bluuebunny/crossref_metadata_2025 huggingface dataset:
999 Ambulance or Blue-Light Taxi Service?: The South Glasgow Experience
Authors: Cowan G M , Gordon M W G , Munro P T
Published: January 2017

Objectives: To determine whether patients brought to the Accident and Emergency (A&E) Department by 999 ambulance genuinely need to attend hospital. Methods: Prospective cohort study of 314 patients transported to the A&E department of the Southern General Hospital by 999 ambulances during a 3-week study period. Additional information was gathered from A&E and in-patient case records. Results: Complete data was available for 290/314 (92.4%) patients. 126 (40.1%) of 999 ambulances arrived between 9am and 5pm, 127 (40.4%) between 5pm and 1am and 61 (19.4%) between 1am and 9am. 202 patients (73.1%) had one or more investigations carried out in the A&E department. 32 (11.0%) had a dressing, 118 (40.7%) had drugs prescribed, 27 (9.3%) had sutures and 4 (1.4%) had a plaster cast applied. 179 (57%) patients were referred to inpatient specialties and 95 (30.3%) were discharged without follow up, 23 (7.9%) of these having required no investigations or treatment. 16 (5.1%) were discharged to outpatient follow up, 6 (1.9%) were transferred to another hospital and 2 patients (0.6%) died. 16 patients (5.1%) discharged themselves against medical advice. Conclusions: The majority of patients currently brought to hospital by 999 ambulance attend appropriately. Over 90% of patients receive investigations or treatment or are admitted. The introduction of prioritisation and telephone advice is unlikely to reduce the number of patients requiring transport to hospital.
Short Stay Head Injuries and the Accident and Emergency Department
Authors: Paterson B , Ramdarshan M , Morrison W
Published: January 2017

Objective: To examine the aetiology and outcome of patients admitted to the Accident and Emergency Short Stay ward with a head injury. Method: Prospective, observational, hospital based cohort study with 8 week follow up. This was conducted in the Accident and Emergency Department, Ninewells Hospital, Dundee. The subjects studied were all patients admitted to the Short Stay ward with a head injury. Results: 78 patients returned usable replies at 8 weeks, a response rate of 37.3%. Falls (55.1%) and assaults (20.5%) were the main cause of admission. Alcohol was involved in 58.1% of falls and 75% of assaults. Post Concussion Symptoms were more frequently associated with those under forty years old and those who had been assaulted. Post Head Injury scores were highest in those under forty seven years and associated with assault. Conclusion: The identification of specific groups, who have higher Post Concussion and Post Head Injury scores, allows possible intervention prior to leaving hospital to try and reduce morbidity. A follow up study assessing intervention by a coping strategy is now under way.
Endocardial Fibroelastosis with Embolism
Authors: Barclay G. P. T. , Morgan H. M. , Millen J. C. C. , MacArthur P.
Published: January 2017

The clinical and pathological features of an unusual type of infantile endocardial fibroelastosis with intra-cardiac thrombus formation and peripheral emboli are described as encountered in a Scottish boy aged 10 months. The rarity of this condition in Europe and America is contrasted with its frequency in Africa.
Syndromes of Water and Electrolyte Depletion of Intestinal Origin
Authors: Shields R.
Published: January 2017

Because of the important part played by the intestine in maintaining the constancy of the internal environment, any disturbance in the orderly sequence of secretion and reabsorption of water and electrolytes can quickly lead to severe fluid depletion. Malabsorption of water and electrolytes may occur in diseases of the intestinal mucosa or following massive resection of bowel or as a result of disordered intestinal motility. The handling of fluids by the bowel may be altered by the action of hormones or of bacterial toxins, or in the presence of neoplasms. Electrolyte disorders may result from the introduction of abnormal solutions into the intestinal lumen.

Management of the clinical problems requires a clear understanding of the abnormal mechanisms and urgent attention to the re-institution of water and salt balance, restoration of acid-base status and replacement of lost potassium.
Scottish Views of Mental Illness
Authors: Maclean Una
Published: January 2017

A brief historical review of Scottish attitudes to the mentally ill is followed by a description of the 1966 Edinburgh survey of opinion on mental illness. This was carried out by structured interview on a random sample of the Edinburgh population. Part of the instrument, which had been carefully pretested and developed for this purpose, was submitted to 12 consultants in the professorial teaching units of Scottish University Medical Schools. The psychiatrists' opinions were compared with those of the general public and several differences were discovered. The public were more fearful and less optimistic than the specialists and their ideas of the causation of mental illness were connected with environmental rather than personality factors. Since the younger, better educated members of the community held views closest to those of the psychiatrists it is suggested that the opinion gap would probably lessen still further, encouraging more patients to seek specialist attention and putting extra pressure upon the available treatment facilities.
The Changing Pattern of Heart Disease in Glasgow School Children
Authors: Rogen A. S.
Published: January 2017

It is common knowledge that rheumatic fever and rheumatic heart disease have fallen in frequency but comparison of the two sets of figures quoted in the text is impressive in stressing that the degree of this is perhaps greater than has been generally realised; at the same time, more children with congenital heart disease are living to school age. Since rheumatic heart disease at the school age group did not make any demand on the cardiac surgeon, it follows that increased demands are made on him by the changing pattern of heart disease in school children.
Factors Affecting Growth in Man
Authors: Thomson John A.
Published: January 2017

Growth is a complex process dependent upon the interaction of many factors. Deficiencies in some of these result in obvious clinical syndromes such as juvenile myxoedema or hypopituitarism. In many other clinical states, for instance primordial dwarfism, we are still far removed from the full explanation and the solution is likely to come from detailed biochemical study of the mechanisms of action of growth hormone and related factors in health and disease.
The Shapiro Cards Scale as a Method of Assessment of Obsessional Symptoms in Clomipramine Therapy
Authors: Capstick N.
Published: January 2017

One of the major problems encountered in research into the value of a new treatment for obsessional states is the small number of patients seen in any one centre. Another problem is the great diversity of symptoms which obsessional patients display. These two problems may be partly overcome by the use of the method of rating devised by Shapiro. The technique is described and its application to the treatment of obsessional disorders illustrated.
Response to Starvation before and after a Jejuno-Ileal Bypass Operation for Morbid Obesity
Authors: Al Shamma G. A. A. , Fell G. S. , Joffe S. N.
Published: January 2017

A greater metabolic response developed during a seven day starvation in two morbidly obese patients three months after a 90 per cent jejuno-ileal bypass operation when compared with a similar fast before operation. There was a greater degree of ketosis, a decreased urinary urea excretion and an earlier utilization of ketone bodies. These changes suggest a metabolic adaptation of the body to the semistarvation state caused by the operation with a more rapid utilization of adipose tissue as a fuel and a sparing of lean body mass.
Reactive Arthritis following Asymptomatic Yersinia Infection
Authors: Dunk A. A. , Dobbie D. T. , Pitkeathly D. A.
Published: January 2017

A case of an acute asymmetrical polyarthritis occurring in a teenage boy is described. This was shown by serological tests to be secondary to a recent infection with Yersinia enterocolitica. Reactive arthritis following infection by this organism is well recognised in Scandinavia. Only recently have two cases been reported in the U.K. (1,2). This is the first reported case in Scotland and is unusual in that the initial infection was asymptomatic. Clinical improvement was associated with falling Y. enterocolitica titres and a reduction in the E.S.R. The patient was HLA B 27 positive. It is suggested that all patients presenting with an acute asymmetrical polyarthritis predominantly affecting the lower limbs should be screened by stool culture and serology for recent Y. enterocolitica infection.
The Effect of Acute Alcohol Withdrawal on the Serum Potassium and Total Body Potassium in Heavy Drinkers
Authors: Watson W S. , Lawson P. McN. , Beattie A. D.
Published: January 2017

In a group of 20 patients with heavy alcohol intake a relation was found between withdrawal symptoms and fall in serum potassium. Total body potassium (TBK) was measured in all subjects and was lower in the group of subjects who displayed symptoms than in the group who did not. The subgroup of the four most severe reactors had a mean TBK value significantly less than the ‘non-reactor’ group. The minimum serum potassium levels observed for all subjects in the four day period following alcohol withdrawal correlated with their TBK values. We suggest that the mechanism for the serum potassium fall might be overactivity of the Na-K pump caused by ethanol consumption.

There was also an association between withdrawal reaction and abnormal liver function and a transient rise in serum phosphate in the more severely reacting subjects.
Myocardial Infarction in Pregnancy
Authors: Hutchison S. J. , Holden R. J. , Lorimer A. R.
Published: January 2017

A young women presented with an anterior myocardial infarction in the first trimester of pregnancy. Her subsequent clinical course was uneventful. Such patients appear to have a good prognosis.
The Incidence of Childhood Diabetes in Certain Parts of Scotland
Authors: Barclay R.P.C. , Craig J.O. , Galloway C.A.S. , Richardson J.E. , Shepherd R.C. , Smail P.J.
Published: January 2017

The incidence of diabetes in children under 12 years of age has been studied in three regions of Scotland from 1976 to 1986. These areas represent more than half of the Scottish population of that age group. The overall annual incidence is 17.6 per 100,000, ranging from 16.8 in densely populated areas to 23.4 in more rural areas. Earlier studies have concerned the age group 0–18 years so the present results from a younger age group are, as expected, slightly lower but show the same trends. After a rise to 1983 there appears to have been a drop, but not in all areas. The danger of drawing conclusions from areas of low population or from short periods of time is stressed.
Long-Term Prognosis after Resuscitation from Primary Ventricular Fibrillation Complicating Acute Transmural Myocardial Infarction in the North East of Scotland
Authors: Chan N.S. , Hughes M. , Irvine N.A. , Kenmure A.C.F.
Published: January 2017

The aim of this study is to determine the long-term prognosis of patients successfully resuscitated from primary ventricular fibrillation in the acute phase of transmural myocardial infarction and to identify predictors of mortality. Details of 75 consecutive patients between October 1971 and May 1981 were reviewed in October 1985. The cumulative survival rates at one year, two year, five year and 10 year were 84%, 77% 67% and 40.5% respectively with a median survial time of 8.7 years. Univariate and Cox survival analyses were used to determine predictors of mortality. Only the age of the patient at the time of infarction was found to be highly significant with a greatly increased mortality rate in the older age group (p < 0.001). The sex, site of infarction (anterior or inferior) and time of entry in the study did not significantly influence long-term prognosis.
Glasgow Marathons 1982–1987 a Review of Medical Problems
Authors: Ridley S.A. , Rogers P.N. , Wright I.H.
Published: January 2017

The race statistics, weather conditions and incidence of medical problems for the six consecutive years of the Glasgow Marathon are reviewed. The results suggest that the popularity of marathon running is declining but that the competitors are becoming more experienced, seeking medical assistance earlier and, as a result, experiencing fewer and less serious problems at the finish. The effect of weather conditions on the runners' performance is discussed.
Clinical and Biochemical Pregnancy in Two Respective Recipients without Ovarian Function following Gamete Intrafallopian Transfers Using Oocytes from a Single Donor
Authors: Oskarsson T. , Edgar DH , Whalley KM , Mills JA
Published: January 2017

Infertility resulting from premature ovarian failure in two independent patients was treated using a combination of steroid replacement, oocyte donation and gamete intrafallopian transfer (GIFT). Following ovarian stimulation four oocytes were retrieved from a volunteer donor undergoing simultaneous laparoscopic sterilisation. Two oocytes were subsequently replaced into each recipient's fallopian tube together with capacitated sperm from their respective husbands. In one recipient (Turner's syndrome) an intrauterine sac with fetal heart present was observed by ultrasound six weeks post GIFT whereas in the second recipient (premature menopause) plasma β-hCG reached a peak value of 954mIU/ml eighteen days after GIFT before decreasing rapidly in the absence of ultrasound evidence of pregnancy. Intramuscular administration of progesterone appeared to be necessary during the post-GIFT period for maintenance of pregnancy. The above treatment was carried out on a predominantly out-patient basis in a small assisted conception unit based in a teaching hospital.
Herniated Thoracic Disc Mimicking Spinal Abscess
Authors: Soutar R.L.
Published: January 2017

Herniated thoracic discs are uncommon. Although uncommon, their potential for spinal cord damage makes them an important cause of backache. History and examination may be unhelpful, and even misleading. A diagnostic clue is disc space calcification on plain radiographs. Diagnosis can be confirmed by myelography or CT scanning. Cord compression can be prevented by surgery, which carries a low risk. Herniated thoracic disc should be remembered as a cause of backache in view of its serious, but treatable nature.
An Analysis of Cases Incorrectly Coded as Inflammatory Bowel Disease in Scottish Hospital In-Patient Statistics (Ships)
Authors: Murchison J. , Barton J.R. , Ferguson A.
Published: January 2017

As part of a large clinical and epidemiological study of inflammatory bowel disease (IBD), we examined the hospital case records of a sample (255) of the 1257 patients aged 0–20 years, recorded in Scottish Hospital In-Patient Statistics (SHIPS) for 1968–1983 as Crohn's disease (CD) or ulcerative colitis (UC). The coded diagnosis was incorrect at the time of coding in 47 instances (18.4% of the sample), for the following reasons: clinical diagnosis wrong (24 cases); IBD correctly diagnosed but wrongly coded as CD for UC or UC for CD (seven cases): various other clerical or computer errors (15 cases). One case that did not meet standard diagnostic criteria for CD at the time of coding was shown to be correctly labelled when confirmatory pathological information became available.

In view of the influence of such statistics on the social and clinical management of chronic illnesses such as IBD, and in view of the impact of analysis of these data on the provision of services and allocation of resources, it is suggested that some indication of the degree of confidence in the clinical diagnosis (possible, probable, definite) should be incorporated in the information submitted for coding and should be reflected in the derived data.
Hypophosphataemic Encephalopathy: A Case Report
Authors: Stolarek I.H. , Gold A.R. , Munro J.F.
Published: January 2017

Hypophosphataemia is not widely considered as part of a neurological differential diagnosis. We present a case of encephalopathy due to phosphate deficiency and review the presenting features of hypophosphataemia.
Computed Tomography (CT) Appearances of Acute Pancreatitis Presenting as Polyarthropathy with Subcutaneous Fat Necrosis
Authors: Patel J.C. , Robertson E.M.
Published: January 2017

A case of severe acute pancreatitis presenting with polyarthropathy and subcutaneous nodules but no abdominal pain is described. Abdominal CT showed multiple subcutaneous soft tissue densities which on histological examination were identified as areas of fat necrosis consistent with pancreatic disease. Such CT appearances have not been described previously.
Spread of Maternal HIV Infection in Scotland from 1990 to 1992
Authors: Tappin D M , Johnstone F D , Smith R , Girdwood R W A , Follett E A C , Davidson C F
Published: January 2017

In Scotland since January 1990, unlinked anonymous testing of Guthrie cards has documented maternal HIV-1 antibody in neonatal blood. District postcode and quarter year of birth determined prevalence and spread of infection. The Fujirebio particle agglutination assay screened for HIV-1 antibody, with confirmation by ELISA and full western blotting. Births to known HIV infected women were reported to the Royal College of Obstetricians and Gynaecologists. 0.3/1000 childbearing women were infectedwith HIV-1 with no significant increase from 1990 to 1992. Spread of infection from 11 to 26 districts has occurred. In 1990, 74%(14/19) of HIV positive deliveries were known to obstetricians falling to 33%(7/21) in 1992. Spread of HIV-1 infection has occurred to mothers who live outside closely defined areas and who do not belong to recognised high risk groups. In Scotland, two thirds of mothers and their infants will not receive early prophylactic care for their HIV disease.
Management of Hypertensive Crises
Authors: Isles C.G.
Published: January 2017

Hypertensive crises are now uncommon in developed countries, and few doctors will have experience in their management. A review of the drugs used by clinicians in Scotland suggests considerable diversity in approach but broadly follows the best advice that is available in the literature. For emergencies such as hypertensive encephalopathy and hypertension associated with aortic dissection in which irreversible damage would occur within hours if left untreated, patients should probably be admitted to Intensive Care Units and be given nitroprusside. Similarly nitroprusside or nitroglycerin would be appropriate choices for hypertension that is complicated by acute left ventricular failure.

By contrast if the risk to the patient is measured in days rather than hours then oral therapy will be quite sufficient. Atenolol or nifedipine retard can safely be given as initial treatment for uncomplicated malignant hypertension, and nifedipine retard can be used for the milder cases of encephalopathy or heart failure. The use of sublingual drugs in the management of hypertensive emergencies and urgencies cannot be recommended as the fall in blood pressure is both unpredictable and uncontrolled with the consequent and unacceptable risk of organ ischaemia.
Home Nebuliser Use in Children with Asthma in Two Scottish Health Board Areas
Authors: Madge P.J. , Nisbet L. , McColl J.H. , Vallance A. , Paton J.Y. , Beattie J.O.
Published: January 2017

Objective: To audit the use of home nebulisers in children with asthma. Design: Postal questionnaire. Setting: Two Health Board Areas in Central Scotland-one large industrialised city, one mixed urban and rural. Subjects: 297 children with asthma. Measures evaluated: Initial supply and technical support for the compressor. Education: Pattern of drug usage. Symptom control: Monitoring and treatment of acute attacks.

Results: The full burden of the home nebulised therapy is not being met by the NHS. Supply and servicing arrangements for home nebuliser therapy were poorly organised. Chronic asthma symptoms did not appear to be optimally controlled on present medication, with 61% reporting sleep disturbance in the previous three months. About 20% of parents admitted that they would give nebulised bronchodilator therapy more frequently than the recommended 3 to 4 hourly.

Conclusion: Re-organisation of resources and arrangements could improve the service and bring it in line with recognised standards of care.
Eye Drops — The Hidden Poison
Authors: Jones A.L. , Keighley J.E. , Gold W. , Good A.M.
Published: January 2017

Eye drops are very commonly prescribed but their potential for systemic absorption and serious toxicity may be forgotten. This paper examines patterns of prescription of eye drops in Scotland by general practitioners. A review of the serious systemic features and toxicity, and their management, of commonly used eye drops is undertaken. Practical recommendations for the monitoring of such effects in clinical practice are made.
The Management of First Seizures in Adults in a District General Hospital
Authors: Morrison A.D. , McAlpine C.H.
Published: January 2017

This study considered the management of first seizures in adults in Stirling Royal Infirmary over a six month period. Thirty-four patients presented of whom 19 were admitted to medical wards. Alcohol was implicated in 35% of cases. Blood tests were done in many but provided little useful information. CT Scan was performed in 53% and was abnormal in 15% (five patients). EEG was requested for 21% and failed to influence management in any. Six patients (18%) were started on anticonvulsant therapy. It was recorded in only three cases that advice on driving had been given.

The literature concerning single seizures is complex, especially with regards to recurrence risk and treatment benefits. We await with interest the publication of the SIGN (Scottish Intercollegiate Guidelines Network) guidelines for seizure investigation and treatment in Scotland.
Successful Retrieval of a Knotted Pulmonary Artery Catheter Trapped in the Right Ventricle Using a Dormier Basket
Authors: Hood S. , McAlpine H.M. , Davidson J. A. H.
Published: January 2017

We report the case of a 71 year old patient in whom a pulmonary artery catheter (Swan Ganz) formed a knot which was fixed within the right ventricle in the region of the tricuspid valve annulus. The catheter was successfully dislodged to the right atrium, subsequently snared by a dormier basket advanced from the right femoral vein and retrieved by localised cut down of the femoral vein.
Case Studies of Coupled Heat and Moisture Diffusion in Wool Beds
Authors: David H. G. , Nordon P.
Published: January 2017

The predictions from a previously developed mathematical model for coupled heat and moisture diffusion in beds of hygroscopic fibers have been tested against experimental observations on wool bales and wool fabrics. The experiments on wool bales were concerned with the changes in regain and temperature consequent upon changes in the relative humidity and temperature of the surrounding air. The experiments on fabrics included measurements of temperature and regain during Hoffman pressing and measurements of heat flow through the fabric during changes in regain. Satisfactory agreement was found between the predictions from the model and the experimental observations.
Mechanics of Texturing Thermoplastic Yarns
Authors: Brookstein David , Backer Stanley
Published: January 2017

The nature of transient changes in twist distribution across the texturing threadline has indicated the presence along me threadline of regions with widely differing torsional rigidities. The current study serves to confirm this variation in rigidities, indicating the presence of torsionally soft spots at the entry to the cold zone and at the entry to the heater. The remaining segments of the threadline reflect torsional response to incremental twist changes which are orders of magnitude greater than the torsional formation response to twisting at the soft spots. Thus, the threadline responds to changes in line torque and/or spindle speed by increasing or decreasing twist at the soft zones, and these changes must propagate across the cold and hot zones before steady-state conditions at new twist levels can be achieved.
Quantum Efficiency of Fading of Disperse Dyes in Textile Substrates
Authors: Shah C. D. , Srinivasan R.
Published: January 2017

Further evidence is obtained that quantum-efficiency values for photolysis of disperse dyes on hydrophobic substrates are very low at all wavelengths, and that they decrease with increase in wavelength of illumination. The values are found to be in the range 10−4 to 10−6.
Seed-Coat Fragments in Ginned Lint: The Effect of Varieties, Harvesting, and Ginning Practices
Authors: Anthony W. S. , Meredith W. R. , Williford J. R. , Mangialardi G. J.
Published: January 2017

Weather, varietal, harvesting, and ginning effects on seed-coat fragment count and weight in ginned lint cotton were evaluated in a 2-year study in the Mississippi Delta. In this study, harvest and lint cleaner treatments had almost no effect on fragment count, while year and variety had strong influences. Based on 3 grams of lint, the fragment count averaged 51 and the total fragment weight averaged 46 mg. Weight was reduced from 83 to 24 mg as lint cleaning stages increased from 0 to 3, but the number of fragments was reduced only slightly. In this study, which included varieties of moderate seed-coat fragment producing potential, weather (year) influences were more important than harvest or varietal factors.
Microcomputers in Applied Settings: The Example of Urban Planning
Authors: Ottensmann John R.
Published: January 2017

Two models of the diffusion of computer use and the use of more sophisticated social science methodology in applied settings are posited: Top-down diffusion involves the spread of sophisticated techniques from larger to smaller agencies, while grass-roots diffusion involves the gradual upgrading of methods used in a wider range of settings. Possible examples of the role of microcomputers in fostering both types of diffusion in urban planning are described. The two models imply different kinds of computer training for professionals.
The Stool Examination Reports Amoeba Cysts: Should You Treat in the Face of over Diagnosis and Lack of Specificity of Light Microscopy?
Authors: Lawson L L O , Bailey J W , Beeching N J , Gurgel R G , Cuevas L E
Published: January 2017

Amoebiasis is a common clinical diagnosis in tropical settings and clinicians continue to treat asymptomatic carriers diagnosed by light microscopy. A minority of carriers, however, are infected with Entamoeba histolytica and the remaining with the non-pathogenic Entamoeba dispar. We compared the diagnostic results of 298 asymptomatic residents of Aracaju, Brazil, obtained by different diagnostic methods, and ascertained their clinical symptoms, to highlight the implications for practitioners. Fifty-eight (19.4%) specimens were amoebae positive by microscopy. Of these, 38 (13%) were E. histolytica IE. dispar enzyme-linked immunosorbent assay (ELISA) positive and 4 (1%) E. histolytica ELISA positive. The frequent use of anti-amoebic treatment on the basis of non-specific symptoms and the findings of light microscopy tests is not justified. Methods for the specific diagnosis of E. histolytica infection for developing countries are urgently needed.
Silver Spoons and Golden Genes: Genetic Engineering and the Egalitarian Ethos
Authors: Fox Dov
Published: January 2017

What mother or father does not want to give his or her child the best chance of leading a happy and successful life? Infertile couples today enlist assisted reproductive technologies (ARTs) such as in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD) to handpick from among available gamete donors or embryo arrays to implant for gestation. As advances in genetic science permit increasing prenatal control over offspring traits, even fertile couples may choose to relocate procreation from the bedroom into the laboratory.

The development of safe genetic therapies capable of curing debilitating conditions in embryos or fetuses would be unequivocal cause for celebration. Less straightforwardly worthy of embrace would be techniques that make it possible to choose offspring genes for non-health related characteristics, such as strength, intelligence, and memory. At present, neither state nor federal law regulates ARTs.
Adjudicating Severe Birth Injury Claims in Florida and Virginia: The Experience of a Landmark Experiment in Personal Injury Compensation
Authors: Siegal Gil , Mello Michelle M. , Studdert David M.
Published: January 2017

Policy debates over medical malpractice in the United States involve a complex amalgam of legal doctrine, public demands to address the problem of medical errors, and the interests of various stakeholder groups. Most parties can agree, however, that the current system for compensating medical injury performs poorly. It falls short of achieving its two main goals: compensation and deterrence. The current system of tort liability is “neither sensitive nor specific in its distribution of compensation:” the vast majority of patients injured by negligent medical care do not receive compensation, yet the system compensates some cases that do not appear to involve negligence. Sometimes, it awards more in noneconomic damages than seems reasonable to many observers. Ultimately, tort liability appears to do little to improve health care quality and safety, yet it spurs costly defensive medicine. Physicians and health care organizations face burdensome insurance and legal costs, leading some to threaten to curtail their services. These concerns about the burden of medical injury and the malpractice “crisis” have sharpened calls for reform.
But Doctor, I Still Have Both Feet! Remedial Problems Faced by Victims of Medical Identity Theft
Authors: Sullivan Katherine M.
Published: January 2017

When Lind Weaver starting receiving collections demands for a foot amputation she never had, she assumed it was a clerical error. Unfortunately, the operation had been performed on someone pretending to be Weaver, causing Weaver's medical history to become entangled in the thief’s. Media reports about identity theft show Weaver's experience is far from unique. For example, a Chicago man was arrested after using his friend's identity to obtain $350,000 worth of cardiovascular surgery at a local hospital. Hackers broke into the medical records of thousands of University of California students. A staff member left a laptop containing records of patients of a local AIDS clinic on Boston public transportation.
Can We Handle the Truth? Legal Fictions in the Determination of Death
Authors: Shah Seema K. , Miller Franklin G.
Published: January 2017

Advances in life-saving technologies in the past few decades have challenged our traditional understandings of death. People can be maintained on life-support even after permanently losing the ability to breathe spontaneously and remaining unconscious and unable to interact meaningfully with others. In part because this group of people could help fulfill the growing need for organ donation, there has been a great deal of pressure on the way we determine death. The determination of death has been modified from the old way of understanding death as occurring when a person stops breathing, her heart stops beating, and she is cold to the touch. Today, physicians determine death by relying on a diagnosis of total brain failure or by waiting a short while after circulation stops. Evidence has emerged that the conceptual bases for these approaches to determining death are fundamentally flawed and depart substantially from our biological and common-sense understandings of death.

We argue that the current approach to determining death consists of two different types of unacknowledged legal fictions. These legal fictions were developed for practices that are largely ethically legitimate but need to be reconciled with the law. However, the considerable debate over the determination of death in the medical and scientific literature has not informed the public of the fact that our current determinations of death do not adequately establish that a person has died. It seems unlikely that this information can remain hidden for long. Given the instability of the status quo and the difficulty of making the substantial legal changes required by complete transparency, we argue for a second-best policy solution of acknowledging the legal fictions involved in determining death. This move in the direction of greater transparency may someday result in allowing us to face squarely these issues and effect the legal changes necessary to permit ethically appropriate vital organ transplantation. Finally, this paper also provides the beginnings of a taxonomy of legal fictions, concluding that a more systematic theoretical treatment of legal fictions is warranted to understand their advantages and disadvantages across a variety of legal domains.
Patient Data: Property, Privacy & the Public Interest
Authors: Rodwin Marc A.
Published: January 2017

Changes in technology sometimes raise important public policy choices and require that we clarify key values and reexamine legal concepts. Such is the case with the development of electronic medical records (EMRs), which facilitate obtaining patient data from provider and insurer records. EMRs expand our ability to tap patient data and thereby create great potential benefits as well as risks. This new technology requires that we clarify the ambiguous property interests in patient data. How the law defines ownership of patient data will shape whether its benefits can be developed and also affects patient confidentiality.

EMRs make it feasible to collect aggregate patient data that can be used to vastly improve medical knowledge, patient safety and public health. Researchers have long used patient data from clinical trials to evaluate the benefits and risks of drugs and medical therapy, compare their relative effectiveness, and analyze health care cost and quality.
Prometheus and Bilski: Pushing the Bounds of Patentable Subject Matter in Medical Diagnostic Techniques with the Machine-or-Transformation Test
Authors: Pessagno Stephen
Published: January 2017

If nature has made any one thing less susceptible than all others of exclusive property, it is the action of the thinking power called an idea, which an individual may exclusively possess as long as he keeps it to himself; but the moment it is divulged, it forces itself into the possession of every one, and the receiver cannot dispossess himself of it.
Protecting Scientific Integrity: The Commercial Speech Doctrine Applied to Industry Publications
Authors: Sax Joanna K.
Published: January 2017

The pharmaceutical industry is a competitive business. Companies spend billions of dollars researching and developing new drugs. Many drugs never make it to market. For the limited drugs that make it through the experimental, regulatory, and clinical rigors of drug development, companies recoup their lost expenditures for the drugs that previously failed.

Pharmaceutical companies face increasing pressure to bring new treatments to market in order to survive. The economic reality of survival and profits may distort a company's decision-making process regarding full disclosure on a particular new drug. An example of this type of conflict was seen in the silicone breast implant fiasco in the 1970s, 1980s, and 1990s. Dow Corning, the manufacturer of the implants, withheld important data from long-term animal models that demonstrated adverse effects from the breast implants. Further, Dow failed to conduct long-term studies on breast implants, even when armed with data indicating that such studies were necessary to ensure the continued health of the patients.
Commercial Speech and Off-Label Drug Uses: What Role for Wide Acceptance, General Recognition and Research Incentives?
Authors: Gilhooley Margaret
Published: January 2017

This article provides an overview of how the constitutional protections for commercial speech affect the Food and Drug Administration's (FDA) regulation of drugs, and the emerging issues about the scope of these protections. A federal district court has already found that commercial speech allows manufacturers to distribute reprints of medical articles about a new off-label use of a drug as long as it contains disclosures to prevent deception and to inform readers about the lack of FDA review. This paper summarizes the current agency guidance that accepts the manufacturer's distribution of reprints with disclosures.

Allergan, the maker of Botox, recently maintained in a lawsuit that the First Amendment permits drug companies to provide “truthful information” to doctors about “widely accepted” off-label uses of a drug. While the case was settled as part of a fraud and abuse case on other grounds, extending constitutional protections generally to “widely accepted” uses is not warranted, especially if it covers the use of a drug for a new purpose that needs more proof of efficacy, and that can involve substantial risks.

A health law academic pointed out in an article examining a fraud and abuse case that off-label use of drugs is common, and that practitioners may lack adequate dosage information about the off-label uses. Drug companies may obtain approval of a drug for a narrow use, such as for a specific type of pain, but practitioners use the drug for similar uses based on their experience. The writer maintained that a controlled study may not be necessary to establish efficacy for an expanded use of a drug for pain. Even if this is the case, as discussed below in this paper, added safety risks may exist if the expansion covers a longer period of time and use by a wider number of patients. The protections for commercial speech should not be extended to allow manufacturers to distribute information about practitioner use with a disclosure about the lack of FDA approval. Distributions of information about unapproved uses should not be acceptable unless experts consider the expanded use to be generally recognized as safe and effective based on adequate studies.

The last part of this paper considers the need to develop better research incentives to encourage more testing and post-market risk surveillance by drug makers on off-label uses of their drugs. Violations of the Federal Food Drug and Cosmetic Act (FFDCA) can be considered violations of the False Claims Act, which opens the way to fraud and abuse suits. The scale of penalties involved in these suits may lead to more examination of the scope of FDA regulation and commercial speech protections. Thus this symposium's consideration of these issues is timely and important.
No Need for More Regulation: Payors and Their Role in Balancing the Cost and Safety Considerations of Off-Label Prescriptions
Authors: Todd Amy E.
Published: January 2017

In 2009, health care expenditures in the United States totaled $2.5 trillion and accounted for almost eighteen percent of the national Gross Domestic Product (GDP). Rising health care costs are an increasing concern in the national health care industry and in government policy reform. When estimates show that thirty percent of health care is unnecessary, improving quality and efficiency of health care could eliminate a significant amount of excessive spending.

Prescription drugs contributed to ten percent of national health expenditures in 2009, comprising about $250 billion. And while the rate of growth for overall health care spending declined as a result of the recent recession, “the number of prescription drugs dispensed rebounded to prerecession rate of growth.” Estimates show that off-label drug use comprises between twenty and sixty percent of U.S. prescriptions. This could be a troubling percentage considering that off-label use carries an increased risk of harm or ineffectiveness.
Retiree Out-of-Pocket Healthcare Spending: A Study of Consumer Expectations and Policy Implications
Authors: Hoffman Allison K. , Jackson Howell E.
Published: January 2017

Even though most American retirees benefit from Medicare coverage, a mounting body of research predicts that many will face large and increasing out-of-pocket expenditures for healthcare costs in retirement and that many already struggle to finance these costs. It is unclear, however, whether the general population understands the likely magnitude of these out-of-pocket expenditures well enough to plan for them effectively. This study is the first comprehensive examination of Americans' expectations regarding their out-of-pocket spending on healthcare in retirement. We surveyed over 1700 near retirees and retirees to assess their expectations regarding their own spending and then compared their responses to experts' estimates. Our main findings are twofold. First, overall expectations of out-of-pocket spending are mixed. While a significant proportion of respondents estimated out-of-pocket costs in retirement at or above expert estimates of what the typical retiree will spend, a disproportionate number estimated their future spending substantially below what experts view as likely. Estimates by members of some demographic subgroups, including women and younger respondents, deviated relatively further from the experts' estimates. Second, respondents consistently misjudged spending uncertainty. In particular, respondents significantly underestimated how much individual health experience and changes in government policy can affect individual out-of-pocket spending. We discuss possible policy responses, including efforts to improve financial planning and ways to reduce unanticipated financial risk through reform of health insurance regulation.
Tobacco Control and Beyond: The Broader Implications of United States—Clove Cigarettes for Non-Communicable Diseases
Authors: McGrady Benn , Jones Alexandra
Published: January 2017

As implementation of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) accelerates and states seek to address risk factors for non-communicable disease more broadly, tension has increased between the law of the World Trade Organization (WTO) and public health. For example, Indonesia recently brought a successful claim against a U.S. law that prohibits cigarettes with a characterizing flavor other than menthol or tobacco. Indonesia succeeded in arguing that the regulation discriminates against clove-flavored cigarettes of Indonesian origin in favor of menthol-flavored cigarettes of U.S. origin.

Also in the WTO context, the Dominican Republic, Honduras, and Ukraine have challenged an Australian law prohibiting the presence of branding on tobacco packaging other than product and variant names in a standardized location, font size, and style. This regulation, commonly referred to as “plain packaging,” is the first of its kind and may represent a turning point in the regulation of tobacco packaging.
Safeguards for Tobacco Control: Options for the TPPA
Authors: Stumberg Robert
Published: January 2017

With tobacco trade, the past is prologue. In the 1980s, the U.S. government used domestic trade remedies (“Super 301”) to pry open markets for U.S. tobacco companies. The targets included Japan, South Korea, Taiwan, and Thailand. A grateful tobacco industry donated a renovation of the Treaty Room in the U.S. Department of State, declaring at the dedication: “Tobacco is intimately and historically associated with American diplomacy.”

Thailand responded by banning imported cigarettes on grounds that the imports were more addictive and marketing of imports was driving up consumption. The United States then challenged Thailand for violating the General Agreement on Tariffs and Trade (GATT). The GATT panel ruled against Thailand, finding that the import ban failed to satisfy the health exception of GATT Article XX.
The Role of Private Law in the Control of Risks Associated with Tobacco Smoking: The Canadian Experience
Authors: Khoury Lara , Couture-Ménard Marie-Eve , Redko Olga
Published: January 2017

Can private law litigation serve as a tool for advancing public health objectives? With this contentious and oft-asked question in mind, we tackle Canada's recent tobacco litigation. This Article first presents critical commentary regarding various lawsuits waged against Canadian cigarette manufacturers by citizens acting as individuals or as parties to class action lawsuits. We then turn to analyze how Canada's provincial governments rely on targeted legislation to facilitate private law recourses for recouping the healthcare costs of treating tobacco-related diseases. We address challenges to the constitutionality of this type of legislation, as well as attempts by manufacturers to transfer responsibility to the federal government.

Canadian litigation in this field is nothing like that of the United States with regards to both the volume and variety of its individual and class action litigation claims. This is also true with regard to the stage of advancement of governmental claims in Canada. Nevertheless, particularities of the Canadian context may provide interesting contrast with the situation in the United States.
Bias at the Gate?: The Pharmaceutical Industry's Influence on the Federally Approved Drug Compendia
Authors: Gabrielsen Lindsey
Published: January 2017

As of 2002, the Federal Food and Drug Administration (FDA) had approved Neurontin, a drug developed by the pharmaceutical company Pfizer, for two uses, the treatment of epilepsy and pain related to shingles. A staggering ninety-four percent of Neurontin prescriptions in the prior five years, however, were for other (non-FDA) approved uses. These other uses effectively tripled Medicaid’s costs for the drug between 1998 and 2003. Insurance companies covered the off-label uses because they appeared in the Drugdex compendium, a federally authorized listing of drugs that includes evidence regarding the drug’s effectiveness, clinical indications, and proper dosing. Drugdex included an additional forty-eight uses for Neurontin, ranging from bipolar disorder to the hiccups. Two other federally approved compendia existed at that time; one listed seven uses for Neurontin while the other listed only one.
Medicaid on the Eve of Expansion: A Survey of State Medicaid Officials on the Affordable Care Act
Authors: Sommers Benjamin D. , Gordon Sarah , Somers Stephen , Ingram Carolyn , Epstein Arnold M.
Published: January 2017

As of January 2014, 26 states had chosen to expand Medicaid under the Affordable Care Act (ACA) to cover individuals with incomes up to 138% of the federal poverty level. In these states, Medicaid agencies are facing one of the largest implementation challenges in the program’s history. We undertook a survey of high-ranking Medicaid officials in these states to assess their priorities, expectations, and programmatic decisions related to the coming expansion.

The Medicaid expansion poses major challenges in the domains of enrollment, management of health care costs, and providing adequate access to services for beneficiaries. Previous research has documented that millions of individuals eligible for Medicaid are currently not enrolled and remain uninsured, suggesting that state outreach strategies may underpin the success or failure of the ACA’s coverage expansion.
Quantitative Exfoliative Cytology of Normal Oral Squames: An Age, Site and Sex-Related Survey
Authors: Cowpe J G , Longmore R B , Green M W
Published: January 2017

This study describes the development of quantitative cytological techniques and their application to oral smears. Nuclear and cell size has been measured and matched with age, sex and site in an attempt to produce a baseline for comparison with identical measurements carried out on pathological smears. The results displayed a significant variation in nuclear and cytoplasmic area between different sites. Nuclear size varied significantly with advancing age; however, this was not the case for cytoplasmic area. There was no significant variation in either criterion between males and females.