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Return to Galen.

AT THE BEGINNING of the previous century, the English editor of a minor work by Galen called for a return to that ancient scholar after centuries of neglect. The appeal did not meet with success. Galen's reputation is currently based on renown arising from tradition, rather than an awareness of his actual contributions to medical science. His methodological approach to experimental medicine seems to have fallen into obscurity, although it anticipated modern principles. This report reviews the rise and fall in popularity of Galen's medical works, in an attempt to highlight the circumstances that still prevent a full appreciation of those writings.

History, Ancient↗

Hospitals without walls: trustees reach out to the community. Interview by Karen Gardner.

"A futurist is someone who either predicts or invents the future, and I really try to do both," says Leland R. Kaiser, Ph.D., president of Kaiser & Associates, Brighton, CO, and associate professor, University of Colorado at Denver School of Business. Kaiser--a former hospital trustee--says, "When you're inventing the future, you're using a vision of how you would like to see the organization be in the future, and then you help the organization achieve that." Kaiser concentrates on helping institutions achieve a vision that has been formed by his many years of health care and management experience as well as an extraordinary sensitivity to the needs of communities and the potential that the United States health care system has to address those needs. Futurist Kaiser recently spoke with Trustee editor Karen Gardner about his vision of health care delivery, the central role that trustees must play in order to realize that vision, and the promise of a truly community-based health care system.

Chief Executive Officers, Hospital↗

Communicating hospitals' concerns to legislators and the community.

The time is past when voluntary hospitals could afford to be uninformed and inactive in public affairs. As decisions in the public sector increasingly threaten not-for-profit institutions, Catholic hospitals particularly must pursue an action-oriented program of communication with legislators and the community. At Carney Hospital, Boston, an especially effective forum for the past eight years has been buffet dinners held on a quarterly basis with state and congressional legislators and representatives of the hospital's management team, board of trustees, associate board, and medical staff. These dinner meetings provide a singular opportunity for law-makers to learn hospitals' perspective on key issues such as the effect of tightened reimbursement on care of the poor. The dinners not only have enhanced relations with legislators but also raised the consciousness of the business community, consumers, and the general public. Frequent mailings to legislators and members of the board of trustees and the associate board also have beeN helpful. The associate board was formed to augment the expertise of the board to trustees and to increase lay participation in the hospital's affairs. Composed of 20 lay leaders representing a diversity of disciplines, the associate board provides a strong base for influencing public policy and community action. Moreover, the hospital's various constituencies--physicians, employees, volunteers, and auxilians-are recruited as appropriate to contact legislators, write letters to the editor, and give media interviews. Also important in the facility's public affairs efforts have been timely responses to requests for action from The Catholic Health Association, the American Hospital Association, and the state hospital association.

Boston↗

[Expected versus real impact factors of publications from Spanish departments of anesthesiology (1991-1996)].

OBJECTIVE: To identify publications by Spanish anesthesiologists in journals indexed by Journal Citation Report from 1991 through 1996; to count the number of citations received and compare the results with the impact factor (IF) of the journals in which they were published. MATERIAL AND METHODS: Articles for which the first author was a member of a Spanish anesthesiology department were searched for in MEDLINE, Science Citation Index and EMBASE. Only publications for which the IF was known were included for analysis. We then counted the number of citations each article received over the two years following publication, recording the source journal in which the citation appeared and country of origin of each citing author. We then calculated the real IF (RIF) of each article, the RIF of all the Spanish articles, and the mean RIF. Also calculated for each article was the expected IF (EIF), based on the IF of the source journal, the overall EIF and the mean EIF. RESULTS: One hundred seventy-two articles were published; 49 of them were letters to the editors. Specialist anesthesiology journals published 72.7%. A total of 186 citations were received. American authors cited the articles more often than did other Spanish authors. Thirty-seven citations (19.9%) were self-citations. Ninety-two articles (53.5%) were never cited. With letters to the editor excluded, the RIF was 85.48 and the global EIF was 213.28; the mean EIF was 1.734 and the RIF was 0.695. Therefore, the rate of citation of the Spanish authors in the period studied was only 40% of the citation rate of the entire population of authors from all countries. The authors of the published articles worked mainly in hospitals in Barcelona, Madrid, La Coruña, Valencia, Cantabria and Murcia. Hospital Germans Trias i Pujol (Badalona, Barcelona) had the largest number of publications and the highest EIF (39.41). Hospital del Mar (Barcelona) had the highest mean RIF and the highest global RIF.A gradual increase in the annual productivity of Spanish scientists can be discerned in a progressive increase in the number of publications as well as their EIF and RIF. CONCLUSIONS: Research by Spanish anesthesiologists is concentrated in only a few hospitals. Although the number of publications is increasing, their international repercussion has still not reached the desired level.

Anesthesia Department, Hospital↗

[Issues of practice guideline].

"Practice Guideline (PG) or management guideline" is not an impeccable guideline but a tool to support a clinical decision, i.e., one of factors to make a clinical decision. When making a clinical decision, medical practice is finalized, taking into consideration of PG, patient's preference, social and national healthcare system. Even if PG provides a treatment method on the basis of high level evidences, we should not always uniformly apply to every patient. We can practice better with combination of PG, physician's expertise, patients' preference. When consulting PG, it is recommended to confirm in advance what society/organization prepared PG, purpose of preparation, preparation process, and developmental method, including social fairness whether healthcare cost is assumed in PG or whether industry is a substantial editor. As to the questions whose answer is not mentioned in PG, their controversial points have to be defined and assessed, retrieving literatures. This is so called implementation of "Evidence-Based Medicine (EBM)." The practice of EMB provides better evidences. PG is fated to be always outdated when published because new evidence will be additionally published, and therefore, it is always required to search for new evidences available at daily practice.

Antiparkinson Agents↗

Air conditioning closely examined.

The intricacies of the provision and control of air conditioning in hospitals have been debated for decades. For this Health Estate Journal 'Then and now' feature, Mike Arrowsmith BSc (Hons) CEng FIMechE FIHEEM, technical editor, provides commentary on an article which was published in The Hospital Engineer, the journal of the Institution of Hospital Engineers, in July 1960. The text of this article, which was based on a paper read before the Glasgow Branch of the Institution, follows that of the commentary.

Air Conditioning↗

An improved sequence handling package that runs on the Apple Macintosh.

We report improvements to our sequence analysis package and adaptation to run on the Apple Macintosh range of machines. The 'standard' version of the programs, which run on a VAX, has been given a new user interface that makes the programs very much easier to work with and has facilitated the move to the Macintosh. The reorganization of the code should simplify moves to other systems that offer WIMP user interfaces. In addition to a large number of small but useful extra features, some important new analytical functions have been devised. These include sequence and contig editors; optimal alignment and comparison methods; and a new method for comparing the observed and expected frequencies of selected oligonucleotides.

Base Sequence↗

ReDiT: Repeat Discrepancy Tagger--a shotgun assembly finishing aid.

UNLABELLED: Finishing, i.e. gap closure and editing, is the most time-consuming part of genome sequencing. Repeated sequences together with sequencing errors complicate the assembly and often result in misassemblies that are difficult to correct. Repeat Discrepancy Tagger (ReDiT) is a tool designed to aid in the finishing step. This software processes assembly results produced by any fragment assembly program that outputs ace files. The input sequences are analyzed to determine possible differences between repeated sequences. The output is written as tags in an ace file that can be viewed by, e.g. the Consed sequence editor. AVAILABILITY: The ReDiT program is freely available at http://web.cgb.ki.se/redit

Algorithms↗

Toward a checklist for reporting of studies of diagnostic accuracy of medical tests.

BACKGROUND: : "Diagnostic accuracy" refers to the ability of medical tests to provide accurate information about diagnosis, prognosis, risk of disease, and other clinical issues. Published reports on diagnostic accuracy of medical tests frequently fail to adhere to minimal clinical epidemiological standards, and such failures lead to overly optimistic assessments of evaluated tests. Our aim was to enumerate key items for inclusion in published reports on diagnostic accuracy, with a related aim of making the reports more useful for systematic reviews. METHODS: : We examined published reports on shortcomings of studies of diagnostic accuracy. We prepared an initial draft of a checklist to address common errors and presented it at a meeting of editors. After incorporation of comments from editors, we published a revised version in Clinical Chemistry in 1997 for comment from readers. One of us (E.M.) additionally circulated copies of the draft to methodologists and others interested in Evidence-Based Medicine. We updated the checklist with input from these sources. RESULTS: : The updated document lists items for inclusion in the title, abstract, methods, results, and discussion sections of published papers. Depending on the nature of the study, the total number of items for a single paper is approximately 40. We invite comments on this document, which is freely available at Clinical Chemistry Online, where it can accessed readily from the Table of Contents for the July 2000 issue at www. clinchem.org/content/vol46/issue7/. Comments (eLetters) can be posted there for general reading. CONCLUSIONS: : The suggested revisions incorporated in this report appear useful to ensure inclusion of additional information that can allow assessment of the validity of the conclusions and the applicability of the study in other settings. The list can be useful in formulating guidelines and a checklist, which will require testing by authors and study of their effect on published studies of diagnostic accuracy.

Clinical Chemistry Tests↗

Aseptic meningitis after vaccination with L-Zagreb mumps strain-virologically confirmed cases. Faulty calculation of rates.

In a Letter to the Editor published in Vaccine recently (Vaccine 24 (2006) 6371-6373), the authors describe clinical features of vaccine associated aseptic meningitis (AM) of patients hospitalized in one hospital, proceeding to calculate incidence rates of AM based on hospital admission data. Since the denominator for hospital-based cases is unknown, the incidence rates calculated in such a way are methodologically incorrect and should not be considered relevant.

Croatia↗

Dielectrophoresis and electrorotation of neurospora slime and murine myeloma cells.

Dielectrophoresis and electrorotation are commonly used to measure dielectric properties and membrane electrical parameters of biological cells. We have derived quantitative relationships for several critical points, defined in Fig. A 1, which characterize the dielectrophoretic spectrum and the electrorotational spectrum of a cell, based on the single-shell model (Pauly, H., and H.P. Schwan, 1959. Z. Naturforsch. 14b:125-131; Sauer, F.A. 1985. Interactions between Electromagnetic Field and Cells. A. Chiabrera, C. Nicolini, and H.P. Schwan, editors. Plenum Publishing Corp., New York. 181-202). To test these equations and to obtain membrane electrical parameters, a technique which allowed simultaneous measurements of the dielectrophoresis and the electrorotation of single cells in the same chamber, was developed and applied to the study of Neurospora slime and the Myeloma Tib9 cell line. Membrane electrical parameters were determined by the dependence of the first critical frequency of dielectrophoresis (fct1) and the first characteristic frequency of electrorotation (fc1) on the conductivity of the suspending medium. Membrane conductances of Neurospora slime and Myeloma also were found to be 500 and 380 S m-2, respectively. Several observations indicate that these cells are more complex than that described by the single-shell model. First, the membrane capacities from fct1 (0.81 x 10(-2) and 1.55 x 10(-2) F m-2 for neurospora slime and Myeloma, respectively) were at least twice those derived from fc1. Second, the electrorotation spectrum of Myeloma cells deviated from the single-shell like behavior. These discrepancies could be eliminated by adapting a three-shell model (Furhr, G., J. Gimsa, and R. Glaser. 1985. Stud. Biophys. 108:149-164). Apparently, there was more than one membrane relaxation process which could influence the lower frequency region of the beta-dispersion. fct1 of Myeloma in a medium of given external conductivity were found to be similar for most cells, but for some a dramatically increased fct1 was recorded. Model analysis suggested that a decrease in the cytoplasmatic conductivity due to a drastic ion loss in a cell could cause this increase in fct1. Model analysis also suggested that the electrorotation spectrum in the counter-field rotation range and fc1 would be more sensitive to conductivity changes of the cytoplasmic fluid and to the influence of internal membranes than would fct1, although the latter would be sensitive to changes in capacitance of the cytoplasmic membranes.

Animals↗

Physicists in mammography--a historical perspective.

Medical physicists and engineers, working with radiologists and technologists, have made significant contributions in the design of mammographic x-ray units and image receptors, as well as in the development of methods for evaluating mammographic image quality and procedures for quality control. More accurate methods of measuring radiation exposure in the energy range of mammography and more relevant calculations of radiation dose to breast tissue at risk have also been realized. This article will discuss some of the major contributions made by medical physicists for the benefit of mammography. Contributions of radiologists in mammography have been published elsewhere [Bassett, Gold, and Kimme-Smith (1994)]. All contributions cited in this article are based on referenced publications and citations in the following: Medical Physics; Radiology; NCRP Report No. 85; Quality Determinants in Mammography; AAPM Report No. 29; Reduced Dose Mammography, W. W. Logan and E. P. Muntz (editors); RSNA Categorical Course: Technical Aspects of Breast Imaging, A. Haus and M. Yaffe (editors); Film Processing in Medical Imaging, A. G. Haus (editor); Screen-Film Mammography: Imaging Considerations in Medical Physics, G. T. Barnes and G. Donald Frey (editors). The article is divided into six sections: (1) x-ray equipment and receptor development, (2) image quality, (3) radiation dose, (4) phantoms, (5) quality assurance, (6) digital mammography, and (7) reports and committees.

Biophysics↗

Interleukin-2 receptor monoclonal antibodies in renal transplantation: meta-analysis of randomised trials.

OBJECTIVE: To study the effect of interleukin-2 receptor monoclonal antibodies on acute rejection episodes, graft loss, deaths, and rate of infection and malignancy in patients with renal transplants. DESIGN: Meta-analysis of published data. DATA SOURCES: Medline, Embase, and Cochrane library for years 1996-2003 plus search of medical editors' trial amnesty and contact with manufacturers of the antibodies. SELECTION OF STUDIES: Randomised controlled trials comparing interleukin-2 receptor antibodies with placebo or no additional treatment in patients with renal transplants receiving ciclosporin based immunosuppression. RESULTS: Eight randomised controlled trials involving 1871 patients met the selection criteria (although only 1858 patients were analysed). Interleukin-2 receptor antibodies significantly reduced the risk of acute rejection (odds ratio 0.51, 95% confidence interval 0.42 to 0.63). There were no significant differences in the rate of graft loss (0.78, 0.58 to 1.04), mortality (0.75, 0.46 to 1.23), overall incidence of infections (0.97, 0.77 to 1.24), incidence of cytomegalovirus infections (0.81, 0.62 to 1.04), or risk of malignancies at one year (0.82, 0.39 to 1.70). The different antibodies had a similar sized effect on acute rejection (test for heterogeneity P=0.7): anti-Tac (0.37, 0.16 to 0.89), BT563 (0.37, 0.1 to 1.38), basiliximab (0.56, 0.44 to 0.72), and daclizumab (0.46, 0.32 to 0.67). The reduction in acute rejections was similar for all ciclosporin based immunosuppression regimens (test for heterogeneity P=1.0). CONCLUSIONS: Adding interleukin-2 receptor antibodies to ciclosporin based immunosuppression reduces episodes of acute rejection at six months by 49%. There is no evidence of an increased risk of infective complications. Longer follow up studies are needed to confirm whether interleukin-2 receptor antibodies improve long term graft and patient survival.

Antibodies, Monoclonal↗

Weight gain mitigation with topiramate in mood disorders.

OBJECTIVE: To review the evidence of weight loss with use of topiramate in patients with mood disorders. DATA SOURCES: Literature search included MEDLINE (1966-December 2003), International Pharmaceutical Abstracts (1970-December 2003), and EMBASE (1980-December 2003). Search terms included topiramate, weight loss, adverse effect, mood disorders, bipolar disorder. DATA SYNTHESIS: Weight gain is a common adverse effect of many agents used to treat mood disorders. Topiramate has been evaluated in the management of some mood disorders, and weight loss may be a beneficial side effect in these patients. Case reports, letters to the editor, prospective investigations, and retrospective observational studies were reviewed to identify evidence of weight loss with topiramate use in patients with mood disorders. CONCLUSIONS: Current evidence suggests an association between topiramate and weight loss. Based on the limited data, controlled studies need to be conducted to define the role of topiramate in patients with mood disorders who would also benefit from weight reduction.

Anticonvulsants↗

[The loose-leaf book of procedures. A regional model for diagnostic and referral routines--a basis for improved cooperation between primary and secondary services].

Initiated by the Telemark branch of the Norwegian Medical Association a loose-leaf book of procedures has been prepared for use in the region of Telemark Central Hospital. The professional advice given in the book is based on an agreement between the chief physicians of the various hospital units, their discussions in the unit, and a group of four general physicians. The advice is only intended as a guide. The editors' idea is to have the book distributed to all G.P.s and hospital units in Telemark. The book is meant to be updated once a year.

Community Health Services↗

Molecular Biocomputing Suite: a word processor add-in for the analysis and manipulation of nucleic acid and protein sequence data.

In all fields of molecular biology, researchers are increasingly challenged by experiments planned and evaluated on the basis of nucleic acid and protein sequence data generally retrieved from public databases. Despite the wide spectrum of available Web-based software tools for sequence analysis, the routine use of these tools has disadvantages, particularly because of the elaborate and heterogeneous ways of data input, output, and storage. Here we present a Visual Basic-encoded Microsoft Word Add-In, the Molecular BioComputing Suite (MBCS), available at the BioTechniques Software Library (www.BioTechniques.com). The MBCS software aims to manage and expedite a wide range of sequence analyses and manipulations using an integrated text editor environment including menu-guided commands. Its independence of sequence formats enables MBCS to be used as a pivotal application between other software tools for sequence analysis, manipulation, annotation, and editing.

Amino Acid Sequence↗

Which studies of therapy merit credence? Vitamin E and estrogen therapy as cautionary examples.

A vast and continuously growing amount of material on drugs exists in the literature to read and evaluate. Frequently, the papers and their recommendations are conflicting and contradictory. Readers are faced with the dilemma of deciding what to believe. The need for evidence-based medicine as a foundation for optimal clinical research and patient care requires application of the best scientific methods. Various methods are discussed. Generally, the most powerful method to test a clinical hypothesis is the randomized, controlled clinical trial. By contrast, epidemiology/observation studies have certain inherent weaknesses that can lead to erroneous conclusions. The examples of estrogen therapy in postmenopausal women and of vitamin E therapy to reduce cardiovascular risk are discussed extensively to provide historical perspective and to demonstrate erroneous conclusions reached using epidemiology/observation studies. The sociology of journal publication is briefly described, and an attempt is made to assess who benefits and who is harmed when leading medical journals publish erroneous results. Types of bias and confounding issues leading to errors are discussed, and the need is emphasized for publication of rigorous studies after careful evaluation by editors to avoid repetition of past mistakes and to ensure publication of correct medical information.

Aged↗

Understanding the adoption of arthritis self-management: stages of change profiles among arthritis patients.

Clinical observations and recent studies suggest that arthritis patients vary considerably in their involvement in self-management efforts. In the literature on health promotion, there is growing recognition that patients may be at different stages of change with respect to the adoption of self-management strategies. The major goal of the present study was to examine whether cluster analysis could be used to identify homogeneous subgroups of patients having persistent arthritis pain based on their responses to a stages of change questionnaire. Participants in this study (103 patients having rheumatoid arthritis and 74 patients having osteoarthritis) completed a stages-of-change measure specific to adoption of a self-management approach to their arthritis. A cluster analysis identified five distinct subgroups of arthritis patients: (1) precontemplation - 44% of the sample; (2) contemplation - 11% of the sample; (3) preparation - 22% of the sample; (4) unprepared action - 6% of the sample; and (5) prepared maintenance - 17% of the sample. These subgroups are generally consistent with what might be expected based on the transtheoretical model of stages of change by Prochaska and DiClemente (Prochaska JO, DiClemente CC. Towards a comprehensive, transtheoretical model of change: states of change and addictive behaviors. In: Miller WR, Heather N, editors. Applied clinical psychology, 2nd ed. Treating addictive behaviors, New York: Plenum Press, 1998. pp. 3-24.), and may have important clinical implications. For example, it is possible that the arthritis subgroups identified may predict arthritis patients' participation in and responsiveness to pain-coping skills training, exercise interventions, or other formal self-management training programs. Also, one may be able enhance the outcomes of self-management interventions for arthritis by tailoring treatment to the patient's particular stage.

Adaptation, Psychological↗