Erythema toxicum neonatorum

Erythema toxicum neonatorum is a common, non-threatening rash in newborns. It appears in 4-70% of newborns within the first week of life, and it typically improves within 1-2 weeks. It only occurs during the newborn period, but may appear slightly later in premature babies. The rash has a variable appearance. It typically includes blotchy red spots, often with overlying firm, yellow-white bumps or pus-filled boils. There may be only a few or many lesions. The lesions can appear almost anywhere on the body, and individual lesions may appear and disappear within hours. There are no other symptoms associated with erythema toxicum neonatorum, and the rash does not have any long-term effects on the skin. Erythema toxicum neonatorum is not harmful and does not require any treatment.
Epidemiology.
The exact prevalence of erythema toxicum neonatorum is unknown, and studies estimate prevalence as low as 3.7 percent to as high as 72 percent. It is one of the most commonly diagnosed rashes in healthy babies. It is more common among infants born at higher gestational age and is rare among premature infants. Erythema toxicum neonatorum is more likely to develop in infants delivered vaginally. Higher birth weight is an additional risk factor. There may be a slightly increased risk in males, but this association is unclear. There are no known associations with race or ethnicity.
Presentation.
Erythema toxicum neonatorum usually appears during the first week of life, most often on day two. It may develop several days or weeks later in premature babies.
The rash has a variable appearance, ranging from a few blotchy red spots to many yellow-white bumps and boils. The classic presentation is 1-3 mm, firm, yellow-white bumps with a surrounding red halo. The rash is often described as "flea-bitten." There may be only a few or many lesions, and they may be clustered or widespread. The rash often appears on the cheeks first and may later spread throughout the face, trunk, arms, and legs. Lesions most often appear on the thighs, buttocks, and trunk. The palms and soles are not affected, likely because the skin in these areas does not have hair follicles.
Individual lesions may grow and shrink over hours or days. They usually fade within a week or two. The rash may recur within the next few weeks, but this is rare.
Cause.
Erythema toxicum neonatorum is related to activation of the immune system, but its exact cause is unknown. Many inflammatory factors have been detected in erythema toxicum neonatorum lesions, including IL-1alpha, IL-1beta, IL-8, and eotaxin. These molecules cause redness and swelling in the skin and attract immune cells.
Eosinophils and other immune cells are found in the upper layer of the skin in erythema toxicum neonatorum lesions. Immune cells tend to cluster around hair follicles in particular. The leading hypothesis about the cause of erythema toxicum neonatorum is that bacteria activate the immune system when they enter hair follicles for the first time. This is part of a normal process in which bacteria from the environment start to grow on a baby's skin. It is unknown whether the immune response that causes erythema toxicum neonatorum is helpful to the baby.
Diagnosis.
Health professionals can diagnose erythema toxicum neonatorum with a skin exam. Most cases of erythema toxicum neonatorum can be diagnosed without further testing. If more testing is needed to make a diagnosis, the contents of a lesion can be examined under a microscope. A health professional may make a small cut into a pus-filled lesion and collect a swab of pus for testing. Lesions caused by erythema toxicum neonatorum contain eosinophils and other immune cells. These cells can be seen under a microscope when a special stain is applied to the sample.
Since the appearance of erythema toxicum neonatorum varies, it may be confused with other newborn rashes. Some newborn infections cause bumps or boils, which may look like erythema toxicum neonatorum. Bacterial infections, including Staphylococcus and Streptococcus infections, almost always cause additional symptoms. These symptoms may be severe, and they are usually not limited to rash. Bacterial rashes can be diagnosed by testing pus from a lesion along with a blood sample. Bacteria can be seen under a microscope with a special stain or may be found on a culture. Fungal infection with Candida may also cause a similar rash in newborns, but it usually causes additional symptoms like thrush. Similarly, fungus can be seen under a microscope or found on a culture. Some viral infections may cause a rash with boils on a reddish base. Rashes caused by herpes simplex virus and varicella zoster virus in particular may be confused with erythema toxicum neonatorum. These viruses are diagnosed by scraping the base of a lesion. Multinucleated giant cells can be seen under a microscope. Some of these tests may be ordered if the diagnosis is unclear.
Treatment.
Erythema toxicum neonatorum resolves without treatment, typically within one or two weeks. There are no associated systemic symptoms or long-term consequences of the rash.
History.
The rash of erythema toxicum neonatorum has been described by doctors for centuries. Ancient Mesopotamians believed that it represented a cleansing mechanism against the mother's blood. Later physicians believed that it was caused by the skin's response to meconium. The name erythema toxicum neonatorum was first used by Dr. Karl Leiner in 1912 because he believed that the rash was caused by enterotoxins. Although Leiner's hypothesis was incorrect and the rash is not actually caused by toxins, the medical community continues to call the rash erythema toxicum neonatorum.


Medical school in Canada

In Canada, a medical school is a faculty or school of a university that trains future medical doctors and usually offers a three- to five-year Doctor of Medicine (M.D.) or Doctor of Medicine and Master of Surgery (M.D., C.M.) degree. Although presently most students enter medicine having previously earned another degree, the M.D. is technically considered an undergraduate degree in Canada. There are currently seventeen medical schools in Canada. As of 2013, approximately 3,900 students were enrolled in Canadian medical schools.
Admissions.
Generally, medical students begin their studies after receiving a bachelor's degree in another field, often one of the biological sciences. However, not all medical schools in Canada require a bachelor's degree for entry. For example, Quebec's medical schools accept applicants after a two-year CEGEP diploma, which is the equivalent of other provinces' grade 12 plus the first year of university. Most faculties of medicine in Western Canada require at least 2 years, and most faculties in Ontario require at least 3 years of university study before application can be made to medical school. The University of Manitoba requires applicants to complete a prior degree before admission. The Association of Faculties of Medicine of Canada (AFMC) publishes a detailed guide to admission requirements of Canadian faculties of medicine on a yearly basis.
Admission offers are made by individual medical schools, generally on the basis of a personal statement, autobiographical sketch, undergraduate record (GPA), scores on the Medical College Admission Test (MCAT), and interviews. Medical schools in Quebec (Francophones and Anglophone alike), the University of Ottawa (a bilingual school), and the Northern Ontario School of Medicine (a school which promotes francophone culture), do not require the MCAT, as the MCAT has no French equivalent. Some schools, such as the University of Toronto and Queen's University, use the MCAT score as a cut-off, where sub-standard scores compromise eligibility. Other schools, such as the University of Western Ontario, give increasing preference to higher performance. McMaster University and the University of Calgary utilize the Critical Analysis and Reasoning section of the MCAT to determine interview eligibility and admission rank.
The annual success rate for Canadian citizens applying for admission to Canadian medical schools is normally below 1%. Just over 2,500 positions were available in first-year classes in 2006-2007 across all seventeen Canadian faculties of medicine. The average cost of tuition in 2006-2007 was $12,728 for medical schools outside of Quebec; in Quebec (for Quebecers only), average tuition was $2,943. The level of debt among Canadian medical students upon graduation has received attention in the medical media.
Curriculum.
Medical school in Canada is generally a 4-year program at most universities. Notable exceptions include McMaster University and the University of Calgary, where programs run for 3 years, without interruption for the summer. McGill University and Université de Montréal in the province of Quebec both offer a five-year program that includes a medical preparatory year to entering CEGEP graduates. While Université Laval in Quebec City offers a four- to five-year program to all entering students (both CEGEP graduates and university-level students), Université de Sherbrooke offers a formal four-year M.D. program to all admitted students.
The first half of the medical curriculum is dedicated mostly to teaching the fundamentals of, or basic subjects relevant to, medicine, such as anatomy, histology, physiology, pharmacology, genetics, microbiology, ethics, and epidemiology. This instruction can be organized by discipline or by organ system. Teaching methods can include traditional lectures, problem-based learning, laboratory sessions, simulated patient sessions, and limited clinical experiences. The remainder of medical school is spent in clerkship. Clinical clerks participate in the day-to-day management of patients. They are supervised and taught during this clinical experience by residents and fully licensed staff physicians. Typical rotations include internal medicine, family medicine, psychiatry, surgery, emergency medicine, obstetrics and gynecology, and pediatrics. Elective rotations are often available so students can explore specialties of interest for residency training.
Some medical schools offer joint degree programs in which a limited number of interested medical students may simultaneously enroll in M.Sc. or Ph.D. programs in related fields. Often this research training is undertaken during elective time and between the basic science and clinical clerkship halves of the curriculum. For example, while Université de Sherbrooke offers a M.D./M.Sc. program, McGill University offers a M.D./Ph.D. for medical students holding an undergraduate degree in a relevant field.
Post-graduate medical education.
Students enter into the "Canadian Resident Matching Service" (CaRMS) in the fall of their final year. Students rank their preferences of hospitals and specialties. In turn, the programs to which they applied rank each student. Both sets of rank lists are confidential. Each group's preferences are entered into a computerized matching system to determine placement for residency positions. 'Match Day' usually occurs in March, a few months before graduation. The length of post-graduate training varies with choice of specialty. Family medicine is a 2-year program accredited by the College of Family Physicians of Canada (CFPC), and third year programs of residency training are available in various areas of practice, including Emergency Medicine, Maternal/Child, Care of the Elderly, Palliative Care or Sports Medicine. All other medical specialty residencies are accredited by the Royal College of Physicians and Surgeons of Canada; most are 5 years long. Internal medicine and pediatrics are 4-year programs in which the final year can be used to complete a fellowship in general internal medicine or general pediatrics, or used towards a longer fellowship (e.g., cardiology). A few surgical residencies, including cardiac surgery, neurosurgery, and some general surgery programs, last 6 years. Sub-specialty fellowships are available after most residencies.
There are subtle differences between how residency training is organized in Canada as opposed to the United States. For example, M.D. graduates proceed directly into their residencies without the intermediate step of internship. However, this difference is somewhat superficial: for many residencies, the first postgraduate year (PGY1) in Canada is very similar to a rotating internship, with 1-2 month-long rotations in diverse fields. On the other hand, in Canada the graduate is often committed to a sub-specialty earlier than a similar American graduate.
Some sub-specialties are organized differently. For example, in the United States, cardiac and thoracic surgery are rolled into one fellowship (cardiothoracic surgery) following residency in general surgery. In Canada, cardiac surgery is a direct-entry residency (equivalent training can be obtained by pursuing a cardiac fellowship following residency in general surgery, but this route is far less popular). A fellowship in thoracic surgery can be pursued following residency in either cardiac or general surgery.
Unlike the United States and United Kingdom, in Canada there are no national guidelines for residents' call schedules or work hours. However, each province in which residency training takes place negotiates such details as part of a collective agreement between the authority and the provincial professional association of residents. An example of this is the Professional Association of Internes and Residents of Ontario.
Continuing medical education.
Both Canadian specialty colleges participate in mandatory continuing medical education (CME) schemes. Examples of CME activities include attendance at conferences, participating in practice-based small group learning, and taking courses such as advanced cardiac life support.
The CFPC program for family physicians is called MAINPRO, short for 'Maintenance of Proficiency.' A certain number of credits must be obtained over 5 year cycles. There are different classes of credits depending on whether the CME activity is considered accredited (e.g., attending accredited workshops or conferences) or non-accredited (e.g., teaching medical students, preparing research papers for publication, reading scholarly journals).
The Office of Professional Affairs of the RCPSC is responsible for a mandatory maintenance of certification (MOC) program as part of its strategy of continuous professional development linked to each Fellow’s professional practice. The framework of CPD options includes a broad spectrum of learning activities linked to a credit system. All Fellows submit their completed learning activities through MAINPORT, the RCPSC learning portfolio. Fellows of the RCPSC must submit a minimum number of credits per year (40 credits) and over a 5-year cycle (400 credits) to maintain their membership with the Royal College and their right to use the designation FRCPC or FRCSC.
That instead gives way to more time.
Evaluation.
During the final year of medical school, students complete part 1 of the Medical Council of Canada Qualifying Examination (MCCQE), which is administered by the Medical Council of Canada and organized as a part-multiple choice, part-short answer computer-adaptive test. Upon completion of the final year of medical school, students are awarded the degree of M.D. Students then begin training in the residency program designated to them by CaRMS. Part 2 of the MCCQE, an Objective Structured Clinical Examination, is taken following completion of 12 months of residency training. After both parts of the MCCQE are successfully completed, the resident becomes a Licentiate of the Medical Council of Canada. However, in order to practice independently, the resident must complete the residency program and take a board examination pertinent to his or her intended scope of practice. In the final year of residency training, residents take an exam administered by either the RCPSC or the CFPC, depending on whether they are training for specialty or family practice. They are then eligible to apply for full licensure with their provincial or territorial medical regulatory authority (i.e., provincial college).
Accreditation.
Together with the Canadian Medical Association (CMA), the AFMC carries out accreditation surveys and rules on the accreditation status of all of the undergraduate medical programs in Canada, as well as all university-based continuing medical education. The Liaison Committee on Medical Education, jointly administered by the Association of American Medical Colleges and the American Medical Association, also accredits Canadian medical schools. The M.D. and M.D.C.M medical degrees are the only medical degrees offered in Canada listed in the WHO/IMED list of medical schools.
Language.
In Canada, physician training is available in both official languages: English and French. Postgraduate trainees are referred to as 'residents'.


Standards for Better Health

Standards for Better Health were a set of standards for the National Health Service in England. The standards were set out by the Department of Health of the United Kingdom in a document of the same name published in 2004. NHS trusts had to declare their level of compliance with these standards to the Healthcare Commission annually as part of the Commission's "annual health check". The standards were replaced from 2009/10 by registration criteria established by the Department of Health and Care Quality Commission, which took over from the Healthcare Commission on 1 April 2009.
Domains.
The standards were listed under seven headings or "domains", three of which focused on "patient experience":
Standards.
The standards were divided into 24 core and 13 developmental standards. Compliance with the core standards had always been mandatory but the approach taken by the Department of Health and Healthcare Commission with respect to the developmental standards varied.


Lesley Webber

Lesley Webber is a fictional character from "General Hospital", an American soap opera on the ABC network. Denise Alexander originated the role from 1973 through February 28, 1984, as a series regular and from 1996 to 2009 in a recurring status. Alexander returned to the series briefly in 2013, to celebrate its 50th anniversary, and has made subsequent appearances in 2017, 2019 and 2021.
Casting.
Actress Denise Alexander originated the role of Dr. Lesley Williams in March 1973. In 1976, although TIME magazine panned "General Hospital" at the time, Alexander's character Lesley was noted as the serial's saving grace. When Alexander and the network could not agree to contractual negotiations, the character was killed off in March 1984. Angry fans picketed the studio, upset that the character had died. In 1996, the series wrote the character back on, and Alexander appeared in a recurring status until October 2009. In 2013, Alexander returned to the role from May 16 to December 13. In November 2017, it was announced she would reprise her role, returning for a one-off visit on December 22.
In March 2019, "Entertainment Weekly" announced that Alexander would again return as Lesley, in celebration of the serial's 56th anniversary; she made her appearance during the April 2 episode. In January 2021, it was announced she would once again return as Lesley; she returned from the January 8 episode to the February 26 episode.
Storylines.
1973–84.
Lesley came to Port Charles in March 1973 and immediately joined the staff at General Hospital. Florence Gray became one of Lesley's first patients. Florence was suffering from stomach ulcers, which she thought were caused by her troubled marriage with Gordon Gray. She started seeing psychiatrist Peter Taylor. Florence told Peter about her husband's affair with one of her students years earlier. He had gotten her pregnant but the child died at birth. Peter told Lesley about Florence's history and was shocked to find out that she was that very student who had the affair with Gordon. He reentered Lesley's life and confessed his love to her. Gordon was about to leave Florence and start a new life with Lesley. She asked Dr. Steve Hardy to be taken off the case. Lesley convinced Gordon to stay with his wife. She was then tormented by the memories of giving birth, and losing her daughter.
Shortly after Lesley married Cameron Faulkner, she found out that the daughter who she thought has died was only living miles from her away. Lesley did a little research and found out that her daughter Laura was adopted by Jason and Barbara Vining. Lesley was desperate to see her daughter again, but Cameron ordered her to stay away from Laura and never make contact to her. Lesley started meeting Laura anyway. Barbara and Jason got curious about Laura's new friendship and soon realized that Lesley had to be Laura's biological mother. As Laura found out the truth, she was thrilled. Lesley was later granted full custody of Laura. When Laura fell ill and Peter told her that the illness was emotion- based, Lesley decided to return Laura to the Vinings. Cameron was thrilled about that development. Lesley couldn't get over losing Laura again. Cameron started an affair with his secretary Peggy and was determined to get Laura out of Lesley's life for good. He first paid an elderly nurse to convince Lesley that Laura wasn't even her daughter. As this didn't work, Cameron paid the Vinings a lot of money to move away with Laura. When Lesley found out about Cameron's scheme to keep her from her daughter, he kidnapped Lesley. As Cameron was driving, Lesley grabbed the steering wheel and the car lunged off the road killing Cameron.
Lesley's colleague Rick Webber started comforting Lesley. As Rick tried to stay away from his brother's wife Monica, he spent more time with Lesley and helped her over the miscarriage of her late husband's baby. Monica became jealous over Rick's friendship with Lesley. Monica confronted Lesley, told her to stay away from Rick and that they were having an affair. Rick and Lesley got closer anyway and Rick helped Lesley to find Laura. Lesley was left crushed when Laura wanted to have nothing to do with her anymore. Rick eventually got through to Laura, telling her how much Lesley loved her and that she never gave up on her. Lesley was grateful to Rick and filled with joy when he confessed his love for her and proposed. Lesley and Rick were eventually married.
A man by the name of David Hamilton was admitted to General Hospital and turned out to be an old college friend of Rick's. David's wife and children were killed, while David was left paralyzed. The doctors couldn't find out why David was unable to walk and he was released. He accepted Rick's offer to stay with him and Lesley to recuperate. While Lesley thought something was strange about David, Laura cared for him. Soon David got his own apartment and tried to make a pass at Lesley who rejected him. Lesley confessed to Rick's brother Jeff about what happened with David. Jeff swore he wouldn't tell Rick. David moved on to Laura after Lesley rejected him and started a secret romantic relationship with the young girl. David was only using Laura to get to Lesley. When David told Laura the truth, that he was really in love with Lesley, Laura pushed David, who fell to his death. Lesley later discovered David's body. In an effort to protect Laura, Lesley decided to confess to murdering David. Laura felt guilty and ran away. She eventually returned and confessed to the murder. The charges against Lesley were dropped and Laura sentenced to six months probation.
Lesley and Rick's marriage became troubled when Lesley started to think that Rick and Monica were having another affair. As General Hospital was put under quarantine, Monica and Rick were among the doctors working at the hospital. After everyone was free from the quarantine Monica and Rick slept together. While Monica was sure of her feelings for Rick, he told her that they would need time to figure things out. Laura's car accident led Rick to rethink his involvement with Monica and he told her that they were over for good. Monica reconciled with her husband, Alan Quartermaine, as she discovered that she was pregnant. In the meantime, Lesley and Rick started to think about a baby of their own. Sadly, Lesley was unable to conceive as it would put her life in danger.
Laura's adopted sister Amy Vining moved to Port Charles around this time to become a nurse and Rick and Lesley welcomed her into their home, often amused by her tendency for gossip, but sometimes overwhelmed by it. Lesley ended up delivering Monica's baby. As Monica feared that she wouldn't survive, she told Lesley that the baby was Rick's. Lesley and Rick separated after he tried to tell her about his affair with Monica and Lesley told him that she already was aware. Rick found out that Alan Jr. could be his son and filed a suit against Monica. Lesley, still being in love with Rick, supported him and even agreed to a divorce so that he could claim his son. It was later discovered that Alan Jr. was in fact Alan's son and not Rick's. During this time, Lesley allowed her former sister-in-law Heather to stay with her when Heather was released from a mental institution after having accidentally taken an overdose of L.S.D. several years before. Lesley was supportive of Heather's mother, Alice Grant, when it was revealed that she had shot Lesley's hospital co-worker Diana Taylor in an effort to keep Diana from killing Heather.
Lesley and Rick remarried and adopted a six-year-old boy named Mike. As Laura disappeared and was presumed dead, Lesley was crushed and had a hard time dealing with the fact that her daughter was dead. Lesley and Rick eventually became foster parents to Blackie Parrish after his mother died. With three young wards living in their home, the Webber residence was never quiet. When Blackie entered the music business, Rick noticed a change in Blackie's personality. He became arrogant and shallow. Blackie ended up accidentally killing his girlfriend Lou. He was arrested and sentenced to time in prison.
An old enemy of Rick's, D. L. Brock, came to town. He wanted revenge on Rick for closing his cannery when Rick was part of the Port Charles Health Commission. Brock brought Ginny Blake to town, who was claiming to be Mike's biological mother. Bobbie Spencer, Brock's wife, figured out that Ginny might be in on the revenge against Rick and warned Lesley. She confronted Ginny and then Lesley ended up in a car accident and was killed.
1996–2005.
It was revealed that Lesley was in fact alive in 1996. Stefan Cassadine, son of Mikkos and brother of Stavros who had kidnapped Laura years ago was keeping Lesley drugged in a catatonic state. Lesley and Laura were reunited and, with Luke's help, they faked their deaths to escape the Cassadines. When they returned months later, their friends and family turned against them out of hurt. Stefan blackmailed Laura into leaving town once more. She lied to Luke that her mother needed treatment in Switzerland and took Lulu with them. In 1998, they returned and Lesley took over being a mother to Laura and grandmother to Laura's sons Nikolas and Lucky and daughter Lesley Lu.
In 2002, a now divorced Rick Webber returned to give his daughter Laura away again at her second wedding to Luke Spencer. Rick was happy to see Lesley alive and well again but his flirtations with old flame Monica upset Lesley and made Monica's husband, Alan, extremely jealous. His return made Laura remember some terrible events. She began having flashbacks involving the garage attic, including wearing a dress covered in blood. Rick and Scott Baldwin could tell that Laura was remembering and tried to prevent the truth from coming out. Years ago Rick was having an affair with nurse Theresa Carter and Laura walked in on them in the attic. Theresa had gotten violent and Laura took an antique camera and hit Theresa over the head with it. It killed her and Rick and Scott buried her in the back yard. Rick then gave Laura a certain drug for her to forget that night. When Rick encountered Laura in the Webber attic, she freaked out and presumably hit him over the head which caused his death. The horror of the events caused Laura to slip into a mental state of catatonia which caused much grief for Luke, Lesley, and in her last appearance, Amy. Lesley not only had to deal with the loss of the love of her life but the prospect of losing her daughter whom she had struggled hard years before to find and reconnect with.
2006–09.
In October 2006, Luke gave Robin Scorpio, now a doctor, his permission to give Laura an experimental drug called LS-49 that would temporarily bring her out of her catatonic state. The drug worked and everyone in Laura's life were overjoyed to have her back for the 3 weeks. In that time. Laura made Luke take her back to the Scorpio attic so she could remember what happened between her and Rick Webber the night she killed her stepfather four years ago; she painfully, tearfully did remember. Lesley, along with Laura's children, the Quartermaines, and the rest of LnL's loved ones were in attendance at Luke and Laura got remarried like they were going to do before Laura had her breakdown. The lavish ceremony took place in Lila's rose garden per Laura's wishes. The marriage was fake however as Luke was married to Tracy Quartermaine at the time. The minister who performed the ceremony was only an actor who Luke had hired to perform it. He only went along with it because it meant so much to Laura and he wanted to make what time she had left as meaningful and memorable as possible. Lesley and the rest were devastated when Laura slowly but finally slipped back into her catatonic state. Before her goodbye with Lulu, Laura told her daughter that she didn't believe that she had actually killed Rick Webber, but not to tell Luke this because it would break his heart. (Luke telling Laura that she killed her stepfather is what actually pushed her to really have her breakdown and into her catatonic state) Lulu vowed to pursue the matter and find Rick's real killer.
After Alan died from a heart attack during the Metro Court Hotel hostage crisis during February sweeps, Lulu and her stepbrother Dillon Quartermaine intercepted a letter addressed to Luke which was to be delivered to him after Alan's death. In the letter, it says that Scott Baldwin is actually the one who killed Rick that night. When Lulu confronts a recently returned to town during the hostage crisis Scott about the letter, he eventually confirms it. He went to the Scorpio house that night to check on Laura and upon hearing her scream found her in the attic fighting with Rick. He was the one who hit him on the head with the candlestick, unintentionally killing him, to stop him from giving Laura the drug. He left just before Luke arrived on the scene and came to the only possible conclusion that he could think of: in an altercation, with Laura's current state of mind, she thought Rick was trying to hurt her so she hit him with the now bloody candlestick and accidentally killed him. Telling her this is what sent her into her catatonic state. Lulu decided that she could never tell her father what she has learned because it would destroy him; he would either a) kill Scott Baldwin for his part and be sent to jail for murder and she would never see him again or b) he would want to kill Scott and he would feel so guilty and heartbroken that he was the one who caused Laura's catatonia telling her something so traumatic when it didn't even happen.
Lesley attended Lucky and Elizabeth's second marriage in March, where she was also introduced to Spinelli when he interrupted the ceremony when the minister asked "if anyone knew why they should not be joined . . ." Spinelli only stood up because it looked like Lulu was about to tell everyone that Elizabeth's baby was really Jason's and not Lucky's. Spinelli recovered and the marriage took place.
Lesley returned to the front-burner temporarily on October 30, 2008 when Scott kidnapped Laura and took her to Los Angeles. She assisted Lucky, Lulu, and Nikolas in finding her location. Laura is eventually found and is leaving Port Charles for Paris to seek further treatment. Not known to anyone at first, Laura is followed by Scott.
Lesley attended Lucky and Elizabeth's engagement party in October 2009 and then disappeared off-screen. She stayed for a while with Laura in Paris, where she became aware that her daughter and Scott got closer again. Not liking Laura and Scott's new found friendship, Lesley joins Nikolas at Lake Como in Italy.
2013.
As of March 2013, Lesley is said to be staying at Nikolas' house in Italy and is taking care of his son Spencer. A couple of weeks later, Lesley returns to Port Charles with Spencer to reunite him with his father. She is surprised to learn of Laura's plans to remarry Scott. Lesley disapproves of Laura's plans and confronts Scott with the murder of her husband, Rick Webber. Laura pleads with Lesley and hopes that she forgive Scott's past mistakes. Scott promises Lesley that he cares for Laura and wants only what's best for her. Not wanting to stay in their way, Lesley gives them her blessing even though she's not happy about it. After Mayor Lomax is unable to perform Laura and Scott's wedding, Lesley jumps in as she's able to officiate the ceremony. At the wedding, Lesley also reunites with her granddaughter Lulu who was recently kidnapped by Stavros Cassadine and since then can't remember her previous life. Lesley becomes aware of Nikolas' interest in Elizabeth, who's attending the ceremony with Monica's son AJ. Later on, Lesley put on a doctor's jacket for the first time in almost 30 years when she pretended to still be a doctor in order to gain information on Luke's medical condition, but ended up being confronted by old rival Monica. After exchanging barbs, Monica allowed Lesley to get the information she was seeking when Lesley pleaded to Monica's motherly instincts. After coming back from escorting Laura to France, Lesley decided to remain in town. On Halloween night, Lesley passed out when she opened the Wyndemere door to find Faison standing there. Later on, old rival Monica was invited over for an off-screen visit with Lesley which included old hospital pals Gail Baldwin and Audrey Hardy where Lesley gave Monica a gift of a painting which unbeknownst to them was painted by Heather!
2017.
Lesley returns in 2017 for Laura's wedding to Kevin Collins, and ends up officiating the ceremony.


Blue Cross and Blue Shield of Kansas City

Blue Cross and Blue Shield of Kansas City (Blue KC) is an independent licensee of the Blue Cross Blue Shield Association and a not-for-profit health insurance provider with more than one million members. Founded in 1938, Blue KC offers healthcare, dental, life insurance and Medicare coverage. Headquartered in Kansas City, the company serves 30 counties in northwest Missouri as well as Johnson and Wyandotte counties in Kansas.
History.
Originally named Blue Cross of Kansas City, the health insurance provider was established in 1938. Kansas City Blue Shield was formed in 1943. In 1982, the Kansas City Blue Cross and Blue Shield Plans merged, creating Blue Cross and Blue Shield of Kansas City.
In 2003, Kansas Insurance Commissioner Sandy Praeger denied a bid from Anthem (the fifth-largest US publicly traded health insurance company at the time) to purchase the company. Both companies sought legal recourse, arguing that the insurance commissioner had over-stepped the authority of the office. The Kansas Supreme Court heard the case and ruled that the state insurance commissioner has the authority to block such mergers and affirmed her ability to do so. Prior to the proposed merger, the company had lost 80,000 policy holders.
From 2014 to 2018, Blue KC participated in the Affordable Care Act exchange. The company decided to pull out of the exchange in 2017 after reporting a $100 million loss. In 2015, the company created the Blue KC Exchange, a private insurance exchange marketplace for small businesses. Danette Wilson became the Blue KC's first female CEO in 2015. When she retired in 2019, Erin Stucky, a 25-year veteran of the company, succeeded her in the role.
In November 2017, Blue KC launched Spira Care, a plan that combines primary care and health insurance.


James Gross

James J. Gross is a psychologist best known for his research in emotion and emotion regulation. He is a professor at Stanford University and the director of the Stanford Psychophysiology Laboratory.
Education.
Gross received his B.A. in philosophy from Yale University in 1987, where he was awarded the Alpheus Henry Snow Prize. He was a graduate visiting student at Oxford University from 1987 to 1988 and received a Ph.D. in Clinical Psychology from the University of California, Berkeley in 1993.
Work in psychology.
Gross' contributions to psychology lie primarily in the area of emotion regulation through psychophysiological research. He has published numerous, frequently cited papers regarding emotion regulation, and recently edited the Handbook of Emotion Regulation.
Awards and fellowships.
Gross has been the recipient of numerous academic awards from psychological and educational associations:


Ernest Besnier

Ernest Henri Besnier (; 21 April 1831 – 15 May 1909, Paris) was a French dermatologist and medical director of the Hôpital Saint-Louis in Paris. He was a native of Honfleur, département Calvados.
He studied medicine in Paris, where in 1857 he received his medical doctorate. In 1863 he became "médecin des hôpitaux". In 1873 he succeeded Pierre-Antoine-Ernest Bazin (1807–1878) as dermatologist at the Hôpital Saint Louis, where later the same year, he was named director.
He built histopathology and parasitology laboratories at the hospital, and is credited with originating the term biopsy for tissue samples. In 1889 he proved an early description of skin lesions associated with sarcoidosis, introducing the name "lupus pernio".
With Pierre Adolphe Adrien Doyon (1827–1907), he founded the medical journal "Annales de dermatologie et de syphiligraphie". Besnier attempted to balance the differences between the French and Viennese approaches to dermatological medicine, and in 1881 with Doyon, translated Moritz Kaposi's famous book on skin diseases ("Pathologie und Therapie der Hautkrankheiten in Vorlesungen für praktische Ärzte und Studirende") from German into French ("Leçons sur les maladies de la peau"). With Louis-Anne-Jean Brocq and Lucien Jacquet, he published a four volume encyclopedia of dermatology, titled "La pratique dermatologique" (1900–04).
The eponymous Besnier's prurigo is named for a skin disorder that often follows infantile atopic dermatitis.


Tadeusz Browicz

Tadeusz Browicz (September 15, 1847 – March 20, 1928) was a Polish pathologist born in Lviv.
He studied medicine in Kraków, earning his medical doctorate in 1873. Afterwards he remained at Kraków as an assistant to the pathologist Alfred Biesiadecki (1839-1889), and in 1875 received his habilitation. From 1880 to 1919 he was a full professor of anatomical pathology at the Jagiellonian University, where in 1894-95 he served as its rector.
Browicz made several contributions to medical science. In 1874 he was the first to describe the bacillus that causes typhoid fever, later to be known as "Salmonella typhi", and in 1898 was the first to correctly identify the liver's Kupffer cells as specialized macrophages. He also performed important research of jaundice, liver cancer and cardiac muscle disorders. Among his written works was the 1905 publication of a Polish medical dictionary.


Peter Grootenhuis

Peter Grootenhuis (March 1960 - August 2019) was a Dutch-American Medicinal Chemist. Grootenhuis was the Project Leader and Co-Inventor of Ivacaftor (VX-770), the first CFTR potentiator FDA approved drug to treat the underlying cause of Cystic Fibrosis (CF) in patients with certain mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene (primarily the G551D mutation.), who account for 4-5% of CF cases. Grootenhuis also led the Vertex team to subsequent discovery of Orkambi, the combination of Ivacaftor and Lumacaftor(VX-809), approved to treat CF in people with two copies of the F508del mutation (~ 50% of CF patients). Most recently, Grootenhuis's team discovered Tezacaftor (VX-661) and Elexacaftor (VX-445), which in combination with Ivacaftor are the components of Trikafta, a drug approved by the FDA in 2019 to treat CF in more than 90% of CF patients. For Grootenhuis’ contributions to the discovery of these compounds, he was awarded the 2018 IUPAC Richter Prize, the American Chemical Society’s 2013 Heroes of Chemistry Award, and inducted into the American Chemical Society Division of Medicinal Chemistry Hall of Fame. Grootenhuis has contributed to the discovery of over 11 clinical candidates, co-authored more than 100 peer reviewed papers and is inventor of 65 + U.S Patents, and more than 50 EU Patents.
Biography.
Grootenhuis completed both his B.Sc and M.Sc in chemistry at the University of Utrecht (1978–1983). He then went on to complete his PhD in organic chemistry under the guidance of David Reinhoudt (1983-1987)
After finishing his PhD, Grootenhuis completed a postdoctoral fellowship at the University of California, San Francisco on a NATO Fellowship, under Peter Kollman (1987–1989). Consequently, he went on to work at Organon (now Akzo-Nobel) for several years, simultaneously holding a part-time Professorship at the University of Groningen and doing a short sabbatical with Martin Karplus at Harvard University (1991). After nine years at Organon, Grootenhuis moved to San Diego, CA to work for CombiChem as Vice President of Computational Chemistry in 1998. Grootenhuis stayed with the company through several corporate mergers by DuPont Pharmaceuticals, Bristol-Myers Squibb, and lastly Deltagen Inc. After Deltagen folded, Grootenhuis worked for 19 years at Vertex Pharmaceuticals, notably as the Project Leader for the CFTR modulator project. From 2005 to 2016, Grootenhuis held a faculty appointment at the Free University of Amsterdam (VU), serving as the Nauta Chair (Professor Emeritus) of Virtual Drug Screening & Design.
Grootenhuis was a lifelong karate student and received multiple black belts. He was specifically interested in the Physics of Kobudō, an ancient Okinawan weapons-based martial arts discipline, eventually writing a book on the subject in 2018. He was awarded the title of Sensei in March 2019 by Grandmaster Jerry Divine of Pacific Martial Arts
Awards.
KNCV Gouden Medaille, Royal Dutch Chemical Society (1995)
Noordwijkerhout-Camerino Prize (1997)
Heroes of Chemistry, American Chemical Society (2013)
IUPAC-Richter Prize in Medicinal Chemistry (2018)
Hall of Fame, American Chemical Society, Division of Medicinal Chemistry (2019)
Distinguished Scientist Award, American Chemical Society, San Diego Chapter (2019)
Professional Affiliations.
Organon (Akzo-Nobel)
CombiChem-DuPont
Bristol Myers Squibb
Deltagen Pharmaceuticals
Vertex Pharmaceuticals
American Chemical Society
Institutions.
University of Utrecht, BSc. and MSc. Chemistry (1983)
University of Twente, PhD Organic Chemistry (1987)
Free University of Amsterdam (VU), Professor Emeritus (2005-2016)
University of California, San Francisco, Postdoctoral Researcher (1987-1989)
Harvard University, Sabbatical (1991)
University of Groningen, Part-Time Professor (1989-1991)


Hugh Clegg (physician)

Hugh Anthony Clegg CBE FRCP (19 June 1900 – 6 July 1983) was a British medical doctor. He was editor of the "British Medical Journal" from 1947 to 1965. He was awarded the Gold Medal of the British Medical Association in 1966 and was appointed a CBE in the same year.
Early life.
Born in St Ives, then in Huntingdonshire, Clegg was the son of the Rev. John Clegg, by his marriage to Gertrude Wilson. His father, a clergyman and schoolmaster who became the head of Lowestoft College in East Anglia, taught him classical languages, and Clegg gained scholarships at Westminster School and Trinity College, Cambridge. He had two older brothers, Arnold (born 1896) and John (born 1898). In 1901, the family moved to Lowestoft, where his younger sisters, Mary, Margaret, and Veronica, and his brother Bernard were all born.
Career.
In 1931 Clegg joined the staff of the "British Medical Journal." He was handed assistant editorship of the journal 3 years later. Clegg became editor of the journal in 1947, and continued in his post until 1965. A 1947 "Nature" article on his work at the "BMJ" said, "Dr. Clegg brings to his task a vigour of character, a broad outlook and an experience of medical journalism which make it certain that the great traditions of the "British Medical Journal" will be maintained." In 1990, epidemiologist Austin Bradord Hill wrote an autobiographical piece in the "BMJ" about his friendship with Clegg, calling him a 'joy to work with'.
In 1943 Clegg wrote a pamphlet for the general public, "How to keep well in Wartime," published by the Ministry of Information.
One of the few surviving photographs of Clegg was taken by Alexander Bassano for the National Portrait Gallery, London.
Personal life.
In 1932 he married Kira von Engelhardt, Baroness von Smolensk, daughter of a Russian émigré, Arthur Engelhardt, Baron von Smolensk. Their son was businessman Nicholas P. Clegg, the father of politician Nick Clegg, who from 2010 to 2015 was Deputy Prime Minister of the United Kingdom.


Alexander Kolisko

Alexander Kolisko (6 November 1857 – 23 February 1918) was an Austrian pathologist who was born in Vienna. He was the father of anthroposophist Eugen Kolisko (1893–1939).
Biography.
In 1881 Kolisko earned his medical doctorate from the University of Vienna, subsequently working as an assistant to Hans Kundrat (1845–1893) at the pathological anatomy institute at the university. Later, he was a prosector at the "Leopoldstädter Kinderspital" in Vienna. In 1898 he succeeded Eduard von Hofmann (1837–1897) as a professor of forensic medicine, and in 1916 was successor to Anton Weichselbaum (1845–1920) as professor of pathological anatomy at the University of Vienna.
He died in Vienna.
Kolisko is remembered for his work in forensic pathology. He was particularly interested in the pathology of sudden death, leaving the criminal and legal aspects of the subject to his assistant Albin Haberda (1868–1933). Also, he conducted extensive studies involving the effects of carbon monoxide poisoning on the brain, and with obstetrician Carl Breus (1852–1914), he developed a classification system for pelvic disorders.


Faculty of Medicine, Prince of Songkla University

The Faculty of Medicine, Prince of Songkla University () is the sixth oldest medical school in Thailand located in Hat Yai District, Songkhla Province and is the fourth oldest faculty of Prince of Songkla University, opening in 1972 by royal decree.
History.
Due to a lack of medical and healthcare personnel in Thailand, as well as various healthcare issues in Southern Thailand, the council of Prince of Songkla University requested for the construction of a Faculty of Medicine on 11 September 1968. The project was approved on 17 August 1971 and construction began at the Hat Yai campus of the university. The first cohort of medical students was accepted in June 1973, consisting of 35 students. Teaching was done in the Faculty of Science for the preclinical years and Hatyai Hospital and Songkhla Hospital during the clinical years.
On 26 August 1976, King Bhumibol Adulyadej and Queen Sirikit laid the foundation for the construction of the faculty's main teaching hospital. Ten years later on 18 September 1986, the King and Princess Sirindhorn opened the hospital and named it 'Songklanagarind' Hospital. Songklanagarind Hospital has become the main teaching hospital since then.
Education.
The following table displays the programs taught at the Faculty of Medicine at Prince of Songkla University.
References.
Article incorporates material from the corresponding article in the Thai Wikipedia.


Articular bone

The articular bone is part of the lower jaw of most vertebrates, including most jawed fish, amphibians, birds and various kinds of reptiles, as well as ancestral mammals.
Anatomy.
In most animals, the articular bone is connected to two other lower jaw bones, the suprangular and the angular. Developmentally, it originates from the embryonic mandibular cartilage. The most caudal portion of the mandibular cartilage ossifies to form the articular bone, while the remainder of the mandibular cartilage either remains cartilaginous or disappears.
In snakes.
In snakes, the articular, surangular, and prearticular bones have fused to form the compound bone. The mandible is suspended from the quadrate bone and articulates at this compound bone.
Function.
In amphibians and reptiles.
In most tetrapods, the articular bone forms the lower portion of the jaw joint. The upper jaw articulates at the quadrate bone.
In mammals.
In mammals, the articular bone evolves to form the malleus, one of the mammalian ossicles of the middle ear. This is an apomorphy of the mammalian clade, and is used to determine the fossil transition to mammals. It is analogous to, but not homologous to the articular process of the lower jaw.
After the loss of the quadrate-articular joint, the squamosal and dentary bones form the new jaw joint in mammals.


International Council of Sport Science and Physical Education

The International Council of Sport Science and Physical Education (international abbreviations: ICSSPE - International Council of Sport Science and Physical Education; CIEPSS - Conseil International pour l'Education Physique et la Science du Sport) is an international umbrella organisation for sport, sport science, and physical education.
The legal seat and the headquarters are both based in Berlin, Germany.
The mission of ICSSPE/CIEPSS) is to:
– Integrate research to enhance physical activity and sport;
– Educate for improved quality of life and health for all people through physical activity and sport;
– Promote policies for active lifestyles, human performance and good governance in physical activity and sport.
ICSSPE membership is composed of:
– Governmental sport, health and education authorities;
– Non-governmental sport organisations;
– Scientific and educational organisations and institutions.
Development.
The first international sports science associations already existed before World War I. In the early days, it was mainly sports physicians who contributed to the science of sport.
In 1956, Fritz Duras organised a scientific congress on the occasion of the Summer Olympics, which attracted 350 participants from all continents. They decided to found a world association of sports science and commissioned Duras to prepare it. The Council was then founded in Paris in 1958 with the support of UNESCO.The German-Australian sports physician of Jewish origin Duras, who had to emigrate to Australia in 1937, thus became the founding president. Since then, the organisation had been registered with UNESCO before the legal seat was moved to Berlin in 2009. Well-known sport officials and scientists subsequently served as presidents, such as Nobel Peace Prize winner Philip Noel-Baker, the former world-class athlete Sir Roger Bannister and the Director of the Federal Institute of Sports Science, Germany, Dr August Kirsch. The current President is Dr Uri Schaefer; Professor Dr Gudrun Doll-Tepper is Honorary President.
At present, 171 organisations and institutions from more than 60 countries are members of ICSSPE.
Structure.
The highest body of ICSSPE is the General Assembly, which is held every two years.
The Executive Board, elected by the General Assembly, serves for a period of four years. It consists of a President, three Vice-Presidents, a Treasurer and six further members.
The office is located in Germany (Friesenhaus I, Hans-Braun-Straße 14053 Berlin). Detlef Dumon has been the Executive Director since 2007.
Presidents.
ICSSPE conducts its activities in the domains of Science, Education and Policy. It promotes interdisciplinary research and participates regularly in a number of projects. The organisation contributes to education of professionals in sport science, physical education and physical activity and supports governmental authorities and non-governmental sport organisations in the development of effective and sustainable policies.
ICSSPE cooperates with a number of national, international and supranational organisations.


Carl Alving

Carl Alving is an American internist, currently at Walter Reed Army Institute of Research and an Elected Fellow of the American Association for the Advancement of Science.


Medicare Shared Savings Program


Lahey Health

Lahey Health System, commonly known as Lahey Health, is an organization based in Burlington, Massachusetts that manages hospitals, physicians and other health services in northeastern Massachusetts. When formed in 2012, the organization was estimated at a value of $1.2 billion. As of 2013, it had hospitals in Burlington, Peabody, Beverly, and Gloucester, including Lahey Hospital & Medical Center, Beverly Hospital and Addison Gilbert Hospital.


Permissive

A permissive cell or host is one that allows a virus to circumvent its defenses and replicate. Usually this occurs when the virus has modulated one or several of the host cellular intrinsic defenses and the host immune system. The permissive state of a host has now been determined to be the primary factor in determining whether a virus will cause pathological symptoms in a host.
Susceptible "versus" permissive.
A virus can enter a susceptible cell, but it cannot replicate. A virus can both enter and replicate in a permissive cell. The significance between the difference of the two has now been elucidated with study of the rabbit-lethal myxoma virus. Many species of rabbit cells in culture (without the presence of any antiviral defenses that would normally be in a host) can be infected by the myxoma virus, causing infection and cell death. However, inoculation of the myxoma virus in many species of rabbit shows that only one species of rabbit is affected, the rest being completely unharmed by the virus (lack of even viral shedding). This has been determined to be a result of the myxoma virus's inability to suppress other species' interferon expression, and hence resulting in the interferon in turn suppressing the myxoma virus.
This is a result of the positive susceptibility of many species of rabbit's cells, but negative permissibility of all but one of the rabbit species' cells.


Human maximisation test

The Human maximisation test (HMT) is a test method for testing for contact allergens. It was first developed by Albert Kligman in 1966 and updated by Kligman and William Epstein in 1975. The first paper appeared 1966 and was a citation classic in 1985.
The test uses human medical volunteers (usually 25) and sodium laureth sulphate to maximise. Because of the potentially large human reaction, it is generally not considered ethical to use today. It does not have a guideline under the OECD Guidelines for the Testing of Chemicals. It has been compared with the murine local lymph node assay
See also patch test.


Joint Commission

The Joint Commission, also known as TJC, is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world. A majority of US state governments recognize Joint Commission accreditation as a condition of licensure for the receipt of Medicaid and Medicare reimbursements.
The Joint Commission is based in the Chicago suburb of Oakbrook Terrace, Illinois.
History.
The Joint Commission was formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and previous to that the Joint Commission on Accreditation of Hospitals (JCAH).
The Joint Commission was renamed The Joint Commission on Accreditation of Hospitals in 1951, but it was not until 1965, when the federal government decided that a hospital meeting Joint Commission accreditation met the Medicare Conditions of Participation, that accreditation had any official impact. However, Section 125 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) removed the Joint Commission's statutorily-guaranteed accreditation authority for hospitals, effective July 15, 2010. At that time, the Joint Commission's hospital accreditation program would be subject to Centers for Medicare and Medicaid Services (CMS) requirements for organizations seeking accrediting authority. To avoid a lapse in accrediting authority, the Joint Commission would have to submit an application for hospital accrediting authority consistent with these requirements and within a time frame that would enable CMS to review and evaluate their submission. CMS would make the decision to grant deeming authority and determine the term.
The Joint Commission's predecessor organization grew from the efforts of Ernest Codman to promote hospital reform based on outcomes management in patient care. Codman's efforts led to the founding of the American College of Surgeons Hospital Standardization Program. In 1951 the Joint Commission on Accreditation of Hospitals was created by merging the Hospital Standardization Program with similar programs run by the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association. In 1987 the company was renamed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, pronounced "Jay-co"). In 2007 the Joint Commission on Accreditation of Healthcare Organizations underwent a major rebranding and simplified its name to The Joint Commission. The rebranding included the name, logo, and tag line change to "Helping Health Care Organizations Help Patients."
The change was part of an effort to make the name more memorable and to assist the commission in its continued responsiveness to the needs of organizations seeking fee-based accreditation. The Joint Commission advocates the use of patient safety measures, the spread of information, the measurement of performance, and the introduction of public policy recommendations.
Joint Commission International (JCI) was established in 1998 as a division of Joint Commission Resources, Inc. (JCR), a not-for-profit, private affiliate of the Joint Commission. Through international accreditation, consultation, publications, and education programs, JCI extends the Joint Commission's mission worldwide by helping to improve the quality of patient care; assisting international health care organizations, public health agencies, health ministries, and others in evaluating, improving, and demonstrating the quality of patient care; and enhancing patient safety in more than 60 countries. International hospitals may seek accreditation to demonstrate quality, and JCI accreditation may be considered a seal of approval by medical travelers from the U.S.
Operation.
All member health care organizations are subject to a three-year accreditation cycle, and laboratories are surveyed every two years. The organization does not make its hospital survey findings public. However, it does provide the organization's accreditation decision, the date that accreditation was awarded, and any standards that were cited for improvement. Organizations deemed to be in compliance with all or most of the applicable standards are awarded the decision of Accreditation.
The unannounced full survey is a key component of The Joint Commission accreditation process. "Unannounced" means the organization does not receive advanced notice of its survey date. The Joint Commission began conducting unannounced surveys on January 1, 2006. Surveys occur 18 to 39 months after the organization's previous unannounced survey.
There has been criticism in the past within the U.S. about how the Joint Commission operates. The Commission's practice had been to notify hospitals in advance of the timing of inspections. A 2005 article in the "Washington Post" noted that about 99% of inspected hospitals are accredited, and serious problems in the delivery of care are sometimes overlooked or missed. Similar concerns have been expressed by the "Boston Globe" who stated "The Joint Commission, whose governing board has long been dominated by representatives of the industries it inspects, has been the target of criticism about the validity of its evaluations." The Joint Commission over time has responded to these criticisms. However, when it comes to the international dimension, surveys undertaken by JCI still take place at a time known in advance by the hospitals being surveyed, often after considerable preparation by those hospitals.
Preparing for a Joint Commission survey can be a challenging process for any healthcare provider. At a minimum, a hospital must be completely familiar with the current standards; examine current processes, policies, and procedures relative to the standards; and prepare to improve any areas that are not currently in compliance. The hospital must be in compliance with the standards for at least four months prior to the initial survey. The hospital should also be in compliance with applicable standards during the entire period of accreditation, which means that surveyors will look for a full three years of implementation for several standards-related issues.
Behavioral health organizations looking to be accredited under the standards outlined in the Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) do not have the same requirements around compliance with applicable standards for any period of time leading up to an initial survey for accreditation. The Joint Commission also provides behavioral health organizations that are being surveyed for the first time with a 30-day notice of their survey date, however, future surveys are unannounced.
The Joint Commission and JCI employ salaried individuals as surveyors who generally work or have worked within health care services but are able to devote half or less of their time for the accrediting organization. The surveyors travel to health care organizations to evaluate their operational practices and facilities against established Joint Commission standards and elements of performance.
Substantial time and resources are devoted by health care organizations ranging from medical equipment suppliers and staffing firms to tertiary care academic medical centers to prepare for and undergo Joint Commission surveys. There is growing concern, however, over the lack of verifiable progress towards meeting the organization's stated goals. Although the Joint Commission increasingly cites and demands "evidence-based medicine" in its regulatory requirements, there is a relative paucity of evidence demonstrating any significant quality improvement due to its efforts, while there is a growing body of literature showing no improvement or actual deterioration in quality despite the increasingly stringent and expensive requirements.
A facility requesting accreditation pays a substantial fee to the Joint Commission (the "accrediting" agency) and, upon receiving a "passing" grade, is able to purchase associated mementos of accomplishment to display to the public.
Alternatives in the United States.
The Joint Commission is not a complete monopoly, and while many states in the U.S. make use of their services, they are not used by all. Some states have set up their own alternative assessment procedures; the Joint Commission is not recognized for state licensure in the states of Oklahoma (except for hospital-based outpatient mental health services), Pennsylvania, and Wisconsin. In California, The Joint Commission is part of a joint survey process with state authorities.
There are also other healthcare accreditation organizations in the U.S. unrelated to the Joint Commission. These include Accreditation Commission for Health Care, Inc. (ACHC), the American Osteopathic Association (AOA), the Commission on Accreditation of Rehabilitation Facilities(CARF), the Community Health Accreditation Program (CHAP), the "Exemplary Provider Program" of The Compliance Team, the Healthcare Facilities Accreditation Program (HFAP), the National Commission on Correctional Health Care, Utilization Review Accreditation Commission (URAC), The National Dialysis Accreditation Commission and the Healthcare Quality Association on Accreditation (HQAA) who are recognised in the state of Ohio.
The Healthcare Facilities Accreditation Program (HFAP) has been in operation since 1945.
On September 26, 2008, the Centers for Medicare and Medicaid Services (CMS) granted deeming authority for hospitals to DNV Healthcare Inc. (DNVHC), an operating company of Det Norske Veritas (DNV), a Norwegian international company that has been operating in the U.S. since 1898.
The Center for Improvement in Healthcare Quality (CIHQ), based in Round Rock, Texas, was granted deeming authority for hospitals by the CMS In July 2013.
Goals and initiatives.
The stated mission of The Joint Commission is: "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."
The company updates its accreditation standards, expands patient safety goals on a yearly basis, and posts them on its web site for all interested persons to review making the information and process transparent to all stakeholders ranging from institutions and practitioners to patients and their advocates.
The purpose of The Joint Commission's National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. The NPSGs highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. Recognizing that sound system design is intrinsic to the delivery of safe, high quality health care. The Goals focus on system-wide solutions, wherever possible.
The NPSGs have become a critical method by which The Joint Commission promotes and enforces major changes in patient safety for thousands of participating health care organizations in the United States and around the world. The 2009 NPSGs included regulations targeting the spread of infection due to multidrug-resistant organisms, catheter-related bloodstream infections (CRBSI), and surgical site infections (SSI). The new regulations for CRBSI and SSI prevention apply not only to hospitals, but also to ambulatory care and ambulatory surgery centers. Engaging patients in patient safety efforts is also a major new component of the NPSGs. The Universal Protocol to reduce surgical errors and existing regulations on medication reconciliation have been modified for 2009, based on feedback received by The Joint Commission.
International healthcare accreditation.
Joint Commission International, or JCI is one group that provides international health care accreditation services to hospitals around the world and brings income into the U.S.-based parent organization. This not-for-profit tax-exempt private corporation (a 501(c) organization) currently accredits hospitals in Asia, Europe, the Middle East, Africa, and South America and is seeking to expand its business further.
The JCI has a small staff which includes principal consultants and a number of other consultants from around the world.
Cost of accreditation.
The actual cost of accreditation is not properly reflected by JCI reported costs due to the number of hospital changes mandated by the Commission that add cost to health care provision without actually improving patient outcomes. There is no obvious remedy to this as there is limited accountability for JCI. Hospital organizations have little ability to object to JCI mandates, even when there is no evidence to support the mandate as a patient outcome improvement measure.
JCI quotes an average fee of $46,000 per year to maintain accreditation, plus travel and other costs.
For hospital to be successful in the accreditation process, there may be additional costs related to consultancy work prior to accreditation.
International accreditors incur different levels of costs with some costing less than JCI.
Criticisms.
A Harvard-led research study published in the BMJ found that US hospital accreditation by independent organizations was not associated with lower mortality or with reduced readmission rates for common medical conditions. The authors concluded that there was no advantage for patients to choose a hospital accredited by the Joint Commission over a hospital accredited by another independent accrediting organization. "The Wall Street Journal" suggested that the underlying reasons for this is the failure of the Joint Commission to revoke or modify the accreditation status of hospitals with major infractions considered to be so significant they caused, or were likely to cause, a risk of serious injury or death to patients.
The nonprofit's revenue was $147M in 2013, and in that fiscal year, it paid its CEO more than $1M. Hospitals pay the Joint Commission up to $37,000 in fees annually to maintain their accreditation status. Inspections cost approximately $18,000 every three years.


Robert Cranston Low

Robert Cranston Low FRSE FRCPE (1879–1949) was a Scottish physician and dermatologist. He served as President of the British Association of Dermatologists 1936–37.
Life.
He was born at Bonarty Lodge on Polwarth Terrace in Edinburgh in 1879, the son of Thomas Low. He was educated at Merchiston Castle School then studied medicine at the University of Edinburgh, graduating with an MB ChB in 1902. He received his doctorate (MD) in 1924 with his thesis "Anaphylaxis and sensitisation". He became Consultant Physician in the Skin Department of Edinburgh Royal Infirmary.
In 1934 he was elected a Fellow of the Royal Society of Edinburgh. His proposers were William Thomas Ritchie, James Hartley Ashworth, Thomas Jehu and Sir Ernest Maclagan Wedderburn.
He died on 3 February 1949 and is buried in Currie Churchyard south of Edinburgh. The grave stands on the north wall of the modern cemetery, backing onto the old churchyard.
Family.
He married twice. In 1914 he married Evelyn Frances Henderson and in 1922 he married Alice Armstrong Grant (1885-1957).


Kenneth Cross (physiologist)

Sir Kenneth William Cross FRCP (26 March 191610 October 1990) was a British physiologist who was principally known for his fundamental contributions to the physiology of newborns that were so relevant to paediatric practice at the time.
Life.
Kenneth Cross was educated at St Paul's School, London from 1930 to 1935 and then at St Mary's Hospital, London where he won a Moran Scholarship, a Rugby Scholarship, that was established by Lord Moran Charles Wilson, 1st Baron Moran as a way of picking up the best students for medicine. Within 2 years, Cross had passed the membership examination of the College, in 1940. After several junior house appointments at the beginning of World War II, Cross served in the emergency medical service. Although considered combative by nature, Cross was a self confessed pacifist by conviction, and even though he spent time with the Friends' Ambulance Unit in China during World War II, Cross rarely spoke about the work.
Cross was married twice. His first wife Joyce Wilson née Lack, was a depressive, who eventually committed suicide in 1970. Cross was also a depressive himself but he usually managed to adapt his depression into "high spirits" which was evidenced by his colleagues, but this resulted in facing many many long hours of misery and gloom while he was at home. The depression was only made bearable by his second wife, Sheila Cross née Lewis, with whom he had a nurturing and fulfilling marriage.
Career.
After returning from China, Cross abandoned a potential career as a physician, to become a physiologist working in the physiology department at St Mary's Hospital. In 1948, he started to research foetal and neonatal physiology for the ventilation of the newborn baby. He was one of the first to apply physiological techniques, to the problem of resuscitating newborn babies. Through this work he became a leading member of a group of physiologists and paediatricians who founded the Neonatal Society in 1959. Cross's life work became neonatal research.
Cross was promoted to the academic rank of reader in 1952. Cross spent a year in America in 1958-1959 at the Cardiovascular Research Institute located in the University of California, San Francisco. Working alongside Julius H. Comroe Jr., Cross helped organize and establish the study into neonatal research that later grew into one of the largest paediatric research groups in America. Upon returning from the US, Cross moved to London Hospital Medical College with a promotion to Professor of Physiology in 1960, a post he held until 1981.
In 1963 he became an honorary director of a Medical Research Council group on the respiration and energy metabolism in the newborn. During 1973, he organized the Joseph Barcroft Centenary meeting for The Physiological Society. In 1974 he gave the Bertram Louis Abrahams lecture called "Investigating the newborn: the ethical imperative"
Contributions.
Cross as an individual, had no time for fools or knaves, and was considered a rather forthright character who didn't value position, but did value and respect people. This was possibly the reason he was passed over for membership of the Royal Society, a position he clearly deserved. Indeed, the physiologist Arthur Huggett later stated, that on his own membership of the society, was in recognition of work carried out by Kenneth Cross.
Cross contributions to medical science before 1957, specifically to physiology of the new-born, were so many and so fundamental that it was a surprise that his first proposal for membership to the Royal College of Paediatrics and Child Health, formerly the British Paediatric Association (BPA) was not automatic. Indeed, when his name was put forward for election, dissenting voices stalled the proposal as they saw no reason to include a physiologist. When he was finally elected to the learned society in 1957 on the second proposal for election, Cross wasn't having an easy professional life. Paediatricians were slow to recognize the importance of his work. Both paediatricians and physiologists found it impossible to believe that the type of fundamental research conducted by Cross, could be done on the new-born. Indeed, as Professor Otto Herbert Wolff stated in his speech, when awarding the James Spence Medal to Cross,
"that Cross was told by his professor St Mary's that now he was turned down by the BPA that it was time he stopped playing with babies and got down to some proper physiology".
Cross's approach to physiology was simple. Once practical solutions were developed, they were turned into a process that could be applied to everyday clinical problems. Cross operated with an exceedingly high standard of approach to ethical standards and used this approach to train a large number of high quality research students, many who would later become neonatologist's themselves.
Awards.
On 28 March 1979 Cross was awarded the James Spence Medal, named after Professor Sir James Calvert Spence, and is the highest award of the British Paediatric Association.


Tarsal tunnel syndrome

Tarsal tunnel syndrome (TTS), is a compression neuropathy and painful foot condition in which the tibial nerve is compressed as it travels through the tarsal tunnel. This tunnel is found along the inner leg behind the medial malleolus (bump on the inside of the ankle). The posterior tibial artery, tibial nerve, and tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles travel in a bundle through the tarsal tunnel. Inside the tunnel, the nerve splits into three segments. One nerve (calcaneal) continues to the heel, the other two (medial and lateral plantar nerves) continue on to the bottom of the foot. The tarsal tunnel is delineated by bone on the inside and the flexor retinaculum on the outside.
Patients with TTS typically complain of numbness in the foot radiating to the big toe and the first three toes, pain, burning, electrical sensations, and tingling over the base of the foot and the heel. Depending on the area of entrapment, other areas can be affected. If the entrapment is high, the entire foot can be affected as varying branches of the tibial nerve can become involved. Ankle pain is also present in patients who have high level entrapments. Inflammation or swelling can occur within this tunnel for a number of reasons. The flexor retinaculum has a limited ability to stretch, so increased pressure will eventually cause compression on the nerve within the tunnel. As pressure increases on the nerves, the blood flow decreases. Nerves respond with altered sensations like tingling and numbness. Fluid collects in the foot when standing and walking and this makes the condition worse. As small muscles lose their nerve supply they can create a cramping feeling.
Symptoms.
Some of the symptoms are:
Tinel's sign is a tingling electric shock sensation that occurs when you tap over an affected nerve. The sensation usually travels into the foot but can also travel up the inner leg as well.
Causes.
It is difficult to determine the exact cause of Tarsal Tunnel Syndrome. It is important to attempt to determine the source of the problem. Treatment and the potential outcome of the treatment may depend on the cause. Anything that creates pressure in the Tarsal Tunnel can cause TTS. This would include benign tumors or cysts, bone spurs, inflammation of the tendon sheath, nerve ganglions, or swelling from a broken or sprained ankle. Varicose veins (that may or may not be visible) can also cause compression of the nerve. TTS is more common in athletes and other active people. These people put more stress on the tarsal tunnel area. Flat feet may cause an increase in pressure in the tunnel region and this can cause nerve compression. Those with lower back problems may have symptoms. Back problems with the L4, L5 and S1 regions are suspect and might suggest a "Double Crush" issue: one "crush" (nerve pinch or entrapment) in the lower back, and the second in the tunnel area. In some cases, TTS can simply be idiopathic.
Rheumatoid Arthritis has also been associated with TTS.
Neurofibromatosis can also cause TTS. This is a disease that results in the formation of pigmented, cutaneous neurofibromas. These masses, in a specific case, were shown to have the ability to invade the tarsal tunnel causing pressure, therefore resulting in TTS.
Diabetes makes the peripheral nerve susceptible to nerve compression, as part of the double crush hypothesis. In contrast to carpal tunnel syndrome due to one tunnel at the wrist for the median nerve, there are four tunnels in the medial ankle for tarsal tunnels syndrome. If there is a positive Tinel sign when you tap over the inside of the ankle, such that tingling is felt into the foot, then there is an 80% chance that decompressing the tarsal tunnel will relieve the symptoms of pain and numbness in a diabetic with tarsal tunnel syndrome.
Risk factors.
Anything compromising the tunnel of the posterior tibial nerve proves significant in the risk of causing TTS. Neuropathy can occur in the lower limb through many modalities, some of which include obesity and inflammation around the joints. By association, this includes risk factors such as RA, compressed shoes, pregnancy, diabetes and thyroid diseases
Diagnosis.
Diagnosis is based upon physical examination findings. Patients' pain history and a positive Tinel's sign are the first steps in evaluating the possibility of tarsal tunnel syndrome. X-ray can rule out fracture. MRI can assess for space occupying lesions or other causes of nerve compression. Ultrasound can assess for synovitis or ganglia. Nerve conduction studies alone are not, but they may be used to confirm the suspected clinical diagnosis. Common causes include trauma, varicose veins, neuropathy and space-occupying anomalies within the tarsal tunnel. Tarsal tunnel syndrome is also known to affect both athletes and individuals that stand a lot.
A Neurologist or a Physiatrist usually administers nerve conduction tests or supervises a trained technologist. During this test, electrodes are placed at various spots along the nerves in the legs and feet. Both sensory and motor nerves are tested at different locations. Electrical impulses are sent through the nerve and the speed and intensity at which they travel is measured. If there is compression in the tunnel, this can be confirmed and pinpointed with this test. Some doctors do not feel that this test is necessarily a reliable way to rule out TTS. Some research indicates that nerve conduction tests will be normal in at least 50% of the cases.
Given the unclear role of electrodiagnostics in the diagnosis of tarsal tunnel syndrome, efforts have been made in the medical literature to determine which nerve conduction studies are most sensitive and specific for tibial mononeuropathy at the level of the tarsal tunnel. An evidence-based practice topic put forth by the professional organization, the American Association of Neuromuscular & Electrodiagnostic Medicine has determined that Level C, Class III evidence exists for the use of tibial motor nerve conduction studies, medial and lateral plantar mixed nerve conduction studies, and medial and lateral plantar sensory nerve conduction studies. The role of needle electromyography remains less defined.
Tarsal Tunnel Syndrome (TTS) is most closely related to Carpal Tunnel Syndrome (CTS). However, the commonality to its counterpart is much less or even rare in prevalence Studies have found that patients with rheumatoid arthritis (RA) show signs of distal limb neuropathy. The posterior tibial nerve serves victim to peripheral neuropathy and often show signs of TTS amongst RA patients. Therefore, TTS is a common discovery found in the autoimmune disorder of rheumatoid arthritis
Prevention.
The exact cause of Tarsal Tunnel Syndrome (TTS) can vary from patient to patient. However the same end result is true for all patients, the compression of the posterior tibial nerve and it branches as it travels around the medial malleolus causes pain and irritation for the patient. There are many possible causes for compression of the tibial nerve therefore there are a variety of prevention strategies. One being immobilization, by placing the foot in a neutral position with a brace, pressure is relieved from the tibial nerve thus reducing patients pain. Eversion, inversion, and plantarflexion all can cause compression of the tibial nerve therefore in the neutral position the tibial nerve is less agitated. Typically this is recommended for the patient to do while sleeping. Another common problem is improper footwear, having shoes deforming the foot due to being too tight can lead to increased pressure on the tibial nerve. Having footwear that tightens the foot for extended periods of time even will lead to TTS. Therefore, by simply having properly fitted shoes TTS can be prevented.
Treatment.
Treatments typically include rest, manipulation, strengthening of tibialis anterior, tibialis posterior, peroneus and short toe flexors, casting with a walker boot, corticosteroid and anesthetic injections, hot wax baths, wrapping, compression hose, and orthotics. Medications may include various anti-inflammatories such as Anaprox, or other medications such as Ultracet, Neurontin and Lyrica. Lidocaine patches are also a treatment that helps some patients.
Conservative treatment (nonsurgical).
There are multiple ways that tarsal tunnel can be treated and the pain can be reduced. The initial treatment, whether it be conservative or surgical, depends on the severity of the tarsal tunnel and how much pain the patient is in. There was a study done that treated patients diagnosed with tarsal tunnel syndrome with a conservative approach. Meaning that the program these patients were participated in consisted of physiotherapy exercises and orthopedic shoe inserts in addition to that program. There were fourteen patients that had supplementary tibial nerve mobilization exercises. They were instructed to sit on the edge of a table in a slumped position, have their ankle taken into dorsiflexion and ankle eversion then the knee was extended and flexed to obtain the optimal tibial nerve mobilization. Patients in both groups showed positive progress from both programs. The medial calcaneal, medial plantar and lateral plantar nerve areas all had a reduction in pain after successful nonoperative or conservative treatment. There is also the option of localized steroid or cortisone injection that may reduce the inflammation in the area, therefore relieving pain. Or just a simple reduction in the patient's weight to reduce the pressure in the area.
Surgical treatment.
If non-invasive treatment measures fail, tarsal tunnel release surgery may be recommended to decompress the area. The incision is made behind the ankle bone and then down towards but not as far as the bottom of foot. The Posterior Tibial nerve is identified above the ankle. It is separated from the accompanying artery and vein and then followed into the tunnel. The nerves are released. Cysts or other space-occupying problems may be corrected at this time. If there is scarring within the nerve or branches, this is relieved by internal neurolysis. Neurolysis is when the outer layer of nerve wrapping is opened and the scar tissue is removed from within nerve. Following surgery, a large bulky cotton wrapping immobilizes the ankle joint without plaster. The dressing may be removed at the one-week point and sutures at about three weeks.
Complications may include bleeding, infection, and unpredictable healing. The incision may open from swelling. There may be considerable pain and cramping. Regenerating nerve fibers may create shooting pains. Patients may have hot or cold sensations and may feel worse than before surgery. Crutches are usually recommended for the first two weeks, as well as elevation to minimize swelling. The nerve will grow at about one inch per month. One can expect to continue the healing process over the course of about one year.
Many patients report good results. Some, however, experience no improvement or a worsening of symptoms. In the Pfeiffer article (Los Angeles, 1996), fewer than 50% of the patients reported improvement, and there was a 13% complication rate. This is a staggering percentage of complications for what is a fairly superficial and minor surgical procedure.
Tarsal tunnel can greatly impact patients' quality of life. Depending on the severity, the ability to walk distances people normally take for granted (such as grocery shopping) may become compromised. Proper pain management and counseling is often required.
Results of surgery can be maximized if all four of the medial ankle tunnels are released and you walk with a walker the day after surgery. Success can be improved to 80%.
Incidence.
Though TTS is rare, its cause can be determined in 70% of reported cases. In the workplace TTS is considered a musculoskeletal disorder and accounts for 1.8 million cases a year, which accumulates to about $15–$20 billion a year New studies indicate an occurrence of TTS in sports placing high loads on the ankle joint (3). This can be seen in figure 1. TTS occurs more dominantly in active adults, with a higher pervasiveness among women. Active adults that experience more jumping and landing on the ankle joint are more susceptible (see figure 2). Though athletics and sport are correlations, cases are individualistically assessed because of the oddity.
Athletic activities.
 The athletic population tends to put themselves at greater risk of TTS due to the participation in sports that involve the lower extremities. Strenuous activities involved in athletic activities put extra strain on the ankle and therefore can lead to the compression of the tibial nerve. Activities that especially involve sprinting and jumping have a greater risk of developing TTS. This is due to the ankle being put in eversion, inversion, and plantarflexion at high velocities. Examples of sports that can lead to TTS include basketball, track, soccer, lacrosse, snowboarding, and volleyball. Participation in these sports should be done cautiously due to the high risk of developing TTS. However athletes will tend to continue to participate in these activities therefore proper stretching, especially in lower extremities, prior to participation can assist in the prevention of developing TTS.
Famous case.
According to South Korea's National Intelligence Service, North Korean leader Kim Jong Un had surgery to correct TTS in his right ankle, the source of a pronounced limp. Kim's disappearance from public for six weeks around the suspected surgery created worldwide speculation about the future of Kim and North Korea.
Society.
As stated earlier, musculoskeletal disorders can cost up to $15–$20 billion in direct costs or $45–$55 billion in indirect expenses. This is about $135 million a day Tests that confirm or correct TTS require expensive treatment options like x-rays, CT-scans, MRI and surgery. 3 former options for TTS detect and locate, while the latter is a form of treatment to decompress tibial nerve pressure Since surgery is the most common form of TTS treatment, high financial burden is placed upon those diagnosed with the rare syndrome.


Murphy Morobe

Murphy Morobe is a historical figure from South Africa's anti-apartheid movement.
He started school in Ermelo. Morobe completed Primary School in Soweto and then went to Orlando North Secondary School and Morris Isaacson High School. While he was in high school he became interested in politics and history. In 1972 Morobe became part of the South African Student’s Movement (SASM). Important things to him were unity and community development.
Many members of the SASM were detained in 1973 and it became quite weak.
In 1974 Morobe helped with the re-building of SASM, and then was made treasurer by them. Later he was one of the student leaders of the Soweto Uprising in June, 1976. Due to his alleged role in the uprising, he spent three years in prison on Robben Island. He served his time alongside other student leaders. He also was in the company of South African political prisoner and African National Congress leader Nelson Mandela. He was released in May 1982.
After being released from prison, he returned to politics, involving himself with several groups, including: Congress of South African Students (COSAS), General and Allied Worker’s Union and he helped to form the United Democratic Front (South Africa) (UDF) in 1983.
In 1994 Morobe had become the Chairperson and CEO of the Financial and Fiscal Commission in South Africa. Morobe was on the Council on Higher Education (CHE). He also is the Chairman of the South African National Parks Board (SANP), and is a part of the International Fundraising Consortium, an organisation that provides money grants to the non-governmental sectors of South Africa. Morobe has also been appointed to the position of Director on the board of the Old Mutual South Africa.
He is currently the spokesman for former South African President Thabo Mbeki.


Double-disk diffusion test

A double-disk diffusion test is a kind of disk diffusion test (to test for the effectiveness of an antimicrobial agent a disk infused with it is placed on a cultivated agar dish of bacteria to see if the antimicrobial agent in the disk inhibits further growth of the bacteria.)
The double-disc synergy test (DDST) utilizes two of these disks on the cultivated agar solution, either infused with a different antimicrobial solution.
This test was recommended the standard by the Clinical and Laboratory Standards Institute in 2004 for its use against MRSA. To test for clindamycin resistance certain strains of Staphylococcus aureus bacteria with natural resistance to erythromycin are chosen for cultivation on the gel. The two antimicrobial disks contain erythromycin and clindamycin and are placed about 20 mm apart. This is called a D-zone test, or D test. If a 'D' shape is formed around the clindamycin disk then the isolate is reported as resistant to clindamycin. This occurs due to erythromycin inducing the bacteria's ERM (B) gene, and thus making it resistant to Clindamycin.


Diploma in the Philosophy of Medicine

The Diploma in the Philosophy of Medicine (DPMSA) is an academic award in the United Kingdom. It is awarded to students who have completed a one-year study of the philosophy of medicine in a course run by the Faculty of the History and Philosophy of Medicine and Pharmacy, and have passed an examination.
Many UK medical schools require their students to complete a project called a student-selected component. One of the required topics includes medical ethics. The diploma is accredited for many medical schools and has an annually-awarded prize.
History.
The curriculum was created by Michael Lockwood in 1978, with assistance from Raanan Gillon. Its structure reflects philosophical developments as applied to medicine. It is the oldest philosophy and ethics of medicine and healthcare course in the UK. Previously, the diploma was earned after a two-year study period on alternating Saturdays, and was predominantly attended by graduates and medical students. After an extensive revision in 1993, the course was shortened to one year and opened up to a wider range of students.
Exam.
Students must maintain a 70% attendance record and receive passing grades on a final written paper, dissertation and essay to be awarded the diploma.


Bohr equation

The Bohr equation, named after Danish physician Christian Bohr (1855–1911), describes the amount of physiological dead space in a person's lungs. This is given as a ratio of dead space to tidal volume. It differs from anatomical dead space as measured by Fowler's method as it includes alveolar dead space.
Description.
The Bohr equation is used to quantify the ratio of physiological dead space to the total tidal volume, and gives an indication of the extent of wasted ventilation. The original formulation by Bohr, required measurement of the alveolar partial pressure PA.
The modification by Enghoff replaced the mixed alveolar partial pressure of CO2 with the arterial partial pressure of that gas.
The Bohr equation, with Enghoff's modification, is commonly stated as follows:
Here formula_3 is the physiological dead space volume and formula_4 is the tidal volume;
Derivation.
Its derivation is based on the fact that only the ventilated gases involved in gas exchange (formula_7) will produce CO2. Because the total tidal volume (formula_8) is made up of formula_9 (alveolar volume + dead space volume), we can substitute formula_7 for formula_11.
Initially, Bohr tells us VT = Vd + VA. The Bohr equation helps us find the amount of any expired gas, , N2, O2, etc.
In this case we will focus on CO2.
Defining Fe as the fraction of CO2 in the average expired breath, FA as the fraction of CO2 in the perfused alveolar volume, and Fd as the CO2 makeup of the unperfused (and thus 'dead') region of the lung;
VT x Fe = ( Vd x Fd ) + (VA x FA ).
This states that all of the CO2 expired comes from two regions, the dead space volume and the alveolar volume. <br>
If we suppose that Fd = 0 (since carbon dioxide's concentration in air is normally negligible), then we can say that:
The only source of CO2 is the alveolar space where gas exchange with blood takes place. Thus the alveolar fractional component of CO2, FA, will always be higher than the average CO2 content of the expired air because of a non-zero dead space volume Vd, thus the above equation will always yield a positive number.
Where Ptot is the total pressure, we obtain:
Therefore:
A common step is to then presume that the partial pressure of carbon dioxide in the end-tidal exhaled air is in equilibrium with that gas' tension in the blood that leaves the alveolar capillaries of the lung.


Sean P. Pinney

Sean Patrick Pinney is an American cardiologist and the Director of both the Advanced Heart Failure and Cardiac Transplant Program and the Pulmonary Hypertension Program at Mount Sinai Medical Center in New York City.
He is an Associate Professor of Cardiology at Mount Sinai School of Medicine, the author of over 20 publications in peer-reviewed medical journals and of multiple book chapters. He lectures frequently on the topic of cardiovascular disease.
Biography.
Pinney was born in St. Louis, Missouri, graduating from St. Louis Priory School in 1986; he received his undergraduate degree from Georgetown University in 1990 and graduated from Georgetown University School of Medicine in 1994. He completed a residency at Deaconess Hospital, in Boston, Massachusetts and was Chief Resident in Medicine at Beth Israel Deaconess Medical Center until 1998. He was a fellow in Congestive Heart Failure and Cardiac Transplants and Chief Fellow in Cardiovascular Medicine at Columbia Presbyterian Medical Center in New York.
His practice has a primary focus on the understanding and treatment of cardiac allograft vasculopathy, a condition affecting about half of all transplant recipients by their fifth year.
Pinney is a reviewer for the medical journals "The Medical Letter", "Mount Sinai Journal of Medicine", "Nature Clinical Practice Cardiovascular Medicine", "Transplantation" and "Transplant Immunology".


Charles Dubost (surgeon)

Charles Dubost (October 1914 – 1991) was a French surgeon who performed the first abdominal aortic aneurysm resection with a homograft replacement. Michael DeBakey later performed a similar operation with a prosthesis and named it “Dubost's operation.” He was also the first to perform a carotid endarterectomy under cardiac bypass.
Early life and education.
Charles Dubost was born in October 1914 and educated in Paris. He had completed his medical studies before the onset of the Second World War.
Surgical career.
Dubost joined Hôpital Broussais after the Second World War and was appointed to cardiac surgery in the blue baby unit in 1947, the same year that Alfred Blalock demonstrated the Taussig-Blalock operation, a procedure Dubost then led in Europe.
In January 1951, Dubost led one of the three surgical teams that performed early kidney transplants in Paris, the others being René Küss and Marceau Servelle. In the same year, he resected an abdominal aortic aneurysm and replaced it with a cadaveric graft that had been preserved by freezing and stored in N. Oeconomous's laboratory.
In 1954, Dubost designed and used a mechanical dilator with two parallel blades which could be passed into the atrium and into the mitral orifice under digital control.
He performed the first carotid endarterectomy under cardiac bypass and later performed one of the early transplants in 1968.
Awards and honours.
In 1940, he won the Croix de Guerre as a young medical lieutenant.
He became an officer of the légion d'honneur and was elected to both Académie Nationale de Médecine and the French Academy of Sciences.
Later life and death.
Dubost retired in 1982, following which he spent the rest of life reading and listening to classical music. He died at Saint-Michel Hospital in 1991.