A Household Survey to Evaluate Access to Surgical Care in Vanuatu

INTRODUCTION

Surgical care is an integral part of any healthcare system, yet there is a paucity of data on the burden of surgical disease, surgical capacity and access to surgical services in the Pacific region. This study aimed to evaluate access to surgical care through a pilot household survey in the Vanuatu island of Efate and five of its surrounding islands.

METHODS

The 2009 Vanuatu census' GPS coordinates were used to randomly select 150 rural and 150 urban households from Efate and its surrounding islands. A total of 143 urban households and 142 rural households were available for inclusion in this study. A household questionnaire was developed to evaluate access to surgical care and included information regarding household demographics, socio-economic indicators and perceived and realised barriers to accessing care. The questionnaire was administered by local health workers, and data were collected electronically.

RESULTS

Questionnaires were completed by 285 households. Two hundred and forty-one out of 254 (94.8%) households reported being able to access Port Vila Hospital, if required. The most commonly cited potential barriers to accessing surgical care were financial constraints (42.4%) and transport (26.4%).

CONCLUSION

Our results provide important insights into the geographic, sociocultural and economic barriers to seeking, reaching and receiving surgical care in this region of Vanuatu. Identifying specific areas and communities with poor access to care, alongside the determinants of access, will help in designing both clinical and policy interventions to improve access to surgical care.

Enhanced Performance of Ge Photodiodes via Monolithic Antireflection Texturing and α-Ge Self-Passivation by Inverse Metal-Assisted Chemical Etching

Surface antireflection micro and nanostructures, normally formed by conventional reactive ion etching, offer advantages in photovoltaic and optoelectronic applications, including wider spectral wavelength ranges and acceptance angles. One challenge in incorporating these structures into devices is that optimal optical properties do not always translate into electrical performance due to surface damage, which significantly increases surface recombination. Here, we present a simple approach for fabricating antireflection structures, with self-passivated amorphous Ge (α-Ge) surfaces, on single crystalline Ge (c-Ge) surface using the inverse metal-assisted chemical etching technology (I-MacEtch). Vertical Schottky Ge photodiodes fabricated with surface structures involving arrays of pyramids or periodic nano-indentations show clear improvements not only in responsivity, due to enhanced optical absorption, but also in dark current. The dark current reduction is attributed to the Schottky barrier height increase and self-passivation effect of the i-MacEtch induced α-Ge layer formed on top of the c-Ge surface. The results demonstrated in this work show that MacEtch can be a viable technology for advanced light trapping and surface engineering in Ge and other semiconductor based optoelectronic devices.

Electrical Neural Stimulation and Simultaneous in Vivo Monitoring with Transparent Graphene Electrode Arrays Implanted in GCaMP6f Mice

Electrical stimulation using implantable electrodes is widely used to treat various neuronal disorders such as Parkinson's disease and epilepsy and is a widely used research tool in neuroscience studies. However, to date, devices that help better understand the mechanisms of electrical stimulation in neural tissues have been limited to opaque neural electrodes. Imaging spatiotemporal neural responses to electrical stimulation with minimal artifact could allow for various studies that are impossible with existing opaque electrodes. Here, we demonstrate electrical brain stimulation and simultaneous optical monitoring of the underlying neural tissues using carbon-based, fully transparent graphene electrodes implanted in GCaMP6f mice. Fluorescence imaging of neural activity for varying electrical stimulation parameters was conducted with minimal image artifact through transparent graphene electrodes. In addition, full-field imaging of electrical stimulation verified more efficient neural activation with cathode leading stimulation compared to anode leading stimulation. We have characterized the charge density limitation of capacitive four-layer graphene electrodes as 116.07-174.10 μC/cm² based on electrochemical impedance spectroscopy, cyclic voltammetry, failure bench testing, and in vivo testing. This study demonstrates the transparent ability of graphene neural electrodes and provides a method to further increase understanding and potentially improve therapeutic electrical stimulation in the central and peripheral nervous systems.

Flexible bottom-gate graphene transistors on Parylene C substrate and the effect of current annealing

Flexible graphene transistors built on a biocompatible Parylene C substrate would enable active circuitry to be integrated into flexible implantable biomedical devices. An annealing method to improve the performance of a flexible transistor without damaging the flexible substrate is also desirable. Here, we present a fabrication method of a flexible graphene transistor with a bottom-gate coplanar structure on a Parylene C substrate. Also, a current annealing method and its effect on the device performance have been studied. The localized heat generated by the current annealing method improves the drain current, which is attributed to the decreased contact resistance between graphene and S/D electrodes. A maximum current annealing power in the Parylene C-based graphene transistor has been extracted to provide a guideline for an appropriate current annealing. The fabricated flexible graphene transistor shows a field-effect mobility, maximum transconductance, and a I_on/I_off ratio of 533.5 cm²/V s, 58.1 μS, and 1.76, respectively. The low temperature process and the current annealing method presented here would be useful to fabricate two-dimensional materials-based flexible electronics.

Controlled three-dimensional interconnected capillary structures for liquid repellency engineering

The wetting properties of solvents on highly periodic, porous substrates with various layer thicknesses of three-dimensional nanoshell structures of TiO₂ with interconnected capillary spaces were demonstrated.

Development of omniphobic behavior in molecular self-assembled monolayer-coated nanowire forests

The wetting characteristics of self-assembled monolayers (SAMs) on three different surface structures of thin film, microcone array, and nanowire forest topologies, which were chemically modified using phosphonic acid (HDF-PA and OD-PA) and trichlorosilane (HDF-S), were investigated. The molecular SAM-coated nanowire forest structures exhibited superhydrophobic properties with contact angles of 150.6°-155.4°, compared with the other structures combined with OD-PA, HDF-PA, and HDF-S SAMs, which displayed contact angles of 99.5°-116.8°. Moreover, the HDF-PA and HDF-S SAM-coated nanowire forest structures showed omniphobic properties for both flat and curved surfaces, irrespective of the substrate form. Four liquid droplets of different viscosities and composition (water, urea solution, oil, and photoresist) slid on the HDF-PA and HDF-S SAM-coated nanowire forest surfaces without leaving any traces. The omniphobic properties of the molecular SAM-coated nanowire forest structures developed in this study could be used for various applications in which their slippery effect is desirable, such as in medical tubes and the interior of pipes. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 204-210, 2017.

Dynamic graphene filters for selective gas-water-oil separation

Selective filtration of gas, water, and liquid or gaseous oil is essential to prevent possible environmental pollution and machine/facility malfunction in oil-based industries. Novel materials and structures able to selectively and efficiently filter liquid and vapor in various types of solutions are therefore in continuous demand. Here, we investigate selective gas-water-oil filtration using three-dimensional graphene structures. The proposed approach is based on the adjustable wettability of three-dimensional graphene foams. Three such structures are developed in this study; the first allows gas, oil, and water to pass, the second blocks water only, and the third is exclusively permeable to gas. In addition, the ability of three-dimensional graphene structures with a self-assembled monolayer to selectively filter oil is demonstrated. This methodology has numerous potential practical applications as gas, water, and/or oil filtration is an essential component of many industries.

Metamaterial Absorber for Electromagnetic Waves in Periodic Water Droplets

Perfect metamaterial absorber (PMA) can intercept electromagnetic wave harmful for body in Wi-Fi, cell phones and home appliances that we are daily using and provide stealth function that military fighter, tank and warship can avoid radar detection. We reported new concept of water droplet-based PMA absorbing perfectly electromagnetic wave with water, an eco-friendly material which is very plentiful on the earth. If arranging water droplets with particular height and diameter on material surface through the wettability of material surface, meta-properties absorbing electromagnetic wave perfectly in GHz wide-band were shown. It was possible to control absorption ratio and absorption wavelength band of electromagnetic wave according to the shape of water droplet–height and diameter– and apply to various flexible and/or transparent substrates such as plastic, glass and paper. In addition, this research examined how electromagnetic wave can be well absorbed in water droplets with low electrical conductivity unlike metal-based metamaterials inquiring highly electrical conductivity. Those results are judged to lead broad applications to variously civilian and military products in the future by providing perfect absorber of broadband in all products including transparent and bendable materials.

The effects of clinical trials on improving breast cancer care at a single institution

198

Background: We reported in 2011 at the Society of Surgical Oncology a 19 year retrospective at a single academic institution which identified practice differences between surgical oncologists and general surgeons which were associated with a significant survival advantage. Clinical trial participation was much higher amongst patients treated by a surgical oncologist.

Methods: This is an IRB approved, retrospective review of all breast cancer patients receiving primary treatment at a single institution from 1/1/2001 to 12/31/2008. Details of pathology, surgical therapy, chemotherapy, hormonal therapy and radiation therapy were compared between patients participating in clinical trials and those not participating. The specific trials were segregated as to type (tissue banking, therapeutic, prevention, etc.) to understand differential effects if any between type of trial participation.

Results: During the time period, there were 1220 patients who received primary breast cancer treatment at this institution. The mean age was 55.6 and mean follow-up >40 months. Stage distribution was stage 0 - 16.8%, Stage 1 - 26.6%, Stage 2 - 33.1%, Stage 3 - 15.9%, and Stage 4 - 6.1%. Patients participating in any clinical trial numbered 468 and 752 participated in no clinical trials. Overall survival (clinical trial 98.8% vs. not in clinical trial 75.7%; p<0.0001). Overall the use of breast conservation was more likely in clinical trial participants (54.3% vs. 44.4%; p<0.0001). The completion of chemotherapy was more likely in clinical trial participants (52.4% vs. 49.5%; p=0.02).The successful completion of systemic therapies (chemo and hormonal) was more likely also (71.4% vs. 64.0%; p=0.009). The type of trial (tissue banking vs. therapeutic) had no effect on improved outcomes. Overall the best predictor of better outcomes was to be treated by a high volume clinical trial enrolling physician.

Conclusions: High volume clinical trial enrollment is associated with the best overall treatment outcomes in breast cancer whether trials are directly related to therapeutic changes or not. Each individual in the breast center treating team can have dramatic effect on outcomes by improving their clinical trial enrollment and participation.

Redefining lumpectomy using a modification of the "sick lobe" hypothesis and ductal anatomy

Objectives. The “Sick Lobe” hypothesis states that breast cancers evolve from entire lobes or portions of lobes of the breast where initiation events have occurred early in development. The implication is that some cancers are isolated events and others are truly multi-focal but limited to single lobar-ductal units. Methods. This is a single surgeon retrospective review of early stage breast cancer lumpectomy patients treated from 1/2000 to 2/2005. Ductal endoscopy was used direct lumpectomy surgical margins by defining ductal anatomy and mapping proliferative changes within the sick lobe for complete excision. Results. Breast conservation surgery for stage 0–2 breast cancer with an attempt to perform endoscopy in association with therapeutic lumpectomy was performed in 554 patients (successful endoscopy in 465 cases). With an average followup of >5 years for the entire group, annual hazard rate for local failure in traditional lumpectomy without ductal mapping was 0.97%/yr. and for lumpectomy with ductal mapping and excision of entire sick lobe was 0.18%/yr. With endoscopy, 42% of patients were found to have extensive disease within their “sick lobe.” Conclusions. Targeting breast cancer lumpectomy using endoscopy and excision of regional associated proliferation seems associated with lower recurrence in this non-randomized series.

Clinical series of oncoplastic mastopexy to optimize cosmesis of large-volume resections for breast conservation

BACKGROUND

Oncoplastic mastopexy has been popularized as a method to hide the cosmetic effects of central or large-volume resections associated with breast conservation surgery for breast cancer.

MATERIALS AND METHODS

This review was undertaken to study the uses and limitations of these techniques in providing adequate breast conservation lumpectomy for breast cancer of any stage in a single surgeon's practice. A review of breast cancer cases March 2004 through December 2009 were analyzed for the use of oncoplastic reconstruction in breast conservation surgery.

RESULTS

A total of 167 patients had lumpectomies during this period associated with oncoplastic mastopexy reconstruction. The average age was 55.6 years with a range of 33-85 years. Stage 0 breast cancer accounted for 33 cases (19.8%), and 134 cases were invasive cancers stages 1-3 (stage 1, 34.1%; stage 2, 30.6%; and stage 3, 15.6%). The most common oncoplastic techniques used were, in order of frequency: batwing mastopexy, parallelogram mastopexy, and Modified Wise pattern mastopexy. Positive or close margins (≤ 2 mm) were present in 37 of 167 cases (22%). Positive margins were most associated with higher stage, positive nodes, positive lymphovascular invasion (LVI), use of neoadjuvant chemotherapy, and larger initial T stage, positive estrogen receptor (ER), and younger age. Of these higher stage, node positive, and use of neoadjuvant chemotherapy were statistically significant in this small series (P values = 0.034, 0.016, and 0.022, respectively). Ki-67 and HER2 status were not associated with positive margins. Positive margins were manageable by local re-excision of a solitary face of the prior resection wall in more than 2/3 of cases to achieve negative pathologic margins. Only 11 of 167 required mastectomy because of failure to achieve adequate margins for oncologic control.

CONCLUSIONS

Oncoplastic mastopexy allows the surgeon to address large tumors or tumors in cosmetically difficult sites adequately for breast conservation. Careful margin marking and re-excision of close or positive margins is still often feasible to achieve adequate negative margin with acceptable cosmesis in spite of the large initial volumes of resection.

Comparison of Synchrotron Images of DCIS of the Breast with Their Pathologic Findings

Background: Synchrotron radiation x-ray imaging have opened a new door to explore breast tissue below the micron scale providing detailed internal structures of the samples with a great magnification and an excellent resolution. Using phase contrast technique, we got monochromated synchrotron images of DCIS (Ductal Carcinoma In Situ) of the breast tissue section. To figure out relation with their optical microscopic features, we compared the synchrotron images of the DCIS with their histopathologic findings of the same stained section.Material and Methods: A x-ray microscope was installed on 1B2 beamline of Pohang Light Source, a third generation synchrotron radiation facility with operating energy of 2.5 GeV in Pohang, Korea. The x-ray energy was set at 11.1 keV, and the x-ray beam was monochromatized by a W/B4C monochromator. Zernike phase-shifter was adapted for phase contrast x-ray microscopy. Formalin-fixed 5µm-thick breast tissue sample was attached onto the Kapton film, and positioned 25 m away from the beam source. The synchrotron image of sample was converted into a visual image on the CsI(TI) scintillation crystal, and this visual image was captured by a full frame CCD camera. After scanning, we patched these images one and another to show the large area of the tissue section. For the comparative analysis with their synchrotron image, synchrotron-scanned breast tissue sections were stained, and the histopathologic findings of the samples were captured by image analyzer. The magnifying power of this microscope was 100x.Results: The monochromated x-ray microscopic images of DCIS of the breast tissue were obtained with a good resolution. These images revealed various structures of DCIS lesion with a good contrast and high visibility by phase contrast technique. They include prominent and intact periductal basement membrane - a hallmark of DCIS lesion, and stippled fine microcalcifications which were indistinct in the histologic section, and a shadow of intense peritumoral inflammatory cell infiltration. But the minute changes of each cancer cell showing the features of cancer tissue such as, cellular differentiation and nuclear grade, were not identified well.Discussion: The x-ray microscopic imaging of DCIS of the breast tissue section with synchrotron radiation showed a good correspondence with the histopathologic findings of their stained tissue sections. And the synchrotron image of DCIS had some unique radiologic features differentiating from histopathogic findings. Therefore the synchrotron images of the DCIS lesion appear to have a new possibility of use for the clinical and research purposes in near future.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5015.

Interventions for basal cell carcinoma of the skin

BACKGROUND

Basal cell carcinoma (BCC) is the commonest skin cancer. BCCs are slow-growing, locally invasive, epidermal skin tumours which mainly affect white skinned people. The first line treatment is usually surgical excision, but numerous alternatives are available.

OBJECTIVES

To assess the effects of treatments for basal cell carcinoma.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (January 2006), the Cochrane Central Register of Controlled Trials (The Cochrane LIbrary Issue 1, 2006), the Cochrane Database of Systematic Reviews (The Cochrane Library Issue 1, 2006), MEDLINE (2004 to January 2006), EMBASE (2005 to January 2006), the metaRegister of Controlled Trials (February 2006). Cited references of all trials identified and key review articles were searched. Pharmaceutical companies were contacted where appropriate for reviews or unpublished trials.

SELECTION CRITERIA

Inclusion criteria were adults with one or more histologically proven, primary basal cell carcinoma. The primary outcome measure was recurrence at three to five years, measured clinically. The secondary outcome included early treatment failure within six months, measured histologically. Adverse treatment effects included aesthetic appearance and pain during and after treatment.

DATA COLLECTION AND ANALYSIS

Two authors independantly carried out study selection and assessment of methodological quality.

MAIN RESULTS

Twenty seven studies were identified. Only one RCT of surgery versus radiotherapy had primary outcome data at four years, showing significantly more persistent tumours and recurrences in the radiotherapy group as compared to the surgery group, (RR 0.09, 95%CI, 0.01 to 0.69). One study found no significant difference for recurrence at 30 months when Moh's micrographic surgery was compared to surgery for high risk facial BCCs, (RR 0.64, 95%CI 0.16,2.64). One study of methylaminolevulinate photodynamic therapy (MAL PDT) versus cryotherapy found no significant difference in recurrences in the MAL PDT group when compared to cryotherapy at one year (RR 0.50, 95% CI 0.22,1.12). Cryotherapy showed no significant difference in recurrences at one year when compared to surgery on one small study. When radiotherapy was compared to cryotherapy there were significantly fewer recurrences at one year in the radiotherapy group compared to the cryotherapy group.Short-term studies suggest a success rate of 87 to 88% for imiquimod in the treatment of superficial BCC using a once-daily regimen for 6 weeks and a 76% treatment response when treating nodular BCC for 12 weeks, when measured histologically.

AUTHORS' CONCLUSIONS

Overall there has been very little good quality research on treatments for BCC. Most trials have only evaluated BCCs in low risk locations. Surgery and radiotherapy appear to be the most effective treatments with surgery showing the lowest failure rates. Although cosmetic outcomes appear good with PDT, long term follow up data are needed. Other treatments might have some use but few have been compared to surgery. An ongoing study comparing imiquimod to surgery should clarify whether imiquimod is a useful option.

Interventions for basal cell carcinoma of the skin

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin malignancy in humans. BCCs are defined as slow-growing, locally invasive, malignant (but not life threatening), epidermal skin tumours which mainly affect white skinned people. The first line treatment is usually surgical excision, but numerous alternatives are available.

OBJECTIVES

To assess the effects of treatments for basal cell carcinoma.

SEARCH STRATEGY

We searched the Cochrane Database of Systematic Reviews (2002 issue 1) and Cochrane Controlled Trials Register (2002 issue 1), the Cochrane Skin Group Specialised Register (January 2002), MEDLINE (from 1966-2002), EMBASE (from 1980-2002), the Mega Register of Controlled trials and the National Research Register (2002 issue 1). In addition the cited references of all trials identified and key review articles were searched. Pharmaceutical companies were contacted where appropriate for reviews or unpublished trials.

SELECTION CRITERIA

Inclusion criteria were adults with one or more histologically proven, primary basal cell carcinoma. The primary outcome measure was recurrence at 3- 5 years, measured clinically. The secondary outcome included early treatment failure within 6 months, measured histologically. Adverse effect of treatment was evaluated by reviewing aesthetic appearance (to patient and blinded observer) and pain during and after treatment.

DATA COLLECTION AND ANALYSIS

Study selection and assessment of methodological quality were carried out by two independent reviewers.

MAIN RESULTS

19 studies (13 published and 6 abstracts) were identified which include 7 broad therapeutic categories. Only one RCT of surgery versus radiotherapy had primary outcome data at four years, which showed that there were significantly more persistent tumours and recurrences, measured histologically, in the radiotherapy group as compared to the surgery group, which translates to an odds ratio of 0.09 (95%CI, 0.01 to 0.67) in favour of surgery. Cryotherapy, although convenient and less expensive than surgery, showed no significant difference in recurrences at one year, measured clinically, when compared to surgery, OR 0.23 (0.01 to 6.78). However when radiotherapy was compared to cryotherapy there were significantly more recurrences at one year, measured histologically, in the cryotherapy group, this translates to an odds ratio of 14.80 (95%CI, 3.17 to 69) in favour of radiotherapy. Preliminary studies suggest a high success rate (87-88%) for imiquimod in the treatment of superficial BCC using a once-daily regimen for 6 weeks and a useful (76%) treatment response when treating nodular BCC for 12 weeks, when measured histologically. However this cream has not been compared to surgery.

REVIEWER'S CONCLUSIONS

There has been very little good quality research on efficacy of the treatment modalities used. Most of the trials have looked only at BCCs in low risk areas. Surgery and radiotherapy appear to be the most effective treatments with surgery showing the lowest failure rates. Other treatments might have some use but few have been compared to surgery. Imiquimod emerged as a possible new treatment although it has not been compared to surgery or any other modality.

Microneurovascular allotransplantation of the canine tongue

INTRODUCTION

Reconstruction of the tongue with existing methods of tissue transfer often leaves glossectomy patients with significant deficits in speech and swallowing. The critical role of the tongue is implied by its unique structure and function. This paper reports the development of an animal model of hemitongue allotransplantation and documents functional and anatomic outcomes of this procedure.

METHODS

Ten pairs of unmatched dogs underwent reciprocal exchange of the left hemitongue with microneurovascular replantation. The unoperated hemitongue acted as the control. Under cyclosporine immunosuppression, animals surviving long term underwent clinical observation, before electromyography, force transduction studies, and histological evaluation being euthanized.

RESULTS

Five animals survived between 6 and 13 months for long-term evaluation. The remaining group were euthanized because of or died of overwhelming infection or uncontrollable transplant rejection. The latter sometimes resulted from difficulty in the delivery of the cyclosporine. Clinical recovery of tongue function was observed, as well as resumption of motor unit potential activity on electromyography. Contractile force recovery of the transplanted tongue averaged 68% of control (range, 47%-97%), and histological study of the hypoglossal and lingual nerves demonstrated anatomic evidence of reinnervation. Preservation of muscle, mucosal, and stromal ultrastructure was seen with light microscopy of the transplanted tongue.

CONCLUSIONS

Allotransplantation of the hemitongue and associated neurovascular apparatus is possible in a large mammalian model, with long-term survival of tissue being accompanied by partial recovery of contractile properties. Anatomical and clinical evidence also points to sensory recovery. These data support the future possibility of employing a similar technique in glossectomy patients.

[Lengemann suture versus bone screw osteosynthesis in treatment of ulnar osseous collateral ligament rupture of the thumb metacarpophalangeal joint]

Out of 95 ligamentous lesions of the thumb metacarpophalangeal joint, those with an isolated bony rupture of the ulnar collateral ligament were chosen. Of these, 15 patients treated with Lengemann suture and 16 with screw fixation were followed-up on average 27.3 and 26.4 months, respectively, after operative treatment. Under only "good" and "very good" clinical results, the statistical analysis of the objective and subjective parameters showed no significant difference, except for the measurement of the soft-tissue circumference (p < 0.01) between either procedure. Although both procedures have a low rate of complications, screw fixation is preferable since implant removal is not necessary.

[Results of early intervention in acute finger infections]

In the examination of 66 patients treated for acute felons, we classified the infections of fingers as (1.) cutaneous/subcutaneous felons; (2.) paronychia/subungual felons, (3.) thecal whitlow; (4.) articular/bony felons. Primarily, the therapy was based on early aggressive surgical treatment, and secondly on antibiotics. With the management described we achieved a good to very good result in 76%.

[Necrotizing fasciitis of the lower extremity]

Three cases of a necrotizing fasciitis, a rare but life- and limb-threatening infection, were treated in the Department of Surgery at the University Hospital of the Ruhr University Bochum (MHH) between October 1992 and January 1994. We compare our experiences with regard to bacteriological etiology, risk factors, localization, and place of entry, course, therapy and mortality with those in the literature.

[Baker's cyst in osteoarticular tuberculosis of the knee joint]

A Baker cyst (synovial cyst) in the right knee-joint was demonstrated by ultrasound in a 70-year-old woman with recurrent knee-joint effusions after minimal trauma to the knee. Radiological examination in two planes showed degenerative changes corresponding to age. Needle puncture of the knee-joint demonstrated numerous neutrophil granulocytes. As the effusion recurred after one week, despite rest and avoidance of weight bearing, arthroscopy with removal of the cyst was indicated. But surprisingly histological examination of synovial tissue revealed epithelioid granulomas and Langerhans giant cells. Culture of fluid obtained on repeat puncture finally grew Mycobacterium tuberculosis. There was no evidence of pulmonary tuberculosis. The knee-joint tuberculosis healed completely without residual damage on antituberculosis treatment, initially 600 mg rifampicin daily, 300 mg isoniazid daily and 2.5 g pyrazinamide daily for 3 months, followed by rifampicin and isoniazid for a further 6 months.

[The "impersonal id" and resolution of the ego. On Karl Philipp Moritz]

Long before Freud, 18th and 19th century thinkers were speculating on the nature of the unconscious. One such thinker was the German littérateur and psychologist Karl Philipp Moritz, a representative of the "Storm and Stress" movement with roots in late German Enlightenment thinking. In the historiography of psychoanalysis his significance as an early theoretician of the unconscious has yet to be adequately appreciated. The author shows that the very term "Es" (German for "id") and an (albeit fragmentary and inconsistent) conception of what the term implies can in fact be traced back to Moritz. His view of the "id" was that of an uncanny force invested with an "energy" that is the very essence of Nature and frequently overwhelms the ego of the individual human agent. Moritz' concept of two opposing urges, one cohesive, the other disintegrative, is related to the Freudian dualism between life instinct and death wish and reveals Moritz as a thinker caught up in the conflict between Enlightenment and Counter-Enlightenment and adumbrating some of the essential features of irrationalist thinking in the late 19th century.