Background: Allogeneic transfusion confers a risk to the recipient and the recent introduction of leucocyte depleted blood has increased cost pressure on health resources. Colorectal surgery is a high blood usage field with 43% of all patients in our unit being transfused, over a three year period. Patient perceptions: Despite the risks associated with transfusion, a majority of patients are willing to have an allogeneic transfusion (85%) and think it is safe (89%), which may have implications in the uptake of alternatives available. The effect of bowel preparation Picolax bowel preparation causes significant dehydrating effects which may impair acute normovolaemic haemodilution (ANH). These effects can be minimised by administering intravenous normal saline. Acute normovoiaemic haemodilution (ANH) ANH significantly reduced allogeneic transfusion rate from 39% to 15% in the pilot study, however the controls were historical. No reduction in transfusion rate was seen (29% and 30%) in the prospective randomised controlled trial (n=160). Preoperative haemoglobin, blood loss, age, and transfusion protocol were the key factors influencing transfusion. The effect of ANH on coagulation ANH causes hypocoagulation, and this may explain why the expected red cell saving, as shown by mathematical modelling, was not seen in patients haemodiluted compared with controls.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Background: The hip joint tends to be highly affected in patients with Cerebral Palsy (CP). Subluxation, problems with ambulation, posture, perineal hygiene, and pain can result. Severe cases often require corrective surgery of the affected dysplastic hip(s). This often is accomplished with varus derotational osteotomy (VDRO), femoral osteotomy, pelvic osteotomy, tendon releases/lengthening, or a combination of any of these procedures. These reconstructive hip surgeries can result in marked blood loss. Due to the highly vascularized nature of bone, surgery can result in marked blood loss. This increases the transfusion burden on the patient and increases exposure to blood products and the associated risks therein. By identifying the risk factors that contribute to intraoperative and postoperative blood loss, targeted strategies may be developed to reduce this risk to the patient. Aims: The purpose of this study is to provide descriptive analysis of the pediatric CP population undergoing corrective hip surgery. We will attempt to identify various risk factors that may predispose patients to significant blood loss during reconstructive hip surgery. This study will be the largest study analyzing blood management therapy with the VDRO procedure. Methods: This is a retrospective chart review of consecutive CP patients who have undergone reconstructive hip surgery at a single institution from 2000 to 2012. Demographic data to be analyzed includes patient age, gender, race/ethnicity, height, weight, BMI, and medical comorbidities. Also, type of procedure performed, bilateral vs unilateral reconstruction, specific diagnosis, preoperative hemoglobin and hematocrit (H and H), pre‐transfusion H and H, estimated blood loss (EBL), total operative time, cell saver volume, units transfused, complications, quantity of postoperative transfusion, and post‐transfusion H and H was recorded. Data was compared using the Chi‐squared method, or non‐parametric analog, to assess the likelihood of the need for postop transfusions as an initial univariate analyses. Results: 87 patients were included in the study. There was no significant relationship between the use of autologous blood and age, gender, weight, height, or BMI. Patients who received autologous blood also had a higher EBL (p=0.029) and were more likely to need allogenic transfusion (p=0.023). Concomitant DEGA procedure carried a 2.25 times relative risk of needing blood transfusion (p<0.001, 95% CI 1.402‐3.611). Bilateral VDRO was 1.64 times more likely to need a transfusion, however this was not quite statistically significant (p=0.052, 95% CI 0.972‐2.756) Conclusion: Varus derotational osteotomy for the correction of neuromuscular hip dysplasia can be associated with excessive blood loss, especially in the CP patient population. The use of autologous vs allogenic blood products carries various risks and benefits. This paper has identified that the need of concomitant DEGA osteotomy is correlated with increased blood loss. Also, the use of autologous blood product is correlated with increased blood loss.

Deltas are important coastal systems throughout the world. River mouth bars are key landforms in the development of deltas, are characterized by sediment deposition, and have high potential for sediment preservation. Scientists and professionals seek to understand the discrete response of mouth bars to the various controls governing their evolution. This study utilizes the numerical modelling software Delft3D to provide additional evidence supporting the morphological and stratigraphic responses resulting from variations in basin configurations and allogenic controls (fluvial discharge, tides, basin width). Mud content within the bar increased analogous to an increase in the tidal modulation, while a decrease in the initial basin depth reduced mud content. Initial basin slope and lateral confinement had less obvious impacts on stratigraphy. Finally, variable fluvial discharge and the incorporation of realistic tidal harmonics produced similar bar morphologies (compared to simulations with constant flow and sinusoidal tides), yet demonstrated significant differences in bar stratigraphy.

This thesis examines the role of autogenic and allogenic forces in determining the timing and development of blanket peat initiation and how the occurrence and growth of blanket peat subsequently constrains human activities. A number of factors involved in the formation of blanket peat have been defined in the literature, in particular the roles of climate change, soil processes and anthropogenic effects, tested in this thesis from a typical peat-covered upland in south west Scotland. Tests are developed from a multi-proxy approach and by comparing peat-stratigraphic and palaeoecological records from a series of nine 14C dated peat profiles from a single hillside. A detailed examination of the sequence and timing of blanket peat initiation in the Holocene Epoch is presented from a case study from the head of the Glen App valley, Lagafater, south west Scotland. The evidence was taken from a total of nine peat transects at 215m OD, 300m OD and 400m OD where agricultural, hydrological and micro-climatic effects are expected to have differed and had different impacts on soils and vegetation. Samples were retrieved from the top, middle and bottom of a gently undulating slope at each altitude. This has allowed a localised picture of peat initiation to be obtained from each locality and with changes in altitude, allowed for an analysis of the factors responsible up and down slope and the identification of synchronous autogenic forces. A number of analytical techniques have been used. Pollen analysis was undertaken as the principal method of vegetation reconstruction at all sites, particularly through the initiation horizon. Variations in mire-surface wetness, determined through dry bulk density and humification analysis, were also employed to generate a record of probable changes in effective precipitation and the effect these may have had on the accumulation rate of the blanket peat. In order to attempt to answer the question of when blanket peat was initiated and to establish the synchroneity of changes, twenty nine AMS 14C dates were obtained. The evidence suggests that blanket peat developed during the Mesolithic period, through to the early Bronze Age. It substantiates an anthropogenic forcing factor for palaeohydrological changes, with early landscape management and cereal cultivation accelerating the process of blanket peat initiation. With progressive changes in precipitation interacting with factors such as weathering of bedrock and vegetation cover, the local landscape at Lagafater was covered by blanket peat by the early Bronze Age. The radiocarbon chronology obtained from the multi-proxy records allowed the synthesis of these data sets and the definition of Holocene vegetation change, climate change and the history of human impact throughout the early prehistoric era across this landscape.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23604号 / 医博第4791号 / 新制||医||1055(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 戸口田 淳也, 教授 河本 宏, 教授 江藤 浩之 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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Syftet med den här undersökningen var att beskriva hur anhöriga upplever och hanterar sin livssituation, med fokus på familjen och deras egen hälsa, under den akuta fasen vid allogen stamcellstransplantation. Undersökningen ägde rum på Centrum för Allogen Stamcellstransplantation vid Karolinska Universitetssjukhuset Huddinge. Sju anhöriga till patienter som genomgick en allogen stamcellstransplantation deltog. Metoden som användes var att genom semistrukturerade intervjuer låta anhöriga själva berätta om sin livssituation. Dessa intervjuer analyserades sedan med hjälp av kvalitativ innehållsanalys vilket resulterade i att temat den nuvarande situationen formulerades. Temat bestod av tre kategorier livspussel, familj och hälsa och hade tio underkategorier totalt. Resultatet blev att när anhöriga får berätta om hur de upplever sin livssituation berättar de om hur de mobiliserar och fokuserar all sin kraft och alla sina resurser till den nuvarande situationen som de befinner sig i. Slutsatsen blev att vidare forskning för att utveckla interventioner för dessa anhöriga behövs, där sårbarhet upptäcks och inre och yttre resurser uppmärksammas och stärks. Att fokusera på anhöriga och den sjuka familjemedlemmen samtidigt, som en enhet, främjar hela familjens hälsa och medför därför en vinst, inte bara för de anhöriga utan även för patienten och dess tillfrisknande. / The aim of this study was to describe family members’ experience of life during the acute phase of allogenic stem cell transplantation. Seven family members of patients at, “Centrum for Allogenic Stem cell transplantation” Karolinska University Hospital in Huddinge participated. The method used was semistruktured interviews that allowed the respondents to tell about their living situation. These interviews were then analyzed through qualitative content analysis. The findings were a theme named; this present time consisting of three categories: living-pieces, family and health. There were also ten subcategories all together. The result was that when family members gives the opportunity to, with their own words, describe and tell about their living situation they tell about the present time and how they focus and mobilise all their strength and energy on their sick family member to get well. The conclusion of this study was that further research and development of interventions, for family members, are necessary and to focus on the family as a unite is an absolute condition in order to maintain health and prevent physical- and mental illness for the whole family. This ought to be beneficial not only for the family but also for the patients’ recovery.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22359号 / 医博第4600号 / 新制||医||1042(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 長尾 美紀, 教授 滝田 順子, 教授 河本 宏 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Using an integrated dataset comprising outcrop, core, GPR and LiDAR data, this study targets a high-quality outcrop "window" of the upper Cretaceous Blackhawk Formation in the eastern Wasatch Plateau in central Utah, spanning a fairly large spatial (~30 km2 area comprising eight contiguous, and vertical cliff faces) and temporal (~4 my) range. This research provides field-validation and -calibration of a wider range of fluvial heterogeneity: 1) large-scale heterogeneity (10’s of m vertically and 100’s of m laterally), 2) intermediate-scale heterogeneity (1’s of m vertically and 10’s of m laterally), and 3) small-scale heterogeneity (10’s of cm vertically and 1’s of m laterally). These sandbody- to facies-scale heterogeneities generate potential for stratigraphic compartmentalization for analogous fluvial reservoirs and prospects. Moreover, these results specifically constitute an outcrop analog to the producing tight-gas fluvial reservoirs of the adjacent hydrocarbon-prolific Uinta and Piceance Basins of Utah and Colorado, including the giant Jonah Field of Wyoming. 3D virtual outcrop model generated from LiDAR-integration has helped in avulsion-scale (~1's-10's kyr) to basin-fill scale (~100's kyr-1's myr) fluvial sandbody organization analysis down to channel-storey level. This high-resolution analysis has brought several intriguing insights. single-storey sandbodies are preferentially attendant to clustering organization, whereas multi-lateral sandbodies (i.e. channel-belt) show compensational-prone behavior. Sandbody organization is broadly compensational for the lower Blackhawk Formation, where the floodplain facies diversity is the highest. In contrast, floodplain diversity decreases stratigraphically upward such that the upper Blackhawk Formation shows the least heterogeneous floodplain with clustering-prone sandbody organization. In the quest of differentiating autogenic from allogenic signal in dynamic systems where their interplay is complexly intertwined, this study presents two incised-valley examples, where resultant fluvial organization has been interpreted, contrary to conventional wisdom, to be preferentially modulated by a dominant controlling mechanism of autogenic forcing. In filling these incised valley deposits, each of which is up to ~15-20 m thick, the dominating behavior of substrate coal compaction as an autogenic mechanism supplanted allogenic forcing (i.e. sea-level fluctuation).

Die vorliegende medizinische Dissertation untersucht nicht-invasive bildgebende Verfahren wie die konventionelle Sonographie, die Acoustic radiation force impulse (ARFI)-Elastographie sowie die Transiente Elastographie (TE) zur Detektion von Komplikationen in der Frühphase nach allogener Stammzelltransplantation. Dem kurativen Therapieansatz der Stammzelltransplantation steht ein hohes Komplikationspotential gegenüber. Besonders hepatobiliär treten Graft-versus-host Erkrankungen (GvHD) sowie Gefäßkomplikationen (VOD) auf. Der bisherige diagnostische Goldstandard, die Leberbiopsie, ist als invasives Verfahren mit einer hohen Intra- und Inter-Untersucher-Variabilität sowie der geringen Repräsentativität als Screeningmethode ungeeignet. Die Elastographieverfahren ARFI und TE als nicht-invasive Alternativen ermitteln die Lebergewebesteifigkeit als Surrogatparameter fibrotischer Veränderungen und wurden bereits in zahlreichen Studien als geeignete Diagnoseverfahren für Leberfibrose und -zirrhose unterschiedlicher Ätiologie definiert. Ziel dieser prospektiven Pilotstudie war die Evaluation der genannten Methoden zur Detektion von Frühkomplikationen nach allogener Stammzelltransplantation. Die Ergebnisse der Studie zeigen, dass sowohl die konventionelle Sonographie als auch die Transiente Elastographie pathologische Organveränderungen vor allem des hepatobiliären Systems detektieren können. Allerdings erscheinen diese Veränderungen unspezifisch. Es bestehen keine signifikanten Unterschiede zwischen Patienten mit und ohne Komplikationen. Anders bei der ARFI-Elastographie. Hier zeigten die Messwerte im linken Leberlappen signifikant höhere Werte bei Patienten mit Komplikationen. Zusammenfassend ist die ARFI-Elastographie zur Prädiktion möglicher Komplikationen nach allogener Stammzelltransplantation geeignet, sollte allerdings mit anderen diagnostischen Verfahren ergänzt werden.