New Scientific Basis of Fluid Therapy in Shock Management: The Complete Evidence Based On New Scientific Discoveries In Physics, Physiology, And Medicine.

By Ahmed N Ghanem

This book would interest all scientists, doctors and nurses involved in the prescription and administration of fluid therapy in the management of shock, acutely ill patients and those undergoing major surgery. It reports on fourteen new scientific discoveries in physics, physiology and medicine that form the new scientific foundation of fluid therapy which will revolutionise current understanding and practice.

• Language: English
• Publisher: Austin Macauley Publishers
• Release date: Apr 26, 2024
• ISBN: 9781398445345

Ahmed N Ghanem

Ahmed N Ghanem was educated in Egypt and qualified in 1974, Mansoura University, Egypt. He gained all postgraduate experience in UK where he was promoted in posts up to the consultant level. He practiced as consultant Urologist in UK, Saudi Arabia, and Egypt. During his career life he attended many conferences and won the award of Princes Alexandra Memorial Award and reported over 100 articles of which he made important discoveries in physics, and physiology medicine. He discovered two new types of vascular shocks, proved that one physiological law is wrong and provided the replacement of G tube hydrodynamic. He resolved the puzzles of 3 clinical syndromes: the TURP syndrome, LPHS and ARDS. Now he is happily retired in Egypt dedicating his time to writing scientific medical articles. Editor in Chief for Surgical Medicine Open Access Journal (SMOAJ).

Book preview

FRONT.jpg

Ahmed N Ghanem was educated in Egypt and qualified in 1974, Mansoura University, Egypt. He gained all postgraduate experience in UK where he was promoted in posts up to the consultant level. He practiced as consultant Urologist in UK, Saudi Arabia, and Egypt. During his career life he attended many conferences and won the award of Princes Alexandra Memorial Award and reported over 100 articles of which he made important discoveries in physics, and physiology medicine. He discovered two new types of vascular shocks, proved that one physiological law is wrong and provided the replacement of G tube hydrodynamic. He resolved the puzzles of 3 clinical syndromes: the TURP syndrome, LPHS and ARDS. Now he is happily retired in Egypt dedicating his time to writing scientific medical articles. Editor in Chief for Surgical Medicine Open Access Journal (SMOAJ).

Copyright © Ahmed N Ghanem 2024

The right of Ahmed N Ghanem to be identified as author of this work has been asserted by the author in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publishers.

Any person who commits any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages.

A CIP catalogue record for this title is available from the British Library.

ISBN 9781398445338 (Paperback)

ISBN 9781398445345 (ePub e-book)

www.austinmacauley.com

First Published 2024

Austin Macauley Publishers Ltd®

1 Canada Square

Canary Wharf

London

E14 5AA

This book is dedicated to my mother Samira and children Samira, Salma, Khaled and Sara, and my wife Nannah Abdellatif Kamel for bearing with me and looking after me during all the years of producing the articles that make this book.

Many thanks go to Designer Engineer, Peter Holder of Eastbourne, UK. Who provided endless supplies of G tubes free of charge before 1985. I thank Mr. Brian J Stoodley and Mr. Peter Brooks, Consultant surgeons for offering me the registrar post in 1983 without attending the interview being at FRCS Ed examination at the time and for teaching me all the surgery I know. Many thanks go to Mr. JP Ward and the late Mr. KC Perry, Consultant Urologists, District General Hospital, Eastbourne, UK for teaching me the Urology I know, and for offering me the post of research fellow without an interview to do the prospective study on the TURP syndrome [17].

I’d like to mention and thank the following late professors for being most kind and helpful with supportive encouraging letters: I thank the late Professor GD Chisholm, Editor of British Journal of Urology for reporting my article [17] and a nice encouraging letter. Many thanks also to the late Professor Dr David Horrobin, physiologist who was the editor-in-chief of the journal Medical Hypotheses and founder in 1975 until his death in 2003 for accepting and reporting my article [8] free of charge. Many thanks to the late Professor Dr Eric Neil, physiologist author of Samson Write Textbook of Physiology for a nice encouraging letter who specially handwritten it for me during his retirement.

I would also like to mention Mr. and Mrs. Robert and Freda Prentice of 70 Glendale Avenue, Eastbourne, East Sussex, BN21 1UD in the UK, good friends who performed like my family in the UK and for permitting the use of their home and garden for conducting the G tube experiments. I thank my family members: My wife, Nannah Abdullatif Kamel, and my children, Sara, Khaled and Salma and my sister-in-law Monera Abdullatif Kamel, for tremendous support and looking after me well. Dr Khaled A Ghanem, MBBCh for his input in editing this article, for buying me a new Laptop and Office 365. Dr Salma A Ghanem, MBBCh, for payment of $200 on my behalf to the scamsters who ripped me of it posing as conference organizers. I thank Monera for taking care of me when Nannah was away and for gifting me with a nice small house Croton tree to use for validating the Tree Branching Law.

I would also like to thank the internet people, Google for its magic Chrome® and Google Scholar® programs, and the people behind the wonderful PubMed, NLM & NCBI for being most helpful over the years, putting such huge amount of information at the researcher’s finger’s tip-though unhappy with them not referencing Open Access Journals. I like to thank Apple® Computers for inventing the Macintosh® before 1985 and Stat View® 512+ Statistical package; both made analyzing the data of the prospective study and the G tube experiments absolute fun between 1984-1988. I thank Microsoft for Office 365 and Windows 10. I thank the authors of free programs such as Picasa, Acrobat Reader and Paint.

Table of Contents

Introduction

Chapter 1: Update on Ghanem’s New Scientific Discoveries in Physics, Physiology, And Medicine.

Chapter 2: The Scientific Basis of Fluid Resuscitation in Shock: Why Starling’s Law Is Wrong?

Chapter 3: Fluid Resuscitation in Shock: Why Starling’s Law Is Wrong?

Chapter 4: Albumen Does Not Work: What Alternative Hypothesis for Starling’s Capillary-Interstitial Transfer Is There? The Hydrodynamics of The Porous Orifice Tube

Chapter 5: The Adult Respiratory Distress Syndrome: Volumetric Overload Shocks in Patho-Aetiology, Correcting Errors and Misconceptions on Fluid Therapy, Vascular and Capillary Physiology

Chapter 6: Volumetric Overload Shocks (VOS) In the Patho-aetiology of The Acute Respiratory Distress Syndrome (ARDS): Correcting Errors and Misconceptions

Chapter 7: What Is Misleading Physicians into Giving Too Much Fluid During Resuscitation of Shock and Surgery That Induces ARDS And/Or Aki?

Chapter 8: Magnetic Field-Like Fluid Circulation of a Porous Orifice Tube and Its Relevance to The Capillary-Interstitial Fluid Circulation: Preliminary Report

Chapter 9: The Proof and Reasons That Starling’s Law for The Capillary-Interstitial Fluid Transfer Is Wrong, Advancing the Hydrodynamics of a Porous Orifice (G) Tube as The Real Mechanism

Chapter 10: The Physiological Proof That Starling’s Law for The Capillary-Interstitial Fluid Transfer Is Wrong: Advancing the Porous Orifice (G) Tube Phenomenon as Replacement

Chapter 11: The Correct Replacement for The Wrong Starling’s Law Is the Hydrodynamic of The Porous Orifice (G) Tube: The Complete Physics and Physiological Evidence with Clinical Relevance and Significance

Chapter 12: Revised Starling’s Principle (RSP): A Misnomer as Starling’s Law Is Proved Wrong.

Chapter 13: Post-Surgical Hyponatremia: Problems of Management Resolved by Revealing Its Relation to Volumetric Overload Shocks

Chapter 14: Postoperative Dilution Hyponatremia and The TURP Syndrome: Critical Analytical Review of Literature on Patho-Aetiology and Therapy

Chapter 15: Volumetric Overload Shocks (VOS) Resolving the Puzzle of The Transurethral Resection of The Prostate (Turp) Syndrome, Dilution Hyponatremia (Hn) And the acute respiratory distress syndrome (ARDS): The Minority Report!

Chapter 16: Preventing Renal Failure in The Critically Ill Patient: Identifying the Problems and Finding the Solutions

Chapter 17: Volumetric Overload Shocks in The Patho-aetiology of The Transurethral Resection of The Prostate (TURP) Syndrome and Acute Dilution Hyponatremia: The Clinical Evidence Based on Prospective Clinical Study Of 100 Consecutive Turp Patients

Chapter 18: Volumetric Overload Shocks in The Patho-aetiology of The Transurethral Resection Prostatectomy Syndrome and Acute Dilution Hyponatremia: The Clinical Evidence Based On 23 Case Series

Chapter 19: Volumetric Overload Shocks in The Patho-aetiology of The Transurethral Resection Prostatectomy Syndrome and Acute Dilution Hyponatremia

Chapter 20: Volumetric Overload Shocks (VOS) Causing the Transurethral Resection of The Prostate (TURP) Syndrome. Case Reports

Chapter 21: Volumetric Overload Shocks (VOS) Resolving the Puzzle of The Transurethral Resection of The Prostate (TURP) Syndrome, Dilution Hyponatremia (Hn) And the acute respiratory distress syndrome (ARDS): The Minority Report!

Chapter 22: Volumetric Overload Shocks in The Patho-aetiology of The Transurethral Resection Prostatectomy (TURP) Syndrome and Acute Dilution Hyponatremia: The Complete Evidence

Chapter 23: Volumetric Overload Shocks: Why Is Starling’s Law for Capillary-Interstitial Fluid Transfer Wrong? The Hydrodynamics of a Porous Orifice G Tube as Alternative

Chapter 24: Shock in Polytrauma: Highlighting the Volumetric Overload Shocks and Hydrodynamic Phenomenon of The Porous Orifice (G) Tube

Chapter 25: Volume Kinetic (Vk) Shock or Volumetric Overload Shocks (VOS) In Surgical Patients

Chapter 26: Volumetric Overload Shocks Cause the acute respiratory distress syndrome: The Plenary Evidence on Patho-Aetiology and Therapy

Chapter 27: Volumetric Overload Shocks Cause the acute respiratory distress syndrome: Building the Bridge Between Physics, Physiology, Biochemistry, And Medicine

Chapter 28: Volumetric Overload Shocks (VOS) Causing the acute respiratory distress syndrome (ARDS): The Complete Evidence

Chapter 29: Capillary Ultrastructure Anatomy and Physiology: What Is Known, What Is Unknown or Missing, What Is Wrong, And What Is New?

Chapter 30: Osmotic and Metabolic Sequelae of Volumetric Overload in Relation to The TUR Syndrome

Chapter 31: Final Proof Starling’s Law Wrong and G Tube Hydrodynamic Is the Correct Replacement: New Results and Critical Analytical Criticisms of Landmark Articles.

Chapter 32: Goodbye Starling’s Law, Hello G Tube

Chapter 33: Fluid Therapy (FT) Complications: Revealing the Overlooked Volumetric Overload (VO) That Induce VO Shocks (VOS) and Cause the Acute Respiratory Distress Syndrome (ARDS)

Chapter 34: Covid-19 Pandemic: The Relevance of My Research to The War Against Covid-19 Pandemic.

Chapter 35: My Experience on The Frontline During the Covid-19 Pandemic: Fighting Another Unique Solo War on The Acute Respiratory Distress Syndrome (ARDS) Caused by Volume Kinetic Shocks

Chapter 36: The New Scientific Foundation of Fluid Therapy in Shock Management.

The Take Home Message. Chapter 37: Fluid Creep in Critically Ill ARDS Surgical Patients: Time to Sop the Flood?!

Chapter 38: New Theory on the Capillary Interstitial Fluid Circulation Based on 40-Years Research Experience

Introduction

This book reports on the scientific basis of Fluid therapy as based on new revolutionary discoveries in physics, physiology, and medicine. It concerns every scholar involved in fluid therapy including physicians particularly surgeons and anaesthetists, researchers, academists, and manufactures. Its material was gathered over 40 years of research and development of a career life. Even a general reader with interest and love of science and new discoveries will find it fascinating to read.

The fascinating unique story of this book’s started in 1981 with the experience of witnessing 3 patients killed after the transurethral resection of the prostate (TURP) surgery by a condition known in urology as The TURP syndrome. Attending their post-mortem examination revealed massive amount of excess fluid retained in their bodies. When I asked the pathologist: Why do not you mention this obvious fluid overload in your reports? His reply was: Because it offends the treating physician

This was the day that I realised that volumetric overload (VO) is an iatrogenic complication of fluid therapy. Immediate investigations to identify what cause it and why incriminated the culprit was the faulty Starling’s law. An investigation was started immediately both in physics and medicine, and the in between physiology as I realised that Starling’s law is the culprit that dictates the faulty rules of the scientific basis of fluid therapy. These faulty rules and misconceptions on fluid therapy were identified and rectified. In doing so, I made 14 new fascinating and revolutionary scientific discoveries reported here.

The discoveries include two physics and two physiological discoveries. Medical discoveries include acute hyponatremia (HN) presents as shock during surgery. It is induced by massive gain of sodium-free fluid recognised as volumetric overload shock type 1 (VOS 1). VOS is of two types. It was also discovered that VOS cause the acute respiratory distress syndrome (ARDS). Features of the multiple organ dysfunction syndrome (MODS) occur, include ARDS; this is VOS 2, Acute renal failure (ARF) and Coma. The prospective study demonstrated volumetric overload is the most significant in patho-aetiology (p=0.0007). A case series of 23 cases demonstrated mistaking VOS for a known shock and treating it with further volume expansion cause death. Correct diagnoses as VOS and treating it with hypertonic sodium of 5%NaCl and/or 8.4%NaCo3 are lifesaving.

Also, an in-depth investigation of capillary ultrastructure and physiology revealed another two misconceptions that have been resolved by the new physics discovery of the Tree Branching Law. Chapter 30 reports first original prospective study reported on the capillary physiology and the original study on the TURP syndrome. Chapter 31 says farewell to Starling’s law. Chapter 32 reports fluid therapy complications in shock therapy. Chapter 33 and 34 reports the relevance of my research to the war on Covid-19 pandemic.

I hope you enjoy your journey reading this book.

Chapter 1

Update on Ghanem’s New Scientific Discoveries in Physics, Physiology, And Medicine.

Abbreviations

HN: Hyponatremia

ARDS: Acute respiratory distress syndrome

TURP: The transurethral resection of the prostate

LPHS: Loin pain haematuria syndrome

IVU 7: Intravenous urography 7sign

G tube: Porous orifice tube

TBL: Tree branching law

Key points

Question: What are the discoveries contributed by the author?

Findings: Two physics, two physiological and two new vascular shocks and treatment are recognised. Starling’s law proved wrong and the correct replacement is the hydrodynamics of the porous orifice (G) Tube. These have resolved the puzzles of TURP syndrome, Hyponatremia and ARDS. The link of loin pain haematuria (LPHS) syndrome with nephroptosis was revealed.

Meaning: Two new vascular shocks are discovered. Starling’s law is wrong, and the correct replacement is the hydrodynamics of the G tube. These resolve the puzzles of syndromes discovering patho-aetiology and successful treatments. A new curative surgery for LPHS was reported.

Abstract

Introduction and objective: To report the new scientific discoveries in physics, physiology, and medicine by one author.

Material and Methods: Results of my research are summarised. It is based on 2 clinical studies one prospective and the second case series on Hyponatremia (HN) of the transurethral resection of the prostate (TURP) syndrome. A physics study on porous orifice (G) tube proves Starling’s law is wrong. I reported prospective study on nephroptosis revealing its link with the loin pain haematuria syndrome (LPHS) and curative surgery for it.

Results: Two physics and two physiological discoveries are reported. Acute HN presents as shock during surgery. It is induced by massive gain of sodium-free fluid recognised as volumetric overload shock (VOS). Features of the multiple organ dysfunction syndrome occur, include ARDS, Acute renal failure (ARF) and Coma. The prospective study demonstrated volumetric overload is the most significant in patho-aetiology. The case series demonstrated mistaking VOS for a known shock and treating it with further volume expansion cause death. Correct diagnoses as VOS and treating it with hypertonic sodium are lifesaving. The physics study on the G tube demonstrated that proximal, akin to arterial, pressure induces suction not filtration producing the hydrodynamic phenomenon that replaces Starling’s law. The link of LPHS with nephroptosis is demonstrated by the IVU 7 sign. The curative surgery for LPHS is renal sympathetic denervation and nephropexy.

Conclusion: Dilution HN presents as shock that is mistaken for known shocks and treated with volume expansion causing death or ARDS. Manifestations include shock, ARDS, ARF and Coma. The correct treatment is hypertonic sodium. Starling s law has proved wrong. The correct replacement is the hydrodynamics of G tube. The puzzle of LPHS was also resolved.

Key words

Shock; Hyponatremia; Fluid therapy; Capillary physiology; Starling’s law; The TURP syndrome; ARDS; LPHS; Bladder cancer

This article summarises the full list of recent scientific discoveries in physics, physiology and medicine made by a single scientific medical investigator and independent researcher who was fully self-financed supported by a full list of reported articles in reputable open access journals.

The discoveries are:

Physics Discoveries

1. The hydrodynamics of the porous orifice (G) tube [1-4]

2. The Tree Branching Law (TBL) [5-8].

Physiological Discoveries

1. Proving Starling’s law for the capillary-interstitial (ISF) fluid is wrong and providing the correct replacement of the magnetic field like fluid hydrodynamics of the G tube [1-4].

2. The TBL Corrects two misconceptions on capillary physiology [4-8] namely:

a. The cross-section areas of all the capillaries are larger than the aorta.

b. The red blood cells (RBCs) speed in a capillary is thought very slow to allow for the slow perfusion of the capillary-ISF transfer as based on Starling’s forces.

Biochemical Discoveries

1. Resolving the puzzle of acute dilutional Hyponatremia identifying its path-aetiology and finding a successful curative lifesaving therapy for it: The Hypertonic Sodium Therapy (HST) of 5% NaCl and/or 8.4% NaCo3 [9-13].

2. Revealing the effects of volume kinetics on the cardiovascular system pressure [14, 15].

Medical Discoveries

1. Discovering two new types of cardiovascular shocks: the volume kinetic shocks or the volumetric overload shocks (VOS) of type one induced by sodium-free fluid and type 2 induced by sodium-based fluid retention [14, 15].

2. Resolving the puzzle of the acute respiratory distress syndrome (ARDS) by identifying its exact patho-aetiology being caused by VOS and a successful therapy of HST [16, 17].

3. Resolving the puzzle of the transurethral resection of the prostate syndrome discovering its link with ARDS and finding the successful lifesaving therapy for it like that of acute Hyponatremia [9-13].

4. In discovering the above the bridge connecting the physics, physiology, biochemistry, and medicine was constructed [16].

5. On a totally different subject, the patho aetiology of the loin pain haematuria syndrome (LPHS) was discovered revealing its link with SN, and 100% curative therapy surgery was devised [18, 19].

6. A new surgical procedure for the therapy of cancer bladder with orthotropic bladder replacement was reported [20].

Despite multiple and powerful reporting in the literature on my multiple and important scientific discoveries the whole medical world is not responding. It seems to be in a deep coma. Even the top Medical, surgical, and scientific journals including Nature, Nature Medicine, Science, Lancet, British Medical Journal, New England Journal of Medicine. Journal of The American Medical Association, The Surgeon-the Journal of the Royal College of Surgeons of Edinburgh, Physiology and Urology journals have repeatedly done serious mistakes rejecting the many articles I sent to them. They may ignore my person, but they cannot wrong any of my new discoveries. Here is a summary of my new discoveries to show you how wrong they all are.

My scientific discoveries are many and most important made over the last 32 years of my career life spent in investigating and reporting these articles. The articles recognise 2 new types of shocks and its treatment proves that Starling’s law for the capillary interstitial fluid transfer is wrong and provides an alternative mechanism: The hydrodynamics of a porous orifice (G) Tube. These discoveries resolve the puzzles of 3 syndromes discovering its patho-aetiology and new successful treatments, namely the transurethral resection of the prostate (TURP) syndrome and acute dilution Hyponatremia (HN), the acute respiratory distress syndrome (ARDS) and the loin pain haematuria syndrome (LPHS). Not only the exact patho-aetiologies of these syndromes were discovered but also successful treatments for it were found. The two new types of vascular shocks are volume kinetic shocks or VOS defined here.

Massive fluid infusions in a short time induce (VO) of two types: Type one (VOS1) and Type two (VOS2). VOS1 is induced by sodium-free fluid of 3.5-5 litres in one hour known as the TURP syndrome5 or hyponatraemic shock. VOS2 may complicate VOS1 or is induced by massive infusion of sodium-based fluids. VOS2 also complicates fluid therapy in critically ill and presents with ARDS.6 volumetric gain of 12-14 litres of sodium-based fluids reported in ARDS.

Two clinical studies to understand the TURP syndrome and recognise VOS were conducted. A prospective study on 100 consecutive TURP patients of whom ten suffered TURP syndrome. Volumetric overload was the only significant factor in causing the condition (Table 1 and Figure 1). The second study was case series of 23 cases of the TURP syndrome manifesting as VOS1. Volumetric overload quantity and type is shown in (Figure 2). Three patients died and remaining 20 patients were correctly diagnosed as VOS1 and treated with hypertonic sodium therapy (HST). Each patient passed 4-5 litres of urine followed by recovery from shock and coma. This treatment was successful in curing all patients, bringing them back from dead.

Table 1 shows 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.

Figure 1 shows the means and standard deviations of volumetric overload in 10 symptomatic patients presenting with shock and Hyponatremia among 100 consecutive patients during a prospective study on transurethral resection of the prostate. The fluids were of Glycine absorbed (Gly abs), intravenously infused 5% Dextrose (IVI) Dext) Total IVI fluids, Total Sodium-free fluid gained (Na Free Gain) and total fluid gain in litres.

Figure 2 shows volumetric overload (VO) quantity (in litres 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 expansion using isotonic saline.

A study of the hydrodynamics of the porous orifice (G) tube comparing it to that of Poiseuille’s tube was done. Measurements of pressures at various parts of a circulatory system incorporating the G tube in a chamber to mimic the capillary-interstitial fluid compartment were done. The effect of changing the proximal (arterial), the distal (venous) pressures and the diameter of the inlet on side pressure of the G tube and chamber pressure as well as the dynamic magnetic field like fluid circulation around the G tube was evaluated. The dynamic magnetic field-like fluid circulation around the G tube and surrounding it in C chamber (Figure 3) provides adequate replacement for Starling’s law. The physiological equivalent of this physics study was done on the hind limbs of sheep. It demonstrated that both saline and plasma induces ooedema when run through the vein not the artery, and the arterial pressure causes suction not filtration due to effect of pre-capillary sphincter.

Starling’s hypothesis was based on Poiseuille work on strait uniform brass tubes. Eight decades latter evidence demonstrated that the capillary is a porous narrow orifice (G) tube as it has a pre-capillary sphincter8 and pores that allow the passage of plasma proteins.9 As the capillary pores allow the passage of plasma molecules, nullifying the osmotic pressure of plasma proteins, a call for reconsideration of Starling’s hypothesis was previously made10 but there was no alternative then. The replacement came to light when the hydrodynamics of the G tube were discovered and reported in 2001.

The hydrodynamics of the G tube [1-4] (Figure 3) demonstrated that the proximal (arterial) pressure induces a negative side pressure gradient on the wall of the G tube causing suction most prominent over the proximal half and turns into positive pressure over the distal half. Incorporating the G tube in a chamber (C), representing the ISF space surrounding a capillary, demonstrated a rapid dynamic magnetic field-like fluid circulation between C and G tube lumen. Incorporating the G tube and C in a circulatory model driven by electric pump induced proximal pressure like arterial pressure: causing suction from C into the lumen of G tube.

This proves that the arterial pressure causes suction not filtration at the capillary interstitial fluid circulation, and hence Starling’s law is wrong on both forces and equations. The hydrodynamics of the G tube provide adequate correct replacement for Starling’s law. This illustrates how 2 new types of vascular shocks and a replacement of Starling’s law were discovered that have resolved the puzzles of 3 clinical syndromes of TURP, Hyponatremia and ARDS.

Figure 3 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 precapillary 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:

1. The inflow pressure pushes fluid through the orifice.

2. Creating fluid jet in the lumen of the G tube**.

3. 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.

4. The side pressure gradient turns positive pushing fluid out of lumen over the distal part maximally near the outlet.

5. 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.

6. 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.

7. 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 (Woodcock and Woodcock 2012) [3]. 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.

The TBL is a fundamental law of nature that governs the ramifications of all tress of green and red of the Aorta-arterial trees. It corrects two important misconceptions on the capillary physiology. This evidence sums up to demonstrate that the capillary-ISF transfer occurs according to a precise fast circulation of the magnetic field like fluid not the slow perfusion. That provides adequately for the demands of cells at rest and increased demand during strenuous physical activity.

On another subject, this article [12] reports the overlooked link of Loin Pain Haematuria Syndrome with Symptomatic Nephroptosis and the Results of a new curative surgery; Renal Sympathetic Denervation and Nephropexy Surgery. Two new signs namely: the IVU 7 sign (Figure 4) and tube stretch hypothesis were reported demonstrating that renal pedicle stretch causing vessel stenosis, ischaemia and neuropathy. Surgical treatment was used in 28 patients; 10 had simple nephropexy and 18 had Renal Sympathetic Denervation and Nephropexy Surgery (RSD&N) for severe LPHS. Four of patients treated with simple nephropexy had recurrence of LPHS while those who had RSD&N were all cured.

Figure 4 shows renal pedicle mapped on a supine IVU film (Horizontal) and erect film (Vertical) limbs of 7 where the renal pedicle is stretched to 3 times its normal length, causing stenosis and ischaemia.

On another subject I reported a surgical point of technique [13] for operable cancer bladder (Figure 5) in which capsule sparing cystoprostadenectomy for orthotopic bladder replacement that overcomes the problems of difficult urethral anastomosis, impotence, and incontinence.

Figure 5 shows diagrammatic representation of the technique’s dissection plane (dotted line). Starting at retro-pubic (1) space, visico-prost-adenectomy including bladder containing tumour (2), prostate gland (3) and urethra (4) are excised in mass. The gland is enucleated and urethral divided within the spared capsule (5) protecting the external sphincter (6) and neurovascular bundle (7). Extra-peritoneal division ligature of vas (8), ureter (9), superior vesical vessels (10) and anterior prostatic veins are done at the start. Branches of inferior vesical vessels (11) and seminal vesicles (12) are divided at the line of capsule division. Excision of peritoneal bladder cover opens peritoneal cavity for constructing bowel bladder replacement. Pelvic ganglion (13) and rectum (14) lie within the concavity of sacrum (15).

Conclusion:

Two new physics discoveries of the G tube hydrodynamics and tree branching law with two related wrong and correcting two misconceptions on capillary physiology, and 6 new medical discoveries are reported. These resolved the puzzles of dilution HN of the TURP syndrome that presents as shock mistaken for known shocks and treated with volume expansion causing death or ARDS. Manifestations include shock, ARDS, ARF and Coma. The correct treatment is hypertonic sodium therapy. Starling’s law has proved wrong. The correct replacement is the hydrodynamics of G tube. The puzzle of LPHS was also resolved. A new point of technique for bladder replacement was reported.

Conflict of interest: The author declares none.

Funds received: The author declares none.

References

1. Ghanem, A. N. (2001) ‘Magnetic field-like fluid circulation of a porous orifice tube and relevance to the capillary-interstitial fluid circulation: Preliminary report’, Medical Hypotheses Mar, 56 (3), 325-334.

2. Ghanem K. A. and Ghanem A. N. (2017) ‘The proof and reasons that Starling’s law for the capillary-interstitial fluid transfer is wrong, advancing the hydrodynamics of a porous orifice (G) tube as the real mechanism’, Blood, Heart and Circ, Volume 1(1), 1-7 DOI:10.15761/BHC.1000102 Available online

3. Ghanem, A.N. and Ghanem, S.A. (2016) ‘Volumetric Overload Shocks: Why Is Starling’s Law for Capillary Interstitial Fluid Transfer Wrong? The Hydrodynamics of a Porous Orifice Tube as Alternative’, Surgical Science, 7, 245-249. http://dx.DOI.org/10.4236/ss.2016.76035

4. Ghanem K. A. and Ghanem A. N. (2017) ‘Volumetric overload shocks in the patho-aetiology of the transurethral resection prostatectomy syndrome and acute dilution Hyponatremia: The clinical evidence based on 23 case series’, Basic Research Journal of Medicine and Clinical Sciences ISSN 2315-6864 Vol. 6(4) pp. xx-xx April 2017 Available online http//www.basicresearchjournals.org

5. Ghanem A. N. ‘The Tree Branching Law: Correcting misconceptions on capillary cross-section areas and blood speed’ (Under consideration).

6. Ghanem A. N. ‘Capillary ultrastructure anatomy and physiology: what is known, what is unknown or missing, what is wrong, and what is new?’ (Under consideration).

7. Ghanem A. N. ‘Final proof Starling’s law wrong and G tube correct replacement: New results and critical analytical criticisms of landmark articles’. (Under consideration).

8. Ghanem A. N. ‘New Physics Discoveries of Relevance to Capillary Physiology and Clinical Significance to Newly Recognised Volumetric Overload Shocks’. (Under consideration).

9. Ghanem A. N. and Ward J. P. (1990) ‘Osmotic and metabolic sequelae of volumetric overload in relation to the TURP syndrome’ Br J Uro, 66, 71-78.

10. Ghanem A. N. (2019) ‘Post-Surgical Hyponatremia: Problems of Management Resolved by Revealing its Relation to Volumetric Overload Shocks’. EC Cardiology 6.8.

11. Ghanem A. N. (2019) ‘Postoperative Dilution Hyponatremia and the TURP Syndrome: Critical Analytical Review of Literature on Patho-aetiology and Therapy’,. EC Emergency Medicine and Critical Care 3.8, 507-514.

12. Ghanem A. N. (2018) ‘Short Communication. Hyponatremia: Nadirs and Paradoxes of the Missing Volumetric Overload’, Open Access Journal of Surgery, Volume 10 Issue 2-December, DOI: 10.19080/OAJS.2018.10.555781

13. Ghanem A. N. ‘Therapy of Hyponatremia: End of Era or Minority Report?’, Biomed J Sci & Tech Res 11(4)-2018. BJSTR. MS.ID.002130. DOI: 10.26717/ BJSTR.2018.11.002130.

14. Ghanem A. N. (2020) ‘Volume Kinetic Shocks in Clinical Practice’, Clin Surg J 3(S3): 1-5. ©. Published by TRIDHA Scholars

15. Ghanem. (2020) ‘Volumetric Overload Shocks (VOS) in Surgical Patients’, Open Access J Surg, 11(2), 555810. DOI: 10.19080/OAJS.2020.11.555810

16. Ghanem A. N. (2020) ‘Volumetric Overload Shocks Cause the Acute Respiratory Distress Syndrome: Building the Bridge Between Physics, Physiology, Biochemistry, and Medicine’, Biomed J Sci & Tech Res 29(1), BJSTR. MS.ID.004758.

17. Ghanem A. N. (2020) ‘Volumetric Overload Shocks Cause the Acute Respiratory Distress Syndrome: The Plenary Evidence on Patho-Aetiology and Therapy’, Op Acc J Bio Sci & Res, 1(4) DOI: 10.46718/JBGSR.2020.01.000024

18. Ghanem A. N. (2016) ‘Prospective Observational Study on Loin Pain Haematuria Syndrome Complicating Symptomatic Nephroptosis and the Results of Renal Sympathetic Denervation and Nephropexy Surgery’, J Nephro Urol, 3(1), 024.

19. Ghanem S. A,, Ghanem K. A., Pindoria N, Ghanem A. N. (2017) ‘Loin Pain and Haematuria Syndrome (LPHS) Linked to Symptomatic Nephroptosis (SN) and Revealing Pedicle Stretch Causing Neuro-Ischaemia Using the New IVU 7 Sign’, Exp Tech Urol Nephrol, 1(1). ETUN.000501

20. Ghanem A. N. (2002) ‘Experience with capsule sparing cystoprostadenectomy for orthotopic bladder replacement: Overcoming the problems of impotence, incontinence, and urethral anastomosis’, BJU International, 90, 617-620. DOI: 10.1046/j.1464-4096.2002.02960.x

Ghanem’s Publications:

Original Articles:

1. Ghanem A. N. ‘The Tree Branching Law: Correcting misconceptions on capillary cross-section areas and blood speed’ (Under consideration).

2. Ghanem A. N. Capillary ultrastructure anatomy and physiology: what is known, what is unknown or missing, what is wrong, and what is new? (Under consideration).

3. Ghanem A. N. Final proof Starling’s law wrong and G tube correct replacement: New results and critical analytical criticisms of landmark articles. (Under consideration).

4. Ghanem A. N. New Physics Discoveries of Relevance to Capillary Physiology and Clinical Significance to Newly Recognised Volumetric Overload Shocks. (Under consideration).

5. Ghanem A. N. Volume Kinetic (VK) Shock or Volumetric overload shocks (VOS) in surgical patients. (Under consideration).

6. Ghanem A. N. (2020) ‘Volumetric Overload Shocks Cause the Acute Respiratory Distress Syndrome: Building the Bridge Between Physics, Physiology, Biochemistry, and Medicine’, Biomed J Sci & Tech Res 29(1), BJSTR. MS.ID.004758.

7. Ghanem, (2020) ‘Volumetric Overload Shocks Cause the Acute Respiratory Distress Syndrome: The Plenary Evidence on Patho-aetiology and Therapy’, Op Acc J Bio Sci & Res, 1(4). DOI: 10.46718/JBGSR.2020.01.000024

8. Ghanem A. N. (2020) ‘Volume Kinetic Shocks in Surgical Practice’, J Emerg. Med Trauma Surg. Care 2: 010.

9. Ghanem A. N. (2020) ‘Twenty-one reasons affirming Starling’s law on the capillary-interstitial fluid transfer wrong and the correct replacement is the hydrodynamic of the porous orifice (G) tube’, Case Rep Open Access J., I(1), 8-11

10. Ghanem A. N. (2020) ‘Volume Kinetic Shocks in Clinical Practice’, Clin Surg J 3(S3), 1-5. © The Authors. Published by TRIDHA Scholars

11. Ghanem A. N. (2020) ‘The Correct Replacement for the Wrong Starling’s law is the Hydrodynamic of the Porous Orifice (G) Tube: The Complete Physics and physiological Evidence with Clinical Relevance and Significance’, Research Article. Cardiology: Open Access Op Acc J Bio Sci & Res 1(4)

12. Ghanem A. N. (2020) ‘New Discoveries in Medicine and Physiology Originated in Urology’, Surg Med Open Acc J.3(3), SMOAJ.000564.. DOI: 10.31031/SMOAJ.2020.03.000564.

13. Essayed Yasmina Saad, Khalid A Ghanem, Salma A Ghanem, Nisha Pindoria and Ahmed N Ghanem Review Article (2019) ‘Volumetric Overload Shocks (VOS) Resolving the Puzzle of the Transurethral Resection of the Prostate (TURP) Syndrome, Dilution Hyponatremia (HN) and the Acute Respiratory Distress Syndrome (ARDS): The Minority Report!’, EC Cardiology, 6.2, 109-122.

14. Ghanem A. N. (2019) ‘Does Raising the Central Venous Pressure (CVP) in Treating Shock with Fluids Induce Volumetric Overload Shocks (VOS)?’, Adv Card Res 1(5), ACR.MS.ID.000120. DOI: 10.32474/ACR.2019.01.000121.

15. Ghanem A. N. (2019) ‘Fluid Resuscitation in Shock: Mini Review. Why Starling’s Law Is Wrong?’, Surgery & Case Studies: Open Access Journal, June 06, DOI: 10.32474/SCSOAJ.2019.02.000149

16. Ghanem A. N. ‘Short Communication. The Scientific Basis of Fluid Resuscitation in Shock: Why Starling’s Law is Wrong?’ Scholarly J Surg, Vol: 2, Issue: 1 (01-04)

17. Ghanem A. N. (2020) ‘Hyponatremia: Something old, Something New and Something for the Surgeon’, Surg Online J, 1(1): 1001. Copyright: © Ahmed N Ghanem Publisher Name: Medtext Publications LLC

18. Ghanem A. N. (2020) ‘Volumetric Overload Shocks (VOS) Causing the Acute Respiratory Distress Syndrome (ARDS): The Complete Evidence’, EC Emergency Medicine and Critical Care 4.2, 01-08.

19. Ghanem. (2020) ‘Volumetric Overload Shocks (VOS) in Surgical Patients’, Open Access J Surg, 11(2), 555810. DOI: 10.19080/OAJS.2020.11.555810

20. Ghanem A. N. (2019) ‘Medical World Wake Up, Pay Attention and Listen: Ghanem’s New Scientific Discoveries in Medicine Physiology, Urology, Nephrology, Cardiovascular and Surgery’, EC Clinical and Medical Case Reports, 2.9 01-06.

21. Ghanem A. N. (2019) ‘Post-Surgical Hyponatremia: Problems of Management Resolved by Revealing its Relation to Volumetric Overload Shocks’, EC Cardiology 6.8

22. Ghanem A. N. (2019) ‘Postoperative Dilution Hyponatremia and the TURP Syndrome: Critical Analytical Review of Literature on Patho-aetiology and Therapy’, EC Emergency Medicine and Critical Care, 3.8, 507-514.

23. Ghanem A. N. (2018) ‘Short Communication. Hyponatremia: Nadirs and Paradoxes of the Missing Volumetric Overload’, Open Access Journal of Surgery, Volume 10 Issue 2, DOI: 10.19080/OAJS.2018.10.555781

24. Ahmed N G. (2018) ‘The Adult Respiratory Distress Syndrome: Volumetric Overload Shocks in Patho-aetiology, Correcting Errors and Misconceptions on Fluid Therapy, Vascular and Capillary Physiology’, Surg Med Open Acc J. 2(2), SMOAJ.000534.2018. DOI: 10.31031/SMOAJ.2018.02.000534

25. Ghanem A. N. (2018) ‘Albumen does not work: what alternative hypothesis for Starling’s capillary-interstitial transfer is there? The hydrodynamics of the porous orifice tube’, Journal of Surgical Research and Therapeutics, 1(1), 03-05

26. Ghanem K. A., Ghanem S. A., Pindoria N, Ghanem A. N. (2018) ‘The Role of Intravenous Urography with Erect Film and Retrograde Pyelography in Revealing Patho-aetiology of the Loin Pain and Haematuria Syndrome by Discovering its Overlooked Link with Symptomatic Nephroptosis’, J Urol Res 5(3), 1108.

27. Ghanem A. N., Salma A. G., Khalid A. G., Nisha P, Yasmina S. E. (2019) ‘Illusive Dynamic Nadirs and Masks of Postoperative Hyponatremia and the TURP Syndrome: Volumetric overload over time (VO/T) concept for resolving its puzzle’, JOJ Uro & Nephron, 6(4), 555691. DOI: 10.19080/JOJUN.2019.06.555691

28. Yasmina Saad El Sayed, Khalid A Ghanem, Salma A Ghanem, Nisha Pindoria, Ahmed N Ghanem (2019) ‘Bilateral blindness complicating the transurethral resection of the prostate (TURP) surgery’, Opth Clin Ther, 3(1), 3-5.

29. Ghanem A. N. (2019) ‘Randomised Trials in Surgery: Problems and Possible Solutions: At last, Sense and Diamonds have been recovered from an Ocean of Nonsense’, Am J Biomed Sci & Res, 2(2), AJBSR.MS.ID.000577. Received: March 20, | Published: April 02, 2019

30. Ahmed N G, Khalid A G, Nisha P, Salma A G. (2018) ‘Loin Pain and Haematuria Syndrome (LPHS) Complicating Symptomatic Nephroptosis (SN), Cured with Renal Sympathetic Denervation and Nephropexy (RSD&N) Surgery: Case Report’, Open Access J Surg, 10(1), 555779. DOI: 10.19080/OAJS.2018.10.555779.

31. Ghanem A. N., Ghanem K. A., Pindoria N, Ghanem S. A.. (2018) ‘Loin Pain and Haematuria Syndrome (LPHS) Complicating Symptomatic Nephroptosis (SN), Cured with Renal Sympathetic Denervation and Nephropexy (RSD & N) Surgery’, Ann Clin Case Rep, 3, 1552

32. Ghanem A. N. (2019) ‘Shock in Polytrauma: Highlighting the Volumetric Overload Shocks and Hydrodynamic Phenomenon of the Porous Orifice (G) Tube’, EC Emergency Medicine and Critical Care, 3.1, 29-33

33. Ghanem A. N. (2019) ‘The Scientific Basis of Fluid Resuscitation in Shock: Why Starling’s Law is Wrong?’, Scholarly J Surg, Vol: 2, Issue: 1 (01-04)

34. Ghanem A. N. (2018) ‘Therapy of Hyponatremia: End of Era or Minority Report?’, Biomed J Sci & Tech Res 11(4), BJSTR. MS.ID.002130. DOI: 10.26717/ BJSTR.2018.11.002130.

35. Ghanem A. N. et al. (2019) ‘Volumetric Overload Shocks (VOS) Resolving the Puzzle of the Transurethral Resection of the Prostate (TURP) Syndrome, Dilution Hyponatremia (HN) and the Acute Respiratory Distress Syndrome (ARDS): The Minority Report!’, EC Cardiology, 6.2, 109-122.

36. Ghanem A, (2019) ‘Peer Review of Statistics in Surgical Research: Identify the X-Factor or Toss a Coin!’, COJ Tech Sci Res, 2(1), COJTS.000526.2019.

37. Ahmed N. Ghanem, Salma A. Ghanem, Khalid A. Ghanem A. N. D., Nisha Pindoria. (2018) ‘The transurethral resection of the Prostate (TURP) syndrome and acute dilutional Hyponatremia (HN): A comprehensive literature review from first incidence in 1947 to disappearance in 2018’, Global Journal of Urology and Nephrology, 1:7

38. Ahmed N Ghanem. (2019) ‘Loin Pain Haematuria Syndrome Complicating Nehroptosis: Case Report’, Biomed J Sci & Tech Res 16(2)-2019. BJSTR. MS.ID.002834

39. Ghanem A. N. (2016) ‘Prospective Observational Study on Loin Pain Haematuria Syndrome Complicating Symptomatic Nephroptosis and the Results of Renal Sympathetic Denervation and Nephropexy Surgery’, J Nephro Urol, 3(1), 024.

40. Ghanem S. A., Ghanem K. A., Pindoria N, Ghanem A. N. (2017) ‘Loin Pain and Haematuria Syndrome (LPHS) Linked to Symptomatic Nephroptosis (SN) and Revealing Pedicle Stretch Causing Neuro-Ischaemia Using the New IVU 7 Sign’, Exp Tech Urol Nephrol, 1(1), ETUN.000501

41. Ghanem A. N., Ghanem K. A., Pindoria N, Ghanem S. A. (2018) ‘Loin Pain and Haematuria Syndrome (LPHS) Complicating Symptomatic Nephroptosis (SN), Cured with Renal Sympathetic Denervation and Nephropexy (RSD&N) Surgery: Case Report’, Open Access J Surg, 10(1), 555779. DOI: 10.19080/OAJS.2018.10.555779.

42. Ghanem A. N., Ghanem K. A., Pindoria N, Ghanem S. A. (2018) ‘Loin Pain and Haematuria Syndrome (LPHS) Complicating Symptomatic Nephroptosis (SN), Cured with Renal Sympathetic Denervation and Nephropexy (RSD & N) Surgery’, Ann Clin Case Rep., 3, 1552.

43. Ghanem K. A., Ghanem S. A., Pindoria N, Ghanem A. N. (2018) ‘The Role of Intravenous Urography with Erect Film and Retrograde Pyelography in Revealing Patho-aetiology of the Loin Pain and Haematuria Syndrome by Discovering its Overlooked Link with Symptomatic Nephroptosis’, J Urol Res, 5(3), 1108.

44. Ghanem A. N., Ghanem S. A., Ghanem K. A. and Pindoria N, Essayed Y. S. (2019) ‘Illusive Dynamic Nadirs and Masks of Postoperative Hyponatremia and the TURP Syndrome: Volumetric overload over time (VO/T) concept for resolving its puzzle’, JOJ Uro & nephron, 6(4), 555691. DOI: 10.19080/JOJUN.2019.06.555691

45. Ghanem A N. (2018) ‘Hyponatremia: Nadirs and Paradoxes of the Missing Volumetric Overload’, Open Access J Surg, 10(2), 555781. DOI: 10.19080/OAJS.2018.10.555781.

46. Ghanem A. N., Ghanem S. A., Ghanem K. A., Pindoria N, Elssayed Y. S. (2019) ‘Illusive Dynamic Nadirs and Masks of Postoperative Hyponatremia and the TURP Syndrome: Volumetric overload over time (VO/T) concept for resolving its puzzle’, JOJ uro & nephron. 6(4), 555691. DOI: 10.19080/JOJUN.2019.06.555691

47. Ghanem A. N. (2018) ‘The Adult Respiratory Distress Syndrome: Volumetric Overload Shocks in Patho-aetiology: Correcting Errors and Misconceptions on Fluid Therapy, Vascular and Capillary Physiology’, Surg Med Open Acc J., 2(2), SMOAJ.000534.2018. DOI: 10.31031/SMOAJ.2018.02.000534

48. Ghanem A. N. (2018) ‘Albumen does not work: what alternative hypothesis for Starling’s capillary-interstitial transfer is there? The hydrodynamics of the porous orifice tube’, J Surg Res Ther, 1(1), 03-05

49. Ghanem A. N., Ghanem S. A., Ghanem K. A. and Nisha Pindoria. (2018) ‘Volumetric Overload Shocks in the Patho-aetiology of the Transurethral Resection Prostatectomy (TURP) Syndrome and Acute Dilution Hyponatremia: The Complete Evidence’, Open Access J Surg, 7(5), 555724. DOI:10.19080/OAJS.2018.07.555724

50. Ghanem K. A., Ghanem A. N. (2017) ‘The Physiological Proof that Starling’s Law for the Capillary-Interstitial Fluid Transfer is Wrong: Advancing the Porous Orifice (G) Tube Phenomenon as Replacement’, Open Acc Res Anatomy, 1(2), OARA.000508. 2017

51. Ghanem A. N. (2018) ‘How the Puzzles of the Transurethral Resection of the Prostate (TURP) Syndrome and the Adult Respiratory Distress Syndrome (ARDS) were Resolved? Discovering Volumetric Overload Shocks’, COJ Tech Sci Res., 1(3), COJTS.000511.

52. Ghanem K. A., Ghanem S. A., Pindoria N, Ghanem A. N. (2018) ‘The Role of Intravenous Urography with Erect Film and Retrograde Pyelography in Revealing Patho-aetiology of the Loin Pain and Haematuria Syndrome by Discovering its Overlooked Link with Symptomatic Nephroptosis,’ J Urol Res, 5(3), 1108.

53. Ghanem A. N., Ghanem K. A., Pindoria N, Ghanem S. A. (2018) ‘Loin Pain and Haematuria Syndrome (LPHS) Complicating Symptomatic Nephroptosis (SN), Cured with Renal Sympathetic Denervation and Nephropexy (RSD & N) Surgery’, Ann Clin Case Rep., 3, 1552

54. Ghanem A. N. (2018) Volumetric Overload Shocks (VOS) in the patho-aetiology of the Adult Respiratory Distress Syndrome (ARDS): correcting errors and misconceptions, Clinical Cardio Cardiovascular Med 2, 12-16

55. Ghanem K. A., Pindoria N, Ghanem S. A., Ghanem A. N. (2018) ‘Volumetric Overload Shocks (VOS) Causing the Transurethral Resection of the Prostate (TURP) Syndrome: Case Reports’, Ann Clin Case Rep., 3, 1551.

56. Ghanem A. N. (2018) ‘Ghanem’s New Discoveries in Medicine, Physiology and Urology and Nephrology?’, Exp Tech Urol Nephrol. 2(2). ETUN.000531.2018. DOI: 10.31031/ETUN.2018.02.000531

57. Ghanem, A.N. (2017) ‘Editorial: New discoveries in Urology, Medicine and Physiology’, Open Acc Res Anatomy, 1(1), OARA.000502. 2017.

58. Ghanem A. N. (2018) ‘Ghanem’s New Discoveries in Medicine, Physiology and Urology and Nephrology?’, Exp Tech Urol Nephrol, 2(2), ETUN.000531.2018. DOI: 10.31031/ETUN.2018.02.000531

59. Ghanem, A.N. and Ghanem, S.A. (2016) ‘Volumetric Overload Shocks: Why Is Starling’s Law for Capillary Interstitial Fluid Transfer Wrong?’, The Hydrodynamics of a Porous Orifice Tube as Alternative. Surgical Science, 7, 245-249. http://dx.DOI.org/10.4236/ss.2016.76035

60. Ghanem S. A., Ghanem K. A., Ghanem A N. (2017) ‘Volumetric Overload Shocks in the Patho-aetiology of the Transurethral Resection of the Prostate (TURP) Syndrome and Acute Dilution Hyponatremia: The Clinical Evidence Based on Prospective Clinical Study of 100 Consecutive TURP Patients’, Surg Med Open Access J., 1(1),1-7

61. Ghanem K. A. and Ghanem A. N. (2017) ‘Volumetric overload shocks in the patho-aetiology of the transurethral resection prostatectomy syndrome and acute dilution Hyponatremia: The clinical evidence based on 23 case series’, Basic Research Journal of Medicine and Clinical Sciences, ISSN 2315-6864 Vol. 6(4), pp. 35-43 April

62. Ghanem K. A. and Ghanem A. N. (2017) ‘The proof and reasons that Starling’s law for the capillary-interstitial fluid transfer is wrong, advancing the hydrodynamics of a porous orifice (G) tube as the real mechanism’, Blood, Heart and Circ, Volume 1(1), 1-7. DOI: 10.15761/BHC.1000102 Available online.

63. Pindoria N, Ghanem S. A., Ghanem K. A. and Ghanem A. N., (2017) ‘Volumetric overload shocks in the patho-aetiology of the transurethral resection prostatectomy syndrome and acute dilution Hyponatremia’, Integr Mol Med, DOI: 10.15761/IMM.1000279 Available online

64. Ghanem KG, Ghanem A. N. (2017) ‘The Physiological Proof that Starling’s Law for the Capillary-Interstitial Fluid Transfer is Wrong: Advancing the Porous Orifice (G) Tube Phenomenon as Replacement’, ‘Open Acc Res Anatomy, 1(2), OARA.000508. 2017.

65. Ghanem S. A. and Ghanem A. N. (2016) ‘Prospective Observational Study on Loin Pain Haematuria Syndrome Complicating Symptomatic Nephroptosis and the Results of Renal Sympathetic denervation and Nephropexy Surgery’, J Nephro Urol., 3(1), 024.

66. Ghanem S. A.lma A, Ghanem Khalid A, Pindoria Nisha, Ghanem A. N. (2017) ‘Loin Pain and Haematuria Syndrome (LPHS) Linked to Symptomatic Nephroptosis (SN) and Revealing Pedicle Stretch Causing Neuro-Ischaemia Using the New IVU 7 Sign’, Exp Tech Urol Nephrol., 1(1), 2-6. ETUN.000501.

67. Ghanem A. N. (2002) ‘Experience with cystoprostadenectomy with prostatic capsule sparing for orthotopic bladder replacement: overcoming the problems of impotence, incontinence, and difficult urethral anastomosis’, BJU Int., October 2002, 90(6), 617-620

68. Ghanem A. N. (2002) ‘Leading Article. Features and Complications of Nephroptosis Causing the Loin Pain and Haematuria Syndrome: Preliminary Report’, Saudi Med. J., Feb, 23(2), 447-455

69. Ghanem A. N. (2001) ‘Magnetic field-like fluid circulation of a porous orifice tube and relevance to the capillary-interstitial fluid circulation: Preliminary report’, Medical Hypotheses 2001 Mar, 56 (3), 325-334.

70. Ghanem A. N., Ward J. P. (1990) ‘Osmotic and metabolic sequelae of volumetric overload in relation to the TURP syndrome’, Br J Uro., 66, 71-78 (Award Winner of Princess Alice Memorial Award, UK 1988).

71. Ghanem A. N., (1987) ‘Brooks PL Gastric gangrene complicating adult Bochdalek hernia’, Br J Surg, 74, 779.

72. Ghanem A. N., Perry K. C. (1985) ‘Malignant Lymphoma as a complication of Uretero-sigmoidostomy’, Br J Surg; 72, 559-60.

73. Ghanem A. N. (1988) The Transurethral Prostatectomy (TURP) Syndrome: An Investigation of the Osmotic and Metabolic sequelae of Volumetric Overload (VO) MD Thesis, Institute of Urology & Nephrology, Mansoura University, Egypt. November 6, 1988.

Conference Presentations:

1. Volumetric overload shocks in the patho-aetiology of the transurethral resection prostatectomy syndrome and acute dilution Hyponatremia. Cardiovascular 2017 Conference London, March 2017.

2. Hypo-osmotic shock: not uncommon condition identified through prospective study on the not so rare TURP syndrome? 25th Annual Meeting of the Egyptian Association of Urological Surgery held on 16-19 October 1990 Cairo, Egypt.

3. Volumetric overload in relation to the TURP syndrome. 25th Annual Meeting of the Egyptian Association of Urological Surgery held on 16-19 October 1990 Cairo, Egypt.

4. How much 1.5% Glycine is absorbed during the TURP procedure? EAUS 1991

5. The TURP syndrome update 28th Annual Meeting of EAUS Cairo, Egypt 1993

6. Results of renal sympathetic denervation and Nephropexy in 31 kidneys of 28 patients suffering from symptomatic nephroptosis 12th Saudi Urological Conference, Taif 22-25 February 1999.

7. Volumetric overload shocks in the pathogenesis of the TURP syndrome. 6th International Conference of the Mediterranean Urological Association. Cairo Sept 1999.

8. New methods for the objective assessment of pain and results of renal sympathetic denervation and nephropexy for symptomatic nephroptosis 6th International Conference of the Mediterranean Urological Association. Cairo Sept 1999.

9. Loin pain Haematuria syndrome complicating symptomatic nephroptosis. Urological Club, Military Hospital, Khamis Masheet Saudi Arabia 1999

10. On the pathogenesis and therapy of the TURP syndrome: a prospective randomised study. Saudi Urological club, 1999. Won the best presentation award

11. Painful Haematuria: Time to upright patients imaging and issues? 13th Saudi Urological Conference Feb 2000.

12. Vascular Volumetric Overload (VO) shocks in the pathogenesis of the TURP syndrome and conditions for life saving 5% NaCl Therapy. ? 13th Saudi Urological Conference Feb 2000.

13. Presentations on Genito-urinary Trauma, Penile Trauma, Cystoprostadenectomy and symptomatic nephroptosis at Hamad Medical Corporation, Qatar 2004

14. In November 2006, the above topics were presented at DGH, Eastbourne UK.

Letters To the Editor of Peer Reviewed Journals

1. Ghanem A. N. (2003) ‘Validation of the ethanol breath test and on-table weighing to measure irrigation absorption during transurethral prostatectomy’, BJU Int. 2003 Jul; 92(1), 154

2. Ghanem A. N. (2003) ‘Intra-Ureteric Capsaicin In Loin Pain Haematuria Syndrome: Efficacy And Complications’, BJU Int. 2003 Mar; 91(4), 429-31.

3. Ghanem A. N., Powley J. M. (1985) ‘Hepatic outflow obstruction’, Lancet, ii: 675.

4. Ghanem A. N. (1985) ‘Hypoalbuminaemic Hyponatraemia: a new syndrome’, Br Med. Jour., 291, 1502

5. Wojtulewski JA, Penney MD. Ghanem A. N. (1987) ‘Dangers in treating Hyponatremia’,. Br Med Jour., 294, 837.

6. Ghanem A. N. (1987) ‘Serum osmolality gap’, Lancet; ii: 223-4.

7. Ghanem A. N. Ward J. P., (1988) ‘Fluid absorption during urological surgery’, Br J Uro,; 61, 168-9.

8. Ghanem A. N. (1988) ‘Hyponatremia and hypo-osmolality’, Lancet; ii: 572.

9. Ghanem A. N. (1998) Microwave Thermotherapy: Long-term follow up. Br J Uro, 82; 314.

10. Ghanem A. N. (1999) ‘The drawbacks of Overspecialisation’, J R Coll Surg Edin, 44(2), 137.

11. Ghanem A. N. (1999) Religious circumcision: a Moslem view’, BJU Int., 84; 543.

12. Ghanem A. N. (1999) ‘Frequency and causes of fluid absorption: a comparison of the three techniques for resection of the prostate under continuous pressure monitoring’, BJU Int, 84, 891-2.

13. Ghanem A. N. (2000) ‘Monitoring the critically ill patient’, J R Coll Surg Edinb, 45 (2), 138-9.

14. Ghanem A. N. (2000) ‘The Urology of Pharaonic Egypt’, BJU Int., 85; 973-4

15. Ghanem A. N. (2000) ‘Radical cystectomy and ilial conduit for bladder tumour’, J R Cull Surg Ed, 45(3), 204

16. Ghanem A. N. (2000) ‘Guidelines and Code of Ethics’, Saudi Med Jour Jul, 21(7), 694.

17. Ghanem A. N. (2000) ‘Disparaged Nephroptosis’, Urology®, 56, 183

18. Ghanem A. N. (2000) ‘Early experience of intra-ureteric capsaicin infusion in loin pain haematuria syndrome’, BJU Int, 86(7),911-4.

19. Ghanem A. N. (2001) ‘Current management of renal and ureteral stones’, Saudi Med. J. Dec 22 (12),1143-5.

20. Ghanem A. N. (2002) ‘Urinary Tract Infection’, Saudi Med. J. Jan 23 (1),118-9.

21. Ghanem A. N. (2002) ‘Hyponatremia during and after TUR prostatectomy’, Saudi Med J., 23 (4), 477-9

22. Ghanem A. N., Halim I. A. (2002) ‘Necrotising Fasciitis’, Saudi Med. J. May; 23(5): 607-610

23. Ghanem A. N. (2002) ‘Haematuria investigation based on a standard protocol’, J R Coll Surg Edinb. Dec;47(6):772

24. Ghanem A. N. (2003) ‘Fracture pens in Karmanshah’, Iran. BJU Int. Feb; 91 (3): 301-3

NON-PEER REVIEWED PUBLICATIONS

Rapid Response Letters to BMJ

25. Something old, something new and something frivolous-about Hyponatremia. Ghanem A. N. BMJ.com/cgi/eletters/321/7266/0#10259, 15 Oct 2000

26. Hyponatremia: nadirs and paradox of the missing volumetric overload. Ghanem A. N. BMJ.com/cgi/eletters/322/7289/780#13979, 24 Apr 2001

27. Preventing renal failure in the critically ill: identifying the problem and finding solution. Ghanem A. N. BMJ.com/cgi/eletters/322/7300/1437#15409, 2 Jul 2001

28. Ghanem A. N. Beating round the bush! BMJ.com/cgi/eletters/322/7294/DC2#14821 29 May 2001

29. Flank pain, haematuria, and urinary tract infection: time to upright patients, images and issues? Ghanem A. N. BMJ., 11 Mar 2002

30. Peer review of statistics in medical research: Identify the X-factor or toss a coin! Ghanem A. N. 29 May 2002.

31. At last, sense and diamonds have been recovered from an ocean of nonsense. Ghanem A. N. BMJ, 20 Jun 2002

32. Good doctor, what makes a good surgeon? Ghanem A. N. BMJ.com/cgi/eletters/324/7353/DC1#23670, 6 Jul 2002

33. Good Doctor, what about the unknown hero soldiers of medicine? Ghanem A. N. BMJ.com/cgi/eletters/324/7353/DC1#23758, 9 Jul 2002

34. Good doctor, further thoughts, and more questions than answers. Ghanem A. N. BMJ.com/cgi/eletters/324/7353/DC1#23812, 11 Jul 2002

35. Good doctor, what is the problem? Ghanem A. N. BMJ.com/cgi/eletters/, 14 Jul 2002

36. Good doctor and sense of humour. Ghanem A. N.

37. Doctor Average, Good and Excellent Mozart of science. Ghanem A. N.

38. Top doctor, the day the Professor met the President. Ghanem A. N. BMJ.com/cgi/eletters/325/7356/DC1#24125, 22 Jul 2002

39. Motor Car Accidents: more dangerous than Bullets in civilian life? Ghanem A. N. BMJ.com/cgi/eletters/324/7346/0/j#22351, 20 May 2002

40. Treating simple small superficial hand wounds: What does the excellent RCT prove? Ghanem A. N. BMJ, 15 Aug 2002

41. Dysnatremia or Hyponatremia: highlighting the volumetric overload/time (VO/T) concept. Ghanem A. N. Rapid response BMJ Feb 17, 2003.

42. Why Albumen Does not Work? Ghanem A. N. Rapid response BMJ 14 April 2004.

43. Albumin Versus Albumin. Ghanem A. N. Rapid response BMJ 22/11/2006

44. SAFE as SAC (Save Albumin Campaign). Ghanem A. N. Rapid response BMJ 22/11/2006

General and Medical Publications:

45. Paper Wars. [Arabic] Al-Megallah, October 1977.

46. Born in the USA. (Computers). British Mac User 1985; 2: 3.

47. Prostatic stent in 110 years old man. Saudi National Newspaper 1993

48. Orthotopic Bladder replacement for cancer bladder. Saudi National Newspaper 1994

49. Male infertility; causes and management. Najran Health Magazine 1996.

50. Management of BPH. Najran Health Magazine 1997

51. The hair clip in the stone! Najran Health Magazine 1997

52. Ptosed Kidneys in Najrani Women. Najran Health Magazine 1998

Chapter 2

The Scientific Basis of Fluid Resuscitation in Shock: Why Starling’s Law Is Wrong?

Editorial

Professor Fifner’s article on saline versus albumin fluid evaluation (SAFE) 2006 [1], concluding: saline or albumin produces similar outcome. In 1998 meta-analysis, albumin fared worse [2], justifying BMJ slogan Why albumin may not work. This is conflicting and perplexing. Professor Vincent [3] mentioned in his editorial at BMJ: the aim of the analysis was to show that albumin administration is safe. I wish all the luck with the Save Albumin Campaign" and confirm that I do not deny albumin safety and usefulness when indicated. The valid painstaking analysis of data and the conclusion of similar or worse outcome, to my mind, re-affirms the fact that albumin oncotic pressure in VIVO is fallacy [3-6], explaining BMJ slogan. It is shameful waste to spend so much effort and money on huge clinical trials, on the wrong basic notion that albumin oncotic pressure exists in VIVO. My aim here, however, is to discuss issues overlooked in all SAFE trials data analysis highlighting a concept that may help to resolve the conflict and more importantly the problems of concerned acutely ill patients on ICU.

Fifner mentioned in discussion: Patients received the amount of fluid the clinician thought necessary to restore or maintain intravascular volume I applaud the truthful reality of this statement, and believe it pinpoint precisely where the problems are (highlighted here). Thus, if the volume of the given fluid during resuscitation is quantified half the battle is won, and if the scientific basis underlying the thought that mislead physician to infuse such volume is verified and rectified the battle is over. In a letter on the BMJ editorial, I mentioned that SAFE trials and analysis are concerned only with the Type of fluid, albumin versus saline, while missing the important issue of volume, measured in either volumetric or gravimetric method.

Volumetric overload (VO) over Time (VO/T) is a concept verifiable by comparing patients’ body weight on ICU to that on hospital admission. This reveals a staggering VO! In 1967, Professor Ashbaugh et al documented fluid gain in the first report on the acute respiratory distress syndrome (ARDS) [7,8], which became later known as the multiple vital organ dysfunction or failure (MODS /F) syndrome. It was 12-14 litres. Such VO data have not ever since been documented. It is consistently missed in prospective trials. Not a single prospective SAFE or other trial report volumetric data on MODS patients!

Fluid Type and Volume, and Time of gain, have vital significance in the pathogenesis and outcome of MODS patients on ICU. Type of fluid gives characteristic serum solute dilution markers. Volume is directly, while time is inversely, related to the severity. Sodium-free fluids (Type 1) or VO1 dilute all serum contents including albumin, but its best marker is Hyponatremia. The well-known transurethral resection of the prostate (TURP) [9] syndrome is a clean model of many such Hyponatremia cases seen in clinical practice. A Clean model of TURP syndrome means it can be, and has been, precisely reproduced in animals in the absence of sepsis, hypothermia, and recognised shocks. Hyponatremia is common hospital complication of fluid therapy that affects men, women and children and is usually lethal.

The TURP syndrome is induced by both the irrigating fluid absorption (1.5% Glycine, Sorbitol or Mannitol) and the infused intravenous fluids such as 5% Glucose [9]. A quantity of 3.5 L, gained during 1-hour surgery, induces a classical condition while 5-6 L may be lethal. The VO of 3.5 L may be considered normal daily intake and is tolerated over couple of hours but when gained in one hour it becomes pathological. The condition manifests clinically with paradoxical hypotension shock (Paradoxical means hyper-NOT hypo-volaemic shock) with features unrecognisable from or identical to hypo-volaemic shock except for bradycardia and transient rare elevation of arterial pressure. It also has paradoxical acute renal failure (ARF) among other features of the MODS syndrome. This must be kept in mind in order to recognise VO/T, induced by SAFE fluids, with scarce markers if any. This is important as the TURP procedure is currently performed in saline irrigation (TURIS), so much more VO/T with scarce or no markers will soon appear.

The common thought and practice of treating physician in such paradoxical VO/T shock is to infuse further volume of SAFE isotonic fluid! He/she aims to elevate pressure by increasing vascular volume in the belief that he is facing hypovolaemic hypotension shock, while data indicate VO/T shock. The action just makes it worse or irreversible shock and establishes MODS when the patient is shifted to ICU. The insult of both SAFE isotonic fluids may occur in resuscitating the TURP syndrome with definite characteristic serum markers and proven clinical features, or may complicate overzealous resuscitation of any recognised shock, trauma, or ICU patient when serum markers are scarce or nil. Nothing to guide physician at all except his thought determined by current basic teaching on vascular volume/ pressures relationship on one hand, and the forces regulating the capillary circulation on the other. The latter determine the type and volume of SAFE fluid used in resuscitation of shock, trauma, burns, haemorrhage, and sepsis.

Sodium-based fluids (VO2) such as saline or albumin induce VO/T