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This Presidential address to the International Society for the History of the Neurosciences was given at Lausanne in September 1999. It reviews some of the contributions given at that conference and provides a brief overview of the history of the mind-brain problem in Western neuroscientific thought.
General dental practitioners have been part of The Royal College of Surgeons of England since the LDS RCS examinations in 1860. For 87 years, it was the general dentists who were part of the College. Later, the political necessity of introducing hospital dentists to the National Health Service changed the ethos for dentists with the formation of the Faculty of Dental Surgery in 1947. Secondary care dentists became entrenched within The College at the expense of the majority of those who practiced dentistry to the same level as secondary care dentists. It took a further 45 years before general practitioners could return to their home. The Faculty of General Dental Practitioners (UK), within a short space of time, has become the largest Faculty for dentists within any of the Royal Colleges. This article includes excerpts from the Dean's address at the Ceremony of Presentation of Diplomats held on 3rd March 2001 (see page 75). It unveils the accidents of history which formulated a Royal College, the perseverance of committed dentists which took them into the fold of The College. It describes the beginning of the Faculty of Dental Surgery and unravels the story of the Advisory Board in General Dental Practice which later became the Faculty of General Dental Practitioners (UK). The next article 'Looking Forwards' will describe a way forward for this Faculty, which has grown up all too quickly in a rapidly changing world.
In his 2001 Presidential Address to the American Association of Neurological Surgeons, Dr. Dunsker calls on all neurosurgeons to become active participants in the ongoing debates over healthcare. He reviews some history of the debates and points out that regulation of healthcare has been left to bureaucrats-both government and private-with physicians, who have intimate knowledge of the field, being excluded. Dr. Dunsker encourages neurosurgeons to volunteer in local, state, and federal medical societies and to join forces with other physicians to gain leverage in the healthcare debate. In this manner it is hoped that better ways of delivering the best healthcare to patients can be accomplished.
Vincent van Gogh's life, letters, and art are the framework for this existential speech about the nature of alienation, as well as its threat to humanity and to the artful practice of medicine. The honest, human voice expressed in van Gogh's art stands in opposition to alienation, which occurs when we divide the world into two parts: the "perfect" world of science versus the "flawed" world of human experience. Bridging this divide allows for an "authentic" life, one which honestly defines itself and faces difficult human truths. The most difficult truth relates to our own mortality, but it must be faced if we are to understand the value of existence. Film clips from Woody Allen's Hannah and Her Sisters illustrate how an artist's portrayal of these issues can be both profound and humorous, and how art brings us closer to our own humanity and to the essence of medicine. Neurosurgeons are warned about the lure of science and technology as a substitute for purpose and meaning, both as physicians and as human beings. The role of the American Association of Neurological Surgeons is explored and found to offer neurosurgeons a bridge away from alienation and toward a neurosurgical community. Neurosurgeons are urged to find meaning through service to their profession and to find the voice and art of medicine. [Note: Actual film clips were used when this address was delivered. Unofficial transcripts of the clips have been included in this article so that the integrity of the speech would not be compromised.]
In his 2003 Presidential Address to the American Association of Neurological Surgeons, Dr. Heros discusses his personal additions to the six basic competencies for which all neurosurgical residents must be tested. The basic competencies are as follows: 1) patient care; 2) medical knowledge; 3) practice-based learning and improvement; 4) interpersonal and communication skills; 5) professionalism; and 6) system-based practice. To these, Dr. Heros proposes to add six supplemental competencies: 1) intellectual honesty, which involves frank discussions about patient complications and admissions of the physician's frailties; 2) scholarship--the art and science of medicine, which recognizes the value of evidence-based medicine but does not discount knowledge derived from experience; 3) practicing in a hyperlegalistic society, which involves tailoring informed consent to fit individual patients' circumstances; 4) time- and cost-efficient practices, in which the physician strives to conserve time and resources by forgoing testing that is not strictly necessary, doing only what is needed to return patients to wellness; 5) approach to patients, which entails acknowledging and respecting the dignity of all patients; and 6) pride in being a neurosurgeon, which carries a sense of elitism without arrogance.
This state of the Academy address was presented at the opening ceremonies of the fourth annual scientific meeting of the American Academy of Health Behavior by the outgoing president of the Academy, February 29, 2004.
The main problems in cancer chemotherapy are related to the fact that the available drugs are not specific nor selective enough in their anticancer action. Therefore, even a low degree of resistance at the target tumor level is sufficient to impart clinical resistance because the dose of drug cannot be increased sufficiently to overcome it without incurring unacceptable toxicity. In the face of the above mentioned difficulties, several directions of research are being currently pursued towards developing more effective and selective treatments of cancer. These include: 1) continuing traditional approaches of drug discovery stemming from lead chemical structures and in many cases utilizing combinational chemistry followed by suitable screening efforts; 2) Increasing the antitumor effectiveness of available drugs through: a) making it possible to increase drug dose intensity by protecting normal tissues from limiting toxicity through genetic manipulation or combination with such agents as GM-CSF or IL15; b) attempting to increase the specificity of drug delivery through the administration of agents encapsulated in suitable liposome or conjugated with appropriate antibodies or cytokines; c) increasing the sensitivity of target tumor to a drug by specific metabolic modulations as it was done, for example, in the case of combinations of fluoropyrimidines with leukovorin; 3) counteracting resistance to drugs through genetic and/or epigenetic approaches aimed at modifying, for example, mechanisms of drug uptake or retention or at reducing anti-apoptotic mechanisms; 4) attempting to improve biotherapeutic treatments, for example, utilizing novel therapeutic vaccines or antibodies, or treatments based on intervention on angiogenesis or on intercellular or cell-matrix relationships; 5) continuing efforts to develop more effective and selective combination treatments with drugs, biologicals or different modalities; and, 6) developing new treatments based on intervention at novel molecular targets which have an essential role in the physio-pathology of the cancer cell. The latter approach is the main subject of this address.
In his 2001 presidential address to the Canadian Association of General Surgeons, the author offers advice to young surgeons, based on his lifetime experience as a surgical educator, researcher and practitioner. He offers the following samples of wisdom for young surgeons: they should be prepared for a lifetime of learning and be willing and able to adapt to new advances; they should listen to their patients as they describe their presenting complaints and not be tempted to interrupt; they should take time in an emergency situation and remember that split-second decisions can affect the patient for a lifetime; they should be willing to take advice from fellow professionals; they should take time to maintain a quality family life and take adequate time away from the workplace; they should be active be a role model in their community; and, finally, they should get involved and adopt an advocacy role in their profession.
In the early 1990s, after more than three decades of studying algorithms within the frame work of theoretical computer science, I shifted my focus to alogrithmic problems arising in genomics. There is a fundamental difference between the views of algorithms in the two fields: in theoretical computer science the input-output behavior of an algorithm is rigorously specified in advance, whereas in computational biology an algorithm is merely a vehicle for discovering Nature's ground truth. In order to be effective in computational genomics I have had to radically change my approach to research. On the occasion of this keynote address I will share some of the lessons I have learned, in the hope of making the way easier for computer scientists and mathematicians entering this field. These lessons will be encapsulated in a list of aphorisms, accompanied by illustrative examples.
We are witnessing profound changes in how experimental science is done and the rate at which scientists are discovering nature's secrets. While we are experiencing this phenomenal change, we are also at risk, because along with these changes comes the potential for altering the values by which we do science. I share with everyone in our field an abiding concern that scientists of the next generation embrace the values that have guided my generation and the generations of scientists that have preceded me. Because relationships in science are key to passing on these values, I have focused the first part of this address on the importance that relationships have played in guiding my scientific process. In the second part; Looking Toward Our Future, I discuss how the mentoring relationship can serve as an antidote to pressures that threaten our scientific values.
Special studies and isolated initiatives over the past several decades in low-, middle- and high-income countries have consistently shown inequalities in health among socioeconomic groups and by gender, race or ethnicity, geographical area and other measures associated with social advantage. Significant health inequalities linked to social (dis)advantage rather than to inherent biological differences are generally considered unfair or inequitable. Such health inequities are the main object of health development efforts, including global targets such as the Millennium Development Goals, which require monitoring to evaluate progress. However, most national health information systems (HIS) lack key information needed to assess and address health inequities, namely, reliable, longitudinal and representative data linking measures of health with measures of social status or advantage at the individual or small-area level. Without empirical documentation and monitoring of such inequities, as well as country-level capacity to use this information for effective planning and monitoring of progress in response to interventions, movement towards equity is unlikely to occur. This paper reviews core information requirements and potential databases and proposes short-term and longer term strategies for strengthening the capabilities of HIS for the analysis of health equity and discusses HIS-related entry points for supporting a culture of equity-oriented decision-making and policy development.
OBJECTIVE: To determine the measles vaccination rate in adolescents that could be achieved with a mailed notification of the recommendation, and to determine if the response rate differed if the mailing was addressed to the parents or to the adolescents. DESIGN: Randomized trial. SETTING: A family medicine residency training clinic serving a low-socioeconomic population. PATIENTS OR OTHER PARTICIPANTS: Four hundred forty-nine adolescents aged 12 through 18 years who were seen in the clinic within the previous 21 months without receiving a documented second dose of measles vaccine were randomized into two groups. INTERVENTION: A letter recommending measles revaccination was sent to the parents in one group (parent group) and to the adolescents themselves in the second group (adolescent group). The content of both letters was basically the same, but they differed in style and reading level. MAIN OUTCOME MEASURE: Measles vaccinations administered to adolescents during the 2-month period following mailing of the letters. RESULTS: Twenty-eight patients were excluded after randomization. Fifty-six letters were undeliverable after two mailing attempts. Eleven (6.3%) of 176 adolescents in the parent group and five (2.6%) of 189 adolescents in the adolescent group received the measles vaccination (P > .05). CONCLUSIONS: Although the adolescents whose parents received the letter were twice as likely to be vaccinated, the response rate was poor in both groups. The letter campaign was not an effective method to reach adolescents for measles revaccination.
BACKGROUND: Ethnoracial disparities in both tobacco-related mortality and treatment outcome for smoking cessation have been reported among adults, but there is a dearth of information on ethnoracial differences among adolescent smokers. OBJECTIVE: To compare smoking-related characteristics in African American and non-African American teenaged applicants for a smoking cessation trial. PARTICIPANTS, DESIGN, AND SETTING: Four hundred thirty-two teenaged smokers (mean [SD] age, 15.6 [1.5] years; 61.8%, female; 31.9%, African American) responded via telephone to various media advertisements. Self-reported sociodemographic, smoking-related, and clinical data were obtained to determine preeligibility for trial participation. MAIN OUTCOME MEASURES: The number of cigarettes smoked per day, Fagerström Test for Nicotine Dependence (FTND) score, motivation to quit, self-reported health problems, and medication use. RESULTS: Compared with non-African Americans, African Americans had lower FTND scores (mean [SD] score, 5.31 [2.24] vs 6.18 [2.18]; P<.01), and smoked fewer cigarettes per day (mean [SD] number of cigarettes, 12.6 [8.3] vs 15.4 [7.5] cigarettes/d; P<.04). The FTND scores were similar in both groups when adjusted for the number of cigarettes smoked per day. African American and non-African American teenagers reported similar motivation to quit (mean [SD] score, 8.64 [1.68] vs 8.53 [1.59], respectively). No difference was found in frequency of physical health problems (eg, asthma), diagnosed psychiatric conditions, or prescribed psychiatric medication although fewer African American teenaged smokers took medication for physical problems (21.2% vs 36.7%). CONCLUSIONS: Cessation treatment interventions designed for African American youths should include lower FTND-defined levels, or the use of other instruments that do not focus on the number of cigarettes smoked per day. Our findings also highlight the importance of ethnocultural issues in treatment research that aims to address health disparities.
TennCare is Tennessee's innovative program that replaces the state's Medicaid program with a health care system based on managed care and designed to cover the vast majority of the state's poor and uninsured. The program provides health care benefits not only to those eligible for Medicaid, but also to the uninsured poor who do not qualify for Medicaid and those who are uninsurable because of existing medical conditions. This article describes the allocation of TennCare graduate medical education funding, which is designed to address the state's physician workforce priorities regarding specialty mix and practice location. Under the new TennCare graduate medical education funding design, funds flow to the state's 4 medical schools and then to the sites of the residents' training. Allocation to the medical schools is based primarily on the number of primary care residents in residency programs under sponsorship of each.
Discussions about end-of-life issues are difficult for clinicians to initiate. Patients, their families, and clinicians frequently collude to avoid mentioning death or dying, even when the patient's suffering is severe and prognosis is poor. In addition to determining from observational research when and where communication problems exist, much can be learned from in-depth discussions with patients, family members, and physicians who are facing these issues together. Using segments of interviews with a patient with advanced pulmonary fibrosis, his son, and his primary care physician, this article illustrates and explores some of these communication issues, including the who, what, when, why, and how of end-of-life discussions. Studies from the medical literature, the patient's and physician's particular experience together, and the author's clinical experience provide practical insights into how to address these issues. Initiating end-of-life discussions earlier and more systematically could allow patients to make more informed choices, achieve better palliation of symptoms, and have more opportunity to work on issues of life closure. JAMA. 2000;284:2502-2507.
This article addresses an emerging policy problem in the United States participation in the electoral process by citizens with dementia. At present, health care professionals, family caregivers, and long-term care staff lack adequate guidance to decide whether individuals with dementia should be precluded from or assisted in casting a ballot. Voting by persons with dementia raises a series of important questions about the autonomy of individuals with dementia, the integrity of the electoral process, and the prevention of fraud. Three subsidiary issues warrant special attention: development of a method to assess capacity to vote; identification of appropriate kinds of assistance to enable persons with cognitive impairment to vote; and formulation of uniform and workable policies for voting in long-term care settings. In some instances, extrapolation from existing policies and research permits reasonable recommendations to guide policy and practice. However, in other instances, additional research is necessary.
Extensive conformational analysis of a series of beta-alkyl substituted cyclopeptides-cyclo(Pro(1)-Xaa(2)-Nle(3)-Ala(4)-Nle(5)-Pro(6)-Xaa(7)- Nle(8)-Ala(9)-Nle(10)) and cyclo[Pro(1)-Xaa(2)-Nle(3)-(Cys(4)- Nle(5)-Pro(6)-Xaa(7)-Nle(8)-Cys(9))-Nle(10)] as well as their corresponding unsubstituted core structures cyclo(Pro(1)-Xaa(2)-Ala(3)-Ala(4)-Ala(5)-Pro(6)-Xaa(7)-Ala(8)-Ala(9)- Ala(10)) and cyclo(Pro(1)-Xaa(2)-Ala(3)-Cys(4)- Ala(5)-Pro(6)-Xaa(7)-Ala(8)-Cys(9)-Ala(10)) has been performed employing both the ECEPP/2 and the MAB force fields (Xaa = Gly, L-Ala, D-Ala, Aib, and D-Pro). Results show that (a) possible three-dimensional structures of the cyclo(Pro(1)-Gly(2)-Lys(3)-Ala(4)-Lys(5)-Pro(6)-Gly(7)-Lys(8)-Ala(9)- Lys(10)) molecule are not limited to a single extended "rectangular" conformation with all Lys side chains oriented at the same side of the molecule; (b) conformational equilibrium in monocyclic analogues obtained by replacements of conformationally flexible Gly residues for L-Ala, D-Ala, Aib, or D-Pro is not significantly shifted towards the target "rectangular" conformational type; and (c) introduction of disulfide bridges between positions 4 and 9 is a very powerful way to stabilize the target conformations in the resulting bicyclic molecules. These findings form the basis for further design of rigidified regioselectively addressable functionalized templates with many application areas ranging from biostructural to diagnostic purposes.
A questionnaire was mailed to 250 psychotherapists selected from the National Register of Health Providers in Psychology to assess attitudes regarding the discussion of exercise in psychotherapy. Responses were received from 110 (44%) of this group. The study focused on (1) reasons therapists do or do not address exercise in therapy; (2) beliefs about the efficacy of exercise; (3) the relationship between theoretical orientation and the likelihood of discussing exercise; and (4) the relationship between gender and the likelihood of discussing exercise. We found that exercising therapists are more likely to raise the issue and discuss exercise with their clients. In addition, male therapists are more likely to discuss exercise with their male clients than with their female clients. Although cognitive-behavioral therapists are more likely than psychodynamic therapists to use a cognitive-behavioral approach, no relationship was found between exercise variables and primary orientation.