bluuebunny/crossref_metadata_2025 huggingface dataset:
General
Authors: Armstrong R F , Aveling W , Grundy E M
Published: October 2023

The question of the epidural in patients with pre-existing back pain is controversial. Although epidurals are often used to treat acute back pain, there is retrospective data to suggest that back trouble is more common in women who have had an epidural for labour but not for an elective section. The current view is that it is not the epidural per se but the position adopted during prolonged motor block that is harmful. It is thought that epidurals with minimal motor blockade are unlikely to lead to later back problems. It is traditional to be wary of CNB in patients with pre-existing neurological disease in case worsening neurology might be blamed on the block. Thereseems little evidence to support this view. The possible risks should bediscussed with the patient. Where there is risk of coagulopathy a normal clotting screen is comforting.Platelets >100 x 109/l are regarded as safe but function rather than numbersare affected by drugs such as aspirin. Bedside estimation of bleeding timehas not proved to be an easy or reproducible method of assessing plateletfunction. The risk of spinal haematoma formation after CNB in association withanticoagulation and DVT prophylaxis has been authoritatively reviewed byVandermeulen et al. (1994). After low-dose heparin and low molecular weight heparin the risk of CNBis acceptable but blocks should not be done or catheters removed within 4 hours of the last dose of heparin or 10 hours after low molecular weightheparin.
Social and economic aspects of prescribing
Authors: Lader Malcolm , Herrington Reginald
Published: October 2023

Treatment with psychotropic drugs is mostly initiated by family doctors. In considering the social function and consequences of this, some attention must be paid to what leads people to seek help from their doctor in the first place and what factors predispose to the inclusion of a prescription in the management package eventually offered, before attempting to assess the consequences, both good and bad, for society at large. The impact of specialist psychiatric opinion on the use of drugs in the treatment of nervous disorder, especially minor disorder, is not readily determined. However, any influence is presumably mainly through advice to general practitioners, at least in the United Kingdom where direct access to specialists is unusual. Psychiatrists themselves are, of course, exposed to similar psychosocial pressures as other doctors and the following analysis draws on evidence from several areas of medical practice.
Pharmacokinetics
Authors: Lader Malcolm , Herrington Reginald
Published: October 2023

Pharrnacokinetics is the study of the body’s effects on drugs and determines whether the drug gets to its site of action and in what concentrations. As both a theoretical and practical topic it has become increasingly important in recent years. An excellent detailed account is given by Grahame-Smith and Aronson (1992).
Manic-depressive Disorder and Lithium
Authors: Lader Malcolm , Herrington Reginald
Published: October 2023

Lithium salts provide one of the most fascinating stories in psychopharmacology and psychiatric treatment (Jefferson and Greist 1994). The therapeutic effects of lithium in mania were reported by John Cade in 1949. Yet it was 20 years before lithium was licensed in the USA and only in the 1970s was it the subject of widespread study (Goodwin 1979). Not surprisingly, our knowledge of its properties and effects, wanted and unwanted, is still incomplete although it has become firmly established on the therapeutic scene. Its main indications remain mania and depression, in their more severe forms.
Anxiety disorders and antianxiety medication
Authors: Lader Malcolm , Herrington Reginald
Published: October 2023

Anxiety is a ubiquitous emotion within everyone’s experience (Sartorius 1980). It is important in psychiatry because it is found in many mental illnesses as a secondary phenomenon as well as constituting syndromes in its own right, the anxiety disorders. It presents in many forms and comprises a multitude of symptoms, psychological and somatic. It is an unpleasant emotion so that many of those who experience it urgently seek relief. It is hardly surprising, therefore, that drugs used to assuage anxiety, the tranquillizers, are among the most widely used of all drugs (Tyrer 1984).
Post-menopausal bleeding
Authors: Bain Christine , Kitchener Henry C
Published: October 2023

The definition of post-menopausal bleeding (PMB) varies, but is usually defined as vaginal bleeding that occurs one year or more after the menopause. It is a clinical sign that causes alarm and anxiety in women and is of concern to the clinician, because of its association with malignant disease. Around 10 per cent of women presenting with this problem will have underlying cancer, with the likelihood increasing with the length of duration from menopause. The bleeding may vary from only a few spots of blood to several days of bleeding, or rarely a profuse haemorrhage. However small the amount, every case must be investigated thoroughly and sensitively. This chapter will be concerned only with bleeding from the genital tract and will outline the causes and modem management of this problem which can be divided into three groups dependent on the location of bleeding (Table 21.1). Bleeding from the urinary or gastrointestinal tract should be referred to the relevant specialist. However, it is important to note that haematuria and rectal bleeding may be confused with vaginal bleeding and if there is uncertainty it is best to investigate both possible sources. Previous studies (Brewer and Miller 1954; Keirse 1973; Caspi et al. 1977) have tried to identify the incidence of each cause of post-menopausal bleeding, but this is difficult due to exclusion criteria. In our centre in Aberdeen, which serves a female population of 300 000 we see 500-600 cases of PMB annually, a rate of around 1 per 500 women per year.
Adenomyosis uteri
Authors: Brosens Jan J , Brosens lvo A
Published: October 2023

Traditionally, the term adenomyosis denotes the presence of endometrial glands and stroma deep within the myometrium. Until recently, the diagnosis could only be made after hysterectomy by which time its clinical relevance was merely academic. This is not the only reason why adenomyosis has been neglected in the last few decades. The wide range of pathological criteria used to define adenomyosis, and differences in myometrial sampling, have hindered many attempts to correlate the presence of these ectopic endometrial foci with a specific clinical syndrome. Although adenomyosis is apparently associated with menorrhagia and dysmenorrhoea, current confusion is so profound that some even doubt its clinical relevance.
Psychiatric morbidity and the menstrual cycle
Authors: Gath Dennis , Day Ann
Published: October 2023

This chapter begins with a review of associations between psychiatric disorders and menstrual disorders. This review is followed by descriptions of common psychiatric conditions such as anxiety disorders and depressive disorders. An account is then given of the causes of emotional disorders (precipitating, predisposing, and perpetuating factors). This account is followed by a review of some gynaecological syndromes including the premenstrual syndrome, dysmenorrhoea, amenorrhoea, menorrhagia (and its treatment with hysterectomy), and the menopause. Finally an account is given of methods of detecting and assessing psychiatric disorders in the gynaecology clinic.
Mothers’ views and experiences of care
Authors: Garcia Jo
Published: October 2023

There are many reasons why women’s views and experiences matter, but perhaps the main one is that women’s reactions to care around the time of birth can affect they way they care for themselves and their baby. These reactions also influence their subsequent contacts with their care-givers (Brown et al. 1994). Feelings of having had a good or bad experience are, of course, partly affected by the clinical events at the time, but the explanations and support they get from staff can go on mattering to them for a long time (Menage 1993; Charles 1994; Crompton 1996; Smith and Mitchell 1996). For some women, the decision about having another child may be one of the outcomes. Two comments from mothers who took part in a recent national postal survey (Garcia et al. 1998) help to illustrate some of these issues.
Information management
Authors: Graham Janice E , Agg Maggie
Published: October 2023

The increase over the past two decades in international epidemiological surveys of the aged, dementia disease case registries, and the computerization of clinical practices, has resulted in a multiplicity of databases whose re¬ liability and validity vary dramatically. Their value to those who access patient and population information for clinical and research purposes depends on systematic organization and quality control. In order for information systems to meet quality assurance requirements, these databases should include individual case-specific data, apply standardized criteria and outcomes, and be rigorous in data accuracy and completion. If these databases are also to be used for clinical research then they should include ‘all known characteristics that affect outcome’ (Black 1997). Details omitted, or more often unknown when the database was set up, may be needed later. Acquiring this missing information may require considerable labour, and/ or it may not be available. When designing an information system, these considerations should be taken into account and the system needs to be able to respond to new demands on the information it contains.
Psychiatric assessment
Authors: Ballard C , Eastwood R
Published: October 2023

Since the first memory clinics were established in the United States in the mid 1970s, there has been a massive expansion in memory clinic services throughout Europe and North America. Indeed, there are now more than 30 memory clinics in the United Kingdom and mainland Europe (Wright and Lindesay 1995; Verhey et al., 1993; Walstra et al., 1992). The objectives of clinics are broadly similar, aiming to provide comprehensive specialist assessment of patients with mild memory disorders, specialist advice on the management of these disorders, and to identify patients who may be suitable for participation in pharmacological or other research projects. The majority of clinics are multidisciplinary, most commonly involving psychiatrists, geriatricians, psychologists, neurologists, nurses, speech therapists, and occupational therapists (Wright and Lindesay 1995). The tradition in North America is slightly different. Few North American studies have described the characteristics of memory clinic attendees (Hogan et al., 1994) but many have utilized ‘dementia clinics’ or ‘memory clinics’ as a source of patients for research, focusing upon diverse subjects such as driving skills (Fitten et al., 1995), neuroimaging (Wolfe et al., 1995), and the validation of instruments to identify non-cognitive symptoms (Sultzer et al., 1992).
Nutrition as a factor in survival
Authors: Reaich David
Published: October 2023

The presence of protein—calorie malnutrition is well recognized in maintenance hemodialysis (HD) patients. The nutritional deficiencies are multifactorial, with both inadequate intake and increased catabolism contributing. There is increasing evidence that malnutrition in HD has a negative impact on morbidity and mortality. Long-term survival of the HD patient is therefore likely to be influenced by nutritional status. The optimum management of the HD patient must therefore include an appropriate assessment of his/her nutritional status and interventions to prevent the development of malnutrition, or correct it, should it arise.
Adequacy of dialysis: the key to survival
Authors: Gotch Frank , Levin Nathan W
Published: October 2023

The rationale for the treatment of uremia with dialysis therapy rests primarily on the premise that the uremic syndrome results from the accumulation of toxic solutes, which are normally cleared from body water by the kidney and can be successfully cleared by dialysis. It is well established that adequate dialysis therapy must normalize the extracellular fluid volume and its composition with regard to the concentrations of Na, K, Pi, Ca, HCO3 and Mg. Consequently, the first criteria to be met for adequate dialysis are the optimal control of extracellular volume and the concentrations of these electrolytes.
Control of the endocrine system (Physiology)
Authors: Laycock John , Wise Peter
Published: October 2023

can consist of protein-bound and free hormone fractions is normally regulated within quite precise physiological limits if increased, invariably leads to the clinical hypersecretion state is independent of the rate of its metabolic removal from the blood e is always maintained in a constant, basal state
Growth and development (Physiology)
Authors: Laycock John , Wise Peter
Published: October 2023

occurs at the fastest rate just before birth b is influenced by maternal nutrition is independent of sex is stimulated by fetal insulin production is generally reduced in mothers who drink more than 40 g alcohol daily generally occurs earlier in boys than in girls is preceded by increased adrenal androgen production in both sexes c is associated with an increase in somatotrophin production begins after sexual maturation has occurred e is associated with increased bone density
The Retreat from the Ordinary
Authors: Lomas Peter
Published: October 2023

If a person is troubled in her heart and cannot see any avenue of escape from her emotional turmoil it would make good sense to seek help from someone who has a reputation for being of use in such matters. The prospective helper may be a wise person or an expert. By expert, I mean someone who has at their disposal a particular ploy, tactic, technique, procedure, or trick upon which they would rely to ease the supplicant’s torment; such a ploy may or may not involve an illusion. In some cultures a technique used for such a purpose would be thought of as magic or religious and involve supernatural powers; today, we would be more likely to look for an explanation in the natural world, one which we would attribute to what we call ‘science’. There has, however, always been a con fusion between wisdom and technique. As anthropologists have noted, the shaman who enacts a magical ritual or who pretends (and perhaps even believes) that it is efficacious may use whatever common sense or wisdom he or she possesses in order to solve the problem.
Spontaneity
Authors: Lomas Peter
Published: October 2023

The further I continued in writing this book the more my heart sank. How can one possibly give a description of psychotherapy which bears sufficient resemblance to the actual article to make the account useful? When I think of some of the most fruitful occurrences in therapy I cannot relate them. This is not because I am ashamed of them. It is because they seem to have no more relevance to a professional undertaking based on a describable method than an account of a slice of life that might appear in a novel. They lack specificity; they do not form part of a planned approach; I do not know how to justify them as a therapeutic endeavour any more than conversations with friends which have been rewarding but from which no formula can be extracted for having rewarding conversations with friends.
The Hazards of Moral Judgement in Psychotherapy
Authors: Lomas Peter
Published: October 2023

One of the many predicaments in life is that of making a judgement between one’s own view and that of others. We are presented with this problem at almost every hour of every day. The issue involved may be a mundane matter but the decision we make will be influenced by our sense of worth and our confidence in our own perception of things; we are, moreover, often genuinely confused as to what is morally the better thing. Debate about human nature does not seem to come up with any clear answer about the motives for our judgements; whereas it is often claimed that we are egotistical beings, out to get our way at all costs, and to believe what it suits us to believe, there is plenty of evidence to show that we tend to be amazingly suggestible and conformist. Perhaps the most that can be said with any assurance is that good judgement is a manifestation of that elusive quality, wisdom.
The Institute of Social Medicine
Authors: Ewin Jeannette
Published: October 2023

During the presentation of the budget on 30 June 1942, Ernest Brown, Head of the Ministry of Health, reported that the Ministry was cooperating with the Ministry of Food, the Board of Education, the Medical Research Council, and the University of Oxford to improve the health of the nation. Regional Medical Officers and the Emergency Hospital Service were supported by local nutritional surveys helped by funds and expertise from the International Health Division of the Rockefeller Foundation. Although Hugh Sinclair’s name was not mentioned, reference to the University of Oxford clearly identified his work, thus adding to his personal credibility.
What type of trial is needed?
Authors: Girling David J , Parmar Mahesh K B , Stenning Sally P , Stephens Richard J , Stewart Lesley A
Published: October 2023

In this chapter, we provide an overview of the general process by which a new treatment is evaluated; from initial clinical investigation through to widescale clinical practice. We review the factors which may determine, at each stage, whether or not a new clinical trial is warranted. Crucial to this is knowing what you want to have achieved by the time each stage is completed.
Anthracyclines
Authors: Robert Jacques
Published: October 2023

Daunorubicin was the first anthracycline isolated, in France and Italy simultaneously in 1963, from the fermentation broth of an actinobacteria Streptomyces peucetius, and its antileukaemic properties in the clinic were rapidly acknowledged.
Vinca alkaloids
Authors: Synold Timothy W
Published: October 2023

The periwinkle plant (Cantharantus roseus; Vinca rosea L.), originally indigenous to Madagascar but now cultivated all over the world, has a long and colourful history of medicinal uses for the treatment of such widely dissimilar conditions as haemorrhage, scurvy, toothache, wound healing, and diabetes. Research into the compounds responsible for the therapeutic effects of the periwinkle led to the discovery of the antitumour vinca alkaloids, vincristine and vinblastine. These cytotoxic vinca alkaloids act by binding to tubulin, thereby preventing the polymerization of microtubules essential for many cellular
Platinum agents
Authors: Johnson Steven W , Stevenson James P , O’Dwyer Peter J
Published: October 2023

Platinum complexes represent a unique and important class of antitumour drugs. Although cis-diammine dichloroplatinum(II) (cisplatin) was initially synthesized in 1845, it was not realized that platinum compounds exhibited antitumour activity until the work of Barnett Rosenberg published in 1969. These studies led to the clinical development of cis-diammine-dichloroplatinum(II) (cisplatin) for the treatment of various solid tumours.
Anti-endocrine drugs used in cancer treatment
Authors: LØnning Per Eystein
Published: October 2023

The discovery by Beatson a century ago that castration may cause tumour regression in premenopausal breast cancer patients marks endocrine therapy as the first successful systemic treatment strategy for malignant diseases. Although other forms of ablative surgery (orchiectomy in males suffering from prostatic carcinomas, and adrenalectomy and hypophysectomy in postmenopausal breast cancer patients) and, in the 1950s and 1960s, additive treatment with oestrogens or glucocorticoids came into
Hyperhomocysteinemia in Chronic Renal Disease
Authors: Culleton Bruce F , Bostom Andrew G
Published: October 2023

Cardiovascular disease (CVD) is the major cause of death both in the general population and in patients with end-stage renal failure (ESRF). CVD is responsible for about 40% of all deaths in both demographic groups.Although the proportion of people dying of cardiovascular causes is similar, the risk of CVD is far greater for patients with ESRF. Even after stratification by age, gender, race, and presence of diabetes, CVD mortality in dialysis patients is 10-20 times higher than in the general population.
Neuroradiological investigation: functional neuroimaging: SPECT/PET
Authors: Alexander Gene E , Pietrini Pietro
Published: October 2023

Advances in nuclear medicine technology over the past two decades have significantly enhanced the ability to evaluate the in vivo neurophysiological effects of neurodegenerative disease. The development of functional neuroimaging methods such as positron emission tomography (PET) and single photon emission computed tomography (SPECT) have provided the opportunity to assess regional neural activity in the awake human brain. With these advances it has become possible to study with increasing sensitivity and specificity the regional changes that occur in the brain as neurodegenerative diseases progress. Applications of these neuroimaging techniques to investigate the neurophysiological effects of the most common form of age-related dementia, Alzheimer’s disease (AD), has increased our understanding of the mechanisms of the progressive cognitive and behavioural dysfunction characteristic of this debilitating illness.
Congenital muscular dystrophies
Authors: Mercuri Eugenio , Muntoni Francesco
Published: October 2023

The clinical diversity of CMD is suggested by the different degrees of motor developmental delay, physical disability and muscle pathology, and by the variable presence of mental retardation. Most of the efforts aimed at delineating and subdividing the various CMD forms have originated from the International Consortium on CMD, that, under he auspices of the European Neuromuscular Centre (ENMC), has convened six dedicated workshops, whose proceedings have been published in Neuromuscular Disorders (Dubowitz 1994; 1997; 1999; Dubowitz and Fardeau 1995; Muntoni and Guicheney 2001). The classification proposed in this chapter, that takes into account the recent advances in the molecular genetic studies, is largely a reflection of the data presented at these workshops.
Duchenne muscular dystrophy or Meryon2019s disease
Authors: Emery Alan E H
Published: October 2023

This disease is eponymously associated with the name Duchenne because this French physician described the condition in detail in the 1860s (Duchenne 1861; 1868). His contributions were concerned with the clinical description of the condition and the muscle histology findings. However, several years previously an English physician, Edward Meryon, not only described the clinical features of the disease in some detail but also emphasized three very important points (Meryon 1851; 1852). Firstly, he emphasized that the disease affected males and was familial (none of Duchenne’s cases were familial).
Facioscapulohumeral muscular dystrophy
Authors: Upadhyaya Meena , Cooper David N
Published: October 2023

The defining clinical features include the onset of weakness of the facial or shoulder girdle muscles, leading eventually to the wasting of these muscles (Fig. 8.1). Significant facial weakness is evident in more than half of all affected FSHD patients. As the disease progresses, the muscles of the shoulder girdle, the scapula fixators, and the upper arm muscles (especially the biceps and triceps) may become affected. Weakness and atrophy may eventually involve many other skeletal muscles, including the musculature of the pelvic girdle and the foot extensor muscles may become involved, resulting in footdrop. Some patients may display involvement of the proximal muscles of the lower limb prior to any evidence of weakness of the distal muscles. Involvement of the musculature of the pelvic girdle is observed infrequently. However, patients who exhibit pelvic girdle muscle weakness before the age of 20 years are more likely to become wheelchair-bound, and at an earlier age. Studies have indicated that although 10-20 per cent of all FSHD gene carriers will require a wheelchair by their fourth decade, a further 22-30 per cent of carriers will only be mildly affected, or may even remain virtually asymptomatic throughout their lives.
Dilated cardiomyopathy and related cardiac disorders in muscular dystrophy
Authors: Urtizberea J Andoni , Duboc Denis , Schwartz Ketty , Bonne Gisèle
Published: October 2023

Heart dysfunction in muscular dystrophy has been noted a long time ago but did not draw much attention until recently. As Duchenne patients live longer and better now a-days, this complication has become, over the years, a major concern as well as a growing cause of death. The spectrum of cardiac abnormalities turned out to be much broader than originally thought: congestive heart failure, secondary to left ventricular dysfunction, is the commonest risk in many muscular dystrophies but rhythm disturbances and/or conduction defects can also be complications of their own, sometimes (DCM) with the same momentum. In the meantime, the spectrum of genetic diversity in muscular dystrophies has expanded formidably and generated new insights into muscle physiology.
Respiratory care in muscular dystrophy
Authors: Simonds Anita K
Published: October 2023

Respiratory problems are a major cause of morbidity and mortality in the muscular dystrophies. Indeed, in Duchenne muscular dystrophy (DMD) respiratory complications are the cause of death in over 70 per cent of patients, and virtually all Duchenne patients will develop ventilatory insufficiency if they survive long enough. In the other muscular dystrophies the extent of respiratory compromise will depend on the degree of respiratory muscle involvement, the presence of a thoracic scoliosis and level of bulbar weakness. In congenital muscular dystrophy merosin negative individuals seem more prone to early respiratory failure than merosin positive patients. Ventilatory failure is relatively uncommon, although not unknown in facioscapulohumeral muscular dystrophy, and has a variable prevalence in limb girdle MD. Although ventilatory support has been used sporadically in neuromuscular patients with chronic ventilatory failure for over 50 years, in the last decade the use of non-invasive ventilation has had a significant impact on survival and long-term outcome, particularly in DMD patients. In this chapter the natural history of respiratory problems in the muscular dystrophies is discussed, with particular emphasis on monitoring, identifying high-risk patients, and the outcome of therapeutic interventions.
Controversies in deep vein thrombosis prophylaxis following total hip arthroplasty: a North American perspective
Authors: Colwell Clifford W , Hardwick Mary E
Published: October 2023

Evidence-based medicine, which seeks to integrate individual clinical expertise and the best external evidence derived from scientific research, provides an argument for prescribing thrombosis prophylaxis for all total hip arthroplasty (THA) patients.
Cognitive therapy formulations and interventions for treating distress in dementia
Authors: Ballard Clive , O’Brien John , James Ian , Swann Alan
Published: October 2023

Cognitive therapy’s Lamarckian progress is generally attributed to three key writers: Beck (1967), Ellis (rational-emotive therapy: Ellis and Whitley 1970) and Meichenbaum (self-instructional training: Meichenbaum 1977). Over recent years, the terms cognitive therapy (CT) and cognitive behavioural therapy (CBT) have become synonymous, with the addition of the term ‘behavioural’ emphasizing the importance of the behavioural component within the treatment.
Alternative therapies: other non-pharmacological therapies
Authors: Ballard Clive , O’Brien John , James Ian , Swann Alan
Published: October 2023

Whether or not a person has cognitive impairment, he/she will have needs. These will include physiological (food, water, shelter) and psychological features (security, activity, companionship, stimulation). It is suggested that people with dementia retain their desire to have needs fulfilled, but become less able to communicate and obtain them. Therefore it is not unusual for a person with dementia to be energized by a need and to become distressed when it is not met. In such circumstances, the energy may be expressed in terms of feelings and emotionally driven activities (shouting, aggression), and thus trigger a challenging behaviour.
Pharmacological treatment of psychosis
Authors: Ballard Clive , O’Brien John , James Ian , Swann Alan
Published: October 2023

This chapter focuses on the pharmacological management of psychotic symptoms in dementia. Issues are discussed to facilitate treatment decisions, such as whether a pharmacological treatment may be appropriate, and the evidence of efficacy from clinical trials for different pharmacological treatment is reviewed. This information is then summarized and illustrative vignettes are given to examine some potential clinical scenarios.
Managing behavioural and psychological symptoms in residential and nursing home care
Authors: Ballard Clive , O’Brien John , James Ian , Swann Alan
Published: October 2023

The expanding elderly population inevitably means that the number of people with dementia will continue to increase well into the twenty-first century (Melzer et al. 1997), with enormous implications for care provision (Knapp et al. 1998). Residential and nursing homes form an integral part of the care network for these individuals, particularly during the later stages of the disease process (Bannister et al. 1998) or when concurrent psychiatric morbidity or behavioural problems arise (Steele et al. 1990).
Ethical issues and evidence-based patient choice
Authors: Ashcroft Richard , Hope Tony , Parker Michael
Published: October 2023

The concept of ‘evidence-based patient choice’ (EBPC) brings together two important movements in modern medicine. The first of these, ‘evidence-based medicine’, has been described as a ‘paradigm shift’ in medical practice (Hope 1996). It is an approach to medicine based on the claim that clinical interventions are to be justified on the existence of evidence for the effectiveness of the intervention rather than on other grounds such as, for example, the authority of the clinician or of tradition. ‘Patient-centred medicine’ too has arisen out of a concern with and a critical response to traditional medical practice and the traditional overemphasis on the authority of the health care professional. Advocates of patient-centred medicine argue that the best protection for patients from excessive paternalism is to be gained by emphasizing the point that patients should play a central role in decision making about their clinical care. Like evidence-based medicine, patient-centred medicine has been described as marking a fundamental shift in medical practice, a ‘Copernican revolution’ (Battista 1993).
Humane judgement
Authors: Downie R S , Macnaughton Jane , Randall Fiona
Published: October 2023

The doctor-patient relationship is commonly seen as the central feature of medical practice: it is by means of this relationship that a doctor exercises professional skills and pursues the aims of medicine. The analysis of this relationship is the main concern of this section, since it is the key to the idea of humane judgement. It will emerge that, in addition to the need for the doctor to interpret and show insight into the symptoms and words of the patient—which are necessary also for the technical aspects of judgement—the humane doctor has ethical sensitivity and a broad educated perspective. The analysis of these factors will begin in this chapter and be completed in Chapter 6.
Judgement and resource management
Authors: Randall Fiona
Published: October 2023

Resource management, or prioritizing, or rationing in health care is an imposed distribution system that has two goals: first, to ensure the best use of resources by using the most cost-effective treatments; and second, to ensure a just or fair distribution of treatment benefits. Rationing takes place at two levels: macro-allocation, where budgets are allocated for the treatments of different diseases, and for medical and nursing care; and micro-allocation, where discrimination between individual patients is necessary because it is not possible to give the most beneficial care or treatment to every patient. Obviously major moral and practical problems arise at both levels. Nevertheless, it will be the contention of this chapter that a rationing system is required now and will continue to be required in the future. To maintain such a position with any hope of plausibility, we must examine both the evidence on which a system of rationing might be based, and the sorts of judgement necessary to implement it. The ways in which rationing can be implemented will obviously vary to some extent, depending on the particular system of health-care delivery and financing that is operative. But many of the broad principles are the same, so while my discussion is centred on the UK National Health Service (NHS), I hope that my arguments will be more widely applicable. It should also be noted that some writers in this area, and all politicians, prefer the terms ‘resource management’ or ‘prioritizing’ to the term ‘rationing’. I do not distinguish between them, and will now move to outlining the bearing of evidence on rationing.
Oral codeine in acute postoperative pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. Codeine 60 mg is not an effective analgesic for postoperative pain. A 60-mg oral dose of codeine had an NNT of 16.7 (11–48) for at least 50% pain relief over 4–6 h compared with placebo in pain of moderate to severe intensity. Codeine is an opium alkaloid, with activity similar to, but weaker than morphine. It is also widely available in combination with aspirin or paracetamol.
Dextropropoxyphene alone and with paracetamol in postoperative pain
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. 65 mg of dextropropoxyphene is not an effective analgesic. Dextropropoxyphene is a relatively weak opioid analgesic that has been widely available since the 1950s. It is used alone and in combination with paracetamol or aspirin. Inclusion criteria were full journal publication, single oral dose, randomised, placebo-controlled, double-blind trials of dextropropoxyphene in acute postoperative pain, baseline pain moderate to severe. Mean TOTPAR and SPID values for each trial were converted to %maxTOTPAR and %maxSPID, and then the proportion of patients achieving at least 50%maxTOTPAR were calculated. This information was used to calculate the NNT and relative benefit. Adverse effects frequency data were used to calculate NNH and relative risk.
Diagnosing headache and Migraine
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

In 1988 the IHS published criteria for the diagnosis of a number of different headache types [1]. Those for some of the common headaches are reproduced below for migraine with and without aura, cluster headache, tension-type headache, and cervicogenic headache. A meta-analysis [2] tells us what clinical features are important, and what irrelevant, in diagnosing migraine. The review used a MEDLINE search up to May 1999 for English language papers with sensitivity and specificity of historical features in patients with primary headaches of migraine, tension-type headaches, or cluster headaches. Headaches caused by other underlying clinical conditions were not examined. Information from studies was pooled to generate overall sensitivity, specificity and likelihood ratios of migraine compared with tension-type headache.
Migraine: league tables of relative efficacy
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

There are a number of treatments available for acute migraine. Choices have to be made about which to prescribe, or even about formularies. Those choices will be influenced by a large number of issues with different resonance in different parts of the world. Policy, patient choice, prescriber preference, cost and experience will all play a part. These league tables allow us to see what is on offer, and make our choices informed by the evidence. The league tables are not there to tell us what to prescribe, or to limit prescribing choice (because there is some evidence that limiting choice is bad for patients and healthcare systems).
Aspirin plus metoclopramide for acute migraine
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

Clinical bottom line. Oral aspirin 900 mg plus metoclopramide 10 mg has been fully tested in three randomised trials with about 750 patients. The NNT for two hour headache response was 3.2 (2.6–4.0). The NNT for 2-h pain free was 8.6 (6.2–14). There was no information for sustained outcomes. Oral aspirin alone has no information yet published in full, though studies have been published in abstract form.
Anticonvulsants for diabetic neuropathy and postherpetic neuralgia
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

For over 30 years the management of neuropathic pain has involved the use of both antidepressants and anticonvulsants, but which drug class should be first line choice remains unclear. The dogma that the character of the pain was predictive of the response, burning pain responding to antidepressants and shooting pain to anticonvulsants, was shown to be incorrect in diabetic neuropathy, where patients experiencing both burning and shooting pain responded to tricyclic antidepressants. Most studies on neuropathic pain have involved diabetic neuropathy and postherpetic neuralgia, because these conditions represent the majority of patients with neuropathic pain.
Fibromyalgia
Authors: Moore Andrew , Edwards Jayne , Barden Jodie , McQuay Henry
Published: October 2023

The American College of Rheumatology has produced diagnostic guidelines. The historical feature of fibromyalgia is widespread pain of three months duration or more affecting the axial skeleton and at least two contralateral quadrants of the body. To this definition of widespread pain, for a diagnosis of fibromyalgia patients have to feel pain in 11 of 18 trigger points when they are palpated with the amount of pressure sufficient to blanch a finger nail.
The ethics of economic evaluation in priority setting
Authors: Dolan Paul , Olsen Jan Abel
Published: October 2023

Economic evaluation techniques have been criticized for being too narrow, focusing on ‘efficiency solutions’ only and ignoring other priority-relevant considerations. This chapter considers additional issues related to equity and ethics, and how they might possibly be incorporated into a societal economic evaluation. Again, the rationale is to help in ‘distributing health care’-but in an ethically preferred way.
Founding the common cold research unit
Authors: Tyrrell David , Fielder Michael
Published: October 2023

Britain in 1946 was a place of stark contrasts. The war was over. Army, navy, and airforce personnel were being demobilised. Men and quite a number of women were coming home to families they had hardly seen through- out the conflict. They were to find a way of life that had changed out of all recognition. Towns were in ruins; factories and equipment were worn out; and food, clothing, and furniture were severely rationed. People were grieving over their personal losses, the friends who were gone for ever. But, in spite of this, there was a feeling of optimism and the sense of a new beginning.
Hunting for treatments
Authors: Tyrrell David , Fielder Michael
Published: October 2023

‘We can land a man on the moon, but we can’t cure a common cold.’ Those involved with research into the common cold are familiar with the jibe. We all hoped that our work would bring a cure nearer, and of course it almost certainly has. But not to the point where something concrete has appeared. In fact no radically new medicines for colds have appeared in the shops since serious scientific research started about a century ago. Not surprisingly, the average person thinks that this is intolerably slow. But that is to misunderstand the nature of the problem and the way in which research and discovery take place.
The use of investigations and imaging in the evaluation of arthritis
Authors: Szer Ilona S
Published: October 2023

The aim of this chapter is to describe the laboratory and imaging evalu-ation for the child who is suspected of having Juvenile Idiopathic Arthritis. Laboratory tests are not usually helpful in positively establishing the diagnosis of Juvenile Idiopathic Arthritis (JIA) but they are helpful in excluding other disorders and providing evidence for the presence and extent of other chronic rheumatic conditions. Laboratory studies may help in determining the type of JIA such as Rheumatoid Factor (RF) Positive Polyarthritis, or HLA B27 associated arthritis.
Classification of childhood arthritis
Authors: Southwood Taunton R
Published: October 2023

The aims of this chapter are to discuss the historical and philosophical background giving rise to the ILAR classification of Juvenile Idiopathic Arthritis (JIA) and to outline the classification itself. The future evaluation of the classification is also discussed. Juvenile Idiopathic Arthritis (JIA) is a diagnosis of exclusion (see Part 1, Chapter 1.3). JIA refers to those forms of arthritis which begin before the 16th birthday, are persistent for longer than 6 weeks, and for which no cause is currently known [1]. Part 1 of this book gives an overview of the multitude of conditions which may be confused with JIA.
The Forty-Five Days, July to September 1943
Authors: Morgan Philip
Published: October 2023

The international consequences of Mussolini’s dismissal by the king on 25 July 1943 were signifiant but contained. The Italian ramifications of Mussolini’s fall were less immediately signifiant, but ultimately uncontainable. There has been so much controversy over the responsibility for and signifiance of the events from Mussolini’s removal in July 1943 to the signing and declaration of the armistice between Italy and the Allies in September 1943, that it becomes extremely diYcult for the historian to clear a path through the retrospective mutual recriminations and mud-slinging of the protagonists. The only place to start is with the announcement to the nation by the 72-year-old Marshal Pietro Badoglio, called out of military retirement by the king to head the new government after the dismissal and arrest of Mussolini on 25 July 1943.
The Invasion and Occupation of Italy, and the Kingdom of the South, 1943–1945
Authors: Morgan Philip
Published: October 2023

In spring 1943, General Sir Bernard Montgomery, commander of the British Eighth Army, gave an order to the head of MI9, the military intelligence service responsible for escaped prisoners of war in Axis-occupied Europe, which in turn was to be communicated secretly to the camps in northern and central Italy which were holding over 85,000 captured Allied servicemen. The instruction was to the effect that in the event of an Italian surrender, Allied POWs should ‘keep fit and stay put’ and await the arrival of Allied troops.1 In the actual event of the Italian armistice of 8 September 1943, and in light of what happened afterwards, this was rather stupid advice. But at the time it was made, the order reflected a condenser among Allied military commanders that Italy could be easily and rapidly conquered and occupied.
Confrontational Coexistence
Authors: Robbins Keith
Published: October 2023

In January 1965 great men, and just a few great women, including the Queen of Tonga, came to London to represent ‘the world’ at the funeral of Sir Winston Churchill, the last Englishman who would be truly a world figure. Churchill had not in fact been in office for a decade; nevertheless his death, twelve years after Stalin’s, had a certain symbolic significance: the Second World War was being buried. The congregation in St Paul’s cathedral represented states both great and small, old and new. Famous and familiar names mingled with newcomers to world politics: men moulded by their experience of wartime power, and a new generation only now coming into significant office. This mixture characterized political leadership in the world between the death of Stalin and the death of Churchill. Indeed, in the case of Churchill himself, during his last period as Prime Minister (1951–5) he was seeing the world as a man who had come of age politically half a century earlier. At the end of his life, he could no longer feel at home in what it had become. The transition to a new generation of leaders, not surprisingly, did not take place in every country at precisely the same time. As the following summaries demonstrate, it was their experience of war which still loomed large in the thinking of the Great Powers’ leadership between 1953 and 1965.
Belligerent Aims
Authors: Robbins Keith
Published: October 2023

Grey, the long-serving British foreign secretary, gloomily took the view in late 1914 that for the duration of the war there was little that the foreign office could do. Diplomacy would be entirely subservient to military events. States would be guided in their dealings with each other by the fluctuating fortunes of battle. He was, perhaps, a little too pessimistic. As far as Britain was concerned, the handling of initially non-belligerent states like Bulgaria or the United States, of neutrals like Denmark or the Netherlands, or an ally like Japan could be of very great significance and did not hinge entirely on military factors. Nevertheless, the scope of foreign policy was generally very limited, at least until a late stage in the conflict. Whether reluctantly or with a good grace, foreign secretaries and foreign offices lost some of their political standing and frequently found new agencies and advisers usurping their role.

Every state had to have war aims and traditional bureaucracies played their part in formulating them. The status of a ‘war aim’ is, however, difficult to determine. Particularly in the case of Germany, some writers have seen in the early formulation of territorial and economic objectives confirmation of the expansionary pressures which thrust the country into war. Others have been more cautious, suggesting that once war had begun it was only natural to attempt to define objectives. To have aims in war was not the same as going to war for certain aims. It can be confidently stated that the shape of Europe and the world in 1919 did not correspond to the ambitions of any state which went to war in 1914.
The Caesarian Party
Authors: Syme Ronald
Published: October 2023

Caesar, who took his stand on honour and prestige, asserted that Pompeius was disloyal. Caesar had made enemies through Pompeius—and now Pompeius had joined them.1 A just complaint, but not integral truth: a Sullan partisan before turning popular is, Pompeius by his latest change of front came back to earlier alliances.
The Predominance Of Antonius
Authors: Syme Ronald
Published: October 2023

HE victor of Philippi proceeded eastwards in splendour to re-establish the rule of Rome and extort for the armies yet more money from the wealthy cities of Asia, the prey of both sides in Rome’s intestine wars. He exacted nine years’ tribute, to be paid in two. Antonius distributed fines and privileges over the East, rewarded friends and punished enemies, set up petty kings or deposed them. So did he spend the winter after Philippi. Then his peregrinations brought him to the city of Tarsus, in Cilicia. Through his envoy, the versatile Q.