being discharged from the ward, the patient experienced recurrence of previous symptoms with a short period of time. The two following diagnoses after hospital treatment were established as a depressive episode with psychotic symptoms. During the fourth hospitalisation, the patient was diagnosed with organic delusional (schizophrenia-like) disorder (F06.2). After six years, thorough analysis of clinical history as well as the course of existing disorder made it possible to diagnose the patient as having dementia with Lewy bodies-DLB (F02.8). Since that time, the patient has been taking rivastigmine, which has turned out to be a successful treatment. It has been 6 months since the patient left the hospital and still remains in remission. Social functioning of the woman is similar to the period before the first episode. CONCLUSIONS: The presented case demonstrates, that DLB symptomatology is a difficult problem in everyday psychiatric practice. A differential diagnosis of psychopathological and neurological symptoms covers many disorders, which together, with the clinical picture variation may delay effective treatment.

Sokó?-Szaw?owska M; Poleszczyk A

2013-01-01

382

Wisdom of people who live through the difficult modern times; Gendai wo ikinuku ningen no chie  

Energy Technology Data Exchange (ETDEWEB)

When placed under adverse circumstances, people are prone to look for a thing that does not exist, to be haunted by pessimistic ideas, and to excuse themselves. What is desired in such dark days is an optimistic, constructive way of thinking. Irrespective of age, and at any cost, one should acquire the art of operating the computer which is now a universally accepted tool and the skill of using English that is spoken the world over. One is never too old to launch something new. There is a view that overworking is a relic of the past and that what is important is to live a life that is free of pressure. But such is just a critique's voice who does not know a man who throws everything he has into his work, even his life. Now is the time of global competition. Most of the business people who are known for competence and ability make full use of early morning hours. When one knows that life is a place for learning, and goes on improving oneself to follow the changes in society bravely facing difficult tasks without giving up one's dream and objective, one is a young person at the age of seventy. (NEDO)

Hishikawa, F.

1999-09-10

383

The approach to the difficult urethral catheterization among urology residents in the United States  

Scientific Electronic Library Online (English)

Full Text Available Abstract in english PURPOSE: To determine the prevalence of different approaches to the difficult urethral catheterization (DUC) among urology residents (UR) in the United States (US). MATERIALS AND METHODS: An email invitation to participate in an online survey regarding DUC was sent to 267 UR and to 22 urology program coordinators for them to forward to their residents. 142 UR completed the survey. RESULTS: After the initial unsuccessful attempt by a nurse, 92% of UR attempted a catheter p (more) rior to resorting to other modalities. The most common choice of the first catheter was a Coude (76%) size 18F (51%). For situations where multiple sizes and types of catheters (12 - 20F) were used without success, 3 scenarios were proposed: 1) Catheter passed the bulbomembranous urethra (BMU) and patient had previous history of transurethral resection of the prostate or radical retropubic prostatectomy, 2) Catheter passed the BMU and no urologic history, 3) Catheter did not pass the BMU and no urologic history. Flexible cystoscopy was used in 74%, 62% and 63%; blind passage of a glidewire was second with 15%, 23% and 20%; and blind use of filiforms and followers was chosen in 7%, 9% and 9% of the scenarios respectively. CONCLUSIONS: The most common approach to the DUC among UR in the US involves using an 18F Coude catheter first. After trying one or more urethral catheters, UR most commonly resort to flexible cystoscopy as opposed to the blind placement of glide wires or filiforms/followers.

Villanueva, Carlos; Hemstreet III, George P.

2010-12-01

384

A key role for abdominal ultrasound examination in "difficult" diagnoses of celiac disease.  

UK PubMed Central (United Kingdom)

PURPOSE: To evaluate the usefulness of abdominal ultrasound examination (US) for the diagnostic workup of cases of suspected CD involving negative serum antibodies and difficult diagnosis. MATERIALS AND METHODS: 524 consecutive patients with symptoms of suspected CD underwent an extensive diagnostic workup. 76 (14 %) were excluded since they were positive for serum anti-tTG and/or EmA antibodies. 377 were excluded since they were diagnosed with something other than CD or did not have the alleles encoding for HLA DQ 2 or DQ 8. A diagnosis of CD with negative serum antibodies was probable in 71 patients who underwent abdominal US and duodenal biopsy for histology evaluation. RESULTS: Intestinal histology and subsequent clinical and histological follow-up confirmed the CD diagnosis in 12 patients (GROUP 1) and excluded it in 59 subjects (GROUP 2). Abdominal US showed that the presence of dilated bowel loops and a thickened small bowel wall had a sensitivity of 83 % and a negative predictive value (NPV) of 95 % in CD diagnosis. Furthermore, in 11 of the 12 CD seronegative patients there was at least one of these two abdominal US signs. Therefore, considering the presence of one of these two signs, abdominal US sensitivity increased to 92 % and NPV to 98 %. CONCLUSION: Abdominal US is useful in the diagnostic workup of patients with a high clinical suspicion of CD but with negative serology.

Soresi M; Pirrone G; Giannitrapani L; Iacono G; Di Prima L; La Spada E; Di Fede G; Ambrosiano G; Montalto G; Carroccio A

2011-01-01

385

Desmoplastic round small cell tumor: a case report of a neoplasm of difficult diagnosis  

International Nuclear Information System (INIS)

Desmoplastic Small Round Cell Tumor (DSRCT) is a rare neoplasm of difficult diagnosis, recently described by Gerald et al. There are reports of nearly 101 cases in the literature, being the intra-abdominal region its most common location and children and young adults its preferred age group. This paper reports a case of DSRCT in a young adult of 24 years of age. This patient presented unspecific symptoms of nausea, vomiting and a single episode of haematemesis. Upon physical examination a solid mass on the epigastrium and left hypochondrium was found. Image diagnostic procedures confirmed the existence of the expansive process and also revealed enlarged retroperitoneal lymphonodes. Diagnosis was achieved through videolaparoscopic biopsy. Histologic sections stained with hematoxylin/eosin were inconclusive and immunohistochemical analysis was required to establish the diagnosis. This analysis revealed positivity to epithelial and mesenchymal markers and weak positivity to chromogranin A, characteristic results of DSRCT. Due to the fact that the disease was locally advanced, the patient was treated with chemotherapy (cyclophosphamide and paclytaxel). However, since there was only partial response to the treatment, the patient refused to undergo any second line option of therapy. Presently, the patient is being submitted only to supportive care, within an 18-month follow-up program. (author)

2005-01-01

386

[Difficult news: meanings attributed by family members of children with cystic fibrosis].  

UK PubMed Central (United Kingdom)

This article studied some of the meanings that difficult news assumes when transmitted by health professionals to relatives of young cystic fibrosis patients undergoing treatment at a public hospital located in the south zone of the city of Rio de Janeiro, Brazil. It is the result of qualitative research and analysis of ten narratives collected during two months in 2010. These meanings are not understood by professionals and interfere with the evolution of the illness, the coping process and the care given to the children. It has been observed that the content of the news is perceived differently depending on: The clarity with which it is transmitted to each family member; The forthright way it is conveyed without the preparation of the listener; The consideration of the context in which people live and the consequences involved; The presence of a family member when the news is delivered; and the fragmentation of information. Results indicate the need to make professionals aware of the importance of communication aspects in clinical meetings and the inclusion of this training process in the medical curriculum as well as during physicians' professional lives. It seems that in delivery of the news the family expects a balance between technical efficiency and conversational tact from professionals.

Afonso SB; Mitre RM

2013-09-01

387

Double guidewire technique for ERCP in difficult bile cannulation: experience with 121 cases.  

UK PubMed Central (United Kingdom)

AIM: The aim of this study is to report our experience using double guide-wire technique (DGT) for biliary cannulation. MATERIAL OF STUDY: From 2007 to 2010, out of 1607 consecutive patients undergoing ERCP with the intent to cannulate the common bile duct (CBD) 1335 were considered suitable for this study. In 131 of these patients deep biliary cannulation with standard cannulation technique (SCT) failed. In these cases DGT was attempted. RESULTS: DGT could be used in 121 patients with success rate of deep biliary cannulation in 117 (96.7%) with a 2.6% rate post ERCP pancreatitis. DISCUSSION: Since difficulties in selective cannulation are sometimes encountered due to anatomical constraints or papillary spasm, pharmacologic aids and other non invasive methods such as papillotome cannulation or guidewire cannulation are used. DGT consented a high rate of successful selective biliary cannulation with a low rate of complications. CONCLUSION: According to our experience we can concluded, that in expert hands, the double guidewire technique (DGT) can be considered useful and safe method in difficult biliary cannulation, reducing the need of more invasive technique such as precut papillotomy.

Belverde B; Frattaroli S; Carbone A; Viceconte G

2012-09-01

388

Difficult intubation managed using standard laryngeal mask airway, flexible fibreoptic bronchoscope and wire guided enteral feeding tube.  

Science.gov (United States)

This case report describes an alternative method of achieving trans-oral intubation in a patient with a difficult airway who was apnoeic secondary to the therapeutic administration of a non-depolarizing neuromuscular blocking drug given to aid laryngoscopy. After attempts to intubate were unsuccessful by means of direct laryngoscopy utilizing various aids including bougies, a standard laryngeal mask airway was used to ventilate the patient and subsequently, with a swivel Y-connector attached in order to maintain PEEP, to aid the passage of a bronchoscope. The flexible guide-wire from an enteral feeding tube was then passed through the suction port of the bronchoscope into the trachea, after which the laryngeal mask airway and bronchoscope were withdrawn. By passing the enteral feeding tube over the guide-wire and then using this as a guide, a cuffed endotracheal tube was inserted into t