Maple syrup urine disease

Maple syrup urine disease (MSUD) is an autosomal recessive metabolic disorder affecting branched-chain amino acids. It is one type of organic acidemia. The condition gets its name from the distinctive sweet odor of affected infants' urine, particularly prior to diagnosis and during times of acute illness.
Classification.
Maple syrup urine disease can be classified by its pattern of signs and symptoms, or by its genetic cause. The most common and severe form of this disease is the classic type, which appears soon after birth, and as long as it remains untreated, gives rise to progressive and unremitting symptoms. Variant forms of the disorder may become apparent only later in infancy or childhood, with typically less severe symptoms that may only appear during times of fasting, stress or illness, but still involve mental and physical problems if left untreated.
Sub-divisions of MSUD:
Generally, majority of patients will be classified into one of these four categories but some patients affected by MSUD do not fit the criteria for the listed sub-divisions and will be deemed unclassified MSUD.
Signs and symptoms.
The disease is named for the presence of sweet-smelling urine, similar to maple syrup, when the person goes into metabolic crisis. Along with the smell being present in ear wax of an affected individual during metabolic crisis. In populations to whom maple syrup is unfamiliar, the aroma can be likened to fenugreek, and fenugreek ingestion may impart the aroma to urine.
Symptoms of MSUD varies between patients and is greatly related to the amount of residual enzyme activity.
Classic MSUD.
Infants with classic MSUD will display subtle symptoms within the first 24–48 hours. Subtle symptoms include poor feeding, either bottle or breast, lethargy, and irritability. The infant will then experience increased focal neurologic signs. These neurologic signs include athetoid, hypertonia, spasticity, and opisthotonus that lead to convulsions and coma. If MSUD is left untreated, central neurologic function and respiratory failure will occur and lead to death. Although MSUD can be stabilized, there are still threats of metabolic decompensation and loss of bone mass that can lead to osteoporosis, pancreatitis, and intracranial hypertension. Additional signs and symptoms that can be associated with classic MSUD include intellectual limitation and behavioral issues.
Intermediate MSUD.
Intermediate MSUD has greater levels of residual enzyme activity than classic MSUD. The majority of children with intermediate MSUD are diagnosed between the ages of 5 months and 7 years. Symptoms associated with classic MSUD also appear in intermediate MSUD.
Intermittent MSUD.
Contrary to classic and intermediate MSUD, intermittent MSUD individuals will have normal growth and intellectual development. Symptoms of lethargy and characterized odor of maple syrup will occur when the individual experiences stress, does not eat, or develops an infection. Metabolic crisis leading to seizures, coma, and brain damage is still a possibility.
Thiamine-response MSUD.
Symptoms associated with thiamine-response MSUD are similar to intermediate MSUD. Newborns rarely present with symptoms.
Later onset.
The symptoms of MSUD may also present later depending on the severity of the disease. Untreated in older individuals, and during times of metabolic crisis, symptoms of the condition include uncharacteristically inappropriate, extreme or erratic behaviour and moods, hallucinations, lack of appetite, weight loss, anemia, diarrhea, vomiting, dehydration, lethargy, oscillating hypertonia and hypotonia, ataxia, seizures, hypoglycaemia, ketoacidosis, opisthotonus, pancreatitis, rapid neurological decline, and coma. Death from cerebral edema will likely occur if there is no treatment. Additionally, MSUD patients experience an abnormal course of diseases in simple infections that can lead to permanent damage.
Causes.
Mutations in the following genes cause maple syrup urine disease:
These four genes produce proteins that work together as the branched-chain alpha-keto acid dehydrogenase complex. The complex is essential for breaking down the amino acids leucine, isoleucine, and valine. These are present in some quantity in almost all kinds of food, but in particular, protein-rich foods such as dairy products, meat, fish, soy, gluten, eggs, nuts, whole grains, seeds, avocados, algae, edible seaweed, beans, and pulses. Mutation in any of these genes reduces or eliminates the function of the enzyme complex, preventing the normal breakdown of isoleucine, leucine, and valine. As a result, these amino acids and their by-products build up in the body. Because high levels of these substances are toxic to the brain and other organs, this accumulation leads to the serious medical problems associated with maple syrup urine disease.
This condition has an autosomal recessive inheritance pattern, which means the defective gene is located on an autosome, and two copies of the gene – one from each parent – must be inherited to be affected by the disorder. The parents of a child with an autosomal recessive disorder are carriers of one copy of the defective gene, but are usually not affected by the disorder.
Pathophysiology.
MSUD is a metabolic disorder caused by a deficiency of the branched-chain alpha-keto acid dehydrogenase complex (BCKAD), leading to a buildup of the branched-chain amino acids (leucine, isoleucine, and valine) and their toxic by-products (ketoacids) in the blood and urine. The buildup of these BCAAS will lead to the maple syrup odor that is associated with MSUD. The BCKAD complex begins by breaking down leucine, isoleucine, and valine through the use of branch-chain aminotransferase into their relevant α-ketoacids. The second step involves the conversion of α-ketoacids into acetoacetate, acetyl-CoA, and succinyl-CoA through oxidative decarboxylation of α-ketoacids. The BCKAD complex consists of four subunits designated E1α, E1β, E2, and E3. The E3 subunit is also a component of pyruvate dehydrogenase complex and oxoglutarate dehydrogenase complex. MSUD can result from mutations in any of the genes that code for these enzyme subunits, E1α, E1β, E2, and E3. Mutations of these enzyme subunits will lead to the BCKAD complex unable to break down leucine, isoleucine, and valine. The levels of these branched chain amino acids will become elevated and lead to the symptoms associated with MSUD. Glutamate levels are maintained in the brain by BCAA metabolism functions and if not properly maintained can lead to neurological problems that are seen in MSUD individuals. High levels of leucine has also been shown to affect water homeostasis within subcortical gray matter leading to cerebral edema, which occurs in MSUD patients if left untreated.
Diagnosis.
Prior to the easy availability of plasma amino acid measurement, diagnosis was commonly made based on suggestive symptoms and odor. Affected individuals are now often identified with characteristic elevations on plasma amino acids which do not have the characteristic odor. The compound responsible for the odor is sotolon (sometimes spelled sotolone).
On 9 May 2014, the UK National Screening Committee (UK NSC) announced its recommendation to screen every newborn baby in the UK for four further genetic disorders as part of its NHS Newborn Blood Spot Screening programme, including maple syrup urine disease. The disease is estimated to affect 1 out of 185,000 infants worldwide and its frequency increases with certain heritages.
Newborn screening for maple syrup urine disease involves analyzing the blood of 1–2 day-old newborns through tandem mass spectrometry. The blood concentration of leucine and isoleucine is measured relative to other amino acids to determine if the newborn has a high level of branched-chain amino acids. Once the newborn is 2–3 days old the blood concentration of branched-chain amino acids like leucine is greater than 1000 μmol/L and alternative screening methods are used. Instead, the newborn's urine is analyzed for levels of branched-chain alpha-hydroxyacids and alpha-ketoacids.
The amount and type of enzyme activity in an affected individual with MSUD will determine which classification the affected individual will identify with:
<br>
Thiamine-Responsive MSUD: Large doses of thiamine will increase enzyme activity.
Prevention.
There are no methods for preventing the manifestation of the pathology of MSUD in infants with two defective copies of the BCKD gene. However, genetic counselors may consult with couples to screen for the disease via DNA testing. DNA testing is also available to identify the disease in an unborn child in the womb.
Treatment.
Monitoring.
Keeping MSUD under control requires careful monitoring of blood chemistry, both at home and in a hospital setting. DNPH or specialised dipsticks may be used to test the patient's urine for ketones (a sign of metabolic decompensation), when metabolic stress is likely or suspected. Fingerstick tests are performed regularly and sent to a laboratory to determine blood levels of leucine, isoleucine, and valine. Regular metabolic consultations, including blood-draws for full nutritional analysis, are recommended; especially during puberty and periods of rapid growth. MSUD management also involves a specially tailored metabolic formula, a modified diet, and lifestyle precautions such as avoiding fatigue and infections, as well as consuming regular, sufficient calories in proportion to physical stress and exertion. Without sufficient calories, catabolism of muscle protein will result in metabolic crisis. Those with MSUD must be hospitalised for intravenous infusion of sugars and nasogastric drip-feeding of formula, in the event of metabolic decompensation, or lack of appetite, diarrhea or vomiting. Food avoidance, rejection of formula and picky eating are all common problems with MSUD. Some patients may need to receive all or part of their daily nutrition through a feeding tube.
Toxin removal.
Following diagnosis, rapid removal of excess leucine from the body reduces the impact of the disease on development. Exchange transfusion, hemodialysis, or hemofiltration may be used.
Diet control.
A diet with carefully controlled levels of the amino acids leucine, isoleucine, and valine must be maintained at all times in order to prevent neurological damage. Since these three amino acids occur in all natural protein, and most natural foods contain some protein, any food intake must be closely monitored, and day-to-day protein intake calculated on a cumulative basis, to ensure individual tolerance levels are not exceeded at any time. As the MSUD diet is so protein-restricted, and adequate protein is a requirement for all humans, tailored metabolic formula containing all the other essential amino acids, as well as any vitamins, minerals, omega-3 fatty acids and trace elements (which may be lacking due to the limited range of permissible foods), are an essential aspect of MSUD management. These complement the MSUD patient's natural food intake to meet normal nutritional requirements without causing harm. If adequate calories cannot be obtained from natural food without exceeding protein tolerance, specialised low protein products such as starch-based baking mixtures, imitation rice and pasta may be prescribed, often alongside a protein-free carbohydrate powder added to food and/or drink, and increased at times of metabolic stress. MSUD patients with thiamine- responsive MSUD can have a higher protein intake diet with administration of high doses of thiamine, a cofactor of the enzyme that causes the condition. The typical dosage amount of thiamine-responsive MSUD depends on the enzyme activity present and can range from 10 mg - 100 mg daily.
Liver transplantation.
Usually MSUD patients are monitored by a dietitian. Liver transplantation is a treatment option that can completely and permanently normalise metabolic function, enabling discontinuation of nutritional supplements and strict monitoring of biochemistry and caloric intake, relaxation of MSUD-related lifestyle precautions, and an unrestricted diet. This procedure is most successful when performed at a young age, and weaning from immunosuppressants may even be possible in the long run. However, the surgery is a major undertaking requiring extensive hospitalisation and rigorous adherence to a tapering regimen of medications. Following transplant, the risk of periodic rejection will always exist, as will the need for some degree of lifelong monitoring in this respect. Despite normalising clinical presentation, liver transplantation is not considered a cure for MSUD. The patient will still carry two copies of the mutated BKAD gene in each of their own cells, which will consequently still be unable to produce the missing enzyme. They will also still pass one mutated copy of the gene on to each of their biological children. As a major surgery the transplant procedure itself also carries standard risks, although the odds of its success are greatly elevated when the only indication for it is an inborn error of metabolism. In absence of a liver transplant, the MSUD diet must be adhered to strictly and permanently. However, in both treatment scenarios, with proper management, those afflicted are able to live healthy, normal lives without suffering the severe neurological damage associated with the disease.
Pregnancy.
Control of metabolism is vital during pregnancy of women with MSUD. To prevent detrimental abnormalities in development of the embryo or fetus, dietary adjustments should be made and plasma amino acid concentrations of the mother should be observed carefully and frequently. Amino acid deficiency can be detected through fetal growth, making it essential to monitor development closely.
Prognosis.
If left untreated, MSUD will lead to death due to central neurological function failure and respiratory failure. Early detection, diet low in branched-chain amino acids, and close monitoring of blood chemistry can lead to a good prognosis with little or no abnormal developments. Average intellectual development is below that of the general population and the severity of the deficit is a related to the time the condition remained undiagnosed and the effectiveness of dietary control including during metabolic crises.
Epidemiology.
Maple syrup urine disease (MSUD) is a rare, inherited metabolic disorder. Its prevalence in the United States population is approximately 1 newborn out of 180,000 live births. However, in populations where there is a higher frequency of consanguinity, such as the Mennonites in Pennsylvania or the Amish, the frequency of MSUD is significantly higher at 1 newborn out of 176 live births. In Austria, 1 newborn out of 250,000 live births inherits MSUD. It also is believed to have a higher prevalence in certain populations due in part to the founder effect since MSUD has a much higher prevalence in children of Amish, Mennonite, and Jewish descent.
Research directions.
Gene therapy.
Gene therapy to overcome genetic mutations cause MSUD has already been proven safe in animals studies with MSUD. The gene therapy involves a healthy copy of the gene causing MSUD is produced and inserted into a viral vector. The adeno-associated virus vector is delivered one-time to the patient intravenously. Hepatocytes will take up vector and functional copies of the affected gene is MSUD patients will be expressed. This will allow BCAA to be broken down properly and prevent toxic build up.
Phenylbutyrate therapy.
Sodium phenylacetate/benzoate or sodium phenylbutyrate has been shown to reduce BCAA in a clinical trial done February 2011. Phenylbutyrate treatment reduced the blood concentration of BCAA and their corresponding BCKA in certain groups of MSUD patients and may be a possible adjunctive treatment.


Tedd Koren

Tedd Koren (born 1950) is a chiropractor who created the Koren Specific Technique (KST) around 2004. Koren said he originated KST after practicing on himself to relieve his own pain. Koren wrote on his website that "KST is an analysis protocol not a chiropractic technique." He resides in Hatfield, Pennsylvania.
Biography.
In 1977, Tedd graduated from Sherman College of Chiropractic in Spartanburg, South Carolina. He practiced as a chiropractor in Philadelphia, and during that time helped to found the (now defunct) Pennsylvania College of Chiropractic. Koren publishes brochures under the name Koren Publications, Inc. which is one of the most prolific publishers of chiropractic literature. His publications cover over 60 topics related to chiropractic care, with titles such as "Allergies", "Asthma & Emphysema", "Blood Pressure", and more.
In 1995, Koren was under investigation by the Federal Trade Commission (FTC) after an anonymous complaint for "false and misleading advertising". Koren rewrote a number of his pamphlets as a result of the proposed FTC consent order, given to him in 1997. No charges were pressed and the investigation was subsequently dropped in 2001.
In 2008, the World Federation of Chiropractic (WFC) accused Koren of "serious professional misconduct" by offering seminars in the technique to non-chiropractic practitioners.
Koren believes chiropractic is about more than treating back pain. He believes the chiropractic method of adjusting subluxations may have positive results that range from asthma to premenstrual syndrome according to his pamphlets.


PHACES syndrome


Robert Goldstone

Robert Goldstone is a Distinguished Professor of psychology and cognitive science at Indiana University in Bloomington, Indiana. His research interests include concept learning and representation, perceptual learning, collective behavior, and computational modeling of human cognition. He has developed and empirically tested neural network models that simultaneously learn new perceptual and conceptual representations, with the learned concepts both affecting and being affected by perception. He has also developed computational models of how groups of people compete for resources, cooperate to solve problems, exchange information and innovations, and form coalitions.
Biography.
He earned his PhD from the University of Michigan, Ann Arbor. He was awarded two American Psychological Association Young Investigator awards in 1995 for articles appearing in Journal of Experimental Psychology, the 1996 Chase Memorial Award for Outstanding Young Researcher in Cognitive Science, a 1997 James McKeen Cattell Sabbatical Award, the 2000 APA Distinguished Scientific Award for Early Career Contribution to Psychology in the area of Cognition and Human Learning, and a 2004 Troland Research Award from the National Academy of Sciences. He was the editor of "Cognitive Science" from 2001–2005, and associate editor of "Psychonomic Bulletin & Review" from 1998–2000. He was elected as a fellow of the Society of Experimental Psychologists in 2004, a fellow of Cognitive Science Society in 2006, and a fellow of the American Academy of Arts and Sciences in 2016. He was Director of the Indiana University Cognitive Science Program from 2006–2011. He is the current Editor (2020-2025) of Current Directions in Psychological Science.
He is married to the computer scientist, Katy Börner.


Common cardinal veins

The common cardinal veins, also known as the ducts of Cuvier, are veins that drain into the sinus venosus during prenatal development. These drain an anterior cardinal vein and a posterior cardinal vein on each side. Each of the ducts of Cuvier receives an ascending vein. The ascending veins return the blood from the parietes of the trunk and from the Wolffian bodies, and are called cardinal veins. Part of the left common cardinal vein persists after birth to form the coronary sinus.


Chitranjan Singh Ranawat

Chitranjan Singh Ranawat is an American orthopedic surgeon of Indian origin.
Ranawat was born in Sarwania, in the Indian state of Madhya Pradesh and did his early medical education at Mahatma Gandhi Memorial Medical College, Indore and his schooling from The Daly College, Indore before moving to the US for advanced training. There, he worked at St. Peters Hospital, Albany and Albany Medical Center and received certification as an orthopedic surgeon by the American Board of Orthopedic Surgery in 1969. Later, he moved to Lenox Hill Hospital where he became the chairman and director of the Orthopedic department. He has also served as a professor at the Weill Medical College of Cornell University and as a visiting faculty at other universities. Ranawat and Albert Burstein of the Hospital for Special Surgery, also in New York City, invented a hip replacement implant marketed by Biomet.
In 1986 he founded the Ranawat Foundation, a philanthropic organization. and in 2001 he received the Padma Bhushan, the third highest Indian civilian award. Each year at its annual meeting, the Knee Society presents the "Chitranjan S. Ranawat, MD Award" and two other awards for the best research papers that year.


Joseph A. Bonanno

Joseph A. Bonanno is an American optometrist.
Biography.
Bonanno obtained his master's degree in 1977 from the University of California, Berkeley in biology and four years later got his O.D. degree. Six years later he received his Ph.D. in physiological optics from the same place and was hired as a postdoc at the Louisiana State University where he worked from 1987 to 1988. Later on, he returned to Berkeley, to his alma-mater, where for a year, he worked at the department of physiology and anatomy. In 1989 he became an assistant professor at the University of California, Berkeley School of Optometry and by 1997 became a professor. In July 1998 he became a faculty member of the Indiana University School of Optometry where as a professor he taught biochemistry and corneal physiology.
From January 2005 to August 2007 he worked as an associate dean at the same place and later held the same position at the Academic Affairs and Student Administration. As of 2017, Bonanno is the Dean of the Indiana University School of Optometry.
Currently he is a fellow at the American Academy of Optometry and a member at both the "Association for Research" in vision and ophthalmology and the American Physiological Society.


Grigoriev Institute for Medical Radiology

Grigoriev Institute for Medical Radiology (GIMR) is a medical radiology and oncology research institution in Kharkiv, Ukraine, founded in 1920. GIMR works in the areas of radiation oncology, radiology, radiotherapy, clinical radiobiology, radiation dosimetry in medicine and radiation safety of patients and medical personnel. The main campus is located at 82 Pushkinskaya St., Kharkiv, Ukraine.
History.
The Institute was founded on July 30, 1920 by the Decree of the Council of People's Commissars of the Ukrainian SSR as the All-Ukrainian X-ray Academy.
In 1925, it was renamed to the Ukrainian X-ray and Radiological Institute, which was reorganized on December 15, 1955 by order No. 591 of the Ministry of Healthcare of Ukraine into the Kharkov Scientific Research Institute of Medical Radiology with the main scientific focus called "Scientific Foundations of Medical Radiology".According to the Decree of the Cabinet of Ministers of Ukraine No. 1232 from 7 August 2000, the Institute was transferred to the Academy of Medical Sciences of Ukraine and renamed as State Organization “Grigoriev Institute for Medical Radiology of the National Academy of Medical Science of Ukraine” (Order of the Academy of Medical Sciences of Ukraine No. 51 from September 29, 2000).
Mission.
For the last 20 years, the institute acts as the chief clinical research body in Ukraine in areas of radiation and clinical oncology, radiotherapy, nuclear medicine, treatment of radiation injuries, clinical radiobiology and radiation protection of patients and medical personnel.
Research.
All scientific and practical activities of the GIMR are aimed at the development and implementation into the healthcare applications of novel solutions in clinical oncology, radiation diagnostics, radiotherapy, radiation pathology, dosimetry and hygiene of medical irradiations.
National and international collaborations.
Scientific interactions with Western and international scientific institutions include a long term cooperation with the International Atomic Energy Agency (Vienna, Austria), the Center of Radiation, Chemical and Environmental Hazards of the Public Health England (former Health Protection Agency, earlier the National Radiological Protection Board, the UK) and various institutions in EU countries via collaboration within the CEC-EU funded research programs.


Medical school in Uganda

Medical schools.
 there are eleven recognized medical schools in Uganda.
Admission.
Admission to medical school in Uganda requires the candidate to have attained the pre-requisite minimum score on the A-level national examinations leading to the award of the Uganda Advanced Certificate of Education or UACE, administered by the Uganda National Examinations Board (UNEB). Proficiency in Biology or Zoology, Chemistry and Physics at A-level standards are requirements for entry into Ugandan medical schools.
Medical training.
Training leading to the award of the degree of Bachelor of Medicine and Bachelor of Surgery (MBChB) lasts five (5) years, if there are no re-takes.
Examinations.
There is a major examination after the first year. If the candidate does not pass, the candidate will repeat first year. Another major examination is given after second year. A failing candidate will have to repeat second year. After each clinical rotation, the candidate is examined and failing candidates are required to repeat that rotation during the next vacation period.
The last major examination is the final 5th Year MBChB examination. This is divided into three parts:
The final year clinical examinations in each of the four clinical disciplines are attended by an "External Examiner", often a professor of International or Regional repute, from a foreign medical school. The examiners arrange it so that the excelling students and those who are on the verge of failing are seen by the External Examiner in at least one of the clinical face-to-face encounters. So if you are a candidate and you go before the "External Examiner", it usually means that you are either excelling in your field or you are on the verge of failing that subject.
Internship.
After successfully passing the final 5th year examinations, one is awarded the degree of Bachelor of Medicine and Bachelor of Surgery (MBChB). A year of internship in a hospital designated for that purpose, under the supervision of a specialist in that discipline is required before an unrestricted license to practice medicine and surgery is granted by the Uganda Medical and Dental Practitioners Council. Six months of the internship must be spent in a medical discipline (either Internal Medicine or Pediatrics) and another six months in a surgical discipline (either Surgery or Obstetrics and Gynecology).
Internship hospitals.
The following hospitals are designated "Internship Hospitals" in Uganda, provided there is a specialist in the required field willing to supervise the intern at the particular hospital:
Postgraduate training.
Specialization training, lasting three years, (provided there are no re-takes), leading to the award of the degree of Master of Medicine (MMed) in the particular discipline is available at Makerere University School of Medicine in the following disciplines: (both medical and surgical disciplines award the MMed)
Makerere University School of Public Health, located on Mulago Hill, offers the degree of Master of Public Health (MPH) following a 22-month period of study which includes field work.
The degree of Doctor of Philosophy (PhD) is awarded following a period of instruction, research and examination (typically three to five years), in select clinical disciplines. A recognized master's degree is required prior to admission into the PhD program.


Charles Fielding

Charles Fielding (also known as Charles Feilding; 2 July 1738 – 11 January 1783) was a British naval officer who was the initiator of the Affair of Fielding and Bylandt in the run-up to the Fourth Anglo-Dutch War. He attained the "rank" of Commodore and died of gangrene after being wounded in action during the Battle of Cape Spartel, commanding HMS "Ganges".
Family life.
Fielding was the son of Charles Feilding, Colonel in the Guards and Equerry to King George II of Great Britain, and Anne Palmer. His biographers apparently thought it more important that he was related to the fourth Earl of Denbigh, whose third son his father was. (He himself was a second son.) He married Sophia Finch, a Woman of the Bedchamber of the Queen (Charlotte) on 29 February 1772. (She was a sister of George Finch, 9th Earl of Winchilsea.) They had three daughters and a son, also called Charles, who became a rear-admiral in the Royal Navy.
Career.
Fielding enlisted in the Royal Navy at an early age, probably following the usual career after starting as a midshipman. From his early career little is known, according to his biographer, Charnock, but he was appointed a Post-Captain on 27 August 1760 (during the Seven Years' War) and given command of HMS "Flamstead" (20). In 1762 he was given command of HMS "Unicorn" which was decommissioned after the end of the war. Apparently, he did not receive a new command until 1770, when he was appointed to HMS "Achilles" (a fourth-rate of 60 guns, launched in 1757) as flag captain of Admiral Sir Francis Geary.
Soon after, he received command of HMS "Rainbow" (44) on which he sailed till he received command of HMS "Kent" in 1772. During his tenure the "Kent" experienced an explosion in July, 1774 in which eleven seamen lost their lives. He was found to be not at fault for the incident, and retained his command for the usual term. In 1776 he received command of HMS "Diamond" with which he transported troops to America, where the American War of Independence had begun. He remained in that area for some years and in 1778 temporarily commanded the Halifax Station, where he distinguished himself.
After his return to Europe in 1779 he was given command of HMS "Namur", a second rate of 90 guns, and put in charge of a squadron of ships of the line cruising the English Channel to intercept Dutch convoys. As officer commanding a squadron he was allowed to carry the title of "commodore" though his formal rank remained that of captain. He intercepted a convoy of Dutch merchantmen escorted by a smaller squadron of naval vessels of the Dutch Republic Navy under command of Rear-Admiral Count Lodewijk van Bylandt, which led to the Affair of Fielding and Bylandt of 31 December 1779. The commotion this incident caused in the Republic would eventually lead to the Fourth Anglo-Dutch War.
Shortly afterwards he was removed to HMS "Minerva" in which he accompanied Admiral George Darby, when the latter relieved Gibraltar in April, 1781. After the commissioning of HMS "Ganges" in 1782 he became her first captain. He accompanied Admiral Howe (with whom he had already served in American waters) to Gibraltar in September, 1782. He was lightly wounded by a splinter in the arm during the skirmish that is known as the Battle of Cape Spartel on 20 October 1782. Though the wound was far from serious, infection set in and Fielding died of gangrene on 11 January of the following year.


George Hector Percival

Prof George Hector Percival FRSE FRCPE (1902–1983) was a British dermatologist, academic author and president of the British Association of Dermatologists.
Life.
He was born in Kirkcaldy in Fife the son of E J Percival.
Percival was educated at George Watson's College in Edinburgh. He then studied Medicine at the University of Edinburgh, graduating MB ChB
He joined the Edinburgh Royal Infirmary's skin department in 1923, rising to become Consultant-in-Charge (Physician) in 1936. From 1946 he was the Grant Professor of Dermatology at the University of Edinburgh.
He became an eminent dermatologist, a fellow of the Royal College of Physicians of Edinburgh, and president of the British Association of Dermatologists in 1961–62. In 1928 he was elected a Fellow of the Royal Society of Edinburgh. His proposers were George Barger, David Murray Lyon, Arthur Logan Turner and James Lorrain Smith. He resigned from the Society in 1933.
His research contributions included work on correlating skin diseases with calcium metabolism and parathyroid hormone, and vascular chemical mediators involved in cutaneous inflammation.
He died in Edinburgh on 3 April 1983.
Family.
In 1937 he married Kathleen Dawson.


Choanal atresia

Choanal atresia is a congenital disorder where the back of the nasal passage (choana) is blocked, usually by abnormal bony or soft tissue (membranous) due to failed recanalization of the nasal fossae during fetal development. It was first described by Roederer in 1755.
Presentation.
It can be unilateral or bilateral.
Associated conditions.
Sometimes babies born with choanal atresia also have other abnormalities:
Also any condition that causes significant depression of the nasal bridge or midface retraction can be associated with choanal atresia. Examples include the craniosynostosis syndromes such as Crouzon syndrome, Pfeiffer syndrome, Treacher Collins and Antley-Bixler syndrome.
Risk factors.
Very few risk factors for choanal atresia have been identified. While causes are unknown, both genetic and environmental triggers are suspected. One study suggests that chemicals that act as endocrine disrupters may put an unborn infant at risk. A 2012 epidemiological study looked at atrazine, a commonly used herbicide in the U.S., and found that women who lived in counties in Texas with the highest levels of this chemical being used to treat agricultural crops were 80 times more likely to give birth to infants with choanal atresia or stenosis compared to women who lived in the counties with the lowest levels. Another epidemiological report in 2010 found even higher associations between increased incidents of choanal atresia and exposure to second-hand-smoke, coffee consumption, high maternal zinc and B-12 intake and exposure to anti-infective urinary tract medications. The anti-thyroid medication methimazole has been associated with the development of choanal atresia in rare cases if given during the first trimester of pregnancy.
Diagnosis.
Choanal atresia can be suspected if it is impossible to insert a nasal catheter.
Also, if one notices a continuous stream of mucus draining from one or both nostrils, it could be a sign of an atresia. Another common sign is cyanosis in an infant while breast feeding, as breathing is dependent on nasal patency in this situation.
Diagnosis is confirmed by radiological imaging, usually CT scan.
In 1950, in Franklin County, NY, a nurse noticed that a day-old infant turned blue when bottle-fed. “There is something wrong with the baby. We are sending her to Montreal!” The baby was hospitalized over a year. The ENT Surgeon had to gerry-rig a dental drill to accomplish the repair. In 2020, neonatal care for bilateral choanal atresia is much improved.
Treatment.
A stent may be inserted to keep the newly formed airway patent or repeated dilatation may be performed.
In popular culture.
In the movie City of Angels, Dr. Maggie Rice (played by Meg Ryan) correctly diagnoses the cause of a newborn baby's failure to thrive as due to choanal atresia.


Hermann Friedrich Gmeiner

Hermann Friedrich Gmeiner (1870–1918) was a physician and first Professor for veterinary internal medicine at the Veterinary Faculty at the University of Giessen (1901–1918). He was succeeded by Friedrich Wilhelm Zwick (1871–1941).


Society for Research in Child Development

The Society for Research in Child Development (SRCD) is a professional society for the field of human development, focusing specifically on child development. It is a multidisciplinary, not-for-profit, professional association with a membership of approximately 5,500 researchers, practitioners, and human development professionals from over 50 countries. The purposes of the society are to promote multidisciplinary research in the field of human development, to foster the exchange of information among scientists and other professionals of various disciplines, and to encourage applications of research findings.
History.
The field of child development received formal recognition in 1922-23 through the appointment of a subcommittee on Child Development of the National Research Council. In 1925, under the direction of Robert S. Woodworth, an eminent experimental psychologist, this group became the Committee in Child Development with offices and staff in the National Academy of Sciences. The purpose of the committee was to integrate research activities and to stimulate research in child development. The committee awarded fellowships, initiated conferences, and began publications. In 1927, 425 scientists were listed in the Directory of Research in Child Development, and that same year the first volume of "Child Development Abstracts and Bibliography" (CDAB) was published. In 1933, the Committee on Child Development disbanded and passed the torch to the newly organized Society for Research in Child Development (SRCD).
A collection of the organization's records is held at the National Library of Medicine in Bethesda, Maryland.
Activities.
International activities.
Nearly 20% of SRCD's members are from nations outside the United States, representing over 50 countries around the world. Special efforts are made by the society, through its Committee on International Relations, to increase interaction and communication between members of the society and all researchers in human development throughout the world.
Ethics.
Of great importance to the society is the establishment and maintenance of ethical standards for research with children. The Committee on Ethical Conduct in Child Development Research promulgates such standards.
Diversity.
The society fosters a commitment to research and training in diversity. The Committees on Ethnic and Racial Issues have made progress in improving, increasing, and disseminating research to members.
Social policy.
Under the guidance of the Policy and Communications Committee, the Society helps to bring the results of research to bear on the formulation of policy affecting children and families. One way in which this is done is through the Policy Fellowship Program in Child Development. Begun in 1978, this program is part of a larger fellowship program administered by the American Association for the Advancement of Science. The goals of this program are to contribute to the effective use of scientific knowledge, to educate the scientific community about the development of public policy, and to establish a more effective liaison between scientists and federal offices. Fellows spend a year as aides or associates in various offices in federal agencies, working with staff in the translation of research to applied issues.
Conference.
In the spring of odd numbered years, the society sponsors a biennial SRCD Conference, a meeting in which members can present individual research reports, symposia, invited lectures, and discussion sessions, among other timely and historical programs. Attendance typically exceeds 5,000 and includes faculty, students, and other individuals who conduct research on child development.


British Gynaecological Cancer Society

The British Gynaecological Cancer Society (BGCS) is a society of medical professionals who seek to improve the care provided to gynaecological cancer patients. The society describes its mission as being "to advance the science and art of gynaecological oncology for the benefit of the public."


Stefan Grzybowski

Stefan Grzybowski, FCFPC, is Canadian obstetrician and researcher in rural medicine. He is a professor of obstetrics at UBC Faculty of Medicine in British Columbia and a co-director of the Centre for Rural Health Research and director of the Rural Health Services Research Network of British Columbia.
Early life and education.
Grzybowski was born into a physician family; his father was a physician and clinical researcher, and his mother an obstetrician. He earned his medical degree from the University of British Columbia and his Master's of Clinical Science from the University of Western Ontario.
Career.
Grzybowski began his career as a family physician in Queen Charlotte on the Haida Gwaii islands of British Columbia, where he began to study safety issues in birthing and more broadly, medical outcomes in rural populations. After twelve years he moved to Vancouver, where he worked at Three Bridges Health Centre from 1994 to 2006; while there he co-published a study of street prices for opioids, one of the earliest studies of pricing for resold prescription drugs. he is a professor in the Department of Family Practice at UBC Faculty of Medicine, co-director of the Centre for Rural Health Research, and director of the Rural Health Services Research Network of British Columbia while occasionally continuing to practise as a locum in British Columbia and the Northwest Territories.
Honors.
The Foundation for Advancing Family Medicine of the College of Family Physicians of Canada honored Grzybowski as a Family Physician of the Year (2002) and Family Medicine Researcher of the Year (2009), and in 2019 gave him a Lifetime Achievement in Family Medicine Research Award.


Duncan Clark (surgeon)

Duncan Clark (1759-1808) was a Loyalist who became an influential figure in Halifax, Nova Scotia. Dr. Duncan Clarke, first and one of the longest serving head of Royal Naval Hospital Halifax (1795-1803). He served in the 82nd Regiment of Foot and arrived in Halifax in 1778. He was a member of the North British Society, eventually becoming president. He was a frequent patron of the Great Pontack (Halifax). Clark also was the head of a Masonic Lodge for Saint John, New Brunswick and later in Nova Scotia. He was also a friend of John Halliburton (surgeon) of the doctor for Prince Edward, Duke of Kent and Strathearn.


North Colombo Medical College

North Colombo Medical College (NCMC) was the first privately funded medical school in Sri Lanka. It started in 1980 with the admission of 100 local and 20 foreign students. The first batch of students began graduating in 1990. Founded by the College of General Practitioners of Sri Lanka, Dr. G. M. Heenilame was its first chairman and Dr. W.D. Ratnavelle, its first director. It was nationalized in 1989 and became the Faculty of Medicine, University of Kelaniya. The first batch of students of the Faculty of Medicine, University of Kelaniya completed their five-year course and graduated with the MBBS degree in September 1996.
History.
In 1979, the College of General Practitioners (CGP) examine the feasibility of establishing a non-profit, fee-levying graduate medical institution as proposed by Dr. G. M. Heennilame which he had been advocating since 1975. Dr Walter Gooneratne and a few others convinced of the feasibility and necessity for a private medical college joined him. In November 1979 the college appointed a Project Implementation Committee comprising Drs Heennilame, Aloysius and Gooneratne “to take all necessary steps to start an undergraduate medical college.”
Between April and July 1980, Drs Sathis Jayasinghe, W D Ratnavale and Shelton Cabraal joined the team. On July 4, 1980 the College of General Practitioners of Sri Lanka appointed the Board of Governors and director of the North Colombo Medical College. The Board of Governors appointed were Drs Heennilame, Aloysius, Gooneratne, Jayasinghe and Cabraal. Dr WD Ratnavale was appointed director. Dr Stanley Kalpage appropriately described this achievement as “truly a miracle”. After all, when these six persons were appointed, the project had no funds, no office, no staff, nothing in writing about approval and little credibility. Yet within one year and two months on 21 September 1981, the President of Sri Lanka, Junius Richard Jayewardene, ceremonially opened the North Colombo Medical College.
The college placed on record those who helped to make the NCMC a reality, with their encouragement and assistance. These included President J R Jayewardene who, from 1979 till the end of his term of office, provided invaluable support. Dr Stanley Kalpage as chairman of the University Grants Commission (Sri Lanka) and secretary of Higher Education played a similar role. The others who provided assistance included Prof Stanley Wijesundera and the academic staff of the University of Colombo, Dr Malinga Fernando, L H R Peiris, Gamini Jayasuriya, B C Perera and Edward Arambawela.
Since its inception the NCMC came under criticism and opposition of many socialist elements in the island, with the Janatha Vimukthi Peramuna which had in 1988 initiated an insurrection carrying out a bomb attack on the NCMC administration section in 1988. The Board of Management conferred its own medical degree MBBS (NCMC) instead of the one from the University of Colombo and affiliated itself with the University of Aberdeen.
In 1989, President Premadasa appointed a committee made up of K.H.J. Wijedasa (Presidential Secretary), W.M.P.B. Menikdiwela (Former Presidential Secretary), Ananda Guruge and Bradman Weerakoon to look into the NCMC. Soon after the NCMC was nationalized with the government sending the army to occupy the buildings at Talagolla stating security reasons. Its board was replaced by a Competent Authority, Prof. Carlo Fonseka. He continued as the first Dean when the NCMC was transferred to the University of Kelaniya as its Faculty of Medicine.


Double bubble (radiology)

In radiology, the double bubble sign is a feature of pediatric imaging seen on radiographs or prenatal ultrasound in which two air filled bubbles are seen in the abdomen, representing two discontiguous loops of bowel in a proximal, or 'high,' small bowel obstruction. The finding is typically pathologic, and implies either duodenal atresia, duodenal web, annular pancreas, and on occasion midgut volvulus, a distinction that requires close clinical correlation and, in most cases, surgical intervention.
Distal gas is more often seen with midgut volvulus, duodenal stenosis and duodenal web, though this not always present. In such cases, distinguishing the diagnoses depends on clinical presentation.
Follow up imaging.
A fluoroscopic study known as an upper gastrointestinal series is often the next step in management in patients that are not critically ill, though if volvulus is suspected, emergent surgical intervention is mandated. If clinical findings are equivocal, caution with non water-soluble contrast is needed, as the usage of barium can impede surgical revision and lead to increased post operative complications. Non ionic water-soluble contrast should be used, as the hyperosmolar agents, if aspirated, can result in life-threatening pulmonary edema. When reflective of duodenal atresia, associations with Down syndrome and VACTERL sequence abnormalities are often seen.
Mimics.
Certain rare anatomic anomalies, such as congenital duodenal duplication and pyloric atresia can cause false positives for the sign on radiographs. Congenital pyloric atresia usually causes a single bubble on radiographs without distal gas, though an intermittent double bubble sign is occasionally seen. Duodenal atresia, while typically without distal gas, has been reported with an absent double bubble, though this variant is quite rare. On neonatal ultrasound, a double bubble can also be caused by a choledochal cyst, omental cyst, or enteric duplication cyst.


M Iqbal Arslan

M Iqbal Arslan is a Bangladeshi physician and academic. He is the incumbent president of Swadhinata Chikitshak Parishad (SWACHIP), an organisation of pro-Awami League doctors of Bangladesh. He is the former dean of the Faculty of Basic Science and Paraclinical Science at Bangabandhu Sheikh Mujib Medical University (BSMMU).
Education.
Arslan passed MBBS from Dhaka Medical College. He completed a M.Phil in biochemistry later.
Academic career.
Arslan joined BSMMU and served as chairman of the Department of Biochemistry. In 2010, Arslan was elected dean of the Faculty of Basic Science and Paraclinical Science.
Organisational affiliation.
Arslan was elected as general secretary of SWACHIP in 2003. He was elected as president of the same organisation in 2015. Arslan was elected general secretary of Bangladesh Medical Association in 2012. Arslan was also elected as member of Dhaka University senate in 2018. Arslan is also a member of the executive committee of the Bangladesh Medical & Dental Council, the regulatory authority for doctors of Bangladesh.
Arslan is appointed as member of the National Technical Advisory Committee of COVID-19 management in Bangladesh.


Voluntary Medical Service Medal

The Voluntary Medical Service Medal is a medal awarded by the British Red Cross and St Andrew's First Aid. It was instituted in 1932 at the direction of George V.
Criteria.
To qualify for the medal, a member must accrue fifteen years' continuous efficient service as a first aid volunteer in either the Red Cross or St Andrew's providing a minimum of ten hours field service per year. Service for the medal was retrospective to the creation of Voluntary Aid Detachments in 1909.
Appearance.
The medal is in diameter and was designed by Percy Metcalfe. The obverse bears a symbolic representation of Florence Nightingale carrying a lamp. The reverse features a design of both the Geneva and St Andrew's crosses to denote the two qualifying organisations. Between the upper arms of the St Andrew's Cross is the text "LONG AND EFFICIENT SERVICE". The medal was originally made of silver, later of silver plated copper, and since the 1960s of copper-nickel. It is suspended from a straight swivel bar and hangs from a ribbon of red with yellow stripes at the edges and a thin white stripe in the centre.
On the suspension ribbon of the medal, clasps embellished with the Geneva cross for Red Cross service or the St Andrew's cross for St Andrews First Aid service are worn to denote five additional years of qualifying service. In undress uniform, on the ribbon of the medal, one silver Geneva or St Andrew's cross emblem is added to the medal ribbon for five additional years of service. At twenty years of additional service the silver emblems are replaced by a silver-gilt emblem. Up to four silver-gilt emblems can replace the silver type to denote 25, 30, and 35 years of service in the applicable voluntary organisation.


Physical medicine and rehabilitation

Physical medicine and rehabilitation, also known as physiatry, is a branch of medicine that aims to enhance and restore functional ability and quality of life to people with physical impairments or disabilities. This can include conditions such as spinal cord injuries, brain injuries, strokes, as well as pain or disability due to muscle, ligament or nerve damage. A physician having completed training in this field may be referred to as a physiatrist.
Scope of the field.
Physical medicine and rehabilitation encompasses a variety of clinical settings and patient populations.
In hospital settings, physiatrists commonly treat patients who have had an amputation, spinal cord injury, stroke, traumatic brain injury, and other debilitating injuries or conditions. In treating these patients, physiatrists lead an interdisciplinary team of physical, occupational, recreational and speech therapists, nurses, psychologists, and social workers.
In outpatient settings, physiatrists treat patients with muscle and joint injuries, pain syndromes, non-healing wounds, and other disabling conditions. Physiatrists are trained to perform injections into joints or muscle as a pain treatment option. Physiatrists are also trained in nerve conduction studies and electromyography.
History.
During the first half of the 20th century, two unofficial specialties, physical medicine and rehabilitation medicine, developed separately, but in practice both treated similar patient populations consisting of those with disabling injuries. Frank H. Krusen was a pioneer of physical medicine, which emphasized the use of physical agents, such as hydrotherapy and hyperbaric oxygen, at Temple University and then at Mayo Clinic and it was he that coined the term 'physiatry' in 1938. Rehabilitation medicine gained prominence during both World Wars in the treatment of injured soldiers and laborers. Howard A. Rusk, an internal medicine physician from Missouri, became a pioneer of rehabilitation medicine after being appointed to rehabilitate airmen during World War II. In 1944, the Baruch Committee, commissioned by philanthropist Bernard Baruch, defined the specialty as a combination of the two fields and laid the framework for its acceptance as an official medical specialty. The committee also distributed funds to establish training and research programs across the nation. The specialty that came to be known as physical medicine and rehabilitation in the United States was officially established in 1947, when an independent Board of Physical Medicine was established under the authority of the American Board of Medical Specialties. In 1949, at the insistence of Dr. Rusk and others, the specialty incorporated rehabilitation medicine and changed its name to Physical Medicine and Rehabilitation.
Treatment.
The major goal of physical medicine and rehabilitation treatment is to help a person function optimally within the limitations placed upon them by a disabling impairment or disease process for which there is no known cure. The emphasis is not on the full restoration to the premorbid level of function, but rather the optimization of the quality of life for those not able to achieve full restoration. A team approach to chronic conditions is emphasized to coordinate care of patients. Comprehensive rehabilitation is provided by specialists in this field, who act as facilitators, team leaders, and medical experts for rehabilitation.
In rehabilitation, goal setting is often used by the clinical care team to provide the team and the person undergoing rehabilitation for an acquired disability a direction to work towards. Very low quality evidence indicates that goal setting may lead to a higher quality of life for the person with the disability, and it not clear if goal setting used in this context reduces or increases re-hospitalization or death.
Not only must a physiatrist know medical knowledge regarding a patient's condition, but they also need to know practical knowledge regarding it as well. This involves issues such as: what type of wheelchair best suits the patient, what type of prosthetic would fit best, does their current house layout accommodate their handicap well, and other every day complications that their patients might have.
Training.
In the United States, residency training for physical medicine and rehabilitation is four years long, including an intern year of general medical training. There are 83 programs in the United States accredited by the Accreditation Council for Graduate Medical Education, in 28 states.
Specifics of training differs from program to program but all residents must obtain the same fundamental skills. Residents are trained in the inpatient setting to take care of multiple types of rehabilitation including: spinal cord injury, traumatic brain injury, stroke, orthopedic injuries, cancer, cerebral palsy, burn, pediatric rehab, and other disabling injuries. The residents are also trained in the outpatient setting to know how to take care of the chronic conditions patients have following their inpatient stay. During training, residents are instructed on how to properly perform several diagnostic procedures which include electromyography, nerve conduction studies and also procedures such as joint injections and trigger point injections.
Subspecialties.
Seven accredited sub-specializations are recognized in the United States:
Fellowship training for other unaccredited subspecialties within the field include the following:


Arthur L. Bloom

Arthur Leslie Bloom FCRP, FRCPath (1930–1992) was a Welsh physician focused on the field of Haemophilia.
He died at the age of 62 on Thursday 12 November 1992.
Positions.
In the 1970s/1980's, he was Chairman of the Haemophilia Centre Directors Organisation.
Bloom served as Director of the Cardiff Haemophilia Centre and had held important positions with the World Federation of Haemophilia.
He was also a senior member of The Haemophilia Society's medical advisory panel and a member of the Central Blood Laboratories Authority (CBLA).
Controversy.
Being centrally placed, Bloom was one of the key figures in what would become known as the Tainted Blood Scandal. Some of his actions were highlighted in The Penrose Inquiry.
In 2017 an episode of BBC Panorama alleged that Bloom had knowingly downplayed the risks of contracting HIV from Factor VIII blood products. In the following year the allegation was repeated in "The Guardian".
Posthumous.
The Arthur Bloom Haemophilia Centre which is a part of The University Hospital of Wales was named after him and provides services for people with haemophilia, HIV/AIDS, & hepatitis C and their families.


Pasteur Institute of Lille

The Pasteur Institute of Lille () is a research centre and member of the Pasteur Institute network.
It includes 14 research units and 1,150 employees including 626 researchers located in Lille, France. There are also 300 employees located outside the Pasteur site. Its revenues are above €70 million. Several neuroscience start-up companies have emerged from the Pasteur Institute of Lille.
Research.
Since Louis Pasteur became the dean of the faculty of sciences in Lille in 1854, the research activities of the institute have been associated with University of Lille, CNRS, INSERM (Community of Universities and Institutions (COMUE) Lille Nord de France; Institute of Biology of Lille - IBL). It is in its premises that the Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis was invented by Albert Calmette and Camille Guérin.
Research areas include


Institute for Research in Biomedicine

The Institute for Research in Biomedicine (IRB Barcelona) is an institution engaged in fundamental research at the interface between molecular and cell biology, computational and structural biology and chemistry, with experts in proteomics, genomics, biostatistics and advanced digital microscopy. The institute was created by the Government of Catalonia in October 2005 and is located at the Barcelona Science Park (Parc Científic de Barcelona - PCB). The director of the Institute is Prof. Francesc Posas and the Prof. Joan Massagué Solé is scientific advisor. IRB Barcelona was recently named a "Severo Ochoa Centre of Excellence" by the Spanish Ministry of Science and Innovation (2011), current Ministry of Economy and Competitiveness.


Ron Waksman

Ron Waksman is a cardiologist. He is the Associate Director, Division of Cardiology, Washington Hospital Center (WHC) and professor of medicine (cardiology) at Georgetown University.
Areas of interest.
His current research interests include brachytherapy for restenosis prevention bioabsorbable/ biodegradable stents, HDL therapy, intracoronary imaging, valvular heart disease and catheter-based treatment of renal denervation. He is also the author/co-author of more than 20 book chapters and the editor/co-editor of six books in the field of cardiology. He serves as the Editor-in-Chief of the journal Cardiovascular Revascularization Medicine (Including Molecular Interventions).
Education.
Ron Waksman earned his medical degree from the Ben Gurion University in Israel and completed residencies in medicine, cardiology, and interventional cardiology at Hadassah University in Jerusalem, Israel. Subsequently Waksman completed his fellowship in interventional cardiology in 1994 at Emory University Hospital Midtown in Atlanta, GA under Spencer B. King, III.


Rocker bottom foot

Unlike the flexible flat foot that is commonly encountered in young children, congenital vertical talus is characterized by presence of a very rigid foot deformity. The foot deformity in congenital vertical talus consists of various components, namely a prominent calcaneus caused by the ankle equines or planter flexion, a convex and rounded sole of the foot caused by prominence of the head of the talus, and a dorsiflexion and abduction of the forefoot and midfoot on the hindfoot. It gets its name from the foot's resemblance to the bottom of a rocking chair. There are two subcategories of congenital vertical talus namely idiopathic or isolated type and non-idiopathic type which may be seen in association with arthrogryposis multiplex congenital, genetic syndromes and other neuromuscular disorders.
It can be associated with Edwards' syndrome (trisomy 18), Patau syndrome (trisomy 13), Trisomy 9 and mutation in the gene HOXD10.
Treatment.
The treatment of congenital vertical talus can be broadly classified into conservative and surgical.
Serial casting.
The mainstay of management of congenital vertical talus is serial manipulative casting also known as the reversed Ponseti technique. This technique involves gradual step-wise correction of the deformity usually on a weekly basis. In the event there is residual deformity or incomplete correction at the end of the serial castings, the orthopedic surgeon may resort to a minimally invasive surgery at the talo-navicular joint to achieve full correction. The results of the serial manipulative casting technique or reversed Ponseti technique are satisfactory especially if started shortly after birth.
Classic soft tissue release.
The classic or extensive soft tissue release involves a peri-talar release of tight or contracted ligamentous and capsular structures with the intent of achieving a complete repositioning or reduction of the talo-navicular joint. In that regard, various surgical techniques have been described.[reference] The extensive soft tissue release may be indicated in cases where the conservative methods - serial manipulative casting technique- have failed to achieved full correction of the deformity. However, the results are guarded. All patients need close long term follow-up to allow for early detection of deformity recurrence. This is irrespective of the treatment modality used to attain deformity correction.
Naviculectomy or resection arthroplasty.
Naviculectomy or simply navicular excision represents a form of mid-tarsal resection arthroplasty. It may be necessary to associate naviculectomy with limited soft tissue releases to address the remaining components of the deformity. Naviculectomy has been practiced on ambulatory and non-ambulatory (non-walkers) patients.<ref name=Laurdin>Naviculectomy is usually reserved for children with resistant or complicated forms of congenital vertical talus such as neglected, previously operated and recurrent cases. Naviculectomy may be indicated in the above resistant case of congenital vertical talus on the condition that a plantigrade foot is considered unlikely by the conservative serial casting methods. And on the condition that extensive soft tissue release is not expected to yield a satisfactory clinical and functional result. Generally, naviculectomy is a more tissue-friendly procedure in contrast to the more aggressive classic and extensive peri-talar soft tissue releases. The clinical and radiologic results of naviculectomy are satisfactory on the short term, and long term follow-up.


Marc Cantin

Marc Cantin (1933–1990) was a Canadian Québécois doctor and professor. His studies were completed at Laval University in Quebec and at the University of Chicago. He was a professor at the University of Montreal and at McGill University and worked with the doctor Hans Selye. In 1980, he began to direct the hypertension research group at the Institute of clinical research at Montreal, Quebec, Canada.


Gopal Prasad Sinha

Gopal Prasad Sinha is an Indian neurologist, politician and a member of the Institutional Ethical Committee of the Indian Council of Medical Research. He was born and brought up in Patna, in the Indian state of Bihar and is an alumnus of Patna University. He unsuccessfully contested in 2014 Indian Parliament elections from the Patna Sahib constituency under the Janata Dal (United) candidacy, against the incumbent Member of Parliament, Shatrughan Sinha.
Sinha was married to late Indira Sinha, an educationist, and has a daughter, Jaya Sinha Kumra, and a son, Ajay Alok, who is a known politician from Bihar. He is a 2004 recipient of the fourth highest Indian civilian award, Padma Shri for his services to the field of medicine.


Joseph-Alexandre Crevier

Joseph-Alexandre Crevier (1824–1889) was a French-Canadian doctor who discovered the microbial transmission of cholera as well as a powerful remedy. He was also a naturalist.


Diffusing capacity

Diffusing capacity of the lung (DL) (also known as Transfer factor is another expression for the formerly used diffusing capacity.) measures the transfer of gas from air in the lung, to the red blood cells in lung blood vessels. It is part of a comprehensive series of pulmonary function tests to determine the overall ability of the lung to transport gas into and out of the blood. DL, especially DLCO, is reduced in certain diseases of the lung and heart. DLCO measurement has been standardized according to a position paper by a task force of the European Respiratory and American Thoracic Societies.
In respiratory physiology, the diffusing capacity has a long history of great utility, representing conductance of gas across the alveolar-capillary membrane and also takes into account factors affecting the behaviour of a given gas with hemoglobin.
The term may be considered a misnomer as it represents neither diffusion nor a capacity (as it is typically measured under submaximal conditions) nor capacitance. In addition, gas transport is only diffusion limited in extreme cases, such as for oxygen uptake at very low ambient oxygen or very high pulmonary blood flow.
The diffusing capacity does not directly measure the primary cause of hypoxemia, or low blood oxygen, namely mismatch of ventilation to perfusion:
Testing.
The single-breath diffusing capacity test is the most common way to determine formula_1. The test is performed by having the subject blow out all of the air that they can, leaving only the residual lung volume of gas. The person then inhales a test gas mixture rapidly and completely, reaching the total lung capacity as nearly as possible. This test gas mixture contains a small amount of carbon monoxide (usually 0.3%) and a "tracer gas" that is freely distributed throughout the alveolar space but which doesn't cross the alveolar-capillary membrane. Helium and methane are two such gasses. The test gas is held in the lung for about 10 seconds during which time the CO (but "not" the tracer gas) continuously moves from the alveoli into the blood. Then the subject exhales.
The anatomy of the airways means inspired air must pass through the mouth, trachea, bronchi and bronchioles (anatomical dead space) before it gets to the alveoli where gas exchange will occur; on exhalation, alveolar gas must return along the same path, and so the exhaled sample will be purely alveolar only after a 500 to 1,000 ml of gas has been breathed out. While it is algebraically possible to approximate the effects of anatomy (the "three-equation method"), disease states introduce considerable uncertainty to this approach. Instead, the first 500 to 1,000 ml of the expired gas is disregarded and the next portion which contain gas that has been in the alveoli is analyzed. By analyzing the concentrations of carbon monoxide and inert gas in the inspired gas and in the exhaled gas, it is possible to calculate formula_2 according to Equation . First, the "rate" at which CO is taken up by the lung is calculated according to:
Similarly,
where
Other methods that are not so widely used at present can measure the diffusing capacity. These include the steady state diffusing capacity that is performed during regular tidal breathing, or the rebreathing method that requires rebreathing from a reservoir of gas mixtures.
Calculation.
The diffusion capacity for oxygen formula_8 is the proportionality factor relating the rate of oxygen uptake into the lung to the oxygen gradient between the capillary blood and the alveoli (per Fick's laws of diffusion). In respiratory physiology, it is convenient to express the transport of gas molecules as changes in volume, since formula_9 (i.e., in a gas, a volume is proportional to the number of molecules in it). Further, the oxygen concentration (partial pressure) in the pulmonary artery is taken to be representative of capillary blood. Thus, formula_8 can be calculated as the rate that oxygen is taken up by the lung formula_11 divided by the oxygen gradient between the alveoli ("A") and the pulmonary artery ("a").
Thus, the higher the diffusing capacity formula_1, the more gas will be transferred into the lung per unit time for a given gradient in partial pressure (or concentration) of the gas. Since it can be possible to know the alveolar oxygen concentration and the rate of oxygen uptake - but not the oxygen concentration in the pulmonary artery - it is the venous oxygen concentration that is generally employed as a useful approximation in a clinical setting.
Sampling the oxygen concentration in the pulmonary artery is a highly invasive procedure, but fortunately another similar gas can be used instead that obviates this need (DLCO). Carbon monoxide (CO) is tightly and rapidly bound to hemoglobin in the blood, so the partial pressure of CO in the capillaries is negligible and the second term in the denominator can be ignored. For this reason, CO is generally the test gas used to measure the diffusing capacity and the formula_1 equation simplifies to:
Interpretation.
In general, a healthy individual has a value of formula_19 between 75% and 125% of the average. However, individuals vary according to age, sex, height and a variety of other parameters. For this reason, reference values have been published, based on populations of healthy subjects as well as measurements made at altitude, for children and some specific population groups.
Blood CO levels may not be negligible.
In heavy smokers, blood CO is great enough to influence the measurement of formula_19, and requires an adjustment of the calculation when COHb is greater than 2% of the whole.
The two components of formula_19.
While formula_22 is of great practical importance, being the overall measure of gas transport, the interpretation of this measurement is complicated by the fact that it does not measure any one part of a multi-step process. So as a conceptual aid in interpreting the results of this test, the time needed to transfer CO from the air to the blood can be divided into two parts. First CO crosses the alveolar capillary membrane (represented by formula_23 ) and then CO combines with the hemoglobin in capillary red blood cells at a rate formula_24 times the volume of capillary blood present (formula_25). Since the steps are in series, the conductances add as the sum of the reciprocals:
Any change in formula_25 alters formula_19.
The volume of blood in the lung capillaries, formula_25, changes appreciably during ordinary activities such as exercise. Simply breathing in brings some additional blood "into" the lung because of the negative intrathoracic pressure required for inspiration. At the extreme, inspiring against a closed glottis, the Müller's maneuver, pulls blood "into" the chest. The opposite is also true, as exhaling increases the pressure within the thorax and so tends to push blood out; the Valsalva maneuver is an exhalation against a closed airway which can move blood "out" of the lung. So breathing hard during exercise will bring extra blood into the lung during inspiration and push blood out during expiration. But during exercise (or more rarely when there is a structural defect in the heart that allows blood to be shunted from the high pressure, systemic circulation to the low pressure, pulmonary circulation) there is also increased blood flow throughout the body, and the lung adapts by recruiting extra capillaries to carry the increased output of the heart, further increasing the quantity of blood in the lung. Thus formula_19 will appear to increase when the subject is not at rest, particularly during inspiration.
In disease, hemorrhage into the lung will increase the number of haemoglobin molecules in contact with air, and so measured formula_19 will increase. In this case, the carbon monoxide used in the test will bind to haemoglobin that has bled into the lung. This does not reflect an increase in diffusing capacity of the lung to transfer oxygen to the systemic circulation.
Finally, formula_25 is increased in obesity and when the subject lies down, both of which increase the blood in the lung by compression and by gravity and thus both increase formula_19.
Reasons why formula_24 varies.
The rate of CO uptake into the blood, formula_24, depends on the concentration of hemoglobin in that blood, abbreviated Hb in the CBC (Complete Blood Count). More hemoglobin is present in polycythemia, and so formula_19 is elevated. In anemia, the opposite is true. In environments with high levels of CO in the inhaled air (such as smoking), a fraction of the blood's hemoglobin is rendered ineffective by its tight binding to CO, and so is analogous to anemia. It is recommended that formula_19 be adjusted when blood CO is high.
The lung blood volume is also reduced when blood flow is interrupted by blood clots (pulmonary emboli) or reduced by bone deformities of the thorax, for instance scoliosis and kyphosis.
Varying the ambient concentration of oxygen also alters formula_24. At high altitude, inspired oxygen is low and more of the blood's hemoglobin is free to bind CO; thus formula_24 is increased and formula_19 appears to be increased. Conversely, supplemental oxygen increases Hb saturation, decreasing formula_24 and formula_19.
Lung diseases that reduce formula_23 and formula_43.
Diseases that alter lung tissue reduce both formula_23 and formula_43 to a variable extent, and so decrease formula_19.
History.
In one sense, it is remarkable that DLCO has retained such clinical utility. The technique was invented to settle one of the great controversies of pulmonary physiology a century ago, namely the question of whether oxygen and the other gases were actively transported into and out of the blood by the lung, or whether gas molecules diffused passively. Remarkable too is the fact that both sides used the technique to gain evidence for their respective hypotheses. To begin with, Christian Bohr invented the technique, using a protocol analogous to the steady state diffusion capacity for carbon monoxide, and concluded that oxygen was actively transported into the lung. His student, August Krogh developed the single breath diffusion capacity technique along with his wife Marie, and convincingly demonstrated that gasses diffuse passively, a finding that led to the demonstration that capillaries in the blood were recruited into use as needed – a Nobel Prize–winning idea.


Camogli Hospital

The Camogli Hospital is a public hospital located in Edinburgh of the Seven Seas on Tristan da Cunha. The building was replaced by a new build in 2017 to meet NHS standards.
History.
Throughout the 19th Century, the islands had no resident healthcare service. A temporary hospital was constructed in 1942. In 1971, the Camogli hospital was constructed, and was named after the hometown of Italian settlers Andrea Repetto & Gaetano Lavarello.
On 7 June 2017 a new facility, named the Camogli Medical Centre was constructed, meeting current NHS standards.
Services.
The hospital provides 2 hospital wards, each containing a bed, with the capability to hold 2. The facility also features an Emergency room, X-Ray, ambulance service, and dental services.


Speleotherapy

Speleotherapy (Greek σπήλαιον "spḗlaion" "cave") is a respiratory therapy involving breathing inside a cave.
Modern use of this therapy started in Germany by Karl Hermann Spannagel.
Research is ongoing what health conditions can be treated with this technique. A 2001 Cochrane summary concluded that as no trials had been done, there is no evidence to determine whether breathing air inside a cave is useful in treating asthma.
History.
In a classic form, speleotherapy was the use of underground mineral and hot springs – underground balneo and hydrotherapy. The ancient Greeks practiced salt-based remedies. Hippocrates (460 BC) had documented salt based therapies including inhalation of steam from salt water. According to Hippocrates procedure was providing relief of respiratory symptoms. There are claims of improvements in the breathing of miners in Roman times and medieval times. Speleotherapy hospitals existed in Italy in the 19th century. In the middle of the 19th century, an attempt has been made to use the air of caves for diseases treatment. The clinic, founded in Mammoth Cave (Kentucky, USA), was intended for tuberculosis patients. A few months after the death of one of the patients, the hospital was closed.
The history of modern speleotherapy dates back to the 1950s. At this time, speleotherapeutic hospitals arise in several countries of Eastern and Central Europe. Unitil recently speleotherapy was not practiced in the US and Great Britain.
The emergence of speleotherapy as a therapeutic method in Encyclopedia of Caves and Karst Science is associated with the episode World War II. Residents of Ennepetal (Germany) used the nearby Klüterköhle cave as a bomb shelter. Dr. Karl Hermann Spannagel drew attention to the improvement of well-being of asthmatics who were in the cave. After the war, he began research into the therapeutic effect of caves in treating bronchial asthma, chronic bronchitis, and whooping cough a. The research results were published in 1949.
After this, speleotherapeutic facilities under the natural conditions of karst caves arise in Hungary and Czechoslovakia. The success of the method led to the birth of the international speleotherapeutic society. In 1969, the Speleotherapy Commission was founded at International Union of Speleologists.
In 1968, in Solotvyn (now in Ukraine), the first speleotherapy clinic was opened on the territory of the USSR, and the next year its territory was expanded for the first time in the world after the construction of additional development on a special project. In 1977, in the Perm Region, the world's first speleotherapy clinic was opened in a potash mine. In 1982, another important step was taken in speleotherapy in the USSR: the first climate chamber was patented, equipped with a salt filter-saturator and recreating the conditions of salt mines on the earth's surface.


Donald Harrison (surgeon)

Sir Donald Frederick Norris Harrison (9 March 1925 – 12 April 2003) was a British surgeon
He was the son of Frederick William Rees Harrison OBE JP of Portsmouth, the Principal of the College of Technology for Monmouthshire. Educated at Newport High School, he then held junior posts at Guy's Hospital and the Royal Gwent Hospital, Newport, followed by National Service in the Royal Air Force, acquiring in the process a particular interest in ear, nose and throat surgery.
In 1962, he was appointed consultant surgeon to the Royal National Ear, Nose and Throat Hospital before becoming in 1963 a professor at the Institute of Laryngology and Otology, now part of the UCL Ear Institute. There he publicly campaigned against the dangers of chewing tobacco. He retired in 1990 and was knighted for his services in the field of ear, nose and throat surgery.
He was elected President of the Royal Society of Medicine in 1994, serving until 1996.
His published work "The Anatomy and Physiology of the Mammalian Larynx"" (Cambridge University Press), 1995) was largely based on his personal collection of some thousand mammalian larynges.
He died in 2003. He had married Audrey Clubb, with whom he had two daughters.


Spartan Health Sciences University

Spartan Health Sciences University is a private, for-profit medical school located in Vieux Fort, St. Lucia, in the Caribbean. Spartan confers upon its graduates the Doctor of Medicine (MD) degree. Spartan graduates can practice medicine in 46 US states.
History.
Spartan was established in Saint Lucia on January 7, 1980, as St. Lucia Health Sciences University. The first campus was located in Castries, the capital city. In November 1983, the school was renamed Spartan Health Sciences University and relocated to Vieux Fort.
In 1989, Spartan University started to participate in the Federal Family Education Loan (FFEL) program under Title IV. They continued their participation until 1997. Almost two thirds of their student body received these loans. Due to a high default rate and inability to provide sufficient documentation during US Department of Education review of financial assistance at the school, the school was ordered to repay several hundred thousand dollars back to the program.
In 1997, it was temporarily delisted from the World Directory of Medical Schools afte the St. Lucia government awkwardly denied knowledge of the existence of the school. Relationships between the goverment and the and the school have since improved, and today some of their graduates intern in the St. Lucia Ministry of Health.
The school started a nursing program in 2012, which by 2017 had graduated two classes of St. Lucian nurses.
Curriculum.
The MD program at Spartan is a ten-trimester course of study that consists of three trimester per calendar year. trimesters 1-5 are completed at the Saint Lucia campus; semesters 6-10 consist of 80 weeks of clinical study that are completed at teaching hospitals approved by the university.
Spartan also has a school of nursing. The nursing program was chartered by The Government of St Lucia and is licensed the University. It is also accredited by the Monitoring Committee appointed by the Government of St. Lucia to ensure that standards are comparable to those set by the Liaison Committee of Medical Education as required by the Department of Education in the United States. A school of veterinary medicine was opened on January 14, 2015, and was developed in collaboration with Techmedics Inc.
Accreditation.
Spartan Health Sciences University is chartered and licensed in Saint Lucia. The university is listed in the FAIMER International Medical Education Directory (IMED) and in the Avicenna Directory for medicine In 2013, Spartan was accredited by the Caribbean Accreditation Authority for Education in Medicine and other Health Professions.
Licensure restrictions.
In the United States, the medical boards of the following states have listed Spartan as an institution whose graduates are ineligible for licensure:
In the United Kingdom, the General Medical Council has listed Spartan as an institution whose graduates (who started their course of study on or before December 31, 2008) are ineligible for licensure.


Stuart W. Cook

Stuart Wellford Cook (April 15, 1913—March 25, 1993) was an American social psychologist known for his research on the societal effects of racism and religious intolerance. He is particularly known for a study he conducted with Isidor Chein and Kenneth Bancroft Clark on the psychological effects of racial segregation. This study was cited by the appellates in the 1954 landmark United States Supreme Court case "Brown v. Board of Education". His research also focused on many other psychological subjects, including clinical psychology, military psychology, and psychological research methods.
Academic career.
After receiving his Ph.D. in 1938, Cook served as a captain in the Army Air Force, working with John C. Flanagan on the aviation psychology program at Santa Ana Army Air Base. In 1949, he founded the Research Center for Human Relations at New York University, subsequently serving as the Center's director. In 1950, he became head of the psychology department at New York University. He was the president of the Society for the Psychological Study of Social Issues from 1951 to 1952. In 1963, he became professor and chair of the psychology department at the University of Colorado. From 1978 to 1980, he was the head of the University of Colorado's Institute of Behavioral Science. He retired from the University of Colorado in 1980 as a Distinguished Professor.


Mast cell activation syndrome

Mast cell activation syndrome (MCAS) is one type of mast cell activation disorder (MCAD), and is an immunological condition in which mast cells inappropriately and excessively release chemical mediators, resulting in a range of chronic symptoms, sometimes including anaphylaxis or near-anaphylaxis attacks. Primary symptoms include cardiovascular, dermatological, gastrointestinal, neurological and respiratory problems.
Unlike mastocytosis, another type of MCAD, where patients have an abnormally increased number of mast cells, patients with MCAS have a normal number of mast cells that do not function properly and are defined as "hyperresponsive". MCAS is still a poorly understood condition and is a current topic of research.
Signs and symptoms.
MCAS is a condition that affects multiple systems, generally in an inflammatory manner. Symptoms typically wax and wane over time, varying in severity and duration. Many signs and symptoms are the same as those for mastocytosis, because both conditions result in too many mediators released by mast cells. It has many overlapping characteristics with recurrent idiopathic anaphylaxis, although there are distinguishing symptoms, specifically hives and angioedema.
Common symptoms include:
Causes.
There are no known causes, but the condition appears to be inherited in some patients. Symptoms of MCAS are caused by excessive chemical mediators inappropriately released by mast cells. Mediators include leukotrienes, histamines, prostaglandin, and tryptase. The condition may be mild until exacerbated by stressful life events, or symptoms may develop and slowly trend worse with time.
Pathophysiology.
Mast cell activation can be localized or systemic. MCAS can present with a wide range of symptoms in multiple body systems, these symptoms may range from digestive discomfort to chronic pain, mental issues as well as an anaphylactic reaction ( The Mastocytosis Society). Some examples of tissue specific consequences of mast cell activation include urticaria, allergic rhinitis, and wheezing. Systemic mast cell activation presents with symptoms involving 2 or more organ systems (skin: urticaria, angioedema, and flushing; gastrointestinal: nausea, vomiting, diarrhea, and abdominal cramping; cardiovascular: hypotensive syncope or near syncope and tachycardia; respiratory: wheezing; naso-ocular: conjunctival injection, pruritus, and nasal stuffiness). This can result from the release of mediators from a specific site, such as the skin or mucosal tissue, or activation of mast cells around the vasculature.
Diagnosis.
MCAS is often difficult to identify due to the heterogeneity of symptoms and the "lack of flagrant acute presentation." The condition can also be difficult to diagnose, especially since many of the numerous symptoms are non-specific in nature. Mast cell activation was assigned an ICD 10 code (D89.40, along with subtype codes D89.41-43 and D89.49) in October 2016.
The World Health Organization has not published diagnostic criteria.
Treatment.
Common pharmacological treatments include:
Prognosis.
The prognosis of MCAS is uncertain because of lack of studies.
Epidemiology.
MCAS is a relatively new diagnosis, being unnamed until 2007, and is believed to be under-diagnosed.
History.
The condition was hypothesized by the pharmacologists John Oates and Jack Roberts of Vanderbilt University in 1991, and following a build-up of evidence featured in papers by Sonneck et al. and Akin et al., finally named in 2007.
Diagnostic criteria were proposed in 2010.


Medicare dual eligible

Dual-eligible beneficiaries (Medicare dual eligibles or "duals") refers to those qualifying for both Medicare and Medicaid benefits. In the United States, approximately 9.2 million people are eligible for "dual" status. Dual-eligibles make up 14% of Medicaid enrollment, yet they are responsible for approximately 36% of Medicaid expenditures. Similarly, duals total 20% of Medicare enrollment, and spend 31% of Medicare dollars. Dual-eligibles are often in poorer health and require more care compared with other Medicare and Medicaid beneficiaries.
Medicare and Medicaid coverage for dual-eligibles.
Medicare is the primary payer for most services, but Medicaid covers benefits not offered by Medicare. Medicare coverage for dual-eligibles includes hospitalizations, physician services, prescription drugs, skilled nursing facility care, home health visits, and hospice care. Under Medicaid, states are required to cover certain items and services for dual-eligibles, including long-term nursing facility services and home health services. Although states are required to cover certain populations and services, they have the option to expand coverage beyond these mandatory levels (i.e., offer home and community-based services), and accordingly state Medicaid programs vary in scope. Dual-eligibles may be categorized as full-benefit or partial-benefit. Those with full benefits may receive the entire range of Medicaid benefits; those with partial-benefits do not receive Medicaid-covered services, but Medicaid covers their Medicare premiums or cost-sharing, or both. Partial benefit dual-eligible beneficiaries have limited income and assets, but their income and assets are not low enough to qualify them for full Medicaid benefits in their state.
Change in prescription drug coverage for dual-eligibles.
With the advent of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, these dual eligibles have automatically been enrolled to a random Medicare Part D plan, effective January 1 of 2006. As a result of this auto assignment, participants who were already enrolled in a Medicare Advantage HMO, may have been automatically disenrolled from their medical plan to allow for part D enrollment. Medicaid will still cover drugs for dual-eligible patients that are not covered by Medicare Part D, including certain controlled substances.
Efforts to integrate Medicare and Medicaid benefits.
Dual-eligibles typically receive their Medicare and Medicaid benefits through each program separately. For Medicare benefits, beneficiaries may opt to enroll in Medicare's traditional fee-for-service (FFS) program or in a private Medicare Advantage (MA) plan (Medicare Part C), which is administered by a Managed Care Organization (MCO), under contract with the Centers for Medicare & Medicaid Services (CMS), the agency in the Department of Health and Human Services that administers the Medicare program and oversees state Medicaid programs. In addition, dual-eligibles may choose a type of MA plan called a dual-eligible special needs plan (D-SNP), which is designed to target the needs of this population. For Medicaid benefits, beneficiaries generally enroll in their state's Medicaid FFS program or a Medicaid managed care plan administered by an MCO under contract with the state.
Recently, Congress and CMS have placed greater emphasis on the coordination and integration of Medicare and Medicaid benefits for dual-eligible beneficiaries. For example, the Medicare Improvements for Patients and Providers Act of 2008 required D-SNPs to contract with state Medicaid agencies to provide Medicaid benefits. More recently, the Affordable Care Act (ACA) established a type of D-SNP, referred to as a Fully Integrated Dual Eligible (FIDE) SNP, which—unlike other D-SNPs—is designed to integrate program benefits for dual-eligible beneficiaries through a single managed care organization, although payment is generally provided separately by each program. In 2011, CMS announced a financial alignment demonstration that is intended to further integrate the programs' services. CMS expects that the demonstration will decrease incentives for cost shifting and increase care coordination, resulting in improved care for beneficiaries and savings to Medicare and Medicaid. CMS projects that approximately 61 to 75 percent of savings will come from reductions in costly Medicare-covered services.
Historical challenges with the dually-eligible.
Historically, one of the major challenges for the dually-eligible has been care coordination between Medicare and Medicaid. These two systems of care do not "talk to each other" systematically, so one physician that bills primarily through Medicare may not be familiar with benefits that are available through Medicaid. Additionally, since Medicaid benefits vary by state, it is difficult for care providers and consumers to understand the complexity that is inherent within the Medicaid system.
Because duals tend to be the most vulnerable, and often sickest, adults, their care has historically been expensive, totaling $319.5 billion in 2011. One proposed reason for this significant cost would be that many Medicaid programs, prior to the 2010 passage of the Affordable Care Act (ACA) used a fee-for-service model. Fee-for-service models are typically more costly because they allow providers to charge for the quantity of care they provide, rather than the quality.
In order to resolve these pain points, the ACA includes provisions that specifically address the coverage and care of duals. On a federal level, the Centers for Medicare and Medicaid Services (CMS) has established two new offices: The Federal Coordinated Health Care Office (FCHCO aka the "duals office") as well as the Center for Medicare and Medicaid Innovation (CMMI) in order to both strategize and monitor the type and quality of care afforded to duals. These offices focus on both monetary expenses as well as care innovation and quality for dual eligible beneficiaries.
Research.
A study by the Government Accountability Office (GAO) found that the integration of Medicare and Medicaid benefits generally improves the care provided to dual-eligibles but does not lead to Medicare savings or a reduction in costly Medicare services (i.e., emergency room visits, hospital admissions, and 30-day risk-adjusted all-cause readmissions). Medicare Advantage health plans that fully integrated Medicare and Medicaid benefits for dual-eligibles (i.e., FIDE-SNPs) generally had better quality of care scores (particularly for intermediate outcome measures) relative to plans with less integration of benefits. However, only FIDE-SNPs that operated in states with long-standing integration programs performed well on quality of care scores. While the care provided generally improved for dual-eligibles enrolled in FIDE-SNPs, very few of these plans reported lower estimated Medicare costs relative to what Medicare's fee-for-service program would have spent for beneficiaries with the same demographic and health characteristics. Furthermore, the FIDE-SNPs that reported potential Medicare savings generally did not demonstrate lower costs than other D-SNPs in the same geographic areas. These results were consistent for dual-eligibles both under the age of 65 and those age 65 and over. While operating specialized plans and integrating benefits could lead to improved care, GAO's results suggest that these conditions have not demonstrated a reduction in dual-eligible beneficiaries' Medicare spending compared with Medicare spending in settings without integrated benefits. Because the GAO study also found that the average number of costly Medicare services increases as the number of chronic and mental health conditions increase, it is possible that savings were not demonstrated because the population being served by FIDE-SNPs is too large to be cost-effective and major complications were averted for relatively few beneficiaries.
A study looking at physician's views of Medicare Part D, and in particular how it pertains to dual-eligibles, found that many physicians expressed concern regarding access to prescription drugs, especially for dual-eligibles. Almost half of physicians responded that the access to prescription drugs for dual-eligibles was worse under Part D than relative to the previous Medicaid, and more than half (63%) reported higher administration burden. Many physicians stated that dual-eligibles had less access under Part D than in three Medicaid restrictive states. This suggests that the transparency of Part D formulary coverage needs to be improved to improve access to these resources for physicians.
A further study by the same group of researchers found that despite the above physicians' views on access to healthcare among dual-eligibles, there were no statistically significant changes in pharmaceutical utilization or out-of-pocket expenditures in the 18 months after Medicare Part D implementation. When comparing a group of dual-eligibles (the experimental group) with a control group of near-elderly Medicaid-covered patients, both groups showed a decline in costs rights after the implementation of Part D, which then leveled off. The expenditures for both groups tracked each other.


Fleischner Society

The Fleischner Society is an international, multidisciplinary medical society for thoracic radiology, dedicated to the diagnosis and treatment of diseases of the chest. Founded in 1969 by eight radiologists whose predominant professional interests were imaging of chest diseases, the Society was named in memory of Felix Fleischner, an inspiring educator, clinician, and researcher who made many contributions to the field of chest radiology. The Society has had an active membership of approximately 65 members throughout its existence as well as approximately 35 senior members, who have retired from active medical practice or work in medical science after years of active membership in the Society.
The Fleischner Society maintains a diverse membership that includes experts in adult and pediatric radiology, pathology, adult and pediatric pulmonary medicine, thoracic surgery, physiology, morphology, epidemiology and other related sciences. The diverse membership supports a primary role of the Society, which is the publication of Fleischner Position Papers, which represent consensus documents that focus on controversial topics.
Recent Fleischner Position Papers include:
The Fleischner Society meets annually for scientific sessions where the latest advances in chest disease diagnosis and treatment are presented and discussed. While the preparation of Fleischner Position Papers is a year-round activity, the annual meeting serves as an important touch point for discussion and consensus around the topics.
The Society is governed by an Executive Committee, composed of the President, President-Elect, Secretary, Treasurer, Chairman of Academic Development and Past-president. In 2011-2012, the President of the Society is Geoffrey D Rubin, MD. from Duke University.
The Society is managed through the American College of Radiology in Reston, Virginia, U.S.