bluuebunny/crossref_metadata_2025 huggingface dataset:
A Scottish Hebridean Antithrombin III Deficient Family — Twelve Years on
Authors: Douglas A.S. , Walker I.D. , Bennett N.B.
Published: January 2017

The members of this family with ATM deficiency have been followed for at least 12 years (1976–1989). All those with previous venous thrombo-embolism have been free from recurrence when on warfarin.

During the half century 1931–1981, all 11 full term pregnancies in four affected patients were associated with venous thromboembolism; one patient was enigmatic having one full term pregnancy, without thrombotic event; between 1982 and 1989 three pregnancies have been actively managed with no clinical thrombosis. Management involved use of monitored, self administered, subcutaneous heparin before or very soon after conception and throughout pregnancy (warfarin having been stopped), planned delivery under cover of intravenous antithrombin III, reduction of heparin dosage at delivery and reintroduction of warfarin in the puerperium. The recognised hazards of heparin therapy in pregnancy did not occur.

The involvement of the arterial system is reviewed. Clinical evidence provides tentative suggestions on (a) possible additional risk of cigarette smoking (b) avoidance of venography (c) avoidance of varicose vein surgery. A probe is now available for the defective antithrombin III gene in this famiy, but there has been no occasion yet to apply this in antenatal diagnosis.
Inter-Observer Variation in Interpretation of Chest X-Rays
Authors: Shaw N. J. , Hendry M. , Eden O. B.
Published: January 2017

139 chest x-rays of children with solid tumours or leukaemia were examined independently by three observers (a radiologist and two physicians) and a consensus report determined. There was total agreement between observers on 40 x-rays (29%). The radiologist agreed with the consensus report on a significantly greater number of x-rays (91%) than both physicians (62% and 46%). There was a high incidence of over-reporting of abnormalities by both physicians. This study reinforces the need for regular dialogue between radiologists and clinicians for optimum interpretation of chest x-rays.
Migraine or Amaurosis Fugax? the Value of Ultrasound
Authors: Sandercock P.A.G. , Smart S.E.
Published: January 2017

Episodes of uniocular visual loss in patients with classical migraine may be due to thromboembolism from atheroma in the internal carotid artery. Non-invasive testing may prove very useful in making the correct diagnosis particularly in patients with an approximately 50% pre-test possibility of disease.
Unplanned Re-Attendance in the Accident and Emergency Department
Authors: Armstrong A.M. , Pennycook A.G. , Swann I.J.
Published: January 2017

The notes of patients who re-attended the Accident and Emergency Department with a problem for which they had already been seen and treated were reviewed over a five-week period. Such patients comprised 2.5% of total attendances.

The commonest reason for re-attendance was persistent pain following an injury and of such patients, about a half required a significant change in management. It was estimated that two-thirds of re-attendances were unavoidable. Twenty patients were admitted following re-attendance, and of these, two had serious medical conditions which were missed on initial presentation. The role of senior Accident and Emergency doctors is discussed in the light of these findings.
Could it be Myotonic Dystrophy? Myotonic Dystrophy Presenting with Atrial Flutter
Authors: McLay J.S. , Norris A. , Kerr F.
Published: January 2017

Myotonic dystrophy is a well recognised and well defined multisystem disorder which is inherited in an autosomal dominant fashion through a locus on chromosome 191. The disease itself is characterised by rigidity and degeneration of skeletal muscle, cataract formation, gonadal atrophy, frontal baldness and mental retardation. Like many inherited disorders there is a variable expression and so diverse clinical presentations can occur2.
Coronary Artery Ectasia: Is it Associated with Myocardial Ischaemia and Infarction?
Authors: Cross S.J. , Lee H. S. , Kenmure A.C.F. , Jennings K.P
Published: January 2017

Coronary artery ectasia is an uncommon finding during coronary angiography. There may be associated stenoses of the affected arteries. We report three cases, which illustrate that ectasia, in the absence of obstructive disease, can result in myocardial ischaemia and infarction.
Patterns of Vascular Pathology in Acute, First-Ever Cerebral Infarction
Authors: Naylor A.R. , Sandercock P.A.G. , Sellar R.J. , Warlow C.P.
Published: January 2017

This was a preliminary study to see whether patterns of vascular pathology correlated with a simple clinical classification of acute cerebral infarction. Thirty-two patients with acute, first-ever hemispheric cerebral infarction were prospectively studied clinically together with an extra- and transcranial Doppler ultrasound.

All 14 patients with the triad of ipsilateral motor/sensory deficit, homonymous hemianopia and higher cortical dysfunction (Total Anterior Circulation Infarction,[TACI]) had occlusion of the symptomatic middle cerebral artery and/or internal carotid artery, or a severe middle cerebral artery stenosis. Three patients with lacunar infarction had no evidence of major vessel occlusion. Eleven of thirteen patients with Partial Anterior Circulation, Infarction (PACI) I(i.e. only one or two clinical features of the TACI triad) had patent symptomatic major vessels, with indirect evidence to suggest distal branch occlusion(s) of the middle cerebral artery in six. The remaining two PACI patients had major vessel occlusions. Two patients were not clinically classifiable, but both had significant vascular pathology on ultrasound.

The findings of this preliminary study therefore suggest that a simple clinical classification was generally capable of predicting patterns of vascular pathology inpatients with acute cerebral infarction, which could have implications for the selection of patients for clinical trials of thrombolytic therapy.
A Survey of Exercise Testing Practice in Scottish Hospitals
Authors: Muir K.W. , Rodger J.C. , DeBono J.S. , McDonald H. , Irving J.B.
Published: January 2017

A 1989 survey (unpublished) of exercise testing practice in Scotland suggested that there were important differences in the practice of exercise testing between hospitals. A postal questionnaire was sent to 30 teaching and district general hospitals in 1991 and followed up by telephone questioning of consultants.

The numbers of exercise tests performed had increased to 22,072 in 1990, and a greater proportion were performed in district general hospitals. General practitioners had very limited access to the service but hospital doctors of any grade had almost free access. Rationing of early post myocardial infarction testing led to attempts to define “high risk” post infarction patients and this included inappropriate patients in many hospitals. A variety of different protocols was used Eighteen out of 30 hospitals surveyed discontinued beta blockers but only four hospitals took account of antianginal, antihypertensive or other medication, and all but one exercised patients while on digoxin. In the majority of hospitals decisions regarding drug therapy were taken by individual physicians. A variety of personnel reported tests, many without specialist training in cardiology. Even among consultants there was no concensus on the degree of ST depression which was significant.

Exercise tests performed in different hospitals in Scotland are not comparable due to the wide variation in patient selection, test conditions, and interpretation of tests. This problem is likely to be exacerbated by the multiple personnel involved in all aspects of testing. It seems probable that there is a problem throughout the United Kingdom, and that there is a need for guidelines.
Tuberous Sclerosis — An Unusual Cause of Seizures in an 18 Year Old
Authors: de Silva D.C. , Johnston A.W. , Dean J.C.S.
Published: January 2017

An 18 year old man presenting with seizures was found to have hypomelanotic macules and a cardiac rhabdomyoma. These features suggested a diagnosis of tuberous sclerosis (TS) but there were no other clinical signs, no family history and cranial imaging failed to reveal the characteristic appearances. The diagnostic criteria for TS are reviewed and the importance of thorough clinical examination and appropriate investigation in this disease is stressed.
Closing the Loop in an Audit of Urinary Incontinence
Authors: Stewart C. I. L. , McMurdo M. E. T.
Published: January 2017

Urinary incontinence (UI) fulfils the criteria for an indicator condition of quality of care. A records review audit in 1992 indicated that the minimum standards for history taking, physical examination and investigation of UI were not being met, so this was repeated in 1993 after full discussion with staff. 40% of the 368 patients studied met the definition of UI. In Assessment and Rehabilitation wards 57% met the standard for history (60% in the previous audit), 24% for examination (50% previously), and 86% for investigation (100% previously). As previously results were worse on Continuing Care wards, where minimum standards were being met in only 17% for history, 14% for examination and 47% for investigation. However, management planning had improved with care plans for 71% of incontinent patients in Assessment and Rehabilitation wards and 97% in Continuing Care wards. Our repeat audit has highlighted the difficulties inherent in encouraging health professionals to alter practice to correct apparent deficiencies.
Cardiorespiratory Disease in Men and Women in Urban Scotland: Baseline Characteristics of the Renfrew/Paisley(Midspan) Study Population
Authors: Hawthorne V.M. , Watt G.C.M. , Hart C.L. , Hole D.J. , Smith G.D. , Gillis C.R.
Published: January 2017

Study objective: To describe the distribution of risk factors, risk behaviours, symptoms and the prevalence of cardiorespiratory disease in men and women in an urban area with high levels of socioeconomic deprivation. A cross-sectional survey of 15,411 men and women aged 45–64, comprising an 80% response rate from the general population in Paisley and Renfrew, Scotland

Main results: The main characteristics of the male Renfrew/Paisley population, compared to previous British studies, were shorter stature, higher blood pressure, a higher proportion of smokers who continue to smoke, lower FEV1 and higher levels of reported angina, breathlessness on effort and chronic bronchitis. In comparison with men, the main characteristics of the female Renfrew/Paisley population were shorter stature, higher plasma cholesterol, lower FEV1′ fewer current and ex-smokers, and a higher prevalence of breathlessness on effort. There were only small differences between men and women in the prevalence of angina, ECG evidence of myocardial ischaemia and chronic bronchitis.

Conclusions: Middle-aged men and women in an urban area with high levels of socio-economic deprivation have different cardio- respiratory risk and disease profiles compared to previous population studies in the UK, based on occupational groups and random national samples.
Severe Hyponatraemia Associated with Selective Serotonin Reuptake Inhibitors
Authors: Taylor I.C. , McConnell J.G.
Published: January 2017

Depression in the elderly is a common problem, cited as occurring in up to 10% of elderly people living at home, half of whom may need specialist referral.1 The introduction of selective serotonin reuptake inhibitors has been reported as a major advance in the treatment of depression in that they are less sedating, have fewer anticholinergic effects and are less toxic in overdose.2 We report three cases of severe hyponatraemia, seen in the past 12 months, associated with the selective serotonin reuptake inhibitors fluoxetine and sertraline. Hyponatraemia has been reported as a rare adverse effect of selective serotonin reuptake inhibitors.3,4
Bacterial Meningitis — The Importance of Cerebro-Spinal Fluid Examination
Authors: McCarron B. , Chaudhuri A.K.R. , Todd A.
Published: January 2017

The role of lumbar puncture in bacterial meningitis has been debated in recent years, especially in the presence of worsening headache, alteration of conscious level, focal neurological signs, papilloedema or a haemorrhagic rash. However valuable bacteriological and epidemiological information will be lost if lumbar puncture is avoided, despite blood cultures being taken. This loss ofinformation will be highlighted if pre-admission antibiotics are administered (this should now be standard practice).
Community-Acquired Toxigenic Clostridium Difficile Diarrhoea in the Normoxaemic Elderly Who Have Received No Antimicrobials: Soft Evidence for Ischaemic Colitis?
Authors: Laing R.B.S. , Dykhuizen R.S. , Smith C.C. , Gould I.W. , Reid T.M.S.
Published: January 2017

We report three examples of community-acquired toxigenic Clostridium difficile diarrhoea in elderly patients who had neither received antimicrobial therapy nor been institutionalised. These cases stimulated interest in the non-antimicrobial changes which might predispose the host to C. difficile-related disease and raised the spectre of bowel ischaemia as a possible aetiological factor.
Venous Thromboembolic Disease in Obstetrics and Gynaecology: The Scottish Experience
Authors: Macklon N.S. , Greer I.A.
Published: January 2017

The incidence and pattern of thromboembolic complications in obstetric and gynaecological patients in Scotland between 1981 and 1992 was investigated by analysing ICD coded data retrieved from the SMR1 and SMR2 database. The effect of mode of delivery and maternal age over 35 on risk of thromboembolism in pregnancy was also assessed. 0.076% of gynaecological episodes were subsequently complicated by thromboembolic events. Nineteen percent of those suffering thromboembolic complications within two weeks of discharge were referred back to gynaecology. The incidence of deep venous thrombosis (DVT) in those under 35 years and over 35 years was 0.615/1000 maternities and 1.216/1000 maternities respectively. Respective figures for postnatal DVT were 0.304/1000 and O. 720/1000 and for pulmonary thromboembolism (PTE), 0.108/ 1000 and 0.405/1000. In both age groups, emergency caesarean section was associated with a higher incidence of DVT than elective caesarean section and vaginal delivery.
A Repeat Audit of Hospital Discharge Letters in Patients Admitted with Acute Asthma
Authors: Mathur R. , Clark R.A. , Dhillon D.P. , Winter J.H. , Lipworth B.J.
Published: January 2017

Subsequent to the implementation of recommendations from a previous audit of acute asthma admission discharge letters from our specialist respiratory unit, a repeat audit of typed discharge letters of 86 patients (33 male, mean age 29 SD 9 years) admittedwith acute asthma to the same unit over a 12 month period was performed. There was significant improvement in the discharge letter documentation of precipitating factors (p<0.001), previous admissions with acute asthma (p<0.01), admission arterial blood gas analysis (p<0.001), admission peak flow rates (p<0.05), discharge peak flow rates (p<0.001), corticosteroid (p<0.01) and inhaled beta 2 agonist (p<0.01) prescription on discharge and on the specification of inhaler delivery device on discharge (p<0.001). No significant differences in discharge letters were found in the documentation of acute therapy or post discharge follow up plan. The improvement in discharge letter quality was attributed to closing the feed back loop from the previous audit though continuing deficiencies in discharge letter contents have been identified again. These deficiencies need to be rectified and the results reaudited.
Clinical Audit; Who is Auditing Who?
Authors: Currie I.S. , Paterson-Brown S.
Published: January 2017

Clinical audit is the principal means by which current clinical practice is improved. Doctors in training must gain positive experience of audit as juniors, so as to establish the importance of audit for future practice. Good audit requires involvement of doctors in training, a high level of participation and a leading role to be taken by the professional bodies. To examine the degree to which such criteria are met currently, the quality and prevalence of clinical audit, the participation of junior doctors in audit, and the preparedness of medical professional bodies' to guide audit were assessed. One hundred and twenty-six junior and senior house officers in three Edinburgh hospitals were administered questionnaires in person, whilst eight Royal Colleges, the British Medical Association and the General Medical Council were assessed by the quality of their written guidelines for audit. The data showed that only thirteen out of twenty four specialties, which employed half the juniors, utilised clinical audit. Half of these audit programs were structured to lead to improved patient care. Surprisingly, only three out of ten professional bodies were able to provide good quality audit information. In conclusion, clinical audit is not universal practice and many existing audit programs are inappropriately structured. Commonly, doctors at all levels seemed unaware of the goals of clinical audit. In addition, the majority of professional bodies provide poor information, thereby impeding successful audit by doctors in training. Clinical audit will not succeed until such deficiencies are rectified.
Nitrogen-Phosphorus Synergism in Flame-Retard Ant Cellulose
Authors: Tesoro G. G. , Sello S. B. , Willard J. J.
Published: January 2017

Recent work on the definition of synergistic effects has provided the basis for designing more efficient new approaches to flame-retardant cellulose. The synergistic role of nitrogen in enhancing flame-retardant characteristics has been confirmed for cotton and rayon fabrics modified with N-hydroxymethyl-3-(dialkylphosphono)propionamide (NMPA) and tris(hydroxymethyl)melamine (TMM).

Results are compared with those reported previously for similar cellulose derivatives formed via the Arbuzov exchange of halogen precursors. Data are further compared for native and regenerated cellulose derivatives in which NMPA and TMM were applied from a single bath with acid curing, and for others in which TMM was subsequently polymerized by wet fixation in NMPA-modified cellulose. Satisfactory flame-retardant properties can be obtained in cotton at phosphorus contents as low as 0.8%, and the total amount of reagent required is lower as the NMPA/TMM ratio is decreased.

An additional contribution of halogen, obtained by using the haloalkyl analog of NMPA, to the flame-retarding effectiveness of these systems is described.
Flame Retardancy of Cotton via a Michael-Type Reaction of Oligomeric Reagents
Authors: Rowland Stanley P. , Mason John S.
Published: January 2017

The reaction of Fyrol 76, an oligomeric vinylphosphonate, with various low molecular weight polyethylenimines was used to deposit a flame-retarding finish in cotton fabric. The balance of textile performance properties was found to be quite attractive, but durability of the finish was deficient. Results are pertinent to development of an understanding of the relationship between structure of the flame-retarding finish and textile performance properties of the chemically modified cotton fabric.
An Attempt to Quantify the Translation of Fiber Bundle Tenacity into Yarn Tenacity
Authors: Neelakantan P. , Subramanian T. A.
Published: January 2017

The concept of a real yarn tenacity, derived by making an allowance for fiber obliquity and for the fibers that do not contribute to the yarn breaking load, has been postulated. An equation has been derived to enable the calculation of real yarn tenacity. In the case of man-made fibers that exhibit only a very weak gauge-length effect in their bundle tenacity, the real yarn tenacity has been shown to be equal to the fiber bundle tenacity at all levels of twist beyond the minimum required to ensure an interlocking structure. In the case of cotton, the effective gauge length for which the bundle tenacity is equal to the real yarn tenacity has been found to depend upon the level of twist in the yarn, being of the order of 1 mm for yarns that have more than the optimum twist.
A Study of the Compression Behavior of Jute Fibers
Authors: Basu A. K. , Mukhopadhyay U.
Published: January 2017

The compression behavior of different varieties of jute fibers were studied. The bulk specific volume, defined as the ratio of the compressed volume to the weight of the sample, was measured under different loads and different conditions. A relation of the form V = aLb was obtained, where V is the bulk sp. vol., L is the load, and a and b are constants. Significant correlation was observed between bulk sp. vol. and fiber tex and a relation between the two was obtained.
Air-Jet Textured Yarns: The Effects of Process and Supply Yarn Parameters on the Properties of Textured Yarns
Authors: Demir A. , Acar M. , Wray G. R.
Published: January 2017

Characteristics of air-jet textured yarns are determined by the instability, linear density, and strength, together with structural properties such as loop size, loop frequency, and degree of entanglement. Such characteristics are affected by various process parameters and supply yarn properties. The effects of these parameters on the final yarn properties have been investigated using instability, linear density, and strength tests, together with SEM photographs for visual assessment of the yarn structure. Optimizing any given yarn property almost always affects other yarn characteristics, and therefore this must be remembered when selecting suitable process parameters and supply yarns for specific end uses. For a given texturing nozzle and conditions, there is an optimum filament fineness and number of filaments that can be textured effectively.
Optimizing the Complex Formulation of Boiling-off Liquor for Ramie Chemical Degumming
Authors: Zheng Yangang , Zhang Ze , Luo Ze-Wei
Published: January 2017

The ramie degumming efficiencies of three auxiliaries, sodium pyrophosphate, sodium metasilicate, and sodium sulfite, have been studied using a quadratic orthogonal rotation experimental design. Sodium pyrophosphate performs the function of a major auxiliary, but it can be replaced and replenished by sodium metasilicate over a definite range. An optimum complex formulation has been developed in the laboratory.
Microcomputers in Anthropological Research
Authors: Kirk Rodney C.
Published: January 2017

This article examines the potential offered by microcomputer technology to radically improve the effectiveness and productivity of team field research in anthropology. Microcomputers can offer in situ storage, retrieval, and analysis of field data and information. A microcomputer system may function as both a stand alone device and as a terminal to a mainframe, time sharing computer. Drawing from pilot projects using microcomputers, the various dimensions of feedback, consequences for fieldwork strategies, and efficiency are explored.
Paediatric Day-Case Surgery at NAUTH, Nnewi, Nigeria
Authors: Osuigwe A N , Ekwunife C N
Published: January 2017

Day-care surgery is strongly advocated in well-selected paediatric cases when the complications are within acceptable limits because it is very cost effective.
Hypokalaemic Paralysis Precipitated by Working in Hot Weather
Authors: El-Sonbaty Mohammed Riad , Abdul-Ghaffar Naser UAMA
Published: January 2017

Twenty-two cases of hypokalaemic paralysis seen over the past 7 years, are presented here. They included five Chinese, five Bangladeshis, six Arabs, four Philippinos and two Indians. The number of cases related to the population of each nationality in our area showed that the Chinese had the biggest number of cases in relation to their population in our area, followed by Philippinos then Bangladeshis. All patients were men admitted in the hot season, dehydrated and not able to walk. It seems that dehydration was an important precipitating factor in our cases. Although family history was positive in one patient, apart from four thyrotoxic patients, the others were apparently healthy. Patients improved dramatically with IV potassium and rehydration. Four patients were readmitted with the same picture.
Canadian Public Television and Preschool Children: Predictors of Viewers and Nonviewers
Authors: Cohen Mitchell E. , Brown Jane D. , Clark Sheridith
Published: January 2017

A socialization model of public television viewing among Canadian preschoolers is proposed and analyzed using discriminant and multiple classification analyses. Of the five sets of variables analyzed, the family's media environment (primarily access to cable television and print media use) and the parent's attitude toward television in general were the strongest predictors of both the viewing and frequency of viewing public television programs by preschool age children in the home.
Equal Treatment for Regulatory Science: Extending the Controls Governing the Quality of Public Research to Private Research
Authors: Wagner Wendy , Michaels David
Published: January 2017

The imperative that agencies use sound science in developing their regulations has become a major preoccupation of the political branches. In only a few years, Congress passed two appropriations riders that provide extensive new mechanisms for the public to critique the science used by agencies. The executive branch quickly followed suit, promulgating regulations to implement these two laws, as well as proceeding on its own sound science missions. In the space of less than one year, the Office of Management and Budget (OMB) circulated for public comment draft peer review requirements for the scientific review of agency science, and the Environmental Protection Agency (EPA) launched a full scale program to improve the quality of the models it uses in regulation, as well as Assessment Criteria to be used by agency officials in reviewing the quality of third-party (primarily state) science.
The Mercury's Falling: The Massachusetts Approach to Reducing Mercury in the Environment
Authors: Harvey Pamela D. , Smith C. Mark
Published: January 2017

Mercury is a persistent, bioaccumulative toxin that adversely affects human beings and wildlife. Mercury, like many such toxins, is a multimedia pollutant that can readily transfer among air, water, and soils, and thus crosses the boundaries of traditional regulatory programs. Mercury can also be transported long distances in the atmosphere, creating transboundary issues that are regional and global in scope. Human exposure to mercury is largely attributable to the consumption of contaminated fish, with women of childbearing age, infants, and children at greatest risk. Because mercury persists in the environment, the risk of neurological or other impairments can span generations. Mercury, largely from anthropogenic sources, enters aquatic systems through a variety of pathways including direct deposition from the atmosphere, runoff, and wastewater discharges.
Surviving Preemption: The Importance of Chapter 58 in the Context of America's Health Care Crisis
Authors: Ten Haagen Anthony
Published: January 2017

Amidst a lavish ceremony in Boston’s Faneuil Hall on April 12, 2006, Massachusetts Governor Mitt Romney signed into law Chapter 58 of the Acts of 2006: An Act Providing Access to Affordable, Quality, Accountable Health Care. At that time, Chapter 58 represented the most comprehensive state health reform ever passed in the country, and the first with the potential to provide near universal health coverage. Since Romney signed Chapter 58, it has been the focus of a great deal of national media attention. Other states are evaluating whether Chapter 58’s complicated bipartisan formula could be effective within their borders, and Romney plans on basing his presidential campaign to a large extent on Chapter 58’s potential as a model for national health reform. However, Chapter 58 faces a potential legal challenge under the preemption clause of the federal 1974 Employee Retirement Income Security Act (ERISA). In part, ERISA acts to limit the burden on employee benefit plans established by multi-state employers from state regulation.
In Tepid Defense of Population Health: Physicians and Antibiotic Resistance
Authors: Saver Richard S.
Published: January 2017

Antibiotic resistance menaces the population as a dire public health threat and costly social problem. Recent proposals to combat antibiotic resistance focus to a large degree on supply side approaches. Suggestions include tinkering with patent rights so that pharmaceutical companies have greater incentives to discover novel antibiotics as well as to resist overselling their newer drugs already on market. This Article argues that a primarily supply side emphasis unfortunately detracts attention from physicians' important demand side influences. Physicians have a vital and unavoidably necessary role to play in ensuring socially optimal access to antibiotics. Dismayingly, physicians' management of the antibiotic supply has been poor and their defense of population health tepid at best. Acting as a prudent steward of the antibiotic supply often seems to be at odds with a physician's commonly understood fiduciary duties, ethical obligations, and professional norms, all of which traditionally emphasize the individual health paradigm as opposed to population health responsibilities. Meanwhile, physicians face limited incentives for antibiotic conservation from other sources, such as malpractice liability, regulatory standards, and reimbursement systems. While multi-faceted efforts are needed to combat antibiotic resistance effectively, physician gatekeeping behavior should become a priority area of focus. This Article considers how health law and policy tools could favorably change the incentives physicians face for antibiotic conservation. A clear lesson from the managed care reform battles of the recent past is that interventions, to have the best chance of success, need to respect physician interest in clinical autonomy and individualized medicine even if, somewhat paradoxically, vigorously promoting population health perspectives. Also, physicians' legal and ethical obligations need to be reconceptualized in the antibiotic context in order to better support gatekeeping in defense of population health. The principal recommendation is for increased use of financial incentives to reward physicians for compliance with recommended guidelines on antibiotic prescribing. Although not a panacea, greater experimentation with financial incentives can provide a much needed jump-start to physician interest in antibiotic conservation and likely best address physicians' legitimate clinical autonomy concerns.
Drug Preemption and the Need to Reform the FDA Consultation Process
Authors: Gilhooley Margaret
Published: January 2017

The scope of product liability for prescription drug injuries is a highstakes matter. As the recent Vioxx litigation illustrates, drug manufacturers can face numerous lawsuits when users are injured by risks discovered only after the drug reaches the market. The extent to which Food and Drug Administration (FDA) decisions preempt tort liability has emerged as a major issue. The agency itself has issued a policy that favors preemption when a drug manufacturer consults with the agency about a new risk. The Supreme Court has found liability preempted for medical devices based on an express preemption provisions and is expected to make an important ruling on drug preemption this term in Wyeth v. Levine. Some believe that the Court will rule in favor of preemption even though there is no express statutory provision for drugs.
Toward An Architecture of Health Law
Authors: Mariner Wendy K.
Published: January 2017

In 1894, John Drinkwater, the befuddled, searching architect in John Crowley’s compelling fantasy, Little, Big, built his own home, Edgewood, “as a kind of compound illustration” of Victorian architectural styles.1 Rounding each corner, the visitor sees a different façade and interior – Italianate villa, Tudor manor house, neo-classical, country cottage – complete in itself, its attachment to the others invisible from a single perspective.

Reading a small flurry of articles from the past few years attempting to describe the field of health law, one feels like a visitor to Edgewood. The different perspectives are pleasing in themselves, without necessarily revealing the whole. This essay examines what I call the “architecture” of the health law field. By this I mean, without pressing the metaphor too far, the framework of beams and studs in which interior spaces can be designed, furnished and accessorized in different ways.
A Reasonable Time, Place and Manner Restriction: Medicare Reimbursement Law Should Require Pharmacists to Fill Prescriptions Regardless of Personal Belief
Authors: Snyder Diana
Published: January 2017

“[T]he [First] Amendment embraces two concepts—freedom to believe and freedom to act. The first is absolute but, in the nature of things, the second cannot be.”
Off-Label Drug Use and Promotion: Balancing Public Health Goals and Commercial Speech
Authors: Kesselheim Aaron S.
Published: January 2017

Off-label promotion of prescription drugs has become a source of substantial controversy in the past decade. Before a new drug reaches the market, its safety and efficacy must be certified by the Food and Drug Administration (FDA). But the FDA does not simply approve a drug for general use. Rather, it approves drugs for the specific uses requested by manufacturers, who choose the universe of possible indications when they undertake pre-marketing clinical trials. The approval is therefore tied to a particular disease that is the subject of the manufacturer's pre-approval testing and the FDA's formal review. The conditions for which the product is approved are spelled out in the official drug label, including the dose evaluated by the FDA, and the details of administration in which the FDA has determined the drug showed efficacy. The label also describes the safety concerns related to the use.
The Money Blind: How to Stop Industry Bias in Biomedical Science, without Violating the First Amendment
Authors: Robertson Christopher T.
Published: January 2017

The pharmaceutical and medical device industries use billions of dollars to support the biomedical science that physicians, regulators, and patients use to make healthcare decisions—the decisions that drive an increasingly large portion of the American economy. Compelling evidence suggests that this industry money buys favorable results, biasing the outcomes of scientific research. Current efforts to manage the problem, including disclosure mandates and peer reviews, are ineffective. A blinding mechanism, operating through an intermediary such as the National Institutes of Health, could instead be developed to allow industry support of science without allowing undue influence. If the editors of biomedical journals fail to mandate that industry funders utilize such a solution, the federal government has several regulatory levers available, including conditioning federal funding and direct regulation, both of which could be done without violating the First Amendment.
Can Speech by FDA-Regulated Firms Ever Be Noncommercial?
Authors: Cortez Nathan
Published: January 2017

For over a century, the Food and Drug Administration (FDA or the Agency) and its precursors have regulated what companies say about their products. The FDA itself notes that the regulatory scheme imposed by the Federal Food, Drug, and Cosmetic Act “depends on the use of words” and that its requirements can “explicitly limit speech.” For seventy years, the FDA had little reason to worry about First Amendment constraints. But since 1976, when the Supreme Court reversed its longstanding position that the First Amendment does not protect commercial speech, the Agency has had to confront–perhaps more than any other federal agency–the free speech rights of regulated firms.

But how far do those rights extend, and what room do they leave for regulators like the FDA? The answer largely depends on another question: Is the speech commercial or noncommercial? The distinction is paramount. If speech by a regulated firm is commercial, then the FDA can ensure that it is not false or misleading; the Agency can require or compel certain speech; it can impose prior restraints; and it can even limit truthful speech, all within certain parameters.
The National Residency Exchange: A Proposal to Restore Primary Care in an Age of Microspecialization
Authors: Cheng Glen
Published: January 2017

Healthcare deficiencies in the United States have long been perpetuated by a shortage of primary care providers. A core purpose of the Patient Protection and Affordable Care Act (PPACA) is to provide health insurance for America's approximately fifty million uninsured. Implementation of universal health insurance, however, does not mean sufficient healthcare access for all, since the supply of physicians does not and will not meet demand. For reasons reviewed in this Article, the current physician shortage mainly impacts primary care providers. This shortage is particularly troubling because increased provision of primary care relative to specialty care has been associated with improvement in health outcomes, disease prevention, cost effectiveness, and coordination of care. This Article highlights provisions in the PPACA that impact primary care physicians. Finally, this Article proposes the creation of a universal primary care loan repayment program and a national residency exchange designed to alleviate the U.S. primary care crisis by facilitating optimal distribution of resident physicians in each medical specialty based on community need.
Regulatory Approaches to Ending Cigarette-Caused Death and Disease in the United States
Authors: Daynard Richard
Published: January 2017

Cigarettes result in over 400,000 preventable American deaths each year. In 2011, fewer than twenty percent of adults smoked. Since the publication of the first U.S. Surgeon General's Report on Smoking and Health nearly fifty years ago, when smoking prevalence was around forty percent, policies such as smoke-free laws, large tax increases, and litigation have collectively contributed to cut smoking prevalence in half. Unfortunately, no one expects the mix of policies currently proposed, which includes further tax increases, spatial smoking restrictions, somewhat higher minimum age restrictions, adverse publicity, and quitting assistance, to reduce U.S. smoking prevalence below fifteen percent in the foreseeable future.

The rule adopted by the U.S. Food and Drug Administration (FDA) to require hard-hitting graphic warnings on cigarette packages, as is currently done in dozens of other countries, has thus far been rejected by federal judges who have found that warnings designed to arouse negative emotions violate cigarette manufacturers’ First Amendment rights.
Exploring the Confines of International Investment and Domestic Health Protections—Is a General Exceptions Clause a Forced Perspective?
Authors: Chaisse Julien
Published: January 2017

The international law of foreign investment is one of the fastest-growing areas of international economic law with several bilateral investment treaties or preferential trade agreements, including an investment chapter, negotiated every year. At the same time, new cases are being lodged at an exponential rate. Thanks to the remarkable effectiveness of its law, the investment regime has become a center of attraction not only for the settlement of disputes strictly related to investment but also problems between governments concerning matters including those of non-economic dimensions. The nature of the international arbitral process is entirely different from a national court process; it is an international tribunal governed by an international convention, mandated to inquire into the conduct and responsibility of a State in light of its treaty and customary international law obligations. This could result in significant State liability and could impact regulatory regimes and policy goals, attracting considerable criticism.
Health Insurance is Dead; Long Live Health Insurance
Authors: Mariner Wendy K.
Published: January 2017

Upon the death of a king or queen, the proclamation “the king is dead, long live the king” announces a new monarch’s accession to the throne, preserving the sovereign order. As the Patient Protection and Affordable Care Act (ACA) is implemented, it is tempting to proclaim the reign of a new system of health insurance. But, will it preserve the old order or initiate a new form of governance? As states and insurers grapple with new rules and regulations being issued from the Department of Health and Human Services, the Treasury Department and the Department of Labor, one might believe an entirely new health insurance system is being built. Yet, the ACA is designed to preserve existing forms of public and private health insurance, such as Medicare and private employer group health plans, which will continue to operate much as they have in the recent past. What has changed is the role that insurance will play and how that will shape the way we think about health policy.
Changes in Plasma Solutes after Food
Authors: Gill G V , Baylis P H , Flear C T G , Lawson J Y
Published: January 2017

In experiments on 8 healthy young male volunteers, the ingestion of a large meal was found to cause plasma osmolality to rise from 288.8 ± 0.8 (mean ± s.e. mean) to 295.6 ± 0.9 mmol/kg at 4 hours ( P < 0.001). There was an accompanying rise in plasma sodium (Na) from 141.9 ± 0.8 to 144.6 ± 0.8 mmol/1, also at 4 hours ( P < 0.01), but little change in other plasma electrolytes. Serum total amino acids rose slightly, non-esterified fatty acid fell minimally and changes in blood glucose concentrations were unremarkable. Thirst was experienced at plasma osmolality of 294.8 ± 0.7 mmol/kg. Repeating the experiment either without food, or with the salt content of the meal only, was without effect on plasma Na, other solutes or osmolality. Postprandial hypersomolality and hypernatraemia is probably due to movement of water from the vascular compartment to the gut, or into cells. Plasma osmolality is best measured in the fasting state.
Visually Impaired Children II: Intervention Strategies
Authors: Erchul William P. , Turner Barbara D.
Published: January 2017

Using Maslow's (1973) Hierarchy of Basic Human Needs as an organizational scheme, this article offers an overview of interventions which are commonly used with visually impaired children. These strategies include: counselling parents to aid acceptance of their child, providing stimulation and enrichment to enhance psychological development, increasing visual efficiency, aiding orientation and mobility, decreasing undesirable behaviours, increasing social skills, fostering classroom acceptance, facilitating academic learning, and counselling the child to aid self-acceptance.
Do gender and socioeconomic status matter when combining work and family: Could control at work and at home help? Results from the Whitehall II study
Authors: Falkenberg Helena , Lindfors Petra , Chandola Tarani , Head Jenny
Published: January 2017

Work and family are sources of both satisfaction and conflicting demands. A challenge is to identify individuals at risk for conflict and factors that potentially reduce conflict. This study investigated how gender and socioeconomic status (SES) were associated with work–family interference (WFI) and family–work interference (FWI) and how control at work and at home related to WFI and FWI. Data from 1991–1993 and 1997–1999 of the Whitehall II study of British civil servants, including 3484 (827 women and 2657 men) employees in three SES-levels, were analysed. Women reported a higher risk for WFI and FWI. High SES employees reported higher WFI. Less control at home increased risks for WFI and FWI as did low control at work but only for WFI. This suggests that high SES women are especially at risk for conflict and that aspects from the spheres of both work and home should be considered in further research and practice.
Carbohydrate Oxidation Rates in Patients With Anorexia Nervosa
Authors: Goldstein Richard E.
Published: January 2017

This study was prompted by the authors' observation that some patients with anorexia nervosa (AN) do not gain weight despite appropriate caloric intake and some recent evidence1 that patients with AN respond differently to caloric supplementation depending on what their body habitus was before developing AN. The primary purpose of this study was to study carbohydrate oxidation rates in patients with AN and determine whether differences could be discerned between those patients who gained weight and those who failed to gain weight.

The study consisted of 21 female AN patients whose average weight was 30.1% ± 1.5% below their ideal body weight and 10‐age matched healthy women serving as controls (NC). Caloric intake was stabilized over a 10‐day period. At the conclusion of the 10‐day period, those 21 AN patients were divided into two groups (AN‐a consisted of 10 patients who gained less than 2% of their body weight, and AN‐b consisted of 11 patients who gained more than 2% of their body weight during the 10‐day feeding period). The average daily caloric intakes in the AN‐a, AN‐b, and NC groups were 1465 kcal/d (42.2 kcal/kg), 2121 kcal/d (58.6 kcal/kg), and 1755 kcal/d (35.2 kcal/kg), respectively. At the beginning of the 10‐day study period, after an overnight fast, the subjects ingested 50 g of glucose at 8 AM. Venous blood was sampled for glucose and insulin over the next 3 hours and oxygen consumption and carbon dioxide production were measured with a metabolic cart. Urine was collected for measurement of urinary nitrogen content.

There was no difference in nonprotein respiratory quotient (NPRQ) between AN‐a and NC groups. However, NPRQ was significantly elevated in the AN‐b group before and after glucose ingestion compared with the NC and AN‐a groups. Before glucose ingestion, carbohydrate oxidation rates were 61 6 13 mg/min in the NC group, 55 6 12 mg/min in the AN‐a group, and 122 6 13 mg/min in the AN‐b group. After glucose ingestion, the rates increased in the NC and AN‐a groups and remained elevated in the AN‐b group. The plasma glucose response was similar in all three groups, whereas the plasma insulin response was decreased in the AN‐b group and tended to be decreased in AN‐a group compared with the NC group.

These authors concluded that measurement of the basal NPRQ may be a predictor of weight gain in patients with AN and they go on to suggest that caloric intake may need to be increased in those patients who fall into the AN‐a category. They also suggest that hepatic glucose processing enzymes (eg, glucokinase and phosphofructokinase) are present in larger amounts in the AN‐b vs the AN‐a group; however, the relationship to weight gain is unclear.
Cocaine Hepatotoxicity in Mice: Histologic and Enzymatic Studies
Authors: Mehanny Sherif Z. , Abdel-Rahman Mohamed S.
Published: January 2017

The severity of hepatotoxicity in CF-1 mice given 5 daily doses of 5, 10, and 20 mg cocaine/kg body weight and sacrificed 24 hr after the last injection appeared to be dose-dependent. Using light microscopy, the hallmark of cocaine early toxicity was manifested by pallor and ballooning of the hepatocytes in the midzonal and then in the centrilobular areas. Degeneration and necrosis of the liver cells in the same zones were encountered while the hepatocytes in the periportal areas remained intact. When examined under the electron microscope, such pallor and ballooning of the hepatocytes appeared to be due to dilation of the rough endoplasmic reticulum (RER) profiles which of ten revealed a significant loss of their ribosomes. Dilation of the smooth endoplasmic reticulum (SER) was also common and moderate proliferation of peroxisomes was frequently seen. In the degenerating hepatocytes, the 2 forms of endoplasmic reticulum were difficult to recognize and the peroxisomes appeared sparse. Cocaine treatment elevated the level of glutamic pyruvic transaminase and glutamic oxaloacetic transaminase in a dose-dependent manner. Although hepatic cytochrome P450 was slightly increased in the low dose groups, a reduction in the enzyme activity was noticed in the group treated with 20 mg cocaine/kg. However, hepatic reduced glutathione content manifested a significant increase in the group which received 20 mg cocaine/kg.