Article Type : Research Article
Authors : Ghanem ANM
Keywords : Blind; Hyponatraemia; TUR syndrome
Objectives: To demonstrate a new standard
of peer reviewing that should not be blind.
Materials and Methods: Using a new standard
of peer reviewing the author critically analyses an article sent to him by
another editor written by his competitor about the TUR syndrome and
complications of fluid therapy. The author contrasts and compares an article he
was requested to review to his own article specially written for comparison.
Results: The author resolves the huge
multi-dimension puzzles while comparing Professor Hahn to Ghanem without
sounding condescending or insulting. It is only with God’s help I consider
myself a special one of his creature that has achieved miracles and has
repeatedly won gambles with an odd of <1% against majority of 99% or even
99.99%, yet he cured himself from all addictions and gambles. He has resolved
the puzzles of the TUR syndrome, Hyponatraemia and ARDS.
Conclusion: The new standard of peer
reviewing is clearly superior but never blind. It should be adopted for future
standard in true science after changing faulty laws and regulations in all and
every country for the eternal piece on earth to take effect immediately. It is
destiny and destiny that operates all the time in marriage and divorce with our
individual choices driven by seeking our own love of life. Conspiracy cannot be
excluded and this the true challenge and danger ahead. May God help us all,
Amen.
When the respected
Editor of the Journal of Basic and Clinical Physiology and Pharmacology (JBCPP)
kindly sent me this article by Professor Robert Hahn to review for the second
time in 5 months, I thought of declining to review it first as I have retired from
peer reviewing, and I had previously reviewed it in February anyway (Please,
see reviewer’s comment on Hahn article [1]. However, I decided to review it for
the second time after reading the article Twice plus another mainly to remind
myself why did I do that and why is there a huge gap of misunderstanding of the
TUR syndrome between Robert Hahn and “I” [2-4]. I dragged myself out of my
retirement and convalescence period being recovering from my recent illness and
hospital admission followed by nurses’ follow up twice daily for a total of 3
months in the UK, and now I am in Egypt. I also dragged myself out from a
hectic extremely busy schedule under extremes of pressures fighting another WAR
(Multitasking at Multidimensional level-curtsy of Late Great GD Chisholm EDITOR
OF BJU in 1990 (Figure 1) who he was so visionary to publish both Hahn’s
article and ours side by side in 1990 (10*+Nobel- if Nobel agreed) - with a
promise to return later with remarks on Plagiarism v Quoted text and
over-referencing oneself v Hahn and who was first at what?) I am just happy to
review the article for my friend Robert for the second time. In the first
review I judged after only reading the abstract that the article should be
accepted and reported without having to comment on it. This is because the
article is impeccable by current peer reviewing standard and top journals
requirements of rules and regulations and instruction to authors as concerns
study objectives, material & methods, and results, but leaves much to be
desired on the twisted wrong conclusion, discussion, and references regarding
the pathogenesis of the TUR syndrome and Volume Kinetic (VK) v Volumetric
Overload (VO). Can you see it Hahn and the respected reader the difference
between VK and VO particularly that of the TUR syndrome as cause of the
cardiovascular shock (VOS)? Also, I have been so disappointed and upset with
Robert who I still consider my best correspondence friend and most
knowledgeable authority on fluid therapy and the TUR syndrome that I have known
since 1990 to date, whom I have the highest admiration, respect and regards for
his person and work acknowledging his massive contributions on the subject
discussed here. I do not aim to teach or breach you or anybody here. I am not
asking you or anybody to change your own religion either. I shall steer well
clear of debates on religions, politics and prejudice but I may be trying
something that is perhaps much harder than that: I am trying to correct wrong
believes that are impediments and cause for misunderstanding in order to get
you out of the loss of wanderings to wake you up from your deep intellectual
coma-17/07/2021 -07:07:52.(bold text and yellow highlighted text realized long
ago from my need to cure my stuttering in spelling and grammar editing I
learned from pdf galley proof reviewing). Due to lack of understanding as a
final attempt to cure these embodiments of mine some goes back to high school
like the difference between B and P and remains until I write the (End) of this
document and all previous articles until I realized my need to see it listed in
PubMed!? Oh yes, professional peer reviewing and Plagiarism checker which I
tried my best to buy one and use or twice by hiring professionals at BMJ and
SAGE Respiratory Medicine when I asked nicely if they would do it with a
promise on belated payment when I have the money. Both said NO- and I could
not, and I can’t afford it and I am sorry I do not think that I personally need
it now anyway [5-7]. After the rejection of an article from Brazil as peer
reviewer advising the authors to use such a wonderful service for those who
need it after knowing it is acceptable by all Top-Rated Journals with high
Impact Factor, when will they admit to their embodiment and ask for help not
that or because of that that I had received in most honest and truthful one
from BJU and BJUI. Open Access Journals (OAJ) came to my resque risqué (I could
have corrected all the words right here in Microsoft Word without risking
forgetting it by the time it takes to go to Google! I also realized that I need
both Google, Google Scholars, PubMed, and Microsoft Word having finished my
purpose to Use Except, Excel, EXCEL, and may be even PowerPoint PowerPoint
(PP). My son’s year rent of Office 365 had finished just before I was admitted
to the hospital and neither me nor my sun could afford it, but I am and only me
responsible for using version 2010 which came free with the restoration
(Reinstalling Windows with complete formatting of HD) after the 4-5th crash of
my Laptop Windows and Office 2010- everybody in Egypt is doing it legally
anyway. Now with the affordable fees by Microsoft for Office 365 I have bought
it as family pack. I am back from my break I had for a cigarette in my hand and
a cup of coffee I had in the balcony for which I did not find Coffee Mate, nor
milk but I found Baby milk in the cupboard where I was Looking for a possible
new Coffee mate (my personal favourite as excuse to explain my just discovered
new embodiment. My wife since she volunteered to be my nurse as well as serving
me as housewife since we got married 33 years ago) caught me sleeping in the
balcony with cigarettes in my hand and a burn in my Frock.” I could not or dare
not tell her that my bad habit caused it while asleep having another Cigarette
break [8-11]. The Cigarette has proved to be my Moses’ stick as have been
proved to be my apparent saver. The majority of OAJ accepted to report my
articles for free > 100 articles as new samples and only 2 OAJ accepted to
be the first and second whose kind editors and editorial managers accepted
minimum APC of $30 for DOI charges the FIRST was ECEC [this good lady editor
was so shy to allow me to mention her names and I think she wants to say yes
but she said only “Just Happy to help” I made her a big promise that I know I
cannot keep unless my dreams come true on the G tube and more self-references
without any plagiarism, and second (PAUSE to get the full names of the Journals
not for A Cigarette and Cup of tea this time but also until I read Hahn Articles
for the second time in full) [12-17]. I have 2 journals that would accept $30
for reporting my articles such as ECEC. There were also other journals that
would not accept <$65 USD [17]. That is enough to prove that I committed
repeatedly “Quoted text” and possible Plagiarism as the checkers call it so did
Hahn (as I shall show later), but surprise, surprise, it was Professor Starling
first who did that in the Lancet X3 and 10 years later in J Physiol 1896
[18,19].
·
Stela
showing "Isis the Great Goddess" sitting and holding a was-sceptre. A
man, the head of necropolis workers, adores her. Middle Kingdom of Egypt,
Petrie Museum of Egyptian Archaeology, London (Figure 1-3).
Other snakes and parted the sea for Moses and Jews to pass while the Pharaoh and army drowned. Thanks to the Editor of Journal of Basic and Clinical Physiology and Pharmacology (JBCPP) for giving me the second chance to review Hahn’s articles and mine knowing this time for sure it deserved to be (Rejected) but I could not possibly miss my last chance to read it again, to get my MD THESIS of mine out and scan it again although I know by Heart what is in it but just to satisfy my Heart and Brain both are needed for (Complete Science- The Stage of Science Philosophy that has already started with no distractions of any kind- except a fly I had to kill now by the insect killer and was about to but it disappeared before doing so). I can honestly say if you can read these 4 articles of mine you have read the whole Thesis and what is missing are only a quote at the beginning on “If we have stopped dreaming. We are old” [20-23] (Figure 4).
Figure 1: Geoffrey D Chisholm ChM, FRCS, FRCS Ed.
Figure 2: The Pharaoh stick.
Figure 3: Pharaoh Staff that
belongs to an ancient pharaoh long before Moses’ but that of Moses had a
special power of God that turned into snake eating all other snakes and parted
the sea for Moses and Jews to pass while the Pharaoh and army drowned.
Figure 5: Shows the Best of British Editors of BJUI.
Figure 6: Shows a diagrammatic representation of the hydrodynamic of G tube based on G tubes and chamber C.
Figure 9: Shows volumetric
overload (VO) quantity (in liters and as percent of body weight) and types of
fluids. Group 1 was the 3 patients who died in the case series as they were
misdiagnosed as one of the previously known shocks and treated with further
volume expansion. Group 2 were 10 patients from the series who were correctly
diagnosed as volumetric overload shock and treated with hypertonic sodium
therapy (HST). Group 3 were 10 patients who were seen in the prospective study
and subdivided into 2 groups; Group 3.1 of 5 patients treated with HST and
Group 3.2 of 5 patients who were treated with guarded volume.
Figure 10: Shows a poem on a
special man Written and gifted to me by Alison Banister.
Figure 11: Shows Dr Richard Horton the Editor-in-Chief of the Lancet.
After considering all
criticisms and comments by the anonymous peer reviewer comments (Supplementary
Information (SI)), the article became ridiculously too long and I had to split
it into two substantial articles [6,7]. Hahn must not understand that there is
nothing personal here, nor is there a vendetta. I have been fighting several
wars at multilevel multi dimensions on the subject but never a selfish one. I
cannot humiliate, attack, insult, or harm you or be offensive, insulting or
condescending to anyone at all- except for the tyrants, arrogant and utterly
stupid’s including or starting with myself. I cannot put the “poison in honey”
for anyone but I might have to give you some bitter tasting medicine to help
you recover from a serious dark state such as the long state of intellectual
coma and being absolutely lost in wanderings and chasing mirage for 3 decades
since we met, even before that: 40-years ago. Most humbly and with utmost
respect and polite manner I shall proceed in this critical, analytical
criticism review of your article, may I please? Robert Hahn has a big problem that
he must cure himself from if he can or allow me to help him curing it. That is
Impediment! I trust he can overcome it by himself but have to say it just in
case he needed help. Either he never read any of my articles and the book at
all, despite me, being (envious!) of his work results, or has a mental block
that prevent him from receiving, understanding, and comprehending my writing in
simple, plain, and good English. What is the matter with you Robert? You fooled
me 4 times by sending me articles of yours that made me think you have come
close enough to my level of understanding, only to discover that you remain
where you were 30 years ago when I met with you in Cairo in 1990 in our only
hello and goodbye meeting. This has happened once on the complication of fluid
therapy on which I shall reproduce your abstract later [2]. The second on your
opinion of the porous orifice (G) tube discovery when you said you were
impressed in January 2020 while in 1990 you shunned it and me down, looking the
other way and refused to allow me to tell all about it and the TUR syndrome
[3]. On that 3rd time you sent me your article on the Revised Starling
Principle (RSP) based on which I wrote my reply article Revised Starling’s
Principle (RSP): a misnomer as Starling’s law is proved wrong [5,21]. The
fourth when you repeatedly reported and talked about volumetric kinetic (VK) in
the pathogenesis of the TUR syndrome as you do in the discussion of this
article but never referenced me as the originator of the concept of VO shock
(VOS) causing both types of ARDS 1 and 2 [24]. Come on Hahn. Open your mind and
eyes up and pull your socks up so I may be able to help you get out of the trap
you locked yourself within and the state of impediment or “intellectual coma”
you have been in for 30 years now. Please, forget about your useless
contributions on Glycine toxicity and alcohol monitoring, the fancy looking but
wrong formulae and figures. That is a mirage man that you have been chasing in
vain for >3 decades now. Look at the real issue of Volume kinetic you keep
repeatedly talking about in similar reports as shown in your discussion. You
have done lots of research on it with excellent results but twisted discussion,
conclusions, and references as demonstrated in your article that is critically
analysed, criticized, and discussed here [1]. Try to better understand me well
here, please. Now allow me to refresh your memory but before I do that allow me
to precisely define the questions and objectives of this new debate just opened
now.
This is a phrase
describing the persuasive power of numbers, particularly the use of statistics
to bolster weak arguments. It is also sometimes colloquially used to doubt
statistics used to prove an opponent's point. This is a quote from the internet
now that was not available before 1985.
There was no internet
on Apple Mackintosh I bought in 1985 but it has Wonderful Stat View 500+
programme that I bought and served me just fine. However, I consulted with 3
Statisticians before and after the study and the editor consulted the BJU
statistician. Have you ever thought about what were you looking for Hahn? These
questions I asked myself since I planned my prospective study in 1981 and
despite trying very hard there was no answers there despite my prayers being
answered by GOD allowing me access to the best 3 statisticians before, during
and after my study for MD Thesis [22].
·
I
cannot wait for you Hahn another 30 years so let us do it now and with or
without validation on the TUR syndrome and RSP. Be careful, vigilant and make
no mistake about the issues that require validation:
·
VK
versus VOS is the urgent most important question now, not albumin versus
saline, and certainly not RSP that is another never ending debate that I have
already done with (Terminated) [5]. Did you read my article on that Hahn that
was my response to one of the two articles on RSP you sent me in 2020 [20,21]?
No one with the type of utter stupidity,
ignorance and arrogance represented by 2 Professor from London should enter
this debate for their own sake. If they are determined I shall recommend to the
editor to accept their testimony and report it with or without me commenting on
it.
Back to the TUR syndrome:
understanding misunderstanding Hahn’s understanding of VK and the TUR
syndrome!?
The distribution and
elimination kinetics of the water volume in infusion fluids can be studied by
volume kinetics. The approach is a modification of drug pharmacokinetics and
uses repeated measurements of blood haemoglobin and urinary excretion as input
variables in (usually) a two-compartment model with expandable walls. Study
results show that crystalloid fluid has a distribution phase that gives these
fluids a plasma volume expansion amounting to 50%-60% of the infused volume as
long as the infusion lasts, while the fraction is reduced to 15%-20% within 30
minutes after the infusion ends. Small volumes of crystalloid barely distribute
to the interstitium, whereas rapid infusions tend to cause edema. Fluid
elimination is very slow during general anaesthesia due to the
vasodilatation-induced reduction of the arterial pressure, whereas elimination is
less affected by haemorrhage. The half-life is twice as long for saline as for
Ringer solutions. Elimination is slower in conscious males than conscious
females, and high red blood cell and thrombocyte counts retard both
distribution and re-distribution. Children have faster turnover than adults.
Plasma volume expansions are similar for glucose solutions and Ringer's, but
the expansion duration is shorter for glucose. Concentrated urine before and
during infusion slows down the elimination of crystalloid fluid. Colloid fluids
have no distribution phase, an intravascular persistence half-life of 2-3
hours, and—at least for hydroxyethyl starch—the ability to reduce the effect of
subsequently infused crystalloids. Accelerated distribution due to degradation of
the endothelial glycocalyx layer has not yet been demonstrated
In this narrative review concerning intravascular
fluid kinetics, perioperative theoretical and practical perspectives are
presented and explained. Avenues for future research in this subject area are
also presented.
Hahn did not mention any quantification of the
pathological VO. What he talks about above is volume kinetic (VK) of
physiological VO of <2 L in < 1 hour. Irrespective of the type of fluid
he uses the maximum volume he can use in the awake volunteers and patients by
IV fluid infusion is <2 L in one hour-Guided by the correct Ethics and
regulations of the Ethical committees. Hahn must show us the VO of type 1 (VO
1) of sodium-free fluid of 3.5-5 L as documented in the patho-aetiology of the
TURP syndrome. (Break AZAN EL-ASR in the near Mosque-curtsey of my Father and
Mother Bob and Freda Prentice of Eastbourne and their true Son Mark- The story
elsewhere) [37-45]. Hahn and all multicentre trials on ARDS must show us the VO
2 of >3 L and up to 7-10 L for surviving ARDS patients and >12 L for the
dead of mainly sodium-based fluids such as saline, Hartman, Ringer and plasma
and substitutes and blood which he may give to anaesthetized patients on using
both types of fluid regimen of Early Goal Directive Therapy (EGDT) of the
Liberal regimen and Conservative of Bolus Fluid Therapy (BFT) [46-48].
Cerebral |
Cardiovascular |
Respiratory |
Renal |
Hepatic &
GIT |
Numbness Tingling SBB1 COC2 Convulsions Coma PMBCI 3 |
Hypotension Bradycardia Dysrhythmia CV Shock* Cardiac Arrest Sudden Death
|
Cyanosis. FAM4 APO)5 RA6 CPA7 Shock lung ARDS$ |
Oliguria Annuria8 Renal failure
or AKI9 Urea ? Creatinine ?
|
Dysfunction: Bilirubin ? SGOT ? Alkaline
Phosph. GIT symptoms. DGR10 Paralytic
ileus Nausea &
Vomiting. |
1 |
Gr1 |
Gr2 |
Gr3 |
Gr3.1 |
Gr3.2 |
Normal Units |
||
2 |
Number
of patients 3 |
10 |
10 |
5 |
5 |
mean |
||
3 |
Age 71 |
70 |
75 |
72 |
78 |
72 Years |
||
4 |
Body
weight (BW) 69 |
70 |
68 |
71 |
65 |
69 Kg |
||
5 |
Postoperative serum solute
concentration
|
|
Preoperative |
|||||
6 |
Osmolality |
271 |
234 |
276 |
282 |
271 |
292 |
Mosm/1 |
7 |
Na+ |
110 |
108 |
120 |
119 |
121 |
139 |
Mmol/1 |
8 |
Ca++ |
1.69 |
1.79 |
1.85 |
1.84 |
1.86 |
2.22 |
'' |
9 |
K+ (P<.05) |
5.6 |
4.8 |
5.0 |
4.9 |
5.0 |
4.46 |
'' |
10 |
Co2 (P=.002) |
23.0 |
23.0 |
25.5 |
24.0 |
26.4 |
27.30 |
'' |
11 |
Glucose |
13.2 |
17.3 |
16.4 |
15.9 |
16.9 |
6.20 |
'' |
12 |
Urea (P=.0726) |
26.5 |
9.0 |
6.6 |
6.8 |
6.4 |
6.7 |
'' |
13 |
Bilirubin (P<.05) |
19 |
16 |
8 |
6 |
9 |
7 |
'' |
14 |
AST |
124 |
32 |
20 |
18 |
21 |
20 |
'' |
15 |
Protein |
43 |
52 |
48 |
44 |
52 |
62 |
g/l |
16 |
Albumin |
23 |
30 |
30 |
28 |
32 |
39 |
'' |
17 |
Hb (P=.0018) |
119.3 |
127.9 |
114.5 |
105.2 |
123.8 |
123.8 |
'' |
18 |
WCC (P<.005) |
18.9 |
16.2 |
7.5 |
7.8 |
7.2 |
8.0 |
per HPF |
19 |
Glycine |
|
|
10499 |
|
|
293 |
µmol/1 |
20 |
Therapy |
CT |
HST |
Randomized: |
HST |
CT© |
|
|
21 |
Outcome |
Death |
Full Recovery |
|
Full Recovery |
Morbidity |
|
|
Table 2: The mean summary of data, therapy and outcome comparing the 3 groups of 23 case series patients who’s (whose) VO.
It is ironic that the only evidence on mortality for
the TUR syndrome till now by other authors is a letter to the editor, from
introduction as haemolytic reaction till reported in women as hyponatraemia
after massive infusion of 5%Glucose during major prolonged surgery [49-51]. I
have known Robert ever since 1990 when he wrote to me after the publications of
our articles side by side in the British Journal of Urology (BJU) and now
International (BJUI) that was deliberately intended by the great late professor
G D Chisholm the editor of BJU An editor with a vision (10*+ Nobel). After a
thoughtful and considerable consideration and self-deliberation, I decided to
write this review imitating the anonymous reviewer’s comment (SI) and standard
review attached to Hahn’s article (and this standalone article pending the BJUI
editor’s decision for kind consideration, acceptance and reporting with Hahn’s
article and mine side by side). This is intended for the sake of this Journal’s
readers who should be well informed and highlighted, and the benefit of
patients who are being killed in hundreds of thousands per year from VO as
complication of fluid therapy for shock in clinical practice that induce VOS
and cause the acute respiratory distress syndrome (ARDS), or the multiple organ
dysfunction syndrome (MODS) [42]. Problems and medical conditions that I have
finalized while Hahn remains lost in his wanderings and own impediments are:
The TUR syndrome, HN and ARDS. All are problems that have been resolved and
must be prevented and stopped immediately by informing physicians all over the
world to become aware of the exact patho-aetiology and the currently available
100% successful preventative and curative therapy of these conditions [6]. I
hope Hahn will finally cooperate and collaborate with me here. I do need his
help as much as he does need mine. I know it will make a few late professors
who were visionary mentors of mine happy in their graves (see Acknowledgements
later) and currently alive consultants and professors, authorities and
administrators who helped me greatly during my career including editors who are
indeed Best of the British (Figure 5).
My beginning with the TURP syndrome started in 1981
after I attended postmortem examinations (PM) on 3 patients who died of the
syndrome. I was only an SHO in urology working for the late Mr. KC Perry and JP
Ward at DGH in Eastbourne. At the PM examination it was clear and very obvious
to me that these patients died of internal drowning as result of massive VO of
fluids used for resuscitation of a cardiovascular shock they had, and the VO
fluid was retained in their bodies. When I asked the pathologist why doesn’t he
mention that retained VO in his report? He replied: “because it offends
treating physicians”? The word offends hit me right on my face and head like a
hammer. My next question to myself was if it offends them why do physicians do
it? This had led me to immediately replace the term fluid overload with the new
and original Volumetric Overload (VO) after adding the cardiovascular Shock to
it (VOS) that was introduced to avoid the word offends. Another few questions
such as: “What is misleading physicians into giving too much fluid during the
resuscitation of shock? What shock is it? I communicated with Richard Harrison
III (who may be late now) (7* and Nobel) who is the originator of the word
hyponatraemic shock of the TUR syndrome and 5%NaCl therapy for years during his
retirement until he was sick and tired of me. I reported later the true
originators of this shock and therapy in dogs (7* each+ Nobil). He advised me
to put the poison in the honey that I could not accept. I stopped immediately
after the PM examination I suspected and incriminated Starling’s law being the
scientific basis of fluid therapy in shock which I have proved that it dictates
the wrong rules on fluid therapy for shock management in books [53-57]. I felt
so strongly about it that I wrote a letter to the late great professor of
physiology Eric Neil (7* a+ Nobel) and author of Sampson Wright Textbook of
Physiology later in 1983 [58,59]. He nicely replied in handwritten letter as he
was in retirement asking: Why and how may Starling’s law cause death of
patients? The answer is there now [56].
My story with Robert G Hahn goes back to 1990. Both
Robert and I communicated by email since our articles appeared side by side at
the British Journal of Urology (BJU) 1in 990 then and International to become
BJUI now. We had the same interest of investigating a clinical condition named
the TUR syndrome that evolved to VK by Hahn and VOS by me as complication of
fluid therapy [58,60]. I thought the late great Professor G D Chisholm was
visionary and had thoughtfully and deliberately put our articles on the TURP
syndrome side by side for a good reason [53-57]. I thought perhaps he wanted us
to get together and collaborate. Hence, I was delighted to receive an email
from Robert soon after the publication of our articles. His email had just
arrived me while I was thinking of what to write to him if he has my article
and I immediately and positively responded. We later agreed to meet at a
conference in Cairo and discuss the issues involved in pathogenesis of the TURP
syndrome and VK in more details. Hahn gave me a pile of his articles to read
which I did. It allowed me to decide he is my man to share my discoveries with.
But, if he carries on, on his own he needs about 30 to 40-years to catch up
with me. Now is the time. Now or never! In the Cairo Urological Conference in
1990, our presentations on the TURP syndrome were based on the 2 articles
reported side by side in BJU in 1990 but I called it then Hypo-osmotic shock.
My second presentation was on the newly discovered link between the loin pain
haematuria syndromes (LPHS) and symptomatic Nephroptosis (SN). My best ever
friend and colleague since medical school, the late Dr. Khaled El-Hamaky, (MD),
who I loved and trusted and was a most successful Consultant Urologist Surgeon
in Al-Mehalla Al-Kobra, Egypt, after whose name I named my son Khalid (KOKO). He
told me that my 2 topics were the only new subjects in the conference book and
all others are repetitions of all the previous years he has been attending this
conference for many years. I said to him you are kind enough to boosting my
morals as he came later this evening after my failure presentation: He said:
“No this is the truth”. I went to my first ever Conference full of hope and
excitement that became little disappointment after finding my two accepted
abstracts to be the last on the conference book!? I said perhaps I joined in
the last minute. I went and had a look at the room where I shall be delivering
my 1st oral presentation just 5 minutes before start time. Nobody was there.
Most of the attendees were walking home or had already left before I started!?
I started to get worried and quickly I asked Khaled and 2 other friends of mine
who were there in the conference to attend my presentation, and they were the
only 3 audience for my presentation. The day before, the main room was full of
audience attending Hahn’s presentation, including me. I just could not believe
that none of the conference attendees were interested in any of my
presentations that most upset, disappointed and dispirited me! Before my
presentation I met for the first and last time my correspondence friend
Professor Robert Hahn from Sweden and the author of the article discussed,
analyzed, and criticized here [1]. On whom I wrote about him in an article of
mine saying: “You may hear and know more about him in the future perhaps as a Noble
Prize winner for a career life achievement of massive contributions in medical
research with publication of >500 articles, most of it on the TURP syndrome
that I have read most of it. Hahn has reported >340 articles on the TURP
syndrome alone and 532 articles in total. Here is what Robert Hahn, Professor
of Anaesthesia and Intensive Care, Head of the National Fluid Academy (NFA) and
Editor-in-Chief of a book on fluid therapy, concluded in abstract of a recent
review article in 2017. I said that as prediction as he has not even nominated
for a Noble yet. In a fair, just, and ideal world I deserve Noble prize this
year for my 40-years career life achievements of 15 new scientific discoveries
in physics, physiology, and medicine with publication of >120 articles and 6
published books, but self-nomination is not allowed [56-60]. I dare also say
that each and all my listed above 15+ discoveries is a worth a Noble on its
own. The achievement of each one of them is certainly greater than that of
Barak Obama- the man himself said that in his speech at the ceremony. It is
also greater than that The Nobel winner from Japan who observed a tree that
follows the sun like a Sunflower- it is called the flower that worships the sun
in Arabic (ABAAD ALSHAMS)! So, what? Having said that and a little more later
addressing the issues on self-nomination and an “Encouragement Award” for the
bright intelligent children and aspiring young scientists. No noble is intended
for “Encouragement Award” or for self-nominated adults or for bright children
and aspiring young scientists. I respect that this was his will (Noble) and the
nomination committee does its best in an impossible task of selecting the right
candidates (Figure 5,6) (Table 1-3).
The
main misunderstanding between Hahn and me Why should everyone have 3 IDs to
eradicate SMAFs?
I most humbly request that all scholars’ peers of
professors and doctors including Robert Hahn and colleagues in Sweden with
interest in the science of physics? physiology and medicine to nominate me for
this year’s Nobel Prize Award. This prize is not offered to a deserved
candidate after his death and at my age of >71-years with serious
comorbidities there is not much time left to go. I have previously won Princess
Alice Memorial Award Eastbourne, UK 1988, the best presentation award and
Winner of X-ray Quiz in 1999 in Saudi Arabia (the hall full of audience were
laughing at me when I raised my hand saying “Yes Sir that is me”, and lately
the best presentation award at a Nursing Conference 2021 on the subject of the
G tube discussed here (Figure 6,7).
The porous orifice
(G) tube was built on a scale to ultrastructure anatomy of the capillary tube
that has porous wall that allow the passage of plasma proteins and
pre-capillary sphincter encircling its inlet [61,62]. Please, do not get me
wrong as this not for the money, I have already promised my wife that she will
get the money and I shall proudly and honourably keep the medal for a reason.
God willing I may live to see the day and my health allow me to be able to
travel for a Noble Ceremony in Sweden. Each one of us, Hahn and I, pursued his
career interest based on his own believe and theory on the pathogenesis of the
TUR syndrome: Hahn is a firm believer in the toxicity of glycine, while I
persevered to prove the VO theory is correct. Ironically, the VO theory of mine
has been so obvious that it has remained invisible even to Hahn himself and all
physicians involved with and prescribed fluid therapy till today. I only became
aware in January 2020 that Hahn has become interested in Volume Kinetic (VK)
and wrote a few articles on it, but has he accepted, recognized and understood
as Volumetric Overload Shock (VOS) and realized, and acknowledged the
pathological VO that cause the TUR syndrome and appreciated its link with ARDS
yet? His article analyzed here testifies: No. His stand, concept, understanding
and theory have remained today exactly as it was back in 1990. This made me
predict at the time that he needs another 30 years to understand. I shall go to
him. I did wrongly think that VK and VO are the same. I said to myself he has
come around far enough to discuss issues on VO kinetic despite failing to
appreciate the huge difference between physiological VK and pathological VO of
VOS! Please allow me to explain humbly with all due respect and hopefully
without sounding disrespectful, offending, arrogant or patronizing who is
teaching and breaching us! I shall explain what is the difference between VK
and VOS now? I made the error by thinking that both Hahn and I are talking
about the same thing and some competition shouldn’t cause any harm to use by
anyone. So far at the time of writing this article I thought that both VK after
Hahn that appeared to be the same as VOS of mine are the same!? That is the
most important error I made that showed in a title of book of mine changing it
from VOS in 2018 to VK and VOS 2021 [53]. It will be immediately rectified here
and in the next edition back to VOS. Before I report the difference discovered
during the writing of this article, please allow me to summarize what is the
TUR syndrome [63-70].
P |
T Value |
Std. Value |
Std. Err |
Value |
Parameter |
|
|
0.773 |
|
|
Intercept |
0.0007 |
3.721 |
1.044 |
0.228 |
0.847 |
Fluid Gain (l) |
0.0212 |
2.42 |
-0.375 |
00.014 |
0.033 |
Osmolality |
0.0597 |
1.95 |
0.616 |
0.049 |
0.095 |
Na+ (C_B) |
0.4809 |
0.713 |
0.239 |
0.087 |
0.062 |
Alb (C_B) |
0.2587 |
1.149 |
-0.368 |
0.246 |
-0.282 |
Hb (C_B) |
0.4112 |
0.832 |
-0.242 |
5.975E-5 |
-4.973E-5 |
Glycine (C_B) |
Table 3: The multiple regression analysis of total per-operative fluid gain, drop in measured serum osmolality (OsmM), sodium, albumin, Hb and increase in serum glycine occurring immediately post-operatively in relation to signs of the TURP syndrome. Volumetric gain and hypo-osmolality are the only significant factors.
The TURP syndrome is a condition induced by gaining
large volume of sodium-free fluid overloading the cardiovascular system and
spelling into the interstitial fluid space of vital organs and subcutaneous.
The fluid of 1.5%Glycine used as irrigating fluid gets absorbed during the TURP
surgery as well as all endoscopic surgeries performed under sodium-free fluid
irrigation of any type, BUT intravenous infusion of 5% Glucose considerably and
significantly contributes to it- as well as saline. What is more saline or any
sodium-based fluid such as Saline, Hartman, Ringer, plasma, and plasma
substitutes, and blood worsens it transferring the shock being treated from VOS
1 into VOS 2 and causing ARDS 1 and 2 with its high morbidity and mortality
later. The TUR syndrome has a characteristic severe drop of serum sodium level
causing acute dilution hyponatraemia (HN) with severe clinical symptoms
affecting all vital organs causing the multiple organ dysfunction syndromes
(MODS), or ARDS with recognizable clinical picture but one system may
predominate such as AKI. The HN of <120 mmol/l has 2 paradoxes and 2 nadirs
that have eluded authorities and physicians on HN, and that has made the TUR
syndrome most elusive and invisible with 2 paradoxes making it though obvious
it has remained invisible even to authorities on HN. Professors and consultant
urologists who are swift good resection experts have testified that the TUR
syndrome does not exist with a negative prospective study of 100 patients [68].
Off course no such hyponatraemia occur when the irrigating fluid is saline
whatever the volume absorbed and infused. Another reason that prevent massive
1.5% glycine absorption and the TUR syndrome is not to open the prostate
capsule and venous sinuses. There was also an urologist who did >1000
consecutive TURP surgeries without seeing the TUR syndrome. The TURP syndrome
starts by presenting with cardiovascular shock to anesthetists and surgeons in
theatre and at times by cardiac or cardiopulmonary arrest and sudden death. By
next morning the surviving patients present with coma, convulsion and bizarre
paralysis to physicians, neurologists and ICU specialists and the
characteristic serum hypo-osmolality BUT other solute contents dilutions seem
to be apparently improving due to water shift into cells. The HN of <120
mmol/l causes cardiovascular shock. Volumetric overload (VO) is the most highly
significant factor causing its patho-aetiology with a (p=0.0007). Osmolality
was also significant (p=0.02) while all other serum solute changes including
sodium and glycine did not reach statistical significance in the multiple
regression analysis yet it did alone when pre and post-operative levels are
compared. This cardiovascular shock is easily confused with hemorrhagic or
septicemia shock and treated with further massive volume expansion [71-80].
Figure 6 shows a diagrammatic representation of the
hydrodynamic of G tube based on G tubes and chamber C. This 37-years old
diagrammatic representation of the hydrodynamic of G tube in chamber C is based
on several photographs. The G tube is the plastic tube with narrow inlet and
pores in its wall built on a scale to capillary ultra-structure of
pre-capillary sphincter and wide inter cellular cleft pores, and the chamber C
around it is another bigger plastic tube to form the G-C apparatus. The chamber
C represents the ISF space. The diagram represents a capillary-ISF unit that
should replace Starling’s law in every future physiology, medical and surgical
textbooks, and added to chapters on hydrodynamics in physics textbooks. The
numbers should read as follows:
·
The inflow pressure
pushes fluid through the orifice.
·
Creating fluid jet in
the lumen of the G tube**.
·
The fluid jet creates
negative side pressure gradient causing suction maximal over the
·
Proximal part of the G
tube near the inlet that sucks fluid into lumen.
·
The side pressure
gradient turns positive pushing fluid out of lumen over the distal
·
Part maximally near the
outlet.
·
Thus, the fluid around
G tube inside C moves in magnetic field-like circulation (5)
·
Taking an opposite
direction to lumen flow of G tube.
·
The inflow pressure 1
and orifice 2 induce the negative side pressure creating the dynamic G-C
circulation phenomenon that is rapid, autonomous, and efficient in moving fluid
and particles out from the G tube lumen at 4, irrigating C at 5, then sucking
it back again at 3,
·
Maintaining net
negative energy pressure inside chamber C.
·
**Note the shape of the
fluid jet inside the G tube (Cone shaped), having a diameter of the inlet on
right hand side and the diameter of the exit at left hand side (G tube
diameter). I lost the photo on which the fluid jet was drawn, using tea leaves
of fine and coarse sizes that run in the centre of G tube leaving the outer
zone near the wall of G tube clear. This may explain the finding in real
capillary of the protein-free (and erythrocyte-free) sub-endothelial zone in
the Glycocalyx paradigm. It was also noted that fine tea leaves exit the distal
pores in small amount maintaining a higher concentration in the circulatory
system than that in the C chamber- akin to plasma proteins.
·
Figure 7 shows the
relationship between SP to the Diameter and length of the G tube which
demonstrate a negative SP starting at the orifice (Point 2) (akin to
precapillary sphincter) and extends as high negative pressure gradient over the
proximal part of the G tube (Point 2-6) to cross 0 line at point 8 and then
turn positive of 7 cm water at Point 9. This SP gradient from orifice at Point
2 to G tube lumen {Points 2-6) is negative to become positive DP at point 9 of
7 cm H20 water along the G tube. The wide section diameter of G tube is 7 mm
all along the entire tube. The orifice is 5 mm while the distance from orifice
to exit represent the tube’ length in which the Fluid jet diameter change with
increasing gradient (Figure 1a). Neither Poiseuille’s law nor Bernoulli’s
equation can predict SP neither at orifice of Venturi’s effect nor at the G
tube proximal part know as Bernoulli’s effect. Thus, the RBCs speed or CBS
depend on the dynamic fluid jet diameter not the G tube diameter. Hence the
equation in and graph are wrong giving low RBCs speed or CBS over the capillary
length but is correct only at point of the G tube where the jet diameter equals
the tube diameter
·
Groip-1 was the 3
patients who died and had post-mortem examination, Group-2 were a series of
severe TURP syndrome cases successful ly treated with hypertonic sodium therapy
(HST), and Group-3 were 10 patients encountered in the prospective study who
were randomized between HST (3.1) and conservative treatment (CT) (3.2). The
significant changes of serum solute contents are shown in bald font with the
corresponding p- value. Most of the patients showed manifestation of ARDS of
which the cerebral manifestation predominated, being on initial presentation
(Regional Anesthesia) and representation of VOS 1 (General Anaesthesia).
However, most patients were given large volume of saline that elevated serum
sodium to near normal while clinical picture became worse. They suffered VOS2
that caused ARDS. The VO of patients to whom these data belong is shown 9.
·
We, Robert Hahn and I,
became good friends but had no correspondence after our hello-goodbye meeting
in Cairo 1990 till Robert got in touch in Feb. 2020 after I sent him some of my
articles as it does not show on PubMed search. I thought he was probably
unaware of my contributions to the field of interest to us both. When we agreed
to meet in Cairo in 1990 where he came to give oral presentation on the TUR
syndrome at the same mentioned above Urology Conference [9]. Although one of my
2 presentations was on the same subject, I called the TUR syndrome then
“Hypo-Osmotic Shock” (p=0.02) then soon latter rectified, named and reported it
appropriately and correctly as VO complication of fluid therapy or VOS,
reported many years later in many articles and books [53-57] as based on
statistical significance of VO with p= 0.0007 and osmolality p=0.02. The
multiple regression analysis on State View 500+ and Apple Mackintosh® did also
show that the changes in other serum solutes such as Glycine, Sodium, Calcium,
Hb and Albumin did not reach a statistical significance in the multiple
regression analysis - despite the markedly high level of glycine and low serum
sodium in the blood. What is the meaning of a VO has a p=0.0007? Ask
statisticians not me as I have clearly replied to this question [6].
·
I was so excited by
this discovery of mine eagerly awaiting to see Robert in 1990 so I can share
with him my knowledge and discoveries about not only VOS but also my new
discovery of the hydrodynamics of the porous orifice (G) tube that was 11 years
later preliminary reported at Medical Hypothesis in 2001 with great and most
appreciated help of its editor Professor of Physiology Dr. David Horrobin, who
was the Editor-in-Chief of the journal Medical Hypotheses and founder in 1975
until his death in 2003 for accepting my article in 2001 free of charge. The
same study without any plagiarism has just been fully reported in a OAJs in
2021. The late Professor Horrobin (May God bless his soul) did also warn me,
and explained what it means, about the “Tall Puppy Syndrome” [81-84].
·
After repeated
rejection of many articles by all top Science, Physics, Physiology and Medical
journals around I decided to throw the towel on them recently. To my
disappointment I checked for my publications on PubMed under my name “Ghanem
AN”, I was horrified when got (0) returned. Only the old previously reported 24
articles before 2013 in closed access PubMed list of journals were found. I realized
that my articles remain invisible to the scholar peers of medical scientific
community; hence I sent Robert a sample in full text PDF format and full list
of my articles in reference format. He reciprocated by sending me 2 most
interesting articles of his. One that I made me believe that Robert has finally
grasped the concept of a pathological VO kinetic and its relation to VOS and
the ARDS syndrome, but his article analyzed here testifies that he remained as
he was in 1990. The second article was on the revised Starling’s principle
(RSP) calling for validation based on which I reported this article [21].
·
I tried to show Robert
the G tube in 1990 and wanted to let him know all about it and VOS but while
keeping it in my hand under the table as we were having lunch, he shunned it
down then and snorted me looking the other way. I said he knows what I said
about VO and the TURP syndrome, but did not bother then to ask him why. He
wrote me an email recently in January 2020 saying he is impressed with the G tube
work. I had hoped he may attend my presentation on the role of VO in the
pathogenesis of the TUR syndrome, but disappointedly he did not.
·
Out of disappointment,
upset, and embarrassment I felt during my presentation at the Urology
Conference in 1990 in Cairo I had a frozen mind during my presentation. I just
could not stop talking while the chairman was shouting at me to stop. The
chairman and committee walked out of the room and left me behind still talking
until I finished 2 minutes later. I felt also most upset, humiliated and
annoyed by the wasted 1200 USA Dollars plus the cost of travel and hotel
accommodation that was a lot of money 30 years ago. I went up to my hotel room
and cried. This is how I gained the immunity against any farther repeated
rejections by top journals of the world that repeatedly followed later till
today. I am just curious to know why?
Khaled my friend gave
me just enough time then he came and joined me in the room we shared.
Immediately after booking in a small cheaper hotel nearby, he came and asked
for the refund of my money. He bent to carry my suit case for me while I am
speechless. . After some negotiation he allowed it, then he said: “take back
your hotel money”. No way can I accept that I am working in Saudi Arabia now
you now. He said: “and I am not giving you money that I paid myself. It is a
drug company that pays for me and my family each year to attend but my family
could not come with me this year. Wow good for you Khaled, why do they do that.
He said because I prescribe the company’s good antibiotic for my patients. You
deserve it. I said sorry khaled I cannot accept that. “It is perfectly OK and
everyone does it. It is Halal money.” I took the money from him and put it in
my pocket and went with him to our 5* hotel room with a beautiful, serene view
on the Nile. I said now I know the meaning of the statement: Egypt is the Gift
of the Nile from Allah. Nobody, whoever who is, is allowed to deprive us from
it. He came back to our room and knocked on the door giving me enough time to
finish crying before he entered. He saw the residual of tears in my eyes and
the upset on my face. He started talking and I just listened, he said: “Do not
be upset, please my friend. Do you know that most of these conferences’
attendees come each year here for and on whose expense? Nobody comes for
science or learning anything new! They come for a holiday, socializing and
food! Do you know the London professor you told me about before? I have seen
him in one of these Cairo conferences before giving a lecture, He is such a
brilliant Urologist Surgeon and resectionest that: “actually his scissors and
resectoscope have eyes that can see! He may never have seen a case of the TUR
syndrome before and may never will.” I asked Khaled the question that begged
itself: “How come he authored a book on the subject, and who wrote it for him?
Khaled said: “I do not know that as I have never read the book or seen it. I do
not know and I have not read the book. Come on let us go out to the Balcony
where we can enjoy looking at the beautiful Nile view so you can have some
benefit from attending this conference and you can have a cigarette or two while
we are talking.” This is when I decided to forget and forgive the man. Khaled
cheered me up and we talked till 4:00 am. Dr. Khaled Al-Hamaky, (MD) never
could find the time to write up his Thesis Book after completing the clinical
study work even though he had the full support and the promise of Professors
and Drs. Mustafa Alrifaai and MA Ghoneim he will be granted one if he only
submitted the book. He was loved by me, my wife, many other friends, and all
his patients may God bless his soul. In my book on Layla’s award, he has earned
it and that is the reason for putting MD after his name plus (10*) even if it
is worth nothing now but it may please his 3 children.All of my >120
articles since my own re-incarnation in 2016 till now have been reported without
any further editing. All have been accepted and reported by OAJs after being
rejected by all top Science, Physics, Physiological, Medical, Urological and
Surgical top-rated journals of the world. All my articles remain unlisted in
PubMed. I said happily to myself OAJs came to risqué me. Now these articles
have also been reported in 6 published books plus 2 other books that remain
unpublished and another forthcoming 9th book on a totally different subject
based on currently undergoing investigations declaring another solo
self-financed war against SMAFs (Scam Master Artists and Fraudsters). The book
will have the title of: “Money, Scam, Fraud and Stupidity”. The first of a
series of articles for the book has just been reported [60]. I hope to complete
the series of 3 articles and more that will complete the book that aims to
confront Karl Marks’ Theory on the threat to Capitalism and challenge his great
theories about “the threat converting capitalism violently to communism
[85,86].
Therapy of the
TUR syndrome and ARDS [6]
Prevention: Based on the above
discussion, ARDS is an iatrogenic complication of fluid therapy in hospital,
never in community, that is overlooked and underestimated. Being iatrogenic;
means it is preventable. In order to prevent VOS and ARDS a limit to the
maximum amount of fluid used during shock resuscitation or major surgery must
be agreed upon. Professor Hahn found that infusing 2 L of saline to human
volunteers produces symptoms. Infusing >3 L is pathological. More than 5 L
is associated with deleterious morbidity [38,39]. So, the maximum volume of
fluids that can be infused safely to an adult patient is 3 L which is the daily
fluid requirement and no more fluid of any kind is given for 24 hours except
replacing the actual loss that does not include urine loss. The patient should
be put on a weighing scale every day from hospital admission till discharge or
death. Any retained volume of fluid above his body weight on admission is
pathological. On using CVP for monitoring fluid therapy, please refrain from
persisting to elevate CVP to levels above 12 and up to 18-22 cm saline [81].
This is a major cause for inducing VO and VOS and ARDS during shock
resuscitation, particularly septic shock [40]. Look up any physiology textbook
to find out that the normal CVP is 0 and it swings between -7 and +7 cm saline
which is the level that should be aimed at in monitoring fluid replacement in
shock of sepsis, trauma and bleeding, acutely ill and during major surgery.
Elevating CVP is not synonymous with elevating arterial pressure. If
hypotension develops later during ICU stay, inotropic drugs, hydrocortisone 200
mg and HST should be used. The latter restores the pre-capillary sphincter tone
(peripheral resistance) so that the capillary works as normal G tube again, but
no isotonic crystalloids or colloids infusions of above the daily fluid
requirement should be given. If persistence with the current liberal regimen of
Early Goal-Directed Therapy (EGDT) and conservative Bolus Fluid Therapy (BFT)
regime continues, then more reports on ARDS will continue. Future authors will
be hopefully taking into consideration the mentioned above data concerning
VO/Time, or the retained fluid VO at the time of inducing ARDS or death on
reporting new trials or case reports. Treatment
of ARDS [6]. Hypertonic sodium therapy(HST) of 5%NaCl and/or 8.4%NaCo3 has
truly proved lifesaving therapy for the TUR syndrome and acute dilution HN as
well as Secondary VOS 2 that complicates fluid therapy of VOS 1 causing ARDS.
It works by inducing massive diuresis; being a potent suppressor of
antidiuretic hormone. My experience in using it for treating established ARDS
with sepsis and primary VOS 2 that causes ARDS is limited. However, evidence on
HST suggests it will prove successful if given early, promptly and adequately
to ARDS patients while refraining from any further isotonic crystalloid or
colloid fluid infusions using saline, Hartman. Ringer, Hydroxyethyle starch
and/or plasma therapy- just give the normal daily fluid requirement and no
more. After giving HST over one hour using the CVP catheter already inserted,
the patient recovers from AKI and produces through a urinary catheter massive
amount of urine of 4-5 L as you watch. THIS URINE OUTPUT SHOULD NOT BE
REPLACED. Just observe the patient recovering from his AKI, coma and ARDS and
asks for a drink. This is done in addition to the cardiovascular, respiratory,
and renal support on ICU. Patients with AKI on dialysis, the treating
nephrologist should aim at and set the machine for inducing negative fluid
balance. The HST of 5%NaCl and/or 8.4%NaCo3 is given in 200 ml doses over 10
minutes and repeated. I did not have to use more than 1000 ml during the
successful treatment of 16 patients. Any other hypertonic sodium concentration
is not recommended- I know Hahn tried 1.8%NaCl and it does not work. A dose of
intravenous diuretic may be given but it does not work in a double or triple
the normal dose. A dose of 200 mg of hydrocortisone is most useful. Antibiotic
prophylactic therapy is given in appropriate and adequate doses to prevent
sepsis and septic shock. No further fluid infusions of any kind of
crystalloids, colloids and blood is given. The urinary loss should not be
replaced as this defeats the objective of treatment
I would recommend a small pilot prospective
controlled cohort study on 100 patients as a start to try HST in established
ARDS cases that would be something to look forward to reading a report on it,
hopefully soon. No multicentre trial or highly expenses study is needed for
that. Not much time is required either. If you cannot do it on a hundred
patients, you probably can’t (as Mr. JP Ward put it to me before the start of
our prospective study [20]). I can assure the investigators that no harm will
come to patients. It is a guaranteed win bit; you may win but you do not lose
anything. In the worst-case scenario, the patient may not respond because of
chronicity of ARDS or after sepsis complicates ARDS and gets the capillary
damage established. As the author of all self-referenced articles here,
published in open access journals, and as copyright holder I give open
permission to any interested investigator to use any of my articles as
template, particularly recommended article and this report after getting the
appropriate permission from the editor.
To
a special man
The affirmative proof, a poem
I have a special surprise for the great Editor of
the Lancet Dr Richard Horton, who I discovered only yesterday his remarkable
comments on fraudulent research in science and Medicine. WOW amazing. This is
Job very well done, Sir! “Our World is nothing but a big Theatre” said a great
late Egyptian actor Yosif BeK Wahby, in which every actor plays his role well-
The Good, The Bad, and The Ugly! The surprise for the Lancet editor is 2
original essays written before the mid-eighties and submitted by mail but
rejected. They remain available which need only updating to show that the
theory on ARDS has been proved and validated. The essay on Egypt, the mother of
all countries in the World, is another is another prediction of Egypt today.
My Affiliation: NHS
It was only discovered yesterday my true affiliation
is MOH, and there is a card to prove it and my name remains on the GMC register
and the card was issued when I worked at Kings College Hospital, London.
Hahn is the
received “system’s chosen spoilt boy” who follows blindly, faithfully and
sincerely obeys all the rules of the currently received laws, rules and
regulations of high impact factor Journals without questions or understanding.
Hahn has contributed massively by his studies in the results section but his
discussion and conclusions were and remain twisted and wrong by following the
mirage of the toxic theory of glycine in the TUR syndrome and possibly the
septic hypothesis in his views and practice on using fluid therapy and patho-aetiology
of ARDS. Hahn had his chances, but he declined. Hahn has never had any problems
with getting grants or having access to the major top-rated journals of the
world. He is a great university professor who deserves due respect and
recognition for his work and contributions during his career life. Knowingly or
unknowingly Hahn’s results (not discussion and conclusion) has been a major
mine source of data for Ghanem’s use in proving, validating and confirmation of
his new theory on ARDS and the presented scientific discoveries. Ghanem is a
dreamer and white revolutionary, independent investigator scientist and
free-lance author who despite trying to be good and obedient he wanted to
understand and have spotted loopholes in the system that he must/have had to
overcome, ignore, or break to proceed with his endeavors for new discoveries in
science reported above in physics, physiology and medicine. Ghanem has remained
a humble dreamer, white revolutionary thinker who aspires to change the world
into a better place for all of us and future generations to live in peace and
love. Status wise nobody. He ran away, declined or refused 3-4 chances to
become a Professor. No regrets. No anger. No disappointments that can upset me.
It is a destiny and destiny. I am content with my fortune and livelihood. I did
it my way and I am happy with my stupid brain. Evidence is provided to
demonstrate that Hahn remains lagging behind about 40 years in understanding
the patho-aetiology of ARDS, entrapped and lost in wanderings of his own wrong
believes on the pathogenesis of the TUR Syndrome of glycine toxicity despite
having a missed chance 30 years ago to know all about it from Ghanem. There is glimpse of light through the
locked Door at the end of the Tunnel (Figure 7-9).
VOS causes ARDS. It may present with cardiopulmonary
arrest in theatre and ARDS later. It is an iatrogenic complication of fluid
therapy in hospitals that is overlooked and under-estimated. VOS is 2 types:
VOS 1 and VOS 2. VOS 1 is induced by 3.5-5 L of mostly sodium-free fluid and is
characterized with dilution HN that has 2 nadirs and 2 paradoxes, is most
dynamic and illusive and currently has a lifesaving therapy of HST. VOS 2 may
complicate VOS 1 or may be de novo complicating sodium-based fluid therapy
during resuscitation of shock, acutely ill patients, and prolonged surgery. It
has no obvious serological markers or none. Many errors and misconceptions
mislead.physicians into giving too much fluid for resuscitation due to faulty
rules on fluid therapy dictated by the wrong Starling's law that induces VOS 2
causing ARDS. The correct replacement for this law is the hydrodynamic of the G
tube. Discovery of VOS has resolved the puzzles of TUR Syndrome, HN and ARDS. A
new therapy for ARDS using HST of 5%NaCl and/or 8.4%NaCo3 is recommended.
The article presents the author’s view on medical
scientific issues as well as the newly presented peer review standard based on
an anonymous peer reviewer the author had received previously. The author also
presents a critical analytical review of an article sent to him by the editor
of this journal and authored by Robert Hahn, a world leading authority on fluid
therapy and volume kinetic and the TUR syndrome, the author presents his views
on suggested new conflict of interest and acknowledgements relevant to the
subjects discussed. In the presented new standard for peer reviewing using
critical analytical criticism method aimed to precise the main questions and
objectives of the article and related debates. A proven most effective method
of determination and/or abortion of obsolete and unnecessary debates on
subjects such as albumin versus saline and RSP that is based on the wrong Starling’s
law.A precise definition of volume kinetic (VK) and Volumetric Overload (VO)
with quantification of the physiological VK of <2 L, and the pathological VO
of >3 L and up to 10-12 L retained in the body of the patients, clearly
separates and segregates the major difference between VK and VO with reference
to Time. The pathological VO is of two types VO1 and VO2 responsible for the
pathogenesis of the TUR syndrome and ARDS, a link observed by the author
40-years ago and has been substantially and affirmatively proven. Both the
sodium-free fluid (VO1) and sodium-based-fluid (VO2) are responsible for the
patho-aetiology of the TUR syndrome and ARDS, respectively, while VK has
nothing to do with it. Understanding the above point has been a cause for the enormous
gap of thinking and receiving the new theory on the pathogenesis of the TUR
syndrome and ARDS identifying causes for major hindrance and blockade by top
journal’s firewall are presented.
A contrast and comparison of the two world
authorities and leaders on the contrast and comparison of the two world
authorities and leaders on the subject of the TUR syndrome and fluid dynamics
is presented in an attempt to understand the huge difference between Hahn and
the author.
The authors do not
declare any conflicts of interest.