bluuebunny/crossref_metadata_2025 huggingface dataset:
Stroke Management
Authors: Fagan Susan C.
Published: January 2017

With as many as 500,000 new strokes per year in the United States, the need for safe and effective therapy of these patients is evident. The area in which the greatest impact has been made is in the development of prophylactic treatments for patients at risk of stroke. Aspirin, long the mainstay of stroke management, has repeatedly been shown to reduce the risk of cerebral ischemia in patients who have had a transient ischemic attack (TIA) or minor stroke and is first-line therapy for these patients. Either 325 mg or 975 mg of aspirin may be used. Ticlopidine (250 mg twice daily) is a new antiplatelet agent that is recommended for the prophylaxis of stroke in patients who cannot tolerate or who are resistant to aspirin therapy. The surgical procedure, carotid endarterectomy, has been shown to reduce the stroke rate in symptomatic patients, with between 70% to 99% stenosis of a carotid artery. The use of warfarin has been shown to be extremely useful in patients with atrial fibrillation for prevention of recurrent embolic events. The use of pharmacological agents in the acute treatment of the ischemic stroke patient has not yet been proven successful. It is hoped that with the trend towards hyperacute (less than 6 hours) intervention, investigators may be successful in finding an agent to decrease the ultimate neurological deficit due to stroke. Some of the more promising agents are thrombolytics, glutamate antagonists, and aminosteroids. Future research in cerebral ischemia will undoubtedly improve the prognosis of stroke patients.
Intravenous Anesthetic Agents
Authors: Salvon Jennifer H.
Published: January 2017

Intravenous (IV) anesthetics are used in the operating room setting for the induction and maintenance of general anesthesia. These agents are used in combination with many other therapeutic agents including inhalational anesthetics, anticholinergics, neuromuscular blockers, local anesthetics, and antihistamines. Currently available intravenous anesthetics include barbiturates (eg, thiopental and methohexital), benzodiazepines (eg, diazepam and midazolam), etomidate, ketamine, propofol, and opioids (eg, morphine, meperidine, fentanyl, alfentanil, and sufentanil). The barbiturates are the most frequently used agents for induction today. The benzodiazepines are used primarily for preoperative sedation intraoperatively; however, they may also be used for induction in certain clinical situations. Etomidate offers the advantage of minimal cardiovascular side effects, while ketamine is distinguished by stimulant cardiovascular effects. Propofol has a short recovery time and a low incidence of nausea and vomiting when compared with that of barbiturates and opioids. The opioids are used most often for the production of analgesia, although they may also be used as primary anesthetic agents in select patient populations. In this article, the pharmacokinetics of these agents will be reviewed as well as factors affecting their pharmacokinetic profile. These factors include age, hemodynamic changes, renal or hepatic dysfunction, and interaction with concomitant medications.
Implementing a Pharmaceutical Care Plan in the Community Pharmacy Setting
Authors: Hoye Robert S. , Drew Kathy
Published: January 2017

The quickly changing healthcare environment has forced many healthcare professionals, including pharmacists, to justify the necessity of their roles in the provision of quality patient care. Pharmaceutical literature has strongly advocated the need for pharmacists to expand their roles into more interactive positions with physicians and other providers. The reasons are not only to increase their level of involvement in patient care, but also to educate professionals to the pharmacist's expertise and capabilities in pharmacotherapeutic treatment of patients. Hepler and Strand1 have written about the value and benefits of including pharmaceutical care planning programs and cognitive services into the daily routines of pharmacists in all settings. This article will explain how a community pharmacy conducted a pilot study to develop and implement its own formalized pharmaceutical care planning program for the treatment of patients with acute and chronic pain.
Psychopharmacy in the Long-Term Care Setting: A New Frontier for Pharmacy Practice
Authors: Daiello Lori A.
Published: January 2017

Despite the promulgation of state and federal regulations mandating psychiatric services and freedom from chemical and physical restraints for residents of long-term care facilities, there exist significant barriers to the delivery of care. Under-recognition and misdiagnosis of psychiatric illness in the elderly may lead to increased functional impairment and possible increased mortality. Development of a focused psychopharmacology practice can aid in the recognition and treatment of psychiatric illness and improved patient outcomes in the long-term care setting.
Perceptions of and Constraints upon Pregnancy-Related Referrals in Rural Rajasthan, India
Authors: Gupta J. , Gupta H.
Published: January 2017

Mortality associated with complications of pregnancy and childbirth remains disproportionately high in the developing world. This paper reports on a study into the reasons for the poor uptake of referrals to specialist medical units in a group of 276 women in a rural area in the state of Rajasthan, India.

Of the 276 cases that were referred, 242 (88%) of the women failed to attend for specialist consultation. In-depth personal interviews were conducted and a series of focus group discussions was held with the women and with their spouses and spouses' mothers. A range of geographic, cultural, socio–economic and medico–administrative factors was identified as influencing decisions to attend referral units.

Recommendations for improving uptake include improving facilities at referral units, providing additional training for healthcare staff (covering technical, managerial and behavioural aspects) and in counselling techniques, a better defined role for traditional birth attendants, improved understanding of the mother's needs by her family (particularly the spouse and his mother) and increasing public awareness of the importance of referral. Finally, there is the requirement that women are encouraged to realize and understand their own needs.
Re-Engineering the Soft Machine: The Impact of Developing Technology and Changing Practice on Diagnostic Radiographer Skill Requirements
Authors: Price R. , Miller L. , Payne G.
Published: January 2017

This paper describes research to investigate the extent to which new technology and changing work practices in diagnostic imaging have changed the skill requirements of working radiographers. Interviews were conducted with radiography managers, radiologists and industry representatives. While changes in technology were viewed as having a significant impact on skill requirements, levels of resourcing and both national and local policy were seen as key factors driving changes in work practice. Respondents believed that significant changes would be required to pre- and post-registration training requirements for radiographers in the light of changing practice.
Diagnosis Related Groups (DRGs): Efficiency and/or Quality Producing? — Some Evidence from Surgical Patients
Authors: Wolfe Barbara L. , Detmer Don E.
Published: January 2017

Hospital charges and length of stay for inguinal hernia and acute appendicitis patients were examined in a university hospital to determine the degree of variation with DRGs. Evidence presented here suggests that DRGs may lead to a reduction in medical care costs without a reduction in patient outcomes. Mode/year DRGs to take account of source of admission and maintaining outliers payments may be desirable to avoid patient selectivity and incentives for lowering quality of care of the most severely ill patients.
Toward a Consensus for Health Care Reform: The Use of Focus Group Interviews
Authors: Potter Margaret A. , Settle Sherrie E.
Published: January 2017

Ten focus group interviews were conducted, with each group representing a different constituency of a regional health care system. Among the groups, there appeared to be similar visions of what the system should be, and similar assessments of the status quo and future trends. But there were differences about what barriers to reform exist and what compromises among the constituencies are necessary. Every group stated the need to educate the public about healthy behaviors, self-reliance, and responsible use of health care resources.
Hospital Service Scope Expansion and Market Share Improvement: A Dynamic Modeling and Multivariate Approach
Authors: Li Shur , Wan Thomas T. H.
Published: January 2017

In a national trend, large, acute-care hospitals located in urban areas of the nation were continuously broadening their service scope, adding services at the rate of one each year, from 1982 to 1987. This study proposes that the underlying rationale of hospital service-scope expansion is status-gap minimization. This perspective was quantitatively interpreted and tested by a dynamic modeling analysis. Findings support status-gap minimization as the rationale for service-scope expansion.

Using multivariate regression and dynamic modeling analysis, the study demonstrates that the cross-sectional relationship between two steady states – the relationship between service scope and market share – is positive and statistically significant. However, the market share change is not related to hospital service scope. The interpretation offered is that hospitals expand the scope of services looking not so much to increase their market share benefit in the short run as to raise their organizational status. In the long run, higher organizational status such as broader service scope then benefits market share.
Perceived Quality of Management Information and the Influence of Overspending Penalties in the NHS
Authors: Marriott N. , Mellett H.
Published: January 2017

The information needs of managers have changed considerably since the introduction of the internal market and many NHS units have invested in new management information systems to enhance the organization's performance. The characteristics of good quality information include accuracy, timeliness and comprehension. Information for management control also benefits from participation between the provider and the user. There are behavioural implications of using information as a control device and managers must internalize the financial objectives of the organization, usually expressed in budget reports. Failure to meet targets must attract penalties that will influence the managers' behaviour. They must respond to the information provided if control is to be exercised. This paper gives the results of a study into managers' perceptions of the adequacy and usefulness of financial information and the impact of penalties for overspending. It concludes that the financial information currently provided fails to meet many of the criteria of good quality information. Any perceived penalty for failing to attain budget-related goals is better than none, and there is little distinction between an overt reprimand and the ultimate sanction of dismissal.
Maximizing the Contribution Doctors Make to NHS Management
Authors: Hearing S. , Dent T. , Swann J. , Gunaratna I. , McLellan I. , Ikidde U.
Published: January 2017

Management is an increasingly important issue for many doctors. If doctors wish to influence resource allocation, they must involve themselves in health service management. This article describes the results of an enquiry action learning project involving six doctors. As part of the project, clinical directors and their business managers were interviewed. In addition, the Police Force and BAA (formerly the British Airport Authority) were visited and their management structure, out-of-hours activities and planning for emergencies assessed. This article examines the reasons why many doctors do not involve themselves in management, such as increased time commitment and negative peer pressure, and suggests some solutions to these problems, including the need for a wider understanding of the role of clinical directors. It also considers how some organizations are already starting to address these issues, and how both doctors and hospitals can benefit from greater involvement of doctors in health service management.
Hepatitis C and HIV Co-Infection
Authors: Leen C L S
Published: January 2017

HIV accelerates progression of hepatitis C virus (HCV)-related liver disease. There are conflicting data on the effect of HCV on the risk of HIV progression and CD4 response to highly active antiretroviral therapy (HAART). Long-term prospective cohort studies are clearly required to resolve these issues. The optimal management of the co-infected patient is also unclear. For the co-infected patient, the optimal HAART regimen for best immune CD4 recovery and least adverse reactions remains unclear. Unfortunately, current HCV treatment is associated with significant side effects and a considerable proportion of HIV co-infected patients are poor candidates for HCV treatment. Better and more effective treatment for HCV (preferably not based on interferon) is urgently required for this group of patients. Patients with good CD4 cell count and with HCV genotypes 2 and 3 are likely to have a reasonable response to treatment.
Private Prescription Costs for Sildenafil within the NHS: A Telephone Survey
Authors: Mostyn PA , Crowley T , Keane F E A
Published: January 2017

Because of the restrictions on prescribing for impotence within the NHS, doctors routinely write private prescriptions for sildenafil. The aim of this study was to determine the variation in cost of a private prescription of four 100mg tablets of sildenafil, A selection of different pharmacy types within five areas in England was surveyed. We telephoned a total of 86 pharmacies and we were quoted prices ranging from £28.20 to £42.33. There was a significant difference in price between area and between pharmacy type. Best prices are not necessarily found at the major pharmacy chains or hospital pharmacies, as might be expected. NHS doctors and patients need to be aware of this significant difference in cost.
Retrospective Review of the Correlation of Symptoms, Signs and Microscopy with the Diagnosis of Chlamydia Trachomatis in Men
Authors: Foo Christopher , Browne Rita , Boag Fiona
Published: January 2017

We have investigated the correlation of symptoms, signs and microscopy on the detection of Chlamydia trachomatis infection in men attending our clinic. One hundred and eleven men diagnosed with chlamydia over an 11-month period in our clinic were reviewed. Of these, 70 (63%) were symptomatic and 41 (37%) were asymptomatic. 84% (59/70) of symptomatic and 51% (21/41) of asymptomatic patients met the UK clinical criteria for diagnosis of non-gonococcal urethritis (NGU) and received treatment appropriate for chlamydia and NGU at their initial clinic visit. Our findings show that 19% (21/111) of men with Chlamydia trachomatis infection would leave the clinic untreated if a urethral smear preparation was not performed on those who were clinically asymptomatic at presentation. We feel that this is a sufficient argument to warrant continuing the current practice of testing asymptomatic men attending GUM clinics for NGU.
Response of HIV-Infected Patients with Asymptomatic Syphilis to Intensive Intramuscular Therapy with Ceftriaxone or Procaine Penicillin
Authors: Smith N H , Musher D M , Huang D B , Rodriguez P S , Dowell M E , Ace W , White A C
Published: January 2017

The objective of this prospective pilot study was to evaluate the response of HIV-infected patients with asymptomatic syphilis to one of two intensive antibiotic treatment regimens. Thirty-one HIV-infected patients with serum rapid plasma reagin titre ≥1:4 and no clinical findings of syphilis were randomized to receive daily intramuscular injections of ceftriaxone or procaine penicillin (plus oral probenecid) for 15 days; 24 returned for follow-up study. Seven of 10 (70%) procaine penicillin-treated patients and 10 of 14 (71%) ceftriaxone-treated patients had a ≥4-fold decline in RPR ( P=0.94); two penicillin-treated and one ceftriaxone-treated patient relapsed. Two patients failed ceftriaxone therapy. Three penicillin-treated, and two ceftriaxone-treated patients were serofast. Serological responses were similar in those patients with and without asymptomatic neurosyphilis. There was no difference in the serologic response to daily treatment with ceftriaxone vs that with procaine penicillin plus probenecid; both treatments were associated with comparatively high rates of serological non-response and relapse.
The Usefulness of the HIV—CHEK Assay as a Simple, Rapid and Sensitive Screening Test for HIV Infection
Authors: Walzman M , Natin D , Shahmanesh M
Published: January 2017

The purpose of this study was to evaluate the usefulness of the HIV–CHEK kit for human immunodeficiency virus (HIV) antibody testing.

A comparison with the Serodia-HIV test was made on 42 fresh serum samples. Both tests accurately identified the 11 true positive serum samples, while there was one false positive with the Serodia-HIV and 3 were difficult to interpret using the HIV–CHEK. To assess the sensitivity of the HIV–CHEK assay, a comparison with other tests was made using serial titrations of stored known HIV-positive frozen serum samples. Here the HIV–CHEK demonstrated a poor sensitivity compared to the others.

In conclusion, although we found the HIV–CHEK to be simple and quick, the difficulty with interpretation of some specimens and the apparent poor sensitivity on frozen samples makes it difficult to recommend this kit in its present form as a principal initial screening test for HIV antibody.
Evaluation of the Significance of Mycoplasma Hominis and Ureaplasma Urealyticum in Female Genital Tract Infection—A Retrospective Case Note Study
Authors: Crawshaw S C , Stocker D I , Sugrue D L , Haran M V
Published: January 2017

Routine screening for sexually transmitted diseases in new patients attending the Genitourinary Clinic in Stoke-on-Trent includes a culture for Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU). A retrospective study was carried out on 400 female patients to ascertain whether there were any significant differences between the group positive for MH and UU and the negative control group. The positive group were found to be younger on average, but to have similar sexual histories to the negative control group. An association was found between the presence of genital mycoplasmas and Gardnerella vaginalis. An odourous vaginal discharge was more common in the positive group.

Erythromycin was ineffective in eradicating the organisms in 62.5% of patients with MH, and 70% of those with UU.

Continuing work is required to identify those women in whom the presence of MH or UU could have pathogenic effects. Treatment regimens for this group of women need to be carefully reassessed, in the light of increasing antibiotic resistance.
Outpatient Medical Care of Injection Drug Use Related HIV
Authors: Brettle R P , Gore S M , McNeil A
Published: January 2017

By the end of March 1990 470 HIV positive patients, 77% injection drug use (IDU) related, had attended the outpatient department of the Regional Infectious Disease Unit with a cumulative loss to follow-up of only 20%. Coincident with the prescribing of oral methadone and a specific all-day IDU-related HIV medical clinic the total number of appointments increased from 28/month in May 1986 to 300/month in May 1989 ( P< 0.001) and the number of defaulted appointments decreased from a maximum of 60% (17/28) to 16% (48/294, P<0.001) in these months.

There was a significant initial increase in the number of defaulted appointments for the infectious disease (ID) clinics from 11% (77/726) to 16% (124/797, P<0.01) which returned to previous levels once a specific IDU-related HIV clinic was established. There was also a significant decline in the number of new patients referred which was greater for the urinary tract infection clinics (108 to 56 per 6 months, P<0.0001) than for the ID clinics (119 to 88 per 6 months, P<0.05).
Clinical and Molecular Aspects of Molluscum Contagiosum Infection in HIV-1 Positive Patients
Authors: Thompson Carol H , de Zwart-Steffe Rita T , Donovan Basil
Published: January 2017

Molluscum contagiosum virus (MCV) lesions from 31 human immunodeficiency type 1 (HIV-1) positive patients and 54 HIV-1 negative adult control patients were examined for the presence and type of MCV DNA by high stringency Southern hybridization using 32P-labelled or digoxigenin-labelled MCV DNA probes. Of the 83 patients whose lesions contained detectable MCV DNA, 77 were infected with a single type of MCV (16 with MCV 1; 29 with MCV 1v; 30 with MCV 2; and 2 with MCV 2v). Five patients had apparent double infections, with hybridization results indicating the presence of various combinations of MCV 1 or lv and MCV 2 or 2v. When these results were analysed in the light of clinical data no correlations were found between the MCV type(s) detected and the clinical stage of HIV-1 infection; nor between the MCV types and the anatomical site of the lesions or persistence of infection. However, the HIV-1 positive patients were significantly more likely to be infected with MCV types 2 or 2v than were the controls (17/29, 59% versus 15/48, 31%; P<0.05). Since a concurrent study of MCV lesions in children aged 15 years or less has shown that the percentage of infections attributable to MCV 2 or 2v is extremely small (3%), this finding suggests that MCV lesions in HIV-1 positive patients are attributable to adult-acquired MCV infection rather than to reactivation of a childhood infection.
Trends in Sexual Behaviour in a Cohort of Homosexual Men: A 7 Year Prospective Study
Authors: Lau R K W , Jenkins P , Caun K , Forster S M , Weber J N , McManus T J , Harris J R W , Jeffries D J , Pinching A J
Published: January 2017

A cohort of homosexual men at risk for human immunodeficiency virus (HIV) infection were studied prospectively over a 7-year period (1982/88) to assess trends in sexual behaviour and amyl nitrite intake. During the period, there were dramatic declines in the proportion of HIV seropositive and seronegative subjects reporting multiple casual partners for anal intercourse, unprotected anal intercourse and recreational use of amyl nitrite. Reported rates of orogenital intercourse remained the same during the period, whilst the total number of seroconversions fell from 17 for the period 1982–84 to 8 for 1985–88. High-risk sexual and related social behaviour among homosexual men, as assessed by patterns of anal intercourse behaviour and nitrite intake, changed over the 7-year period, with the greatest changes apparent before the widespread availability of HIV antibody testing and public education campaigns. This highlights the effectiveness of peer-group and community-based programmes in modifying the sexual behaviour or their members.
Meatoscopy: An Important Technique for Assessing Meatal Warts in Men
Authors: Thin R N
Published: January 2017

A total of 506 meatoscopic examinations showed this is a simple, safe, rapid, well-tolerated, useful procedure to assess the extent of warts at the meatus and in the distal urethra of men. The procedure was performed in 307 patients. Sixty-five (52.5%) of 124 men with meatal warts had additional urethral lesions not readily treatable. All proximal warts were confined to the fossa navicularis. Meatoscopy assisted in immediate rational planning of therapy.

In assessing patients without meatal warts, lesions in the fossa navicularis were observed in 4 (6.7%) of 60 men with external penile warts, 4 (7.8%) of 51 men with a history of 3 previous episodes of urethritis, and in 8 (23.5%) of 34 men who had been in contact with warts.

No relation was found between the distribution of warts, demographic details of patients, or duration of warts; the effect of previous urethritis on development of warts was unclear. It was concluded, following 199 repeated examinations, that the procedure was not associated with recurrence or proximal extension. Only 2 minor adverse events were recorded.

Meatoscopy is recommended as part of the assessment of men with meatal warts and men who have been in contact with warts. The procedure should be considered in patients with external warts but no meatal warts, and in patients with a history of 3 previous episodes of urethritis over 3 years.
Bacterial Vaginosis in a District Genitourinary Medicine Department: Significance of Vaginal Microbiology and Anaerobes
Authors: Saidi S A , Mandal D , Curless E
Published: January 2017

The aim of this study was to correlate the significance of vaginal microbiology, in particular its anaerobic component, to the presence of bacterial vaginosis (BV), and to review the clinical criteria used in the diagnosis of this condition. Ninety-two female patients who received routine STD screening were studied. After routine history, presence and character of vaginal discharge and vaginal pH were noted, an amine test performed, and a wet stain observed microscopically. Routine Gram stain smears and cultures were prepared. BV was diagnosed clinically in 28 (30%) of our sample, and Gardnerella vaginalis was cultured in 41 patients (45%). Both clue cells and anaerobes were closely associated with each other and both mutually exclusive with the presence of lactobacilli on Gram stain ( P<0.001). BV was found to be strongly associated with the presence of clue cells on the wet film, anaerobes and G. vaginalis. In conclusion, bacterial vaginosis is not only strongly associated with the presence of G. vaginalis in the vaginal flora, but more strongly with the presence of anaerobes. The study suggests that the microaerophile G. vaginalis is a commensal organism in a significant proportion of sexually active women. If the aerobic status of the healthy vagina is disrupted, anaerobes (including Gardnerella) will flourish, producing the clinical picture of bacterial vaginosis.
1996 Diagnostic and Classification Criteria for the Antiphospholipid/Cofactors Syndrome: A ‘Mission Impossible’?
Authors: Piette J-C
Published: January 2017

Due to recent acquisitions, diagnostic criteria for the antiphospholipid/cofactors syndrome need to be improved. In the absence of a “common biological denominator”, the best approach should be based on a scoring system mixing clinical and immunological items. APS might be composed of different biological subsets characterized by antibodies directed to various cofactors. Among clinical subsets, the categorization between “primary” and SLE-related APS may be difficult to achieve. Contrasting with the innumerable conditions associated with the presence of aPL, the diversity of “true” secondary APS should probably be restrained. Attempts at establishing correlations between clinical and biological APS subsets will require further studies.
Non β2-Glycoprotein I Cofactors for Antiphospholipid Antibodies
Authors: Galli M
Published: January 2017

The Antiphospholipid Syndrome is defined by the association between peculiar clinical manifestations, namely arterial and/or venous thrombosis, recurrent abortions and thrombocytopenia, and the antiphospholipid antibodies. These antibodies are directed to plasma proteins bound to anionic phospholipids or other anionic surfaces: so far, β2-glycoprotein I is the best known and characterized antiphospholipid ‘cofactor’ ( this issue is specifically treated in other parts of this journal). In recent years, such a role has been reported also for prothrombin, activated Protein C, Protein S, Annexin V, Thrombomodulin, high- and low-molecular weight kininogens. Anti-prothrombin antibodies are detected in approximately 50% of the antiphospholipid-positive patients; conversely, limited data are available regarding the prevalence the other antibodies. ‘Cofactors' are necessary for the expression of both the immunological and the functional properties of their respective antiphospholipid antibodies. In particular, the recognition of the calcium-mediated prothrombin/lipid complex by anti-prothrombin antibodies hampers prothrombin activation, thus causing the prolongation of the phospholipid-dependent coagulation reactions. The interaction between antiphospholipid antibodies and natural inhibitors of coagulation such as activated Protein C, its non-enzymatic accessory protein Protein S or Thrombomodulin might increase the risk to develop thromboembolic events. Similarly, the presence of antibodies to surface-bound Annexin V has been hypothesized to play a role in recurrent abortions and fetal deaths. However, to clearly establish whether and which antiphospholipid antibodies represent risk factors for the thromboembolic events of the antiphospholipid syndrome, further studies of their behaviour and properties as well as the identification and characterization of (possibly) other antibodies are required.
Antigenic Specificities of Antiphospholipid Autoantibodies: Implications for Clinical Laboratory Testing and Diagnosis of the Antiphospholipid Syndrome
Authors: Roubey RAS
Published: January 2017

Most autoantibodies associated with the antiphospholipid (aPL) syndrome and detected in standard anticardiolipin and/or lupus anticoagulant assays are directed against β2-glycoprotein I (β2-GPI) or prothrombin. Recent data indicate that these antibodies can also be detected in immunoassays utilizing purified protein antigens, in the absence of phospholipids. Initial clinical studies suggest that positivity in anti-β2-GPI immunoassays is more closely associated with the clinical manifestations of the aPL syndrome than is positivity in conventional anticardiolipin ELISAs. Anti-β2-GPI immunoassays may detect certain anti-β2-GPI antibodies that are not detectable in conventional anticardiolipin assays, but do not detect authentic (β2-GPI-independent) anticardiolipin antibodies. It appears that the former, but not the latter, antibodies are associated with the clinical manifestations of the aPL syndrome. The potential advantages and disadvantages of these new immunoassays in the clinical evaluation of the aPL syndrome are discussed.
In Vivo Models of Thrombosis for the Antiphospholipid Syndrome
Authors: Pierangeli SS , Harris EN
Published: January 2017

Utilizing this unique animal model of thrombosis we demonstrated that human (IgG, IgM or IgA) polyclonal and monoclonal antiphospholipid antibodies derived from APS patients have a significant enhancing effect on thrombus formation. This effect is reversed by treatment of the mice with hydroxychloroquine (plaquenil). In addition murine polyclonal and monoclonal anticardiolipin antibodies induced by active immunization with human β2-GP1 or human anticardiolipin antibodies showed to have thrombogenic properties in CD1 mice. Antibodies with antihuman β2-GP1 activity alone did not seem to affect thrombus formation.
Antiphospholipid Antibody Syndrome: Treatment
Authors: Espinoza LR
Published: January 2017

Of the many clinical manifestations seen in the antiphospholipid antibody syndrome (APAS), two deserve major therapeutic consideration: recurrent fetal loss and vascular thromboses. Treatment of these two major complications remain empirical, although recent studies appear to indicate the beneficial use of multiple therapeutic options including low dose aspirin, alone or in combination with a moderate amount of prednisone, heparin and intravenous gammaglobulin for the prevention of fetal loss, and longterm anticoagulation with maintenance of an international normalized ratio (INR) of 3 to 4 as an effective measure in the prevention of vascular thrombosis. The use of interleukin-3 in animal models of the syndrome has been shown to be effective in the prevention of fetal loss, and this therapeutic modality appears promising, particularly because of its recognized low frequency of side effects in therapeutic trials in humans.
Management of Thrombosis in the Antiphospholipid Syndrome
Authors: Khamashta MA
Published: January 2017

Optimal management of patients with the antiphospholipid syndrome (APS) remains a problem. There is now good evidence that those with thrombosis will be subject to recurrences and require long-term, possibly lifelong, oral anticoagulation. Steroids and immunosuppressive drugs aiming at a reduction of the antibody levels have not provided long-term benefit. Only prospective and controlled clinical trials can give a definitive answer to the optimal thrombotic prophylaxis in patients with the APS.
Protein C and other Cofactors Involved in the Binding of Antiphospholipid Antibodies: Relation to the Pathogenesis of Thrombosis
Authors: de Groot PG , Horbach DA , Derksen RHWM
Published: January 2017

In this review we will discuss the possible interference of antiphospholipid antibodies with the protein C system. Antiphospholipid antibodies can interfere with the protein C system in different ways: (i) via inhibiting the formation of thrombin; (ii) via interference with the activation of protein C by the thrombomodulin-thrombin complex; (iii) via inhibition of the assembly of the protein C complex; (iv) via inhibition of the activity of protein C, directly or via its cofactor protein S, and (v) via antibodies directed against the substrates of APC, factors Va and VIIIa, thereby protecting them for inactivation. The experimental and theoretical indications that one of these mechanisms will explain the pathogenesis of the antiphospholipid syndrome is critically examined.
Francesco Redi (1626–1697): Tuscan Philosopher, Physician and Poet
Authors: Hawgood Barbara J
Published: January 2017

From 1660 to 1697 Francesco Redi was physician to two Grand Dukes of Tuscany as well as a natural philosopher and poet at the Medici court. Redi produced the first experimental evidence that insects do not spontaneously generate from decaying matter and that the poison of the viper resides in the yellow fluid in fang sheaths. He was also a pioneer parasitologist. His bacchanalian poem in praise of Tuscan wines is still read in Italy today.
Jokichi Takamine (1854–1922), The Samurai Chemist, and His Work on Adrenalin
Authors: Yamashima Tetsumori
Published: January 2017

The samurai chemist Jokichi Takamine (1854–1922) crystallized adrenalin, the first hormone to be isolated in the twentieth century, from the adrenal medulla, in the summer of 1900. This paper reviews Takamine's route to the discovery of adrenalin and presents historical photographs and documents collected in Kanazawa, Japan, where he grew up, and the United States, where he made his major discoveries.
John Aitken (d. 1790) — Grinder or Scholar?
Authors: Kaufman Matthew H
Published: January 2017

John Aitken attended the University of Edinburgh between 1763 and 1769 but did not graduate MD. He gained the membership (i.e. fellowship) of the Royal College of Surgeons of Edinburgh in 1770, and was for two sessions Senior President of the Royal Medical Society. Between 1771 and 1790 he published numerous books and pamphlets on surgery, medicine, midwifery, anatomy and physiology. As a surgeon at the Royal Infirmary, from 1779, he lectured on most subjects in the medical curriculum. John Struthers was particularly scathing of Aitken's scholarship, and this article attempts to restore Aitken's reputation as a scholar and probably one of the first of the extra-academical lecturers, who taught both anatomy and surgery in Edinburgh from 1779 until his death in 1790.
Observations on Continental Hospitals and Practice as Described by the English Surgeon James Fitzjames Fraser West (1833–1883)
Authors: Goodman Geraldine M
Published: January 2017

During his travels to Continental Europe, the Birmingham surgeon James Fitzjames Fraser West (1833–1883) observed innovative procedures and sound hospital practice. He also witnessed things that dismayed and sometimes disgusted him. West was renowned for recording these experiences in his diaries and snaring them with colleagues in medical society meetings and published reports. This paper provides an insight into some of these observations.
Roman Emperors Suffering from Apoplexy: The Medical and Historical Significance of Classical Literary Sources
Authors: Moog Ferdinand Peter , Karenberg Axel
Published: January 2017

According to various Greek and Latin texts, several Roman emperors died of “apoplexy”. This paper presents a systematic collection and evaluation of these sources. The contents of the texts are compared with contemporary knowledge as well as present-day perspectives. In retrospect, few of the “royal cases” can be classified as cerebrovascular disorders.
John Elliotson (1791–1868): A Bitter Enemy of Legitimate Medicine? Part I: Earlier Years and the Introduction to Mesmerism
Authors: Ridgway Elizabeth S
Published: January 2017

John Elliotson's involvement with mesmerism forms one of the most remarkable chapters in medical history. To tell this story alone, however, would belie the curious truth behind an eminent professor whose whole life was hallmarked by unsuppressed, unorthodox tendencies. With a reputation for flouting convention and a history of unorthodox affiliations, Elliotson went on to embrace the phenomenon of “mesmerism” with ungovernable enthusiasm. What follows is extraordinary, as mesmerism's most controversial patron lost his reputation, position, fortune and friends.
Effectiveness of Three Community Based Strategies to Promote Screening for Cervical Cancer
Authors: Byles Julie E , Sanson-Fisher Rob W , Redman Selina , Dickinson James A , Halpin Stephen
Published: January 2017

Evaluation of three potential methods for increasing Pap smear use: television media, television media combined with letter based recruitment, and television media combined with general practitioner based (GP based) recruitment.

A trial of each intervention was carried out in three postal regions in New South Wales, Australia — a rural locality (containing about 1000 women), a country town (about 3000 women), and a major rural centre (about 10000 women). Three control regions were selected to be demographically similar to the corresponding intervention regions.

Outcome data on regional Pap smear rates were obtained from government health insurance claims for cervical screening, and from pathology service records. Expected Pap smear rates for the three months after the intervention were predicted from 45 pre-intervention months and were compared with observed rates for this period.

Television media alone was associated with a significant increase in attendances for screening in one of the three regions where a trial was carried out: 13.3% in the rural centre. The media/ letter based campaign was associated with a significant increase in attendances in two out of three regions: 52.7% in the rural locality, 43.2% in the rural centre. The media/GP based campaign was associated with significant increases in attendances in all three regions: 50.2% in the rural locality, 80.8% in the country town, 15.7% in the rural centre. All three interventions were associated with significant increases in the number of women attending for cervical screening above those observed in the control regions. Furthermore, these increases were not restricted to women at low risk. They were also found for older women (aged 50–69 years) and women who had not had a Pap smear within the past three years.
Impact of a Regional Screening Programme Using Maternal Serum a Fetoprotein (AFP) and Human Chorionic Gonadotrophin (hCG) on the Birth Incidence of Down's Syndrome in the West of Scotland
Authors: Crossley Jennifer A , Aitken David A , Berry Esther , Connor J Michael
Published: January 2017

To evaluate the impact of a large scale population screening programme on the birth incidence of Down's syndrome in the west of Scotland over a 12 month period.

Biochemical screening for Down's syndrome using maternal serum α fetoprotein, chorionic gonadotrophin, and maternal age was offered to a pregnant population of 37 226 women in the west of Scotland between 1991 and 1992. The combined risk of Down's syndrome pregnancy was reported for each of the 30 084 women who opted for screening. Results — When a threshold risk of 1:220 was used 1523 women (5.1% of the screened population) were assigned to the high risk group, of whom 1070 (70%) proceeded to diagnostic ammiocentesis or midtrimester chorionic villus sampling. When multiple sources of ascertainment were used 37 Down's syndrome pregnancies were identified within the screened population, 26 (70%) of which were within the high risk group and 21 (57%) of which were prenatally diagnosed. In addition, three Down's syndrome pregnancies were diagnosed by first trimester chorionic villus sampling before biochemical screening. A further 10 Down's syndrome pregnancies were identified at birth, eight to women who had not had a screening test and two to women who had moved into the area, making a total of 50 Down's syndrome pregnancies in the whole pregnant population of 37 226. Thus the potential prenatal detection rate in the screened population was 70% (26/37), the actual prenatal detection rate in the screened population was 57% (21/37), and the overall prenatal detection rate in the total (screened and unscreened) population was 48% (24/50).

Biochemical screening for Down's syndrome is practical and effective in routine clinical practice, enabling women to make an informed choice about prenatal diagnosis and providing better use of scarce resources when a suitable protocol is applied to the whole pregnant population. Its maximum potential for the reduction of the birth incidence of Down's syndrome is limited by incomplete uptake of screening and compliance with diagnostic testing in the high risk group.
An Appraisal of the Efficacy and Cost Effectiveness of Antenatal Screening for Hepatitis B
Authors: Jordan Rachel , Law Malcolm
Published: January 2017

In this review published data are used to determine the benefits and costs of antenatal screening for hepatitis B carriers to prevent the later occurrence of hepatoma and chronic liver disease in their offspring. In Britain, babies born to carrier mothers have a 25% risk of perinatal infection and of becoming carriers themselves (the risk is 82% if their mothers are positive for the e antigen and 10% if negative). The carrier state increases the risk of hepatoma an estimated 86 times and the risk of chronic liver disease 20 times. Life table analysis showed that there is an 11% lifetime risk in carriers in Britain of dying from hepatoma (which results in seven years of life lost on average) and a 7% risk of chronic liver disease (14 years of life lost). Neonatal vaccination reduces the risk of the infant becoming a carrier by about 90%.

Perinatal transmission occurs in 38 of every 100 000 neonates in Britain. Antenatal screening of all women and vaccinating babies of carrier mothers would prevent perinatal transmission in 34 of the 38 children (90%), or 255 per year in Britain. Of these 34, 8.4 children would be Chinese in ethnic origin, 4.2 African, 11.5 South Asian (from the Indian subcontinent), 2.0 Caribbean, and 7.3 would be white. Six deaths in the 34 from hepatoma or chronic liver disease caused by hepatitis B would then be prevented. The direct cost in Britain of screening all women, irrespective of ethnicity, at their first pregnancy only, would be £1300 for each year of life saved (undiscounted) or £2500 if screening at every pregnancy. Screening just Chinese, Africans, and South Asians, at first pregnancy only, would cost £330 for each year of life saved but would prevent only 64% of these deaths.

Vaccinating the infants of carrier mothers is likely also to prevent horizontal transmission of hepatitis B in early childhood and prevent the carrier state developing in an estimated three extra children for each child protected from vertical transmission. When this is taken into account the number of deaths prevented increases fourfold, reducing the cost for each year of life saved by 75%.

Screening all women at first pregnancy only is an acceptably cost effective policy in Britain (£1300 for each year of life saved), actually preventing 45 deaths a year from hepatoma and chronic liver disease (or about 180 deaths if those horizontally infected are included), at a total cost of £540000 a year. It has the advantage of being comprehensive, equitable, and easier to implement than a policy based on screening of high risk ethnic groups.
Heterozygosity for Tay-Sachs and Sandhoff Diseases among Massachusetts Residents with French Canadian Background
Authors: Prence Elizabeth M , Jerome Cheryl A , Triggs-Raine Barbara L , Natwicz Marvin R
Published: January 2017

Objectives—

The frequency of Tay-Sachs disease (TSD) heterozygosity is increased among French Canadians in eastern Quebec. A large proportion of the New England population has French Canadian heritage; thus, it is important to determine if they too are at increased risk for TSD heterozygosity. This prospective study was designed to assess the TSD heterozygote frequency among people with French Canadian background living in Massachusetts. A simultaneous screen for heterozygosity for Sandhoff disease, a related genetic disorder, was also undertaken.

Methods—

1260 non-pregnant subjects of French Canadian background were included in the study, β hexosaminidase activity was measured in blood samples, and results were evaluated for TSD and Sandhoff disease heterozygosity. Samples from the TSD heterozygotes were also subjected to mutation analysis.

Results—

Of the 1260 samples studied, 22 (1 in 57; CI 1 in 41, 1 in 98) were identified as TSD heterozygotes by enzymatic analyses and 11 subjects (1 in 114; CI 1 in 72,1 in 280) were identified as Sandhoff disease heterozygotes. Three of the 22 TSD heterozygotes were found to have benign pseudodeficiency mutations, resulting in a maximum TSD heterozygote frequency of 19 in 1260 (1 in 66; CI 1 in 46, 1 in 120). Together, these data provide a maximum frequency of heterozygosity for TSD or Sandhoff disease of 30 in 1260 (1 in 42; CI 1 in 31, 1 in 64) in this population.

Conclusions—

Simultaneous screening for TSD and Sandhoff disease heterozygosity by assay of β hexosaminidases A and B activities provides a possible method for use with subjects of French Canadian background. The relevance of some of the novel mutations identified in this group needs further study. However, the comparatively high combined frequency of TSD and Sandhoff disease heterozygosity indicates a need for discussion regarding the appropriateness of carrier testing for these disorders for persons of French Canadian background in Massachusetts.
Screening for Diabetic Retinopathy in Primary Care: Retinal Photography Alone can Be Used Efficiently and Effectively to Exclude Those with Sight Threatening Lesions
Authors: Evans P M S , Purewal T S , Hopper A , Slater H , Jones D R L , O'Hare J P
Published: January 2017

Background—

Good screening performance of retinal photography and ophthalmoscopy together in screening for diabetic retinopathy in primary care have been reported. This study reanalysed the data to evaluate the screening performance of photography alone.

Methods—

One thousand and ten patients screened by fundal photography and ophthalmoscopy were studied retrospectively. Fundal photographs were quality graded with poor quality pictures being excluded from the analysis. Each patient was reviewed initially by both retinal photographs and ophthalmoscopy by an ophthalmologist, the “gold standard”. Six months later the fundal photographs were reviewed and reported in a blinded manner by the ophthalmologist.

Results—

Two thousand and fourteen photographs were obtained, of which 162 (8%) had to be excluded because of poor quality. On review of the remaining 18S2 photographs in isolation, of 77 cases of severe retinopathy as determined by the “gold standard”, 67 had severe changes on photography—detection rate 87%. Of the 1775 cases without sight threatening retinopathy only five were judged to have sight threatening changes on photography—false positive rate 0.3%. Considering sight threatening and background retinopathy together, the detection rate was 69% (2S7 of 375) and the false positive rate 1.6% (23 of 1477).

Conclusion—

Good quality fundal photographs alone seem specific enough to screen for sight threatening diabetic retinopathy, but will underdetect background retinopathy.