Anoxemia and brain disease

The author advances the concept that anoxemia, either in its general or restricted form, or both, is probably responsible for a considerable portion of "degenerative diseases," whose etiologic delineation has not yet been traced. It is necessary, he believes, to enlarge greatly the comprehension of the disordered circulatory states to include oxygen want and thereby account for a number of conditions hitherto considered to be of unknown cause. More than this, he finds in oxygen want an explanation of the mechanism of a number of individual lesions or details of lesions otherwise not well understood. The author believes it is very likely that an understanding of cerebral anoxia in its ultimate ramifications will open still wider doors to the understanding of certain clinical syndromes the cause of which remains obscure.     

THE LARGE INGUINAL RING—Its Significance in the Diagnosis of Inguinal Hernia

A large external inguinal ring is often reported by a medical examiner as a “potential hernia.” This finding may cause the subject to be denied job opportunities and may make him apprehensive about many normal activities.The author believes that unless a sac is present and is causing symptoms that necessitate surgical relief, the term hernia should not be used, regardless of how it is qualified. The ordinary intraabdominal stresses due to coughing, sneezing, etc. increase intraabdominal tension more than heavy lifting, except with loads of nearly the body''s own weight. The lifetime effect of such stresses can contribute to the development of a direct hernia, but most of these cannot be eliminated.     

PSYCHIATRY AND THE LAW

In Rex vs. Arnold (1724) it was held that to avail himself of the defense of insanity “a man must be totally deprived of his understanding and memory, so as not to know what he is doing, no more than an infant, a brute, or a wild beast.” Although there has been some modification of this formula in most jurisdictions, the courts still operate under the McNaghten Rule (1843) which is no more logical and actually is more difficult to apply. That such a situation exists in 1956 is a reflection on the indifference of society—and particularly the courts which it elects—as well as on the failure of modern psychiatry to communicate its viewpoint to society. If we are to correct the sad formulae of the “right and wrong” and “policeman at the elbow” tests, we must have more study and better methods of communication in this area.A similar state of confusion exists in the methods of commitment of mentally ill people to psychiatric hospitals. The methods prescribed by law are archaic and cruel—and again reflect the failure of modern psychiatry to communicate its understanding to the legislatures and courts.There are many other areas of conflict between law (which looks to the past for its insights) and psychiatry (which seeks for its concepts in the current scientific advances).     

Understanding U.S. Healthcare Providers’ Practices and Experiences with Molluscum Contagiosum

Introduction

Molluscum contagiosum is a common superficial skin infection caused by the poxvirus, Molluscum Contagiosum virus. The study objective is to obtain a better understanding of physician practices and experiences with molluscum contagiosum in order to focus informational and guidance material.

Methods

A cross-sectional survey to assess medical practitioners’ knowledge and practices with molluscum contagiosum was conducted using the 2009 DocStyles survey. Questions regarding category and number of molluscum contagiosum patients seen, treatments used and advice given to patients were included in the survey.

Results

Dermatologists saw the most cases, with the majority seeing 51–100 molluscum contagiosum cases/year. The most common cases seen were children with multiple lesions and adults with genital lesions. Respondents were most likely to recommend treatment to immunocompromised individuals, HIV patients, adults with genital lesions and children with multiple lesions. Cryotherapy was the top choice for all specialties with the exception of OB/GYNs, whose top choice was curettage. “Avoid intimate contact until lesions resolve”, “Avoid touching lesions to reduce further spread”, and “Don’t be concerned, this will go away” were the top advice choices.

Discussion

Most survey respondents have dealt with molluscum contagiosum in their practice during the previous year. Overall, respondents picked appropriate choices for treatment and advice given; however some ineffective or unnecessary treatments were chosen and recommendations to prevent spread were chosen infrequently. Knowledge gaps for appropriate transmission precaution advice might cause unnecessary spread or autoinoculation. This survey has demonstrated that molluscum contagiosum is a common infection seen by many types of practitioners and therefore guidance on treatment considerations and infection control is valuable.     

Resuscitation of the terminally ill

The CMA believes that there are conditions of ill health and inevitable death for which a “no resuscitation” order, signed by the attending physician, is appropriate and ethically acceptable. The association encourages physicians who are faced with the decision of writing a “no resuscitation” or “do not resuscitate” order to consider the clinical criteria and procedural guidelines in the Joint Statement on Terminal Illness. This protocol is intended as a basic, national guideline for those involved in the care of the terminally ill. Individual institutions may wish to develop their own directives as an adjunct to the national statement.     

From Chattel to Consenter: Adolescents and Informed Consent: 2009 Grover Powers Lecture

Angela Holder was to give the Grover Powers Memorial Lecture at the weekly Grand Rounds conducted by the Yale Department of Pediatrics on Wednesday, May 27, 2009, but unfortunately, she died one month earlier, on April 22, leaving behind her prepared address, “From Chattel to Consenter: Adolescents and Informed Consent,” which she had regarded as the pinnacle of a remarkable career, much of it spent at Yale. As the Grover Powers honoree, the department’s highest honor, Ms. Holder was only the fourth woman of 46 recipients and the first who was not a physician. On the date scheduled for her address, tributes were presented by her son, John Holder, and her longtime colleague, Dr. Robert Levine, co-founder of Yale’s Interdisciplinary Bioethics Center. Their comments follow Angela Holder’s completed but undelivered Grover Powers address. — Myron Genel, MD, Professor Emeritus of PediatricsUnder the common law of England and in the early years of the United States, a minor (defined as anyone under 21) was a chattel or possession of his or her father [1-4]. A father had the right to sue a physician who treated his son or daughter perfectly properly but without the father’s permission because such an intervention contravened the father’s right to control the child. Beginning in the early years of the 20th century, by the end of World War II and into the 1950s, the notion that a 16-year-old was a legally different entity from a 6-year-old gradually became law in all states.¹ The first hospital unit for adolescents was created in 1951 at Boston Children’s Hospital, and the concept of “adolescent medicine” was born [5].As the law in this area currently defines “adolescent,” we are discussing someone 14 or older who may be (1) living at home with his or her parents; (2) Not living at home but still dependent on parents (i.e., a 16-year-old college freshman living in a dorm); (3) an “emancipated minor” who is married, emancipated by a court order, or a parent (other than in North Carolina), living away from home and self-supporting; or (4) a runaway or throwaway. At any time in this country, there are about 200,000 adolescents living on the streets with no adult supervision or involvement [6].Regardless of the age of the patient, informed consent consists of five elements: (1) An explanation of what will happen; (2) explanation of the risks; (3) explanation of the projected benefits; (4) alternatives (including doing nothing); and (5) why the physician thinks it should be done, which I interpret as a right to know one’s diagnosis. While the doctrine of “therapeutic privilege” means that in rare cases a physician may withhold some information from an adult patient if she or he believes the patient cannot “deal with the information,” there can never be any withholding of information from an adolescent. If the patient can’t deal with the information to be presented, then parents have to be involved and give permission to treat the adolescent.In some cases, when parents are involved, they do not want their adolescent to know his or her diagnosis. While this is usually not a good idea, it normally falls under the rubric of “professional judgment,” and the physician has every right to decide to follow the parents’ instruction if she agrees with it. In some situations, however, the adolescent must be told what his or her illness is, whether parents like it or not. For example, if a teenager is HIV positive, he or she must be told, must be instructed about safe sex, and must be asked to divulge the names of any sex partners. Parents who say, “Oh, no, don’t tell him, he would never do anything like that, so it doesn’t matter,” should be tactfully but firmly led to accept the fact that he may well have and if he hasn’t yet, he will certainly in the future. There has been at least one successful malpractice case in which the physician did not, at the request of the parents, tell his adolescent patient that he had HIV. The patient’s girlfriend caught it and sued the physician [7]. I feel sure there are many more cases like this that have been quietly settled and no one will ever hear about.Usually, questions about adolescents giving consent to treatments that their parents don’t know about involve outpatient treatment. In the first place, hospital administrators, who are much more interested in getting paid than they are in advancing the rights of autonomous adolescents, are not going to admit for a non-emergency problem a minor whose parent has not made some sort of financial arrangement to pay for it. Secondly, in most households, if Little Herman doesn’t show up for supper or throughout the evening, someone notices and a few telephone calls later discovers that Little Herman is in the hospital.     

A New Bibliometric Index Based on the Shape of the Citation Distribution

In order to improve the h-index in terms of its accuracy and sensitivity to the form of the citation distribution, we propose the new bibliometric index . The basic idea is to define, for any author with a given number of citations, an “ideal” citation distribution which represents a benchmark in terms of number of papers and number of citations per publication, and to obtain an index which increases its value when the real citation distribution approaches its ideal form. The method is very general because the ideal distribution can be defined differently according to the main objective of the index. In this paper we propose to define it by a “squared-form” distribution: this is consistent with many popular bibliometric indices, which reach their maximum value when the distribution is basically a “square”. This approach generally rewards the more regular and reliable researchers, and it seems to be especially suitable for dealing with common situations such as applications for academic positions. To show the advantages of the -index some mathematical properties are proved and an application to real data is proposed.     

Researchers’ Individual Publication Rate Has Not Increased in a Century

Debates over the pros and cons of a “publish or perish” philosophy have inflamed academia for at least half a century. Growing concerns, in particular, are expressed for policies that reward “quantity” at the expense of “quality,” because these might prompt scientists to unduly multiply their publications by fractioning (“salami slicing”), duplicating, rushing, simplifying, or even fabricating their results. To assess the reasonableness of these concerns, we analyzed publication patterns of over 40,000 researchers that, between the years 1900 and 2013, have published two or more papers within 15 years, in any of the disciplines covered by the Web of Science. The total number of papers published by researchers during their early career period (first fifteen years) has increased in recent decades, but so has their average number of co-authors. If we take the latter factor into account, by measuring productivity fractionally or by only counting papers published as first author, we observe no increase in productivity throughout the century. Even after the 1980s, adjusted productivity has not increased for most disciplines and countries. These results are robust to methodological choices and are actually conservative with respect to the hypothesis that publication rates are growing. Therefore, the widespread belief that pressures to publish are causing the scientific literature to be flooded with salami-sliced, trivial, incomplete, duplicated, plagiarized and false results is likely to be incorrect or at least exaggerated.     

A Moist Crevice for Word Aversion: In Semantics Not Sounds

Why do people self-report an aversion to words like “moist”? The present studies represent an initial scientific exploration into the phenomenon of word aversion by investigating its prevalence and cause. Results of five experiments indicate that about 10–20% of the population is averse to the word “moist.” This population often speculates that phonological properties of the word are the cause of their displeasure. However, data from the current studies point to semantic features of the word–namely, associations with disgusting bodily functions–as a more prominent source of peoples’ unpleasant experience. “Moist,” for averse participants, was notable for its valence and personal use, rather than imagery or arousal–a finding that was confirmed by an experiment designed to induce an aversion to the word. Analyses of individual difference measures suggest that word aversion is more prevalent among younger, more educated, and more neurotic people, and is more commonly reported by females than males.     

Empirical studies of escape behavior find mixed support for the race for life model

Escape theory has been exceptionally successful in conceptualizing and accurately predicting effects of numerous factors that affect predation risk and explaining variation in flight initiation distance (FID; predator–prey distance when escape begins). Less explored is the relative orientation of an approaching predator, prey, and its eventual refuge. The relationship between an approaching threat and its refuge can be expressed as an angle we call the “interpath angle” or “Φ,” which describes the angle between the paths of predator and prey to the prey’s refuge and thus expresses the degree to which prey must run toward an approaching predator. In general, we might expect that prey would escape at greater distances if they must flee toward a predator to reach its burrow. The “race for life” model makes formal predictions about how Φ should affect FID. We evaluated the model by studying escape decisions in yellow-bellied marmots Marmota flaviventer, a species which flees to burrows. We found support for some of the model’s predictions, yet the relationship between Φ and FID was less clear. Marmots may not assess Φ in a continuous fashion; but we found that binning angle into 4 45° bins explained a similar amount of variation as models that analyzed angle continuously. Future studies of Φ, especially those that focus on how different species perceive relative orientation, will likely enhance our understanding of its importance in flight decisions.     

2009 Society for Medical Anthropology Conference: The Intersection of Anthropology and Medicine as Portrayed in Paul Farmer’s Photo Album

Paul Farmer, physician, anthropologist, and author, spoke at the 2009 Society for Medical Anthropology Conference at Yale University in September.Medical anthropology is a very young field, only approximately 50 years old. The underpinnings of medical anthropology have been around for some time, but as a discipline, the burden to ensure that it continues to flourish and grow belongs to future generations of students and scholars. However, future generations of medical anthropologists cannot carry the field forward unless they examine the teachings of previous teachers and scholars. By narrating his own story, just as he so frequently narrates the intricacies of Haiti [1], Paul Farmer, physician, anthropologist, and author of Pathologies of Power: Health, Human Rights, and the New War on the Poor [2], displayed a parallel between the stories of his own past with that of medical anthropology.At the 2009 Society for Medical Anthropology Conference at Yale University in September, Farmer began his aptly titled presentation, Photo Album, with a discussion of his introduction to medical anthropology while an undergraduate at Duke. He stumbled upon medical anthropology quite by chance as an ambitious pre-med who was interested in taking every course that had the word “medical” in its title. He credited many people, including Patricia Pessar, Arthur Kleinman, and Linda Garro with aiding the development of his ideas and perception of the world and teaching him to use medical anthropology not only in passive observation, but in the active practice of medicine. You “don’t have to be a faculty member to teach,” stressed Farmer. Some of the most important lessons to learn come from the poor, to whom few listen.Farmer believes that listening can form the work we do. He honed his listening skills, which are used in anthropology in an ethnographic context, after his first night in an emergency room, when he saw that many minor cases were brought in solely because individuals had no other outlet for treatment. Being a good listener allowed Farmer to understand the full impact of a 1981 slavery case involving migrant workers in Florida. It was this skill of listening that enabled Farmer to understand and tell Haiti’s story, as well as understand the intricate web that exists between privilege and privation. Just as the line between medical anthropology and primary care is often blurred, the “bracing connection between privilege and privation” becomes even more apparent the longer one spends studying both extremes.This is a vantage point Farmer was particularly susceptible to, given his trips from Haiti to Harvard and back again. Listening to his patients in Haiti and the United States would allow Farmer to draw parallels of inequality and injustice that exist for the impoverished in both places. The only difference between the United States and Haiti is that eventually many impoverished individuals in the United States will wind up in somewhat adequate medical facilities. In the story of global economics, Farmer said, “Good things get stuck in customs and bad things get traded freely.” A practicing physician may easily note that inequalities between the rich and poor are not unique to the United States or to Haiti, but what, Farmer asks, can anthropologists say about this division?The cursory glance through Farmer’s photo album ended with a picture of friends whom he fondly termed “the structural violence mafia” and anthropological ideas regarding unequal access to health care. While at first, the portion of anthropology that dissects the structures of violence seems isolated from medical anthropology, those structures of violence institute the vast inequalities that cause medicine to seem inaccessible. Farmer also stressed that “how we think about social theory influences global health.” Work in Haiti taught Farmer firsthand about the phenomenon of blaming the victim [3]. To understand this entrenched system of structural violence fully, an intensive bio-social analysis must be undertaken. Structural violence results in a system in which the victims are blamed, empowering those who suppress the victim while inhibiting the victim’s access to health care. Pointing fingers at the vulnerable is illustrated by the fact that Haiti is often blamed for the introduction of AIDS into North America [4,5]. Farmer stressed not only the inherent trauma of structural violence, but Carolyn Nordstrom’s ideas on violence having a distinct tomorrow [6]. The perpetual cycle of structural violence enables this concept of violence having a clear future with the inherent cultural systems that allow for violence remaining stagnant while the individuals entrapped within the system change.Beyond this concept of structural violence is that of structural healing [3]. Though structural healing is a new phenomenon being examined by anthropologists, it provides a balance to structural violence with the idea being that there are certain societal standards that are either in place or can be introduced that allow for an alleviation of the suffering caused by structural violence. While Farmer’s discussion of the path that led him to his current position was inspirational in itself, the sharing of his story is of even more importance because he has been a teacher to so many. His story reinforces the idea that even though structural violence has a definite past and future, so do medical anthropology and the idea of structural healing. Thankfully, medical anthropology may be used as a relatively new force to combat structural violence. Farmer’s speech may have been unexpected in its autobiographical content, but perhaps the main point is that the intersection between medicine and anthropology can be seen not as a single point but a line that runs the full length of each of these disciplines. We all have a distinct responsibility to not only hear but to listen and learn, not to just passively observe, but actively understand. It is with this listening and acting, that future medical anthropologists can bridge the gap between social sciences and practical medicine.     

The Brain’s Response to the Human Voice Depends on the Incidence of Autistic Traits in the General Population

Optimal brain sensitivity to the fundamental frequency (F0) contour changes in the human voice is important for understanding a speaker’s intonation, and consequently, the speaker’s attitude. However, whether sensitivity in the brain’s response to a human voice F0 contour change varies with an interaction between an individual’s traits (i.e., autistic traits) and a human voice element (i.e., presence or absence of communicative action such as calling) has not been investigated. In the present study, we investigated the neural processes involved in the perception of F0 contour changes in the Japanese monosyllables “ne” and “nu.” “Ne” is an interjection that means “hi” or “hey” in English; pronunciation of “ne” with a high falling F0 contour is used when the speaker wants to attract a listener’s attention (i.e., social intonation). Meanwhile, the Japanese concrete noun “nu” has no communicative meaning. We applied an adaptive spatial filtering method to the neuromagnetic time course recorded by whole-head magnetoencephalography (MEG) and estimated the spatiotemporal frequency dynamics of event-related cerebral oscillatory changes in beta band during the oddball paradigm. During the perception of the F0 contour change when “ne” was presented, there was event-related de-synchronization (ERD) in the right temporal lobe. In contrast, during the perception of the F0 contour change when “nu” was presented, ERD occurred in the left temporal lobe and in the bilateral occipital lobes. ERD that occurred during the social stimulus “ne” in the right hemisphere was significantly correlated with a greater number of autistic traits measured according to the Autism Spectrum Quotient (AQ), suggesting that the differences in human voice processing are associated with higher autistic traits, even in non-clinical subjects.     

A High-Throughput Screening Approach to Discovering Good Forms of Biologically Inspired Visual Representation

While many models of biological object recognition share a common set of “broad-stroke” properties, the performance of any one model depends strongly on the choice of parameters in a particular instantiation of that model—e.g., the number of units per layer, the size of pooling kernels, exponents in normalization operations, etc. Since the number of such parameters (explicit or implicit) is typically large and the computational cost of evaluating one particular parameter set is high, the space of possible model instantiations goes largely unexplored. Thus, when a model fails to approach the abilities of biological visual systems, we are left uncertain whether this failure is because we are missing a fundamental idea or because the correct “parts” have not been tuned correctly, assembled at sufficient scale, or provided with enough training. Here, we present a high-throughput approach to the exploration of such parameter sets, leveraging recent advances in stream processing hardware (high-end NVIDIA graphic cards and the PlayStation 3''s IBM Cell Processor). In analogy to high-throughput screening approaches in molecular biology and genetics, we explored thousands of potential network architectures and parameter instantiations, screening those that show promising object recognition performance for further analysis. We show that this approach can yield significant, reproducible gains in performance across an array of basic object recognition tasks, consistently outperforming a variety of state-of-the-art purpose-built vision systems from the literature. As the scale of available computational power continues to expand, we argue that this approach has the potential to greatly accelerate progress in both artificial vision and our understanding of the computational underpinning of biological vision.     

Uncovering a Microbial Enigma: Isolation and Characterization of the Streamer-Generating,Iron-Oxidizing,Acidophilic Bacterium “Ferrovum myxofaciens”

A betaproteobacterium, shown by molecular techniques to have widespread global distribution in extremely acidic (pH 2 to 4) ferruginous mine waters and also to be a major component of “acid streamer” growths in mine-impacted water bodies, has proven to be recalcitrant to enrichment and isolation. A modified “overlay” solid medium was devised and used to isolate this bacterium from a number of mine water samples. The physiological and phylogenetic characteristics of a pure culture of an isolate from an abandoned copper mine (“Ferrovum myxofaciens” strain P3G) have been elucidated. “F. myxofaciens” is an extremely acidophilic, psychrotolerant obligate autotroph that appears to use only ferrous iron as an electron donor and oxygen as an electron acceptor. It appears to use the Calvin-Benson-Bassham pathway to fix CO₂ and is diazotrophic. It also produces copious amounts of extracellular polymeric materials that cause cells to attach to each other (and to form small streamer-like growth in vitro) and to different solid surfaces. “F. myxofaciens” can catalyze the oxidative dissolution of pyrite and, like many other acidophiles, is tolerant of many (cationic) transition metals. “F. myxofaciens” and related clone sequences form a monophyletic group within the Betaproteobacteria distantly related to classified orders, with genera of the family Nitrosomonadaceae (lithoautotrophic, ammonium-oxidizing neutrophiles) as the closest relatives. On the basis of the phylogenetic and phenotypic differences of “F. myxofaciens” and other Betaproteobacteria, a new family, “Ferrovaceae,” and order, “Ferrovales,” within the class Betaproteobacteria are proposed. “F. myxofaciens” is the first extreme acidophile to be described in the class Betaproteobacteria.     

Ocular Manifestations of Hemoglobin S-C Disease

Three patients with hemoglobin S-C disease, all with ocular lesions, were studied and contrasted with four other patients who had predominantly either hemoglobin S or C but no ocular lesions. Attention is drawn to the diagnostic value of hemoglobin electrophoresis in such cases. With this technique a diagnosis of hemoglobin S-C disease was made in a patient previously thought to the “Eales'' disease”; one sister was found to have asymptomatic hemoglobin S-C disease and unsuspected early ocular lesions. The number of persons in Canada with hemoglobinopathies is increasing. Awareness of an association between abnormal hemoglobins and ocular disease may lead to the recognition of an unsuspected blood disorder or of an unsuspected retinopathy.     

The traits of “trait ecologists”: An analysis of the use of trait and functional trait terminology

Trait and functional trait approaches have revolutionized ecology improving our understanding of community assembly, species coexistence, and biodiversity loss. Focusing on traits promotes comparability across spatial and organizational scales, but terms must be used consistently. While several papers have offered definitions, it remains unclear how ecologists operationalize “trait” and “functional trait” terms. Here, we evaluate how researchers and the published literatures use these terms and explore differences among subdisciplines and study systems (taxa and biome). By conducting both a survey and a literature review, we test the hypothesis that ecologists’ working definition of “trait” is adapted or altered when confronting the realities of collecting, analyzing and presenting data. From 486 survey responses and 712 reviewed papers, we identified inconsistencies in the understanding and use of terminology among researchers, but also limited inclusion of definitions within the published literature. Discrepancies were not explained by subdiscipline, system of study, or respondent characteristics, suggesting there could be an inconsistent understanding even among those working in related topics. Consistencies among survey responses included the use of morphological, phonological, and physiological traits. Previous studies have called for unification of terminology; yet, our study shows that proposed definitions are not consistently used or accepted. Sources of disagreement include trait heritability, defining and interpreting function, and dealing with organisms in which individuals are not clearly recognizable. We discuss and offer guidelines for overcoming these disagreements. The diversity of life on Earth means traits can represent different features that can be measured and reported in different ways, and thus, narrow definitions that work for one system will fail in others. We recommend ecologists embrace the breadth of biodiversity using a simplified definition of “trait” more consistent with its common use. Trait‐based approaches will be most powerful if we accept that traits are at least as diverse as trait ecologists.     

A Cellular Automaton Model for Tumor Dormancy: Emergence of a Proliferative Switch

Malignant cancers that lead to fatal outcomes for patients may remain dormant for very long periods of time. Although individual mechanisms such as cellular dormancy, angiogenic dormancy and immunosurveillance have been proposed, a comprehensive understanding of cancer dormancy and the “switch” from a dormant to a proliferative state still needs to be strengthened from both a basic and clinical point of view. Computational modeling enables one to explore a variety of scenarios for possible but realistic microscopic dormancy mechanisms and their predicted outcomes. The aim of this paper is to devise such a predictive computational model of dormancy with an emergent “switch” behavior. Specifically, we generalize a previous cellular automaton (CA) model for proliferative growth of solid tumor that now incorporates a variety of cell-level tumor-host interactions and different mechanisms for tumor dormancy, for example the effects of the immune system. Our new CA rules induce a natural “competition” between the tumor and tumor suppression factors in the microenvironment. This competition either results in a “stalemate” for a period of time in which the tumor either eventually wins (spontaneously emerges) or is eradicated; or it leads to a situation in which the tumor is eradicated before such a “stalemate” could ever develop. We also predict that if the number of actively dividing cells within the proliferative rim of the tumor reaches a critical, yet low level, the dormant tumor has a high probability to resume rapid growth. Our findings may shed light on the fundamental understanding of cancer dormancy.