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An Allis clamp (also called the Allis forceps ) is a commonly used surgical instrument . It was invented by Oscar Allis a renowned American surgeon, from 1883. He designed them specifically for use in abdominal surgeries, and they are now a used in many surgical procedures due to their versatility.
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Allopathic medicine , or allopathy , is an archaic and derogatory label originally used by 19th-century homeopaths to describe heroic medicine , the precursor of modern evidence-based medicine . [ 1 ] [ 2 ] There are regional variations in usage of the term. In the United States, the term is sometimes used to contrast with osteopathic medicine , especially in the field of medical education. In India, the term is used to distinguish conventional modern medicine from Siddha medicine , Ayurveda , homeopathy , Unani and other alternative and traditional medicine traditions, especially when comparing treatments and drugs.
The terms were coined in 1810 by the creator of homeopathy, Samuel Hahnemann . [ 3 ] Heroic medicine was the conventional European medicine of the time and did not rely on evidence of effectiveness . It was based on the belief that disease is caused by an imbalance of the four " humours " (blood, phlegm, yellow bile, and black bile) and sought to treat disease symptoms by correcting that imbalance, using "harsh and abusive" methods to induce symptoms seen as opposite to those of diseases [ 4 ] rather than treating their underlying causes: disease was caused by an excess of one humour and thus would be treated with its "opposite". [ 5 ]
A study released by the World Health Organization (WHO) in 2001 defined allopathic medicine as "the broad category of medical practice that is sometimes called Western medicine , biomedicine , evidence-based medicine , or modern medicine." [ 6 ] The WHO used the term in a global study in order to differentiate Western medicine from traditional and alternative medicine , noting that in certain areas of the world "the legal standing of practitioners is equivalent to that of allopathic medicine" where practitioners can be separately certified in complementary/alternative medicine and Western medicine. [ 6 ]
The term allopathy was also used to describe anything that was not homeopathy. [ 5 ] Kimball Atwood , an American medical researcher and alternative medicine critic, said the meaning implied by the label of allopathy has never been accepted by conventional medicine and is still considered pejorative. [ 7 ] American health advocate and sceptic William T. Jarvis , stated that "although many modern therapies can be construed to conform to an allopathic rationale (e.g., using a laxative to relieve constipation), standard medicine has never paid allegiance to an allopathic principle" and that the label "allopath" was "considered highly derisive by regular medicine." [ 8 ] Most modern science-based medical treatments ( antibiotics , vaccines , and chemotherapeutics , for example) do not fit Hahnemann's definition of allopathy, as they seek to prevent illness or to alleviate an illness by eliminating its cause . [ 9 ] [ 10 ]
The terms "allopathic medicine" and "allopathy" are drawn from the Greek prefix ἄλλος ( állos ), "other," "different" + the suffix πάθος ( páthos ), "suffering".
The practice of medicine in both Europe and North America during the early 19th century is sometimes referred to as heroic medicine because of the extreme measures (such as bloodletting ) sometimes employed in an effort to treat diseases. [ 11 ] The term allopath was used by Hahnemann and other early homeopaths to highlight the difference they perceived between homeopathy and the "conventional" heroic medicine of their time. With the term allopathy (meaning "other than the disease"), Hahnemann intended to point out how physicians with conventional training employed therapeutic approaches that, in his view, merely treated symptoms and failed to address the disharmony produced by underlying disease. [ clarification needed ] Homeopaths saw such symptomatic treatments as "opposites treating opposites" and believed these methods were harmful to patients. [ 3 ]
Practitioners of alternative medicine have used the term "allopathic medicine" to refer to the practice of conventional medicine in both Europe and the United States since the 19th century. In that century, the term allopath was used most often as a derogatory name for the practitioners of heroic medicine, [ 12 ] [ 13 ] a precursor to modern medicine that itself did not rely on evidence of effectiveness .
James Whorton discusses this historical pejorative usage:
One form of verbal warfare used in retaliation by irregulars was the word "allopathy". ..."Allopathy" and "allopathic" were liberally employed as pejoratives by all irregular physicians of the nineteenth century, and the terms were considered highly offensive by those at whom they were directed. The generally uncomplaining acceptance of [the term] "allopathic medicine" by today's physicians is an indication of both a lack of awareness of the term's historical use and the recent thawing of relations between irregulars and allopaths. [ 14 ]
The controversy surrounding the term can be traced to its original usage during a heated 19th-century debate between practitioners of homeopathy and those they derisively referred to as "allopaths." [ 15 ]
Hahnemann used "allopathy" to refer to what he saw as a system of medicine that combats disease by using remedies that produce effects in a healthy subject that are different (hence the Greek root allo- "different") from the effects produced by the disease to be treated. The distinction comes from the use in homeopathy of substances that are meant to cause similar effects as the symptoms of a disease to treat patients ( homeo - meaning "similar").
As used by homeopaths, the term allopathy has always referred to the principle of treating disease by administering substances that produce other symptoms (when given to a healthy human) than the symptoms produced by a disease. For example, part of an allopathic treatment for fever may include the use of a drug which reduces the fever, while also including a drug (such as an antibiotic ) that attacks the cause of the fever (such as a bacterial infection). A homeopathic treatment for fever, by contrast, is one that uses a diluted dosage of a substance that in an undiluted form would induce fever in a healthy person. These preparations are typically diluted so heavily that they no longer contain any actual molecules of the original substance. Hahnemann used this term to distinguish medicine as practiced in his time from his use of infinitesimally small (or nonexistent) doses of substances to treat the spiritual causes of illness.
The Companion Encyclopedia of the History of Medicine states that "[Hahnemann] gave an all-embracing name to regular practice, calling it 'allopathy'. This term, however imprecise, was employed by his followers and other unorthodox movements to identify the prevailing methods as constituting nothing more than a competing 'school' of medicine, however dominant in terms of number of practitioner proponents and patients". [ 16 ]
Contrary to the present usage, Hahnemann reserved the term "allopathic medicine" to the practice of treating diseases by means of drugs inducing symptoms unrelated (i.e., neither similar nor opposite) to those of the disease. He called the practice of treating diseases by means of drugs producing symptoms opposite to those of the patient "enantiopathic" (from the Greek ἐνάντιος ( enántios ), meaning "opposite") or "antipathic medicine". [ 17 ]
In the United States, the term is used in the modern era to differentiate between two types of US medical schools (both of which teach aspects of science-based medicine and neither of which teach homeopathy): Allopathic (granting the MD degree) and Osteopathic (granting the DO degree). [ 18 ] [ 19 ]
In India the term is used principally to distinguish "Western medicine" from Ayurveda , especially when comparing treatments and drugs. [ 20 ]
A study released by the World Health Organization (WHO) in 2001 defined "allopathic medicine" as "the broad category of medical practice that is sometimes called Western medicine, biomedicine , evidence-based medicine , or modern medicine." [ 6 ] The WHO used the term in a global study in order to differentiate Western medicine from traditional medicine , and from complementary/ alternative medicine , noting that in certain areas of the world “the legal standing of practitioners is equivalent to that of allopathic medicine” where practitioners are certified in both complementary/alternative medicine and Western medicine. [ 6 ]
As of 2004, use of the term remained common among homeopaths and had spread to other alternative medicine practices. Kimball Atwood , an American medical researcher and alternative medicine critic, said the meaning implied by the label of allopathy has never been accepted by conventional medicine and is still considered pejorative by some. [ 7 ] American health educator and skeptic William T. Jarvis , stated in 2008 that "although many modern therapies can be construed to conform to an allopathic rationale (e.g., using a laxative to relieve constipation), standard medicine has never paid allegiance to an allopathic principle" and that the label "allopath" was "considered highly derisive by regular medicine". [ 8 ]
Most modern science-based medical treatments (antibiotics, vaccines, and chemotherapeutics, for example) do not fit Samuel Hahnemann's definition of allopathy, as they seek to prevent illness, or remove the cause of an illness by acting on the cause of disease. [ 9 ] [ 10 ]
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Allopregnane , also known as 5α-pregnane or as 10β,13β-dimethyl-17β-ethyl-5α-gonane , is a steroid and a parent compound of a variety of steroid derivatives . [ 1 ] [ 2 ] It is one of the epimers of pregnane , the other being 5β-pregnane . Derivatives of allopregnane include the naturally occurring steroids allopregnanolone , allopregnanediol , isopregnanolone , and 5α-dihydroprogesterone .
This article about a steroid is a stub . You can help Wikipedia by expanding it .
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Allostasis (/ˌɑːloʊˈsteɪsɪs/ ) is a physiological mechanism of regulation in which an organism anticipates and adjusts its energy use according to environmental demands. First proposed by Peter Sterling and Joseph Eyer in 1988, the concept of allostasis shifts the focus away from the body maintaining a rigid internal set-point, as in homeostasis , to the brain's ability and role to interpret environmental stress and coordinate changes in the body using neurotransmitters, hormones, and other signaling mechanisms. Allostasis is believed to be not only involved in the body's stress response and adaptation to chronic stress; it may also have a role in the regulation of the immune system as well as in the development of chronic diseases such as hypertension and diabetes .
The concept of organisms' ability to stabilize internal bodily mechanisms independently of environmental variations was first popularized by French physiologist Claude Bernard in 1849, coined the constancy of the milieu intérieur (internal environment). [ 1 ] He sought to replace the ancient Greek notion of vitalism that proposed the governing of the body through non-physical means with a physiological understanding of the mechanisms of the body through feedback and regulation. Harvard physiologist Walter Cannon took Bernard's theory of the milieu intérieur and expanded it to incorporate an evolutionary framework of energy efficiency and preservation. Cannon coined this concept homeostasis in 1926, demonstrating that the organism's body is a self-governing system of regulation with certain steady-state conditions for optimal functioning. [ 2 ] By the late 20th-century, neurobiologist Peter Sterling and epidemiologist Joseph Eyer noticed generational patterns of chronic stress and its effects on various human physiological mechanisms that could not be easily explained by homeostasis. They developed the concept of 'allostasis' [from the Greek ἄλλος ( állos , "other," "different") + στάσις ( stasis, "standing still") to mean "remaining stable by being variable"] to incorporate the body's ability to adjust steady-state conditions based on the perception and interpretation of environmental stressors. [ 3 ] [ 4 ]
In the 1970s, Sterling and Eyer were studying the 20th-century morbidity and mortality rates of age-specific cohorts in the United States and noticed a correlation between mortality rates of age-specific cohorts and the saturation of the labor market at the time the age-specific cohorts were entering the labor force. [ 5 ] They discovered that the cohorts who entered the labor market during the Great Depression and the resulting economic boom in the 1940s had a lower increased mortality rate due to less job competition and insecurity compared to the cohorts prior to the 1930s and since the 1950s. They also noted a correlation of major stressful events, such as bereavement , divorce, unemployment, and migration, to a higher mortality rate. Despite a preconceived notion that a reduced mortality rate in a younger cohort would experience more chronic diseases later in age, Sterling and Eyer found contradictory evidence that younger cohorts with higher mortality rates actually experienced more chronic health problems such as cardiovascular disease later in life, following the trend of consistently increased morbidity and mortality rates throughout their generation. To explain these epidemiological phenomena, Sterling and Eyer suggested social and systemic stress in the setting of advancing capitalism and industrialization to be the main driver of increased morbidity and mortality rates in age-specific cohorts. These studies became the foundation of conceptualizing allostasis a decade later.
Sterling and Eyer proposed the concept of allostasis in 1988 to better explain the process of physiological changes in the individual level that are shaped by large-scale epidemiological patterns. [ 3 ] They noticed a pattern that populations in the United States with the greatest impact of social disruption correlated with higher morbidity and mortality rates. For instance, the rate of elevated blood pressure (or hypertension ) was the highest amongst groups that experienced the most social disruption, namely the unemployed and African Americans. Previous physiological explanations attributed this prevalence to African Americans being genetically predisposed to ineffective kidney filtration causing dysregulation of blood pressure; however, genetics could not explain why the high prevalence of hypertension was seen in African Americans but not in a close genetically-related population of West Africans. Sterling and Eyer proposed that there was a mind-brain-body component to permanent physiological changes of the body's internal conditions in the setting of external stress.
Sterling and Eyer argued that homeostasis did not paint the whole picture of the body's physiological motives. Although individual organs and tissues when taken out of the body function homeostatically and exhibit their normal functioning with negative feedback , this is not always the case seen in organisms. Another example that does not completely follow homeostasis is blood pressure: if abiding by homeostasis, 24-hour blood pressure monitoring should show the body returning to its normal pressures through negative feedback whenever there is a deviance from optimal functioning. However, the human body exhibits a wide range of resting blood pressure numbers with no correction throughout the day depending on the environment, such as low pressures during sleep and higher pressures in the morning. [ 6 ] Animal studies have also shown non-homeostatic patterns in times of arousal (or stress). The body elevates blood pressure during stress and returns to normal when the stressor is removed; yet, when the stress becomes chronic, the blood pressure may not return to normal and instead stay elevated. [ 7 ]
Allostasis depends on the brain's ability to coordinate all of the organs' functions by innervating organ cells to perform a certain function as well as synthesizing and releasing signaling mechanisms, such as hormones and neurotransmitters. In response to stress, the brain directly innervates the thyroid and pancreas for energy regulation, sends signals to the cardiovascular system to increase cardiac output, stimulates the adrenal glands to release cortisol and aldosterone, and releases hormones from the pituitary gland such as ACTH to regulate urine output through the renin-angiotensin-aldosterone system . [ 8 ] The brain is able to overcome negative feedback in these localized systems and continuously evaluate the body's internal set-points. By doing so, the body can regulate its resources and energy storage efficiently.
Another key component of allostasis is the brain's perception and subsequent adaptation to chronic stress. Sterling and Eyer theorized that the brain can anticipate stressors to prepare the body to respond adequately to environmental demands through classical conditioning . If the brain persistently interprets or even anticipates stress, then it may cause epigenetic changes to permanently adapt to a chronic state of arousal that results in physiological changes such as thickened blood vessels to support the increased cardiac output and down-regulation of stress hormone receptors.
The brain normally coordinates an immune response against a foreign threat that involves the synthesis, differentiation, and migration of immune cells, release of cytokines and interleukins , elevating the internal temperature set-point, and redirecting metabolic needs to support this effort. [ 3 ] However, if the brain interprets an external stress demand as more urgent, it may supersede the immune and inflammatory responses and stimulate release of immune-suppressing stress hormones such as ACTH and cortisol. Once the stressor is resolved, the body resumes to amounting an adequate immune and inflammatory response, which may explain why it is often seen that a person falls ill after acute stress. Due to the interconnected nature of the brain's regulation of stress, the immune system, and the endocrine system, allostasis may play a role in the development of cancer .
Allostasis emphasizes that regulation must be efficient, whereas homeostasis makes no reference to efficiency. Prediction requires the brain to: (i) collect information across all spatial and temporal scales; (ii) analyze, integrate, and decide what will be needed; (iii) exert feedforward control of all parameters. Naturally, many needs are somewhat unpredictable, so errors are inevitable; and for those errors, homeostatic mechanisms – feedback control – are available to correct them. [ 9 ] [ 10 ] Allostatic (predictive) regulation allows the brain to prioritize needs, for example, by sending more oxygen and nutrients to organs that need it most. For this example, during peak exercise muscle requires an 18-fold increase in oxygenated blood, but the heart can increase its capacity only 3.5-fold. Therefore, the brain temporarily borrows blood from the digestive system and kidney rerouting it to muscle. It later repays the debt when muscle's increased need subsides. Without the ability to prioritize trade-offs between organ systems, the heart and lungs would need to be far larger while much of this costly extra capacity would go unused. [ 11 ] [ 12 ]
Every system evolves to operate over a particular range. For example, cone photoreceptors evolved to sense daylight over a 10,000-fold range of intensities, whereas rod photoreceptors evolved a different design to sense moonlight and starlight down to detection of single photons. To function optimally across their wide operating ranges, all systems adapt their sensitivities. A rod photoreceptor adapts to bright moonlight and requires minutes to increase its sensitivity to starlight. [ 12 ] When a system is chronically forced beyond its intended operating range—as by chronic high carbohydrate diet or other stress—the limits of adaptation are exceeded, and systems break down. This condition was termed by neuroscientist Bruce McEwen as allostatic load . [ 13 ] The health of an organism is maintained when operating within certain parameters, but having dynamic variability of range. [ 14 ]
Too much allostasis, also known as allostatic overload, is when the body's attempts to adapt to the environment cause more harm than benefit and can lead to various negative consequences in the form of mental and physical diseases. [ 15 ] From a metaphorical perspective this can be interpreted as a machine running continuously as the machine is overworked; it becomes less efficient over time because more stress is placed on it. Similarly, the process of allostasis becomes less efficient at managing the body's resources when the body endures increased levels of unhealthy stress due to wear and tear on the body and the brain. [ 16 ] An increase in allostatic load can impair and reduce neuroplasticity as stress causes the brain to age quicker. This is because with more stress, more synaptic connections are lost in the prefrontal cortex which is responsible for body regulation.
McEwen and endocrinologist John C. Wingfield proposed two types of allostatic overload which result in different responses:
Whereas both types of allostasis are associated with increased release of cortisol and catecholamines , they differentially affect thyroid homeostasis: Concentrations of the thyroid hormone triiodothyronine are decreased in type 1 allostasis, but elevated in type 2 allostasis. [ 19 ] This may result from type 2 allostatic load increasing the set point of pituitary-thyroid feedback control. [ 20 ]
Sung Lee introduced the paradigm of allostatic orchestration (PAO), extending the principle of allostasis by stating, “The PAO originates from an evolutionary perspective and recognizes that biological set points change in anticipation of changing environments.” [ 14 ]
The brain is the organ of central command, orchestrating cross-system operations to support optimal behavior at the level of the whole organism. The PAO describes differences between homeostasis and allostasis paradigms and conciliation of the paradigms illustrated with alternative views of post-traumatic stress disorder (PTSD). Lee states:
The allostatic state represents the integrated totality of brain-body interactions. Health itself is an allostatic state of optimal anticipatory oscillation , hypothesized to relate to the state of criticality… Diseases are allostatic states of impaired anticipatory oscillations, demonstrated as rigidifications of set points across the brain and body (disease comorbidity).
The PAO implications for health extend beyond blood pressure and diabetes to include addiction, depression , and deaths of despair (from alcohol, drugs, and suicide) that have been increasing since 2000, [ 21 ] emphasizing that an integrated view of health includes environmental context. Allostasis encourages increased attention to new solutions at the level of society, as well as the individual and immediate community. [ 22 ] [ 14 ]
An evolutionary perspective of allostasis includes the development of the brain. Lisa Feldman Barrett , a neuroscientist and professor of psychology, argues that during evolution, organisms' internal systems became much more advanced, and continuing to just have several groups of cells would have poorly managed these new systems that these bodies were acquiring. [ 23 ] A brain was needed instead because its large size is much more capable of efficient management. However, in rare cases animal species do not rely on brains nor a similar allostatic process. The sea squirt is one example because once the larvae have fully grown they “absorb their brain.” The sea squirt's allostatic process would not be as complex as a human's for example since both species have ecological niches that are of different complexities (i.e. ”All animals have brains that are adapted to their environmental niches and life cycles”).
Allostasis proposes a broader hypothesis than homeostasis: The key goal of physiological regulation is not rigid constancy; rather, it is flexible variation that anticipates the organism's needs and promptly meets them. [ 22 ] Rather than simply responding to the environment, allostasis utilizes predictive regulation, which has a more complex goal in evolution of adaptation by changing based on what it anticipates, rather than by staying the same or "in balance" in response to environmental changes, as homeostasis suggests. This places homeostasis as a function within allostasis; however, some argue it is a larger paradigm altogether. [ 14 ] Allostasis redefines health and disease beyond the stable measures from lab tests or blood pressure, for example; and expands it to define health as the flexibility of these values. Blood pressure is one of Sterling's prime examples of a health measure that is best when it can fluctuate in anticipation of the brain-body's expected demands, so it can match this demand. The alternative, or a less healthy state on the health-disease continuum, would be for blood pressure to remain the same, or "stable," and not meet the new demand. [ 18 ] Allostatic regulation reflects, at least partly, cephalic involvement in primary regulatory events, in that it is anticipatory to systemic physiological regulation. [ 24 ]
Wingfield states:
The concept of allostasis, maintaining stability through change, is a fundamental process through which organisms actively adjust to both predictable and unpredictable events... Allostatic load refers to the cumulative cost to the body of allostasis, with allostatic overload... being a state in which serious pathophysiology can occur... Using the balance between energy input and expenditure as the basis for applying the concept of allostasis, two types of allostatic overload have been proposed. [ 25 ]
Sterling (2004) proposed several interrelated points that constitute the allostasis model: [ 22 ] [ 26 ]
Allostasis occurs at the cellular and systems levels. When humans are chronically stressed, the brain chronically raises blood pressure; then arterial muscles predict higher pressure and respond with hypertrophy (like skeletal muscles when we lift weights). Gradually the whole cardiovascular system adapts to life at an elevated pressure level. This is known as chronic hypertension , which elevates mortality from cardiovascular disease and stroke . Similarly, a chronically high carbohydrate diet requires chronically high blood glucose and leads to chronically high levels of insulin that increase in anticipation of the need to manage the high level of carbohydrates. Cells that express insulin receptors, predicting high insulin, adapt by reducing their sensitivity (like photoreceptors in bright light). This leads to type 2 diabetes and elevated mortality from many causes. Although physicians term this response insulin resistance, it can be better understood as consequent to predictive regulation. [ 22 ]
Allostasis can be carried out by means of alteration in HPA axis hormones, the autonomic nervous system, cytokines, or a number of other systems, and is generally adaptive in the short term. [ 17 ] Allostasis is essential in order to maintain internal viability amid changing conditions. [ 18 ] [ 27 ] [ 13 ] [ 24 ]
Allostasis provides compensation for various problems, such as in compensated heart failure , compensated kidney failure , and compensated liver failure . However, such allostatic states are inherently fragile, and decompensation can occur quickly, as in acute decompensated heart failure .
The term heterostasis is also used in place of allostasis, particularly where state changes are finite in number and therefore discrete (e.g. computational processes). [ 28 ]
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In pharmacology and biochemistry , allosteric modulators are a group of substances that bind to a receptor to change that receptor's response to stimuli. Some of them, like benzodiazepines or alcohol , function as psychoactive drugs. [ 1 ] The site that an allosteric modulator binds to (i.e., an allosteric site ) is not the same one to which an endogenous agonist of the receptor would bind (i.e., an orthosteric site ). Modulators and agonists can both be called receptor ligands . [ 2 ]
Allosteric modulators can be 1 of 3 types either: positive, negative or neutral. Positive types increase the response of the receptor by increasing the probability that an agonist will bind to a receptor (i.e. affinity ), increasing its ability to activate the receptor (i.e. efficacy ), or both. Negative types decrease the agonist affinity and/or efficacy. Neutral types don't affect agonist activity but can stop other modulators from binding to an allosteric site. Some modulators also work as allosteric agonists and yield an agonistic effect by themselves. [ 2 ]
The term "allosteric" derives from the Greek language. Allos means "other", and stereos , "solid" or "shape". This can be translated to "other shape", which indicates the conformational changes within receptors caused by the modulators through which the modulators affect the receptor function. [ 3 ]
Allosteric modulators can alter the affinity and efficacy of other substances acting on a receptor. A modulator may also increase affinity and lower efficacy or vice versa. [ 4 ] Affinity is the ability of a substance to bind to a receptor . Efficacy is the ability of a substance to activate a receptor, given as a percentage of the ability of the substance to activate the receptor as compared to the receptor's endogenous agonist . If efficacy is zero, the substance is considered an antagonist . [ 1 ]
The site to which endogenous agonists bind to is named the orthosteric site . Modulators don't bind to this site. They bind to any other suitable sites, which are named allosteric sites . [ 2 ] Upon binding, modulators generally change the three-dimensional structure (i.e. conformation ) of the receptor. This will often cause the orthosteric site to also change, which can alter the effect of an agonist binding. [ 4 ] Allosteric modulators can also stabilize one of the normal configurations of a receptor. [ 5 ]
In practice, modulation can be complicated. A modulator may function as a partial agonist , meaning it doesn't need the agonist it modulates to yield agonistic effects. [ 6 ] Also, modulation may not affect the affinities or efficacies of different agonists equally. If a group of different agonists that should have the same action bind to the same receptor, the agonists might not be modulated the same by some modulators. [ 4 ]
A modulator can have 3 effects within a receptor. One is its capability or incapability to activate a receptor (2 possibilities). The other two are agonist affinity and efficacy. They may be increased, lowered or left unaffected (3 and 3 possibilities). This yields 17 possible modulator combinations. [ 4 ] There are 18 (=2*3*3) if neutral modulator type is also included.
For all practical considerations, these combinations can be generalized only to 5 classes [ 4 ] and 1 neutral:
Due to the variety of locations on receptors that can serve as sites for allosteric modulation, as well as the lack of regulatory sites surrounding them, allosteric modulators can act in a wide variety of mechanisms. [ citation needed ]
Some allosteric modulators induce a conformational change in their target receptor which increases the binding affinity and/or efficacy of the receptor agonist. [ 2 ] Examples of such modulators include benzodiazepines and barbiturates , which are GABA A receptor positive allosteric modulators . Benzodiazepines like diazepam bind between α and γ subunits of the GABA A receptor ion channels and increase the channel opening frequency, but not the duration of each opening. Barbiturates like phenobarbital bind β domains and increase the duration of each opening, but not the frequency. [ 9 ]
Some modulators act to stabilize conformational changes associated with the agonist-bound state. This increases the probability that the receptor will be in the active conformation, but does not prevent the receptor from switching back to the inactive state. With a higher probability of remaining in the active state, the receptor will bind agonist for longer. AMPA receptors modulated by aniracetam and CX614 will deactivate slower, and facilitate more overall cation transport. This is likely accomplished by aniracetam or CX614 binding to the back of the "clam shell" that contains the binding site for glutamate , stabilizing the closed conformation associated with activation of the AMPA receptor. [ 5 ] [ 9 ]
Overall signal can be increased by preventing the desensitization of a receptor. Desensitization prevents a receptor from activating, despite the presence of an agonist. This is often caused by repeated or intense exposures to an agonist. Eliminating or reducing this phenomenon increases the receptor's overall activation. AMPA receptors are susceptible to desensitization via a disruption of a ligand-binding domain dimer interface. Cyclothiazide has been shown to stabilize this interface and slow desensitization, and is therefore considered a positive allosteric modulator. [ 5 ]
Modulators can directly regulate receptors rather than affecting the binding of the agonist. Similar to stabilizing the bound conformation of the receptor, a modulator that acts in this mechanism stabilizes a conformation associated with the active or inactive state. This increases the probability that the receptor will conform to the stabilized state, and modulate the receptor's activity accordingly. Calcium-sensing receptors can be modulated in this way by adjusting the pH . Lower pH increases the stability of the inactive state, and thereby decreases the sensitivity of the receptor. It is speculated that the changes in charges associated with adjustments to pH cause a conformational change in the receptor favoring inactivation. [ 10 ]
Modulators that increase only the affinity of partial and full agonists allow their efficacy maximum to be reached sooner at lower agonist concentrations – i.e. the slope and plateau of a dose-response curve shift to lower concentrations. [ 4 ]
Efficacy increasing modulators increase maximum efficacy of partial agonists. Full agonists already activate receptors fully so modulators don't affect their maximum efficacy, but somewhat shift their response curves to lower agonist concentrations. [ 4 ]
Related receptors have orthosteric sites that are very similar in structure, as mutations within this site may especially lower receptor function. This can be harmful to organisms, so evolution doesn't often favor such changes. Allosteric sites are less important for receptor function, which is why they often have great variation between related receptors. This is why, in comparison to orthosteric drugs, allosteric drugs can be very specific , i.e. target their effects only on a very limited set of receptor types. However, such allosteric site variability occurs also between species so the effects of allosteric drugs vary greatly between species. [ 11 ]
Modulators can't turn receptors fully on or off as modulator action depends on endogenous ligands like neurotransmitters , which have limited and controlled production within body. This can lower overdose risk relative to similarly acting orthosteric drugs. It may also allow a strategy where doses large enough to saturate receptors can be taken safely to prolong the drug effects. [ 4 ] This also allows receptors to activate at prescribed times (i.e. in response to a stimulus) instead of being activated constantly by an agonist, irrespective of timing or purpose. [ 12 ]
Modulators affect the existing responses within tissues and can allow tissue specific drug targeting. This is unlike orthosteric drugs, which tend to produce a less targeted effect within body on all of the receptors they can bind to. [ 4 ]
Some modulators have also been shown to lack the desensitizing effect that some agonists have. Nicotinic acetylcholine receptors , for example, quickly desensitize in the presence of agonist drugs, but maintain normal function in the presence of PAMs. [ 13 ]
Allosteric modulation has demonstrated as beneficial to many conditions that have been previously difficult to control with other pharmaceuticals. These include:
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Allovectin-7 is a substance that is being studied as a gene therapy agent in the treatment of cancer , such as malignant melanoma. It is a plasmid/lipid complex containing the DNA sequences encoding HLA-B7 and ß2 microglobulin - two components of major histocompatibility complex (MHC, class I). It increases the ability of the immune system to recognize cancer cells and kill them.
In 1999, FDA granted Allovectin-7 orphan drug designation for the treatment of invasive and metastatic melanoma.
This article incorporates public domain material from Dictionary of Cancer Terms . U.S. National Cancer Institute .
This oncology article is a stub . You can help Wikipedia by expanding it .
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Allow Natural Death ( AND ) is a medical term defining the use of life-extending measures such as cardiopulmonary resuscitation (CPR). These orders emphasize patient comfort and pain management instead of life extension. [ 1 ] Currently, American medical communities utilize " do not resuscitate ," (DNR) orders to define patients' medical wishes. Those who propose to replace DNR with AND posit that DNR orders are ambiguous and require complex understanding between several parties, while AND orders are clearer. [ 1 ] [ 2 ] Proponents of replacing DNR with AND believe that AND terminology is more ethically conscientious DNR terminology. [ 1 ] Research has been conducted regarding participant preference for AND vs. DNR terminology. The ease with which the terminology change can be practically incorporated depends on many factors such as costs and staff reeducation. [ 1 ]
DNR orders range in the extent of life-saving measures to be avoided, from solely prohibiting the use of resuscitation to prohibiting any action seen as life extending. Because there are many parties involved in a patient's end of life care - significant others, family, personal doctors, specialists and nurses - DNR orders are not always completely clear, leaving open possible violation of the patient's wishes. [ 1 ] DNR terminology was replaced in 2005 by the American Heart Association with Do Not Attempt Resuscitation (DNAR) in an effort to make clearer the meaning of the order. [ 3 ] However, DNR remains the popularly understood and used term in the medical and layperson settings. AND is yet another phrase for similar orders, and implementing it involves a term change. [ 3 ] [ 4 ]
Those who propose to replace DNR orders with AND orders posit that AND is less ambiguous, clearly instructing medical personnel to not use any artificial, life extending measures. This would be especially helpful in regards to emergency care, when medical personnel who are unfamiliar with the patient must decide what medical practices should be used. Pros are that AND increases clarity on meaning and the choice of life or death. [ 3 ] AND orders also don't use negative wording that could be confusing to interpret. Furthermore, proponents of AND claim that because it contains "death" in the title it is more clear to the patient and family exactly what the patient is agreeing to. Critics of AND claim it is simply the replacement of one ambiguous term with another. Cons include that death can be vague and CPR isn't mentioned in the phrase. [ 3 ] Just as DNR particulars vary, so too would AND particulars vary. [ 3 ] Thus, they argue that change would be ineffective.
AND terminology represents an ideology of patient care that emphasizes bodily autonomy and respect of the individual. [ 1 ] This is in contrast to the terminology associated with DNR, or "do not resuscitate," which has been criticized for placing emphasis on potential negative outcomes associated with hospitalization, i.e. the act of "not" resuscitating is a conscious decision to "not" engage in life-extending care. Proponents of AND argue that, by "allowing" natural death, the provider is, instead, consciously deciding to engage in care; although such care is not life-extending, this form of care respects the wishes of patients to die peacefully and without suffering. [ 5 ]
AND and DNR share similar ethical considerations with regards to end-of-life care. These considerations can involve the four main principles of biomedical ethics, including autonomy, beneficence, nonmaleficence, and justice. [ 6 ] Autonomy can be thought of as a patient's right to self-determination and the right to decide what kind of care they should receive, which can be achieved through ANDs or DNRs. The principles of beneficence and nonmaleficence require that the healthcare providers are aware of their patient's AND and DNR statuses, and of their roles in that patient's end-of-life care. Lastly, the principle of justice refers to the obligation for healthcare providers to advocate for fair and appropriate treatment of their patients at the end of their lives, which requires abiding by the conditions expressed through AND and DNR. [ 7 ]
In the cases of attempted suicide or medical mismanagement, there are questions around the meaning of what a "natural" death is. It is argued that in these cases, physicians should have the capability to revoke a patient's DNR or AND, though a wide consensus has yet to be reached. [ 8 ] [ 9 ]
Most studies regarding AND are surveys based on hypothetical situations and are given to specific groups. One study gave a scenario regarding loved ones to nurses, nursing students, and people with no nursing background. [ 2 ] Each group rated how likely they were to agree to end of life care when DNR or AND was used. Participants were significantly more likely to agree to end of life care when AND was used.
Another study found similar results when giving a scenario to 524 adults- end of life care was more accepted when AND was used. [ 10 ]
However, when patients with cancer were given a scenario about how much time they had left to live (1 year, 6 months, or 1 month), the results were different. In two studies conducted by the same authors, there was no significant difference in choosing end of life care when AND or DNR was used. [ 11 ] [ 12 ]
Finally, an anonymous survey asked residents and doctors about their experience with end of life care after their hospital switched to using AND over DNR. A majority agreed that using AND improved discussions about end of life care and decreased the burden of decision making. [ 13 ]
There are barriers that exist in implementing "allow natural death". Some argue that costs will occur with the need to reeducate clinical staff and replace forms and edit electronic medical databases. People are looking into high-end care for when it comes to end of life decisions and AND can help provide more autonomy for patients. [ 3 ]
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NP_001125 NP_001341646
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Alpha-fetoprotein ( AFP , α-fetoprotein ; also sometimes called alpha-1-fetoprotein , alpha-fetoglobulin , or alpha fetal protein ) is a protein [ 5 ] [ 6 ] that in humans is encoded by the AFP gene . [ 7 ] [ 8 ] The AFP gene is located on the q arm of chromosome 4 (4q13.3). [ 9 ] Maternal AFP serum level is used to screen for Down syndrome , neural tube defects , and other chromosomal abnormalities . [ 10 ]
AFP is a major plasma protein produced by the yolk sac and the fetal liver during fetal development. It is thought to be the fetal analog of serum albumin . AFP binds to copper , nickel , fatty acids and bilirubin [ 8 ] and is found in monomeric , dimeric and trimeric forms.
AFP is a glycoprotein of 591 amino acids [ 11 ] and a carbohydrate moiety . [ 12 ]
The function of AFP in adult humans is unknown. AFP is the most abundant plasma protein found in the human fetus. In the fetus, AFP is produced by both the liver and the yolk sac. It is believed to function as a carrier protein (similar to albumin) that transports materials such as fatty acids to cells. [ 13 ] Maternal plasma levels peak near the end of the first trimester, and begin decreasing prenatally at that time, then decrease rapidly after birth. Normal adult levels in the newborn are usually reached by the age of 8 to 12 months. While the function in humans is unknown, in rodents it binds estradiol to prevent the transport of this hormone across the placenta to the fetus. The main function of this is to prevent the virilization of female fetuses. As human AFP does not bind estrogen, its function in humans is less clear. [ 14 ] In human liver cancer, AFP is found to bind glypican-3 (GPC3), another oncofetal antigen. [ 15 ]
The rodent AFP system can be overridden with massive injections of estrogen, which overwhelm the AFP system and will masculinize the fetus. The masculinizing effect of estrogens may seem counter-intuitive since estrogens are critical for the proper development of female secondary characteristics during puberty. However, this is not the case prenatally. Gonadal hormones from the testes, such as testosterone and anti-Müllerian hormone , are required to cause development of a phenotypic male. Without these hormones, the fetus will develop into a phenotypic female even if genetically XY . The conversion of testosterone into estradiol by aromatase in many tissues may be an important step in masculinization of that tissue. [ 16 ] [ 17 ] Masculinization of the brain is thought to occur both by conversion of testosterone into estradiol by aromatase, but also by de novo synthesis of estrogens within the brain. [ 18 ] [ 19 ] Thus, AFP may protect the fetus from maternal estradiol that would otherwise have a masculinizing effect on the fetus, but its exact role is still controversial.
In pregnant women, fetal AFP levels can be monitored in the urine of the pregnant woman. Since AFP is quickly cleared from the mother's serum via her kidneys, maternal urine AFP correlates with fetal serum levels, although the maternal urine level is much lower than the fetal serum level. AFP levels rise until about week 32. Maternal serum alpha-fetoprotein (MSAFP) screening is performed at 16 to 18 weeks of gestation. [ 20 ] If MSAFP levels indicate an anomaly, amniocentesis may be offered to the patient.
The normal range of AFP for adults and children is variously reported as under 50, under 10, or under 5 ng/mL. [ 21 ] [ 22 ] At birth, normal infants have AFP levels four or more orders of magnitude above this normal range, that decreases to a normal range over the first year of life. [ 23 ] [ 24 ] [ 25 ] [ 26 ] [ 27 ] [ 28 ]
During this time, the normal range of AFP levels spans approximately two orders of magnitude. [ 25 ] Correct evaluation of abnormal AFP levels in infants must take into account these normal patterns. [ 25 ]
Very high AFP levels may be subject to hooking (see Tumor marker ), which results in the level being reported significantly lower than the actual concentration. [ 29 ] This is important for analysis of a series of AFP tumor marker tests, e.g. in the context of post-treatment early surveillance of cancer survivors, where the rate of decrease of AFP has diagnostic value.
Measurement of AFP is generally used in two clinical contexts. First, it is measured in pregnant women through the analysis of maternal blood or amniotic fluid as a screening test for certain developmental abnormalities, such as aneuploidy . Second, serum AFP level is elevated in people with certain tumors, and so it is used as a biomarker to follow these diseases. Some of these diseases are listed below:
A peptide derived from AFP that is referred to as AFPep is claimed to possess anti-cancer properties. [ 36 ]
In the treatment of testicular cancer it is paramount to differentiate seminomatous and nonseminomatous tumors. This is typically done pathologically after removal of the testicle and confirmed by tumor markers. However, if the pathology is pure seminoma but the AFP is elevated, the tumor is treated as a nonseminomatous tumor because it contains yolk sac (nonseminomatous) components. [ 37 ]
This article incorporates text from the United States National Library of Medicine , which is in the public domain .
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α-Methylacyl-CoA racemase ( AMACR , EC 5.1.99.4 ) is an enzyme that in humans is encoded by the AMACR gene . [ 5 ] [ 6 ] [ 7 ] AMACR catalyzes the following chemical reaction :
In mammalian cells, the enzyme is responsible for converting (2 R )-methylacyl-CoA esters to their (2 S )-methylacyl-CoA epimers and known substrates, including coenzyme A esters of pristanic acid (mostly derived from phytanic acid , a 3-methyl branched-chain fatty acid that is abundant in the diet) and bile acids derived from cholesterol. This transformation is required in order to degrade (2 R )-methylacyl-CoA esters by β-oxidation , which process requires the (2 S )-epimer. The enzyme is known to be localised in peroxisomes and mitochondria , both of which are known to β-oxidize 2-methylacyl-CoA esters. [ 8 ] [ 9 ]
This enzyme belongs to the family of isomerases , specifically the racemases and epimerases which act on other compounds. The systematic name of this enzyme class is 2-methylacyl-CoA 2-epimerase . In vitro experiments with the human enzyme AMACR 1A show that both (2 S )- and (2 R )-methyldecanoyl-CoA esters are substrates and are converted by the enzyme with very similar efficiency. Prolonged incubation of either substrate with the enzyme establishes an equilibrium with both substrates or products present in a near 1:1 ratio. The mechanism of the enzyme requires removal of the α-proton of the 2-methylacyl-CoA to form a deprotonated intermediate (which is probably the enol or enolate [ 10 ] ) followed by non-sterespecific reprotonation. [ 11 ] Thus either epimer is converted into a near 1:1 mixture of both isomers upon full conversion of the substrate.
Both decreased and increased levels of the enzyme in humans are linked with diseases.
Reduction of the protein level or activity results in the accumulation of (2R)-methyl fatty acids such as bile acids which causes neurological symptoms. The symptoms are similar to those of adult Refsum disease and usually appear in the late teens or early twenties. [ 12 ]
The first documented cases of AMACR deficiency in adults were reported in 2000. [ 12 ] This deficiency falls within a class of disorders called peroxisome biogenesis disorders (PBDs), although it is quite different from other peroxisomal disorders and does not share classic Refsum disorder symptoms. The deficiency causes an accumulation of pristanic acid , dihydroxycholestanoic acid (DHCA) and trihydroxycholestanoic acid (THCA) and to a lesser extent phytanic acid . This phenomenon was verified in 2002, when researchers reported of a certain case, "His condition would have been missed if they hadn't measured the pristanic acid concentration." [ 13 ]
AMACR deficiency can cause mental impairment, confusion, learning difficulties, and liver damage. It can be treated by dietary elimination of pristanic and phytanic acid through reduced intake of dairy products and meats such as beef, lamb, and chicken. Compliance to the diet is low, however, because of eating habits and loss of weight. [ 14 ] [ 15 ]
Increased levels of AMACR protein concentration and activity are associated with prostate cancer , and the enzyme is used widely as a biomarker (known in cancer literature as P504S ) in biopsy tissues. Around 10 different variants of human AMACR have been identified from prostate cancer tissues, which variants arise from alternative mRNA splicing. Some of these splice variants lack catalytic residues in the active site or have changes in the C-terminus, which is required for dimerisation . Increased levels of AMACR are also associated with some breast, colon, and other cancers, but it is unclear exactly what the role of AMACR is in these cancers. [ 9 ] [ 16 ] [ 17 ]
Antibodies to AMACR are used in immunohistochemistry to demonstrate prostate carcinoma , since the enzyme is greatly overexpressed in this type of tumour. [ 18 ]
The enzyme is also involved in a chiral inversion pathway which converts ibuprofen , a member of the 2-arylpropionic acid (2-APA) non-steroidal anti-inflammatory drug family (NSAIDs), from the R -enantiomer to the S -enantiomer. The pathway is uni-directional because only R -ibuprofen can be converted into ibuprofenoyl-CoA, which is then epimerized by AMACR. Conversion of S -ibuprofenoyl-CoA to S -ibuprofen is assumed to be performed by one of the many human acyl-CoA thioesterase enzymes (ACOTs). The reaction is of pharmacological importance because ibuprofen is typically used as a racemic mixture, and the drug is converted to the S -isomer upon uptake, which inhibits the activity of the cyclo-oxygenase enzymes and induces an anti-inflammatory effect. Human AMACR 1A has been demonstrated to epimerise other 2-APA-CoA esters, [ 19 ] suggesting a common chiral inversion pathway for this class of drugs.
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Alpha cell hyperplasia is defined as a specific (without similar change in other islet cells), diffuse (not limited to a particular part of pancreas), and overwhelming (many-fold) increase of the number of pancreatic alpha cells . [ 1 ] [ 2 ] The pancreatic islets normally contain 4 types of cells; the alpha cells produce and release glucagon , a hormone that regulates the metabolism of glucose and amino acids . Although first described in early 1990s, alpha cell hyperplasia had remained an esoteric topic until the mid-2010s. Based on the pathogenesis and clinical presentation, alpha cell hyperplasia can be divided into 3 types: reactive, nonfunctional, and functional.
Any means to inhibit normal glucagon signaling in any vertebrate animals tested so far (zebra fish, mice, monkeys, and humans) causes reactive alpha cell hyperplasia. [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] There is a negative feedback loop linking the pancreatic alpha cells and the liver. [ 9 ] [ 10 ] When glucagon signaling is inhibited, the liver (the main target organ of glucagon) releases excess amounts of amino acids into the circulation ( hyperaminoacidemia ) which stimulate the alpha cells to proliferate and to produce and release more glucagon . [ 11 ] Humans and animals with reactive alpha cell hyperplasia do not exhibit signs of glucagon excess as their glucagon signaling is inhibited at the first place. Reactive alpha cell hyperplasia is a preneoplastic lesion. Humans with inactivating glucagon mutations (i.e. Mahvash disease ) and several murine models of reactive alpha cell hyperplasia all eventually develop pancreatic neuroendocrine tumors . [ 9 ] [ 12 ] [ 6 ] [ 13 ]
Nonfunctional and reactive alpha cell hyperplasia are indistinguishable histologically. Nonfunctional alpha cell hyperplasia, however, is not associated with hyperglucagonemia. [ 14 ] [ 15 ] The cause of nonfunctional alpha cell hyperplasia in humans requires further investigation. Nonfunctional alpha cell hyperplasia is also a preneoplastic lesion.
Functional alpha cell hyperplasia differs from reactive and nonfunctional alpha cell hyperplasia in that the functional alpha cell hyperplasia is associated with hyperglucagonemia and the hyperglucagonemia results in glucagonoma syndrome. [ 16 ] Functional alpha cell hyperplasia is poorly characterized so far.
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Alphacaine (or Alpha-Caine ) is a brand name for a local anesthetic preparation used in dental procedures. It is formulated to provide temporary pain relief and numbness during treatments such as tooth extractions, fillings, and root canals. [ 1 ]
Depending on location and manufacturer it may contain either benzocaine , articaine , or lidocaine (with or without adrenaline ).
This drug article relating to the nervous system is a stub . You can help Wikipedia by expanding it .
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Alternating hemiplegia (also known as crossed hemiplegia ) is a form of hemiplegia that has an ipsilateral cranial nerve palsies and contralateral hemiplegia or hemiparesis of extremities of the body. The disorder is characterized by recurrent episodes of paralysis on one side of the body. [ 1 ] There are multiple forms of alternating hemiplegia, Weber's syndrome, middle alternating hemiplegia, and inferior alternating hemiplegia. This type of syndrome can result from a unilateral lesion in the brainstem affecting both upper motor neurons and lower motor neurons . The muscles that would receive signals from these damaged upper motor neurons result in spastic paralysis. With a lesion in the brainstem, this affects the majority of limb and trunk muscles on the contralateral side due to the upper motor neurons decussation after the brainstem. The cranial nerves and cranial nerve nuclei are also located in the brainstem making them susceptible to damage from a brainstem lesion. Cranial nerves III (Oculomotor) , VI (Abducens) , and XII (Hypoglossal) are most often associated with this syndrome given their close proximity with the pyramidal tract , the location which upper motor neurons are in on their way to the spinal cord. Damages to these structures produce the ipsilateral presentation of paralysis or palsy due to the lack of cranial nerve decussation (aside from the trochlear nerve ) before innervating their target muscles. The paralysis may be brief or it may last for several days, many times the episodes will resolve after sleep. Some common symptoms of alternating hemiplegia are mental impairment, gait and balance difficulties, excessive sweating and changes in body temperature. [ 1 ]
Superior alternating hemiplegia (also known as Weber syndrome) has a few distinct symptoms: contralateral hemiparesis of limb and facial muscle accompanied by weakness in one or more muscles that control eye movement on the same side. [ 2 ] Another symptom that appears is the loss of eye movement due to damage to the oculomotor nerve fibers. The upper and lower extremities have increased weakness. [ 3 ]
Middle alternating hemiplegia (also known as Foville Syndrome) typically constitutes weakness of the extremities accompanied by paralysis of the extraocular muscle, specifically lateral rectus , on the opposite side of the affected extremities, which indicates a lesion in the caudal and medial pons involving the abducens nerve root (controls movement of the eye) and corticospinal fibers (carries motor commands from the brain to the spinal cord). [ 3 ]
Inferior alternating hemiplegia (also known as medial medullary syndrome) typically involves a "weakness of the extremities accompanied by paralysis of muscles on the ipsilateral side of the tongue (seen as a deviation of the tongue on that side on protrusion). These symptoms indicate a lesion in the medulla involving the corticospinal fibers in the pyramid and the exiting hypoglossal nerve roots. [ 3 ]
Note that this description is focused on alternating hemiplegia of childhood. Similar syndromes may develop following a brainstem infarction.
The cause of alternating hemiplegia of childhood is the mutation of ATP1A3 gene. In a study of fifteen female and nine male patients with alternating hemiplegia, a mutation in ATP1A3 gene was present. Three patients showed heterozygous de-novo missense mutation. Six patients were found with de-novo missense mutation and one patient was identified with de-novo splice site mutation. [ 4 ] De novo mutation is a mutation that occurs in the germ cell of one parent. Neither parent has the mutation, but it is passed to the child through the sperm or egg. [ 5 ]
First, the symptoms must be observed before the patient is 18 months of age. Second, there must be frequent episodes of hemiplegia, involving either side of the body. Third, other paroxysmal disorders including tonic attacks, dystonia , nystagmus , strabismus , dyspnoea , and other uncontrollable disorders are noticed to occur. Although common, the paroxysmal disorders involving the eye, nystagmus and strabismus, may not be apparent in older children and may not have been remembered in childhood so a lack of these symptoms does not rule out alternating hemiplegia. Fourth, all symptoms clear up directly after falling asleep and usually come back after waking during an attack. This occurrence is very indicative of alternating hemiplegia and as such those who display this are usually diagnosed with probable alternating hemiplegia. Fifth, indications of developmental delays, learning disability, or neurological irregularities are present. These issues may not be obvious in very young patients; however, it appears in almost all older patients. [ 6 ] : 777 The final criteria before a diagnosis of alternating hemiplegia can be made is that all of these symptoms must not be due to another disorder. If the symptoms can be attributed to another disease or disorder, then a definitive diagnosis is difficult to make. [ 6 ] : 778
Weber's syndrome is the only form of alternating hemiplegia that is somewhat easy to diagnose beyond the general criteria. Although Weber's syndrome is rare, a child born with the disorder typically has a port-wine stain on the face around the eye. While the port-wine stain does not necessarily mean the child has Weber's syndrome, if the port-wine stain involves the ophthalmic division of the trigeminal nerve than the likelihood of it being weber's syndrome greatly increases. If a port-wine stain around the eye is found, the patient should be screened for intracranial leptomeningeal angiomatosis . Magnetic resonance imaging (MRI) can be used to determine the presence and severity while computed cranial tomography can be used to determine the effect. MRI is the preferred diagnostic test on children presenting with port-wine stain. Other imaging techniques can be used in addition to further determine the severity of the disorder. The initial diagnosis is made based on the presence of neurologic and ophthalmic disease but the disease progresses differently in each patient so after initial diagnosis the patient should be monitored frequently in order to handle further complications resulting from the syndrome. [ 7 ]
Medical treatment of hemiplegia can be separate into several different categories: [ 6 ] : 779
Seizure trigger include exposure to cold, emotional stress, fatigue, bathing, hyperthermia/hypothermia, and upper respiratory infection. A drug called flunarizine , which is a calcium channel blocker can help to reduce the severity and the length of attacks of the paralysis. [ 1 ]
Many children affected by alternating hemiplegia also have epilepsy. Seizures may occur during an attack but more often occur between attacks. Anti-epilepsy drugs are given to prevent or lessen the seizures, but the drugs often don't work and have severe side effects that require the patient to discontinue use. Flunarizine , which blocks calcium channels, is an antiepilepsy drugs used in 50% of patients, and has been shown to shorten the duration of attacks as well as reducing the severity of the attacks. While Flunarizine does not stop the attacks, it is the most common drug prescribed to treat those with alternating hemiplegia. [ 6 ] : 779
Sleep is also used as a management technique. An early indication of an episode is tiredness so medication such as melatonin or Buccal midazolam can be administered to induce sleep and avoid the episode.
People with alternating hemiplegia are often underweight and with the help of dietitians, a meal plan should be developed for times of attack when consumption of food may be difficult. [ 6 ] : 779–780
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Alternating hemiplegia of childhood ( AHC ) is a rare neurological disorder named for the transient episodes, often referred to as "attacks", of hemiplegia (weakness or paralysis) that those with the condition experience. It typically presents before the age of 18 months. These hemiplegic attacks can cause anything from mild weakness to complete paralysis on one or both sides of the body, and they can vary greatly in duration. Attacks may also alternate from one side of the body to the other, or alternate between affecting one or both sides during a single attack. Besides hemiplegia, symptoms of the disorder include an extremely broad range of neurological and developmental impairments which are not well understood. Normally, hemiplegia and other associated symptoms cease completely with sleep, but they may recur upon waking. [ 1 ]
Most frequently AHC is caused by a spontaneous mutation in the ATP1A3 gene. [ 2 ] [ 3 ] [ 4 ] It is an extremely rare disorder – approximately one in one million people have AHC. It was only recently discovered, having first been characterized in 1971. [ 4 ] [ 5 ]
AHC patients exhibit a wide range of symptoms in addition to hemiplegic attacks. [ 1 ] These can be further characterized as paroxysmal and non-paroxysmal symptoms. Paroxysmal symptoms are generally associated with hemiplegic attacks and may occur suddenly with hemiplegia or on their own. Paroxysmal symptoms may last for variable amounts of time. Non-paroxysmal symptoms tend to be side effects of AHC which are present at all times, not just during episodes or attacks. Epilepsy , which is also considered a paroxysmal symptom, plays an important role in the progression and diagnosis of AHC. [ citation needed ]
Chronologically, hemiplegic attacks are not always the first symptom of AHC, but they are the most prominent symptom, as well as the symptom for which the disorder is named. Hemiplegic attacks may affect one or both sides of the body, and attacks which affect both sides of the body may be referred to as either bilateral or quadriplegic attacks. One of the unique characteristics of AHC is that hemiplegic attacks, as well as other symptoms which may co-occur with hemiplegia, cease immediately upon sleep. During strong attacks, the symptoms may reoccur upon waking. [ 4 ] [ 6 ] Hemiplegic attacks can occur suddenly or gradually, and the severity of an attack can vary over its duration. [ 6 ] The attacks may alternate from one side of the body to another, though this is rare. [ 7 ] The length of attacks may also vary from minutes to weeks, [ 4 ] though the length of attacks varies more greatly between people than between attacks for one person. [ 6 ] Both bilateral and hemiplegic attacks are associated with pseudobulbar features such as dysphagia , dysarthria , and respiratory difficulty. [ 4 ] [ 6 ] [ 7 ] Paralysis is also often accompanied by changes in skin color and temperature, sweating, restlessness, tremor, screaming, and the appearance of pain. [ 6 ] Hemiplegic attacks happen irregularly and can occur with speech, eating, and swallowing impairment. Patients with AHC are frequently underweight due to these side effects. [ 7 ] The average age of onset for hemiplegic episodes has been found to be 6–7 months of age. [ 4 ] This early onset gives the name of this disorder the slightly misleading ending "of childhood". AHC is not exclusively limited to childhood – attacks in some cases become milder after the first ten years of life, but they never completely disappear. [ 7 ]
AHC patients have exhibited various paroxysmal symptoms which manifest to different degrees in each person. [ 6 ] Paroxysmal symptoms include tonic , tonic–clonic , or myoclonic limb movements, [ 8 ] dystonic posturing, choreoathetosis , ocular nystagmus , and various other ocular motor abnormalities. [ 1 ] [ 6 ] Almost half of all people have dystonic symptoms prior to experiencing hemiplegia. [ 4 ] These symptoms generally begin before 8 months of age. [ 8 ] Ocular motor abnormalities occur early, and these are the most frequent early symptoms of AHC, particularly nystagmus. [ 4 ] [ 6 ] Almost 1/3 of people with this disorder had episodic ocular motor features within 1–2 days of birth. Many also experienced hemiplegia and dystonia before 3 months of age. [ 4 ] A final symptom that may be considered paroxysmal is a temporary change in behavior - some patients will become unreasonable, demanding, and aggressive either before or after an attack. [ 9 ]
Not all patients have all of these symptoms, and it is not known whether they are caused by AHC. [ 1 ] Symptoms usually manifest in the first 3 months of the child's life, with an average onset of 2.5 months. Frequently, some of these symptoms will manifest in the neonatal period. These paroxysmal symptoms are often used to help diagnose AHC, since there is no simple test for it. [ citation needed ]
In some cases, EEGs taken during these paroxysmal events were characterized by a generalized background slowing. [ 4 ] [ 8 ] Overall however, EEG during episodes and other investigative methods such as brain MRI, TACs, angiographic MRIs and CFS have normal results. [ 10 ]
In the long term, many paroxysmal symptoms occur along with AHC, and while these symptoms vary in strength depending on the person, they are consistent features of AHC. [ 11 ] It is thought that some of these symptoms are brought on or worsened by hemiplegic attacks, though it is not known for certain. Patients experience persistent motor, movement ( ataxia ), and cognitive deficits. [ 4 ] [ 6 ] [ 7 ] These deficits become more apparent over time and include developmental delays, social problems, and retardation. [ 1 ] It is rare for someone with AHC not to have cognitive deficits, but a study in Japan did find two patients who met all of the diagnostic criteria for AHC but who were not mentally impaired. [ 12 ] It is not known whether AHC is a progressive disease, but severe attacks are suspected to cause damage which results in permanent loss of function. [ 7 ] 100% of children studied in the USA have had some form of mental impairment, which is usually described as mild to moderate, [ 4 ] but varies greatly among individuals.
At least 50% of people with AHC also have epilepsy , [ 4 ] and AHC is often misdiagnosed as epilepsy because of this. [ 7 ] These epileptic events are distinguished from other episodes by an alteration of consciousness, as well as frequent tonic or tonic–clonic activity. Epileptic episodes are generally rare, though they do increase with age. Due to the rarity of epileptic episodes, there are few EEG confirmations of them. [ citation needed ]
Recent research suggests that AHC is caused by a de novo (spontaneous) genetic mutation in the ATP1A3 gene [ 13 ] [ 14 ] [ 2 ] on chromosome 19 ( locus 19q13.31) which encodes enzyme ATP1A3. A small number of cases seem to be caused by a mutation in the ATP1A2 gene. [ 14 ] Where the mutation is inherited, it has the autosomal dominant pattern of inheritance. [ 14 ]
Previously AHC was thought to be a form of complicated migraine because of strong family histories of migraine reported in AHC cases. [ 4 ] AHC has also been considered to be a movement disorder or a form of epilepsy. Suggested causes have included channelopathy , mitochondrial dysfunction, and cerebrovascular dysfunction. [ 9 ] The disorder most closely related to AHC is familial hemiplegic migraine which is caused by a mutation in a gene for calcium channel receptors. It was thus thought that AHC may be caused by a similar channelopathy. [ 12 ]
As of 1993 only approximately 30 people with AHC had been described in scientific literature. [ 6 ] Due to the rarity and complexity of AHC, it is not unusual for the initial diagnosis to be incorrect, or for diagnosis to be delayed for several months after the initial symptoms become apparent. [ 7 ] The average age of diagnosis is just over 36 months. [ 4 ] Diagnosis of AHC is not only difficult because of its rarity, but because there is no diagnostic test, making this a diagnosis of exclusion. There are several generally accepted criteria which define this disorder, however other conditions with a similar presentation, such as HSV encephalitis, must first be ruled out. Due to these diagnostic difficulties, it is possible that the commonness of the disease is underestimated. [ citation needed ]
The following descriptions are commonly used in the diagnosis of AHC. The initial four criteria for classifying AHC were that it begins before 18 months of age, includes attacks of both hemiplegia on either side of the body, as well as other autonomic problems such as involuntary eye movement (episodic monocular nystagmus), improper eye alignment, choreoathetosis , and sustained muscle contractions (dystonia). [ 4 ] [ 6 ] Finally, those with the condition often develop intellectual disabilities, delayed development, and other neurological conditions. [ 7 ] [ 9 ] These diagnostic criteria were updated in 1993 to include the fact that all of these symptoms dissipate immediately upon sleeping. Diagnostic criteria were also expanded to include episodes of bilateral hemiplegia which shifted from one side of the body to the other. [ 9 ]
Recent criteria have been proposed for screening for AHC early, in order to improve the diagnostic timeline. These screening criteria include focal or unilateral paroxysmal dystonia in the first 6 months of life, as well as the possibility of flaccid hemiplegia either with or separate from these symptoms. Paroxysmal ocular movements should also be considered, and these should include both binocular and monocular symptoms which show in the first 3 months of life. [ 4 ]
Overall outcomes for AHC are generally poor, which is contributed to by AHC's various diagnostic and management challenges. In the long term, AHC is debilitating due to both the hemiplegic attacks and permanent damage associated with AHC. This damage can include cognitive impairment, behavioral and psychiatric disorders, and various motor impairments. [ 7 ] There is, however, not yet any conclusive evidence that AHC is fatal or that it shortens life expectancy, but the relatively recent discovery of the disorder makes large data for this type of information unavailable. Treatment for AHC has not been extremely successful, and there is no cure. [ 1 ] There are several drugs available for treatment, as well as management strategies for preventing and dealing with hemiplegic attacks. [ citation needed ]
Hemiplegic attacks can be brought on by particular triggers, and management of AHC often centers around avoiding common or known triggers. While triggers vary greatly from person to person, there are also some common ones which are prevalent in many patients. Common triggers include temperature changes, water exposure, bright lights, certain foods, emotional stress, and physical activity. While avoiding triggers may help, it cannot prevent all hemiplegic episodes because many occur without being triggered. Because attacks and other associated symptoms end with sleep, various sedatives can be used to help patients sleep. [ 4 ] [ 7 ]
The most common drug used to treat AHC is flunarizine . Flunarizine functions by acting as a calcium channel blocker. Other drugs, in order of frequency of use are benzodiazepines, carbamazapine, barbiturates, and valproic acid. Flunarizine is prescribed for the purpose of reducing the severity of AHC attacks and the number of episodes, though it rarely stops attacks altogether. [ 4 ] Minimizing the attacks may help reduce damage to the body from hemiplegic attacks and improve long-term outcomes as far as mental and physical disabilities are concerned. [ 1 ] [ 12 ]
Experts differ in their confidence in flunarizine's effectiveness. [ 6 ] [ 12 ] Some studies have found it to be very effective in reducing the duration, severity, and frequency of hemiplegic attacks. [ 12 ] It is generally considered the best treatment available, but this drug is thought by some to be of little benefit to AHC patients. Many affected people experience adverse effects without seeing any improvement. [ 6 ] Flunarizine also causes problems because it is difficult for patients to obtain, as it is not readily available in the United States. [ citation needed ]
In 2009 through 2011 clinical research at the University of Utah investigated whether sodium oxybate , also known as gamma-hydroxybutyric acid is an effective treatment for AHC. [ 15 ] Thus far, only a small number of patients have been sampled, and no conclusive results are yet available. While some success has been had thus far with the drug, AHC patients have been known to respond well initially to other drugs, but then the effectiveness will decline over time. Currently, sodium oxybate is used as a narcolepsy - cataplexy treatment, though in the past it has been used controversially in nutritional supplements. This drug was chosen to test because of a possible link between the causes of narcolepsy-cataplexy and AHC. [ citation needed ]
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The Alternative DSM-5 Model for Personality Disorders , introduced in Section III of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-5 ), [ 1 ] provides an alternative conceptual framework for the classification and understanding of personality disorders . It differs from previous DSM models of personality disorders, including the standard model in the DSM-5, in that it is based on a dimensional approach to personality pathology , whereas previous models have been characterized by rigid diagnostic criteria for each individual personality disorder. [ 2 ] The alternative model, on the other hand, aims to better capture the complexity of personality pathology by assessing impairments in personality functioning and pathological personality traits . Designed to address limitations of the categorical system—such as excessive comorbidity and lack of diagnostic precision [ 2 ] —the alternative model offers a nuanced perspective that aligns more closely with contemporary research and clinical practice. Its focus on the interplay between personality traits and functioning aims to improve diagnostic accuracy and treatment planning, though it remains a topic of ongoing debate and research. [ 3 ] The alternative model features the following specified personality disorders, in alphabetical order: antisocial , avoidant , borderline , narcissistic , obsessive-compulsive , and schizotypal . [ 2 ] This constitutes a reduction of entities, as the standard model contains the additional diagnoses of dependent , histrionic , paranoid , and schizoid personality disorders.
In the alternative model, personality disorders are conceptualized based on level of impairment of personality functioning, as well as specific pathological personality traits present in the subject. Central to this model is the Level of Personality Functioning Scale (LPFS), which quantifies impairment on a spectrum from 0 ( little to no impairment ) to 4 ( extreme impairment ). Personality functioning is divided into two interrelated domains: self-functioning (encompassing identity coherence and self-direction) and interpersonal functioning (involving empathy and capacity for intimacy). Each of these four elements operates along a continuum, spanning from adaptive functioning to severe dysfunction. Additionally, the AMPD identifies five broad trait domains— Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism —that manifest in varying degrees across distinct personality disorders.
The AMPD contains both criteria in general for what constitutes a personality disorder (PD), as well as criteria for specific personality disorders. The general criteria apply to any diagnosis of a PD, and as such, to any specified personality disorder, as well as to Personality Disorder - Trait Specified. [ 2 ]
The level of personalty functioning is assessed in accordance with a scale provided with the AMPD called the Level of Personality Functioning Scale (LPFS), which ranges from 0 ("Little or no impairment") to 4 ("Extreme impairment"), thus making the model truly dimensional and inclusive of the entire spectrum of personality functioning. [ 4 ] Personality functioning is conceptualized as consisting of self functioning on the one hand, comprising identity and self-direction, and interpersonal functioning on the other hand, comprising empathy and intimacy. [ 2 ] The functioning levels of each of these four components are on a continuum ranging from optimal functioning to extremely dysfunctional. A diagnosis of a personality disorder requires that the impairment is moderate or greater (impairment ≥ 2). [ 5 ]
The introduction of the LPFS in the alternative model was driven by findings that personality disorders share substantial commonalities. Assessment of the level of personality functioning as a core element in the diagnosis of personality disorder also has the benefit of clearly defining how severe the impairment must be and how it manifests in general functioning, rather than diagnosis relying merely on traits, which may not necessarily cause impairment significant enough to warrant a diagnosis. In addition to this, the LPFS captures a clearly defined core of what personality functioning is, and how impairment generally manifests, regardless of specified pathological traits. [ 4 ]
The pathological personality traits, known as trait facets , are grouped into the following domains : antagonism, detachment, disinhibition , negative affectivity , and psychoticism. These domains differ in prominence between specific personality disorders; for example, schizotypal personality disorder is characterized by traits of detachment and psychoticism, according to the criteria in the AMPD. In addition to their role in diagnosing specific personality disorders, these traits, along with a rating based on the LPFS, can be used to construct a diagnosis of personality disorder–trait specified (PD-TS). The AMPD specifies 25 different trait facets, each with its own definition. [ 2 ] The trait domains are explained below:
The trait domains in the AMPD were developed to be consistent with the more broadly used Five Factor Model of personality , but with focus on the mal-adaptive ends of each of these personality factor spectra. [ 8 ] [ 9 ] The relationship between the Five Factor Model's openness and the AMPD's psychoticism has been subject to dispute. Studies on the topic have utilized different measures and definitions of the two concepts and have given mixed results, with some studies showing little to no connection while other studies report a weak correlation. Conceptualizations of openness differ from each other, with some focusing on traits such as self-actualization and open-mindedness, whereas others align more closely with schizotypal tendencies , the latter resulting in higher correlations with psychoticism . [ 9 ]
The alternative model requires that the impairments in the functioning of the personality are "relatively inflexible" and significantly affect the subject's overall functioning across time and in different types of situations. As such, these impairments cannot be only situational, and the pathology persists despite its patterns being mal-adaptive. Impacts of the pathology affect the subject's perceptions, thoughts, emotions, as well as way of relating to others and to self. Thus, the subject has trouble functioning in a multitude of important areas of life. [ 10 ]
The condition must not be attributable to other medical (criterion F) or psychiatric (criterion E) conditions, substances (criterion F), and the impairment in personality functioning and the expression of personality traits cannot be sufficiently accounted for by typical developmental stages or the individual's sociocultural background (criterion G). [ 10 ] Criterion E requires a differential diagnosis in order to verify that personality disorder is the appropriate diagnosis. Other conditions, such as bipolar disorder [ 11 ] and autism spectrum disorder [ 12 ] can be difficult to differentiate from a personality disorder. At the same time, the AMPD manual states that "patients with other mental disorders should be assessed for co-morbid personality disorders", [ 10 ] because there is no dichotomy between personality disorders and having another mental disorder, and because the presence of personality disorder is relevant to the clinical picture. [ 10 ]
Each of the six specific personality disorders included in the AMPD have their own short description, which captures the overall features of the respective disorder. For example, avoidant personality disorder (AvPD) is described in the following manner:
"Typical features of avoidant personality disorder are avoidance of social situations and inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment." [ 13 ]
In the sections for the specific personality disorders, the general description is followed by descriptions of the characteristic manner in which the specific personality disorder impacts each of the elements of personality functioning, as well as descriptions of how mal-adaptive traits characteristic of the disorder commonly manifest themselves as part thereof. A certain number of impairments in elements of personality functioning, as well as of pathological personality traits, has to be fulfilled in order for the criteria to be met. [ 7 ]
In addition to a description and criteria specific to the personality disorder, every specific personality disorder has a section dedicated to specifiers , [ 7 ] i.e. traits which can be specified in addition to the required ones if they "may have clinical relevance". [ 14 ] One example of this is narcissistic personality disorder (NPD) having suggested specifiers of additional antagonistic traits as well as traits of negative affectivity for malignant and vulnerable manifestations of NPD, respectively. [ 15 ] The specificity of suggested specifiers varies between disorders; e.g. whereas suggestions concerning NPD are somewhat more specific, the AMPD states that non-required traits vary substantially in the case of AvPD. [ 13 ] Level of personality functioning may optionally be recorded for any of the disorders. [ 7 ]
The AMPD also contains a diagnostic category called Personality Disorder - Trait Specified (PD-TS). This diagnosis consists of pathology within at least two elements of personality functioning, as well as of at least one domain of pathological traits. PD-TS thus includes personality pathologies which do not align well with the established specific diagnoses in the AMPD. [ 16 ] A study conducted among a sample of outpatients as well as non- patients deemed high-risk showed that slightly more than a fifth of people who met criterion A for personality disorder fit a specific personality disorder well, meaning that a great majority of people who are eligible for a diagnosis of personality disorder have a clinical picture better captured by PD-TS, unless diagnosed with several specific personality disorders and/or specifiers to those disorders, in case the criteria for at least one specific PD are met. [ 17 ]
Both the categorical standard model and, to a lesser extent, [ 17 ] the specific PD diagnoses in the AMPD share the weakness of being polythetic in nature; a diagnostic category may require only a subset of the total amount of criteria to be fulfilled in order for a diagnosis to be made. For example, the standard model requires that five out of nine criteria be met for a borderline personality disorder diagnosis, [ 18 ] which means that two individuals diagnosed with the same disorder could exhibit entirely different symptom profiles, with only one overlapping criterion. The aforementioned problem is ameliorated by the introduction of the PD-TS diagnosis, which is specific with regard to the traits present in a subject. [ 17 ]
Although the AMPD has been criticized for possibly complicating communication and classification of personality disorder (s), due to its dimensional nature comprising a multitude of factors, a diagnosis based in a dimensional model may prove more useful because it provides a descriptive rather than purely categorical diagnosis. [ 19 ] As such, an AMPD diagnosis has advantages such as giving a more in-depth description of the nature of an individual's mental impairment and suffering, in addition to documenting both the presence of a personality disorder and the specific ways in which it manifests, [ 19 ] with the specified PD categories found in the AMPD maintaining a degree of compatibility with the standard model. [ 19 ] [ 2 ] This compatibility has been demonstrated through correlations between personality disorders in the AMPD and their standard model counterparts being strong [ 20 ] for all AMPD PDs except obsessive-compulsive and schizotypal PDs, which had moderate [ 20 ] correlations of 0.57 and 0.63, respectively; [ 21 ] this was suggested to "likely to be as high as [the agreement] between two diagnosticians on DSM-IV (and now DSM-5 Section II) diagnoses". [ 21 ]
Contrary to the aforementioned concern regarding possible complexities introduced by the AMPD, ease of use has also been described as being an advantage pertaining to the alternative model. [ 21 ] In addition to this, although the standard model – in this case the one in the DSM-IV-TR , which is the same as the standard model in section II of the DSM-5 [ 22 ] – has been described as useful and easy to use by professionals, a study has shown that in the majority of domains measured, professionals rated the AMPD to be at least equal to or even superior to the standard model. The standard model was not evidently perceived as being superior to the AMPD, whereas there is significant evidence for the alternative model being perceived by professionals as having multiple advantages compared to the standard model. [ 23 ]
An example of the AMPD being useful in practice is its use to assess one patient by several different treatment providers at different points in time. In this case, changes in the level of personality functioning, assessed in accordance with the LPFS, have and can be noted for inclusion in the basis for treatment. [ 24 ] Research suggests that clinicians tend to provide consistent assessments of both personality functioning and mal-adaptive traits. [ 25 ] While the level of personality functioning may vary across time, subject to treatment, research supports that mal-adaptive traits tend to be more consistent. [ 24 ] While the benefit has not been as clear in the case of criterion A, clinicians have noted several benefits to the AMPD's criterion B, such as its ability to capture an individual's personal set of trait pathology, which is useful both for communication with the patient and for documenting an individual's clinical picture more comprehensively. [ 1 ]
Although there is limited research and scientific knowledge regarding the relationship between AMPD criterion B pathological traits and treatment decision-making as well as the results thereof, [ 1 ] there is some evidence indicating that negative affectivity, by virtue of being related to neuroticism, could predict SSRI -type [ 26 ] antidepressants having an ameliorating effect. [ 1 ] The AMPD has additionally undergone a trial in clinical settings as part of a psychological assessment conducted on patients before they undergo bariatric surgery , which has shown the AMPD's assessment of mal-adaptive personality traits to hold significance in the pre-surgery psychological assessment. [ 24 ] There is empirical support for Five Factor Model traits – to which AMPD criterion B traits are related [ 9 ] – being useful when deciding on treatment approaches. [ 27 ]
Since being published in the DSM-5, the Alternative DSM-5 Model for Personality Disorders (AMPD) has given rise to, and been subject to, a multitude of research with the purpose of proving or disproving the AMPD's validity and usefulness in clinical settings, as well as how it compares to other models, such as the standard model in the DSM-5. The results of the research have largely supported the model's overall validity. [ 24 ] [ 25 ] Regarding the main criteria (A and B) of the model, research has found a strong correlation between results from assessment regarding level of personality functioning, and mal-adaptive personality traits, respectively, which makes it difficult to separate in which way each of these influences the personality disorder. [ 25 ] Another trait-related point of criticism leveled against the AMPD is that the model fails to define the amplitude of a trait required for its inclusion in the basis for a diagnosis to be made. [ 28 ]
The AMPD has additionally received criticism for the decision not to include four of the distinct diagnostic categories found in the standard model, which was not supported by a broad consensus of professionals at the time. Thus, an online survey was conducted among members of the Association for Research on Personality Disorders and the International Society for the Study of Personality Disorders to assess perceptions of the utility and validity of the DSM-IV-TR personality disorder categories, [ 3 ] which are the same as the categories found in the DSM-5 standard model. [ 22 ] The results indicated that most respondents regarded all personality disorders, particularly antisocial and borderline personality disorders, as valid. The only diagnosis regarding the inclusion of which the majority of respondents were not clearly supportive, was histrionic personality disorder . Likewise, most participants opposed the removal of any personality disorder from the classification system, with no disorder receiving majority support for deletion. [ 3 ]
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Alternative cancer treatment describes any cancer treatment or practice that is not part of the conventional standard of cancer care. [ 2 ] These include special diets and exercises, chemicals, herbs , devices, and manual procedures. Most alternative cancer treatments do not have high-quality evidence supporting their use and many have been described as fundamentally pseudoscientific . [ 3 ] [ 4 ] [ 5 ] [ 6 ] Concerns have been raised about the safety of some purported treatments, and some have been found unsafe in clinical trials. Despite this, many untested and disproven treatments are used around the world.
Alternative cancer treatments are typically contrasted with experimental cancer treatments – science-based treatment methods – and complementary treatments, which are non-invasive practices used in combination with conventional treatment. All approved chemotherapy medications were considered experimental treatments before completing safety and efficacy testing. [ citation needed ]
Since the late 19th century, medical researchers have established modern cancer care through the development of chemotherapy , radiation therapy , targeted therapies , and refined surgical techniques . As of 2019 [update] , only 32.9% of cancer patients in the United States died within five years of their diagnosis. [ 7 ] Despite their effectiveness, many conventional treatments are accompanied by a wide range of side effects, including pain, fatigue, and nausea. [ 8 ] [ 9 ] Some side effects can even be life-threatening. [ citation needed ] Many supporters of alternative treatments claim increased effectiveness and decreased side effects when compared to conventional treatments. However, one retrospective cohort study showed that patients using alternative treatments instead of conventional treatments were 2.5 times more likely to die within five years. [ 10 ]
Most alternative cancer treatments have not been tested in proper clinical trials. Among studies that have been published, the quality is often poor. A 2006 review of 196 clinical trials that studied unconventional cancer treatments found a lack of early-phase testing, little rationale for dosing regimens, and poor statistical analyses. [ 11 ] These treatments have appeared and vanished throughout history. [ 12 ]
Complementary and alternative cancer treatments are often grouped, in part because of the adoption of the phrase complementary and alternative medicine by the United States Congress. [ 13 ] The World Health Organization uses the phrase traditional, complementary, and integrative medicine (TCIM) to describe a similar set of treatments. [ 14 ]
Complementary treatments are used in conjunction with proven mainstream treatments. They tend to be pleasant for the patient, not involve substances with any pharmacological effects, inexpensive, and intended to treat side effects rather than to kill cancer cells. [ 15 ] Medical massage and self-hypnosis to treat pain are examples of complementary treatments.
About half the practitioners who dispense complementary treatments are physicians, although they tend to be generalists rather than oncologists . [ 12 ] As many as 60% of American physicians have referred their patients to a complementary practitioner for some purpose. [ 12 ] While conventional physicians should always be kept aware of any complementary treatments used by a patient, many physicians in the United Kingdom are at least tolerant of their use, and some might recommend them. [ 16 ]
Alternative treatments, by contrast, are used in place of mainstream treatments. The most popular alternative cancer therapies include restrictive diets , mind-body interventions , bioelectromagnetics , nutritional supplements , and herbs . [ 12 ] The popularity and prevalence of different treatments varies widely by region. [ 17 ] Cancer Research UK warns that alternative treatments may interact with conventional treatment, may increase the side effects of medication, and can give people false hope. [ 16 ]
Survey data about how many cancer patients use alternative or complementary therapies vary from nation to nation as well as from region to region. Reliance on alternative therapies is common in developing countries because people cannot afford effective medical treatment. [ 14 ] For example, in Latin America, most cancer patients have used natural products, nutritional supplements , and spiritual practices (such as praying ) in addition to, or instead of, medical care. [ 14 ] In Africa, where millions of people do not have financial or geographical access to an oncologist , many Africans with cancer rely on traditional African medicine , which uses divination , spiritualism , and herbal medicine . [ 14 ] About 40% of African cancer patients take herbal preparations. [ 14 ] Three-quarters of Chinese people with cancer use some form of Traditional Chinese medicine , especially Chinese herbal preparations . [ 14 ] About a third of people with cancer in India use Ayurveda or other elements of AYUSH . [ 14 ]
A 2000 study published by the European Journal of Cancer evaluated a sample of 1023 women from a British cancer registry who had breast cancer and found that 22.4% had consulted with a practitioner of complementary therapies in the previous twelve months. The study concluded that the patients had spent many thousands of pounds on such measures and that use "of practitioners of complementary therapies following diagnosis is a significant and possibly growing phenomenon". [ 18 ]
In Australia , one study reported that 46% of children with cancer have been treated with at least one non-traditional therapy. Further, 40% of those of any age receiving palliative care had tried at least one such therapy. Some of the most popular alternative cancer treatments were found to be dietary therapies, antioxidants, high dose vitamins, and herbal therapies. [ 19 ]
In the United States, nearly all adults who use non-conventional medical therapies do so in addition to conventional medical treatment, rather than as an alternative to it. [ 20 ] Use of unconventional cancer treatments in the United States has been influenced by [ citation needed ] the U.S. federal government's National Center for Complementary and Alternative Medicine (NCCAM), initially known as the Office of Alternative Medicine (OAM), which was established in 1992 as a National Institutes of Health (NIH) adjunct by the U.S. Congress . More specifically, the NIC's Office of Cancer Complementary and Alternative Medicine sponsors over $105 million a year in grants for pseudoscientific cancer research. [ citation needed ] Over thirty American medical schools have offered general courses in alternative medicine, including the Georgetown , Columbia , and Harvard university systems, among others. [ 12 ]
People drawn to alternative treatments tend to believe that evidence-based medicine is invasive or ineffective, while still hoping that their health could be improved. [ 21 ] They are loyal to their alternative healthcare providers and believe that "treatment should concentrate on the whole person". [ 21 ] Among people who (correctly or incorrectly) believe their condition is untreatable, "desperation drives them into the hands of anyone with a promise and a smile." [ 22 ] Con artists have long exploited patients' perceived lack of options to extract payments for ineffectual and even harmful treatments. [ 22 ]
No evidence suggests that the use of alternative treatments improves survival. [ 23 ] In 2017, one retrospective, observational study suggested that people who chose alternative medicine instead of conventional treatments were more than twice as likely to die within five years of diagnosis. [ 10 ] Breast cancer patients choosing alternative medicine were 5.68 times more likely to die within five years of diagnosis. [ 10 ]
Although they are more likely to die than non-users, some users of alternative treatments feel a greater sense of control over their destinies and report less anxiety and depression. [ 24 ] They are more likely to engage in benefit finding , which is the psychological process of adapting to a traumatic situation and deciding that the trauma was valuable, usually because of perceived personal and spiritual growth during the crisis. [ 25 ]
In a survey of American cancer patients, baby boomers were more likely to support complementary and alternative treatments than people from an older generation. [ 26 ] White, female, college-educated patients who had been diagnosed more than a year ago were more likely than others to report a favorable impression of at least some complementary and alternative benefits. [ 26 ]
Many therapies without evidence have been promoted to treat or prevent cancer in humans. In many cases, evidence suggests that the treatments do not work. Unlike accepted cancer treatments , unproven and disproven treatments are generally ignored or avoided by the medical community . [ 3 ]
Despite this, many of these therapies have continued to be promoted as effective, particularly by promoters of alternative medicine . Scientists consider this practice quackery , [ 27 ] [ 28 ] and some of those engaged in it have been investigated and prosecuted by public health regulators such as the US Federal Trade Commission , [ 29 ] the Mexican Secretariat of Health [ 30 ] and the Canadian Competition Bureau . In the United Kingdom , the Cancer Act makes the unauthorized promotion of cancer treatments a criminal offense. [ 31 ] [ 32 ]
In 2008, the United States Federal Trade Commission acted against some companies that made unsupported claims that their products, some of which included highly toxic chemicals, could cure cancer. Targets included Omega Supply, Native Essence Herb Company, Daniel Chapter One, Gemtronics, Inc., Herbs for Cancer, Nu-Gen Nutrition, Inc., Westberry Enterprises, Inc., Jim Clark's All Natural Cancer Therapy, Bioque Technologies , Cleansing Time Pro, and Premium-essiac-tea-4less. [ 33 ]
Most studies of complementary and alternative medicine in the treatment of cancer pain are of low quality in terms of scientific evidence. Studies of massage therapy have produced mixed results, but overall show some temporary benefit for reducing pain, anxiety, and depression and a very low risk of harm, unless the patient is at risk for bleeding disorders. [ 40 ] [ 41 ] There is weak evidence for a modest benefit from hypnosis, supportive psychotherapy and cognitive therapy . Results about Reiki and touch therapy were inconclusive. The most studied such treatment, acupuncture, has demonstrated no benefit as an adjunct analgesic in cancer pain. The evidence for music therapy is equivocal, and some herbal interventions such as PC-SPES, mistletoe, and saw palmetto are known to be toxic to some cancer patients. The most promising evidence, though still weak, is for mind–body interventions such as biofeedback and relaxation techniques. [ 42 ]
As stated in the scientific literature, the measures listed below are defined as 'complementary' because they are applied in conjunction with mainstream anti-cancer measures such as chemotherapy, in contrast to the ineffective therapies viewed as 'alternative' since they are offered as substitutes for mainstream measures. [ 12 ]
Some alternative cancer treatments are based on unproven or disproven theories of how cancer begins or is sustained in the body. Some common concepts are:
This idea says that cancer progression is related to a person's mental and emotional state. Treatments based on this idea are mind–body interventions . Proponents say that cancer forms because the person is unhappy or stressed, or that a positive attitude can cure cancer after it has formed. A typical claim is that stress, anger, fear, or sadness depresses the immune system, whereas love, forgiveness, confidence, and happiness cause the immune system to improve, and that this improved immune system will destroy the cancer. This belief that generally boosting the immune system's activity will kill the cancer cells is not supported by any scientific research. [ 51 ] In fact, many cancers require the support of an active immune system (especially through inflammation) to establish the tumor microenvironment necessary for a tumor to grow. [ 52 ]
In this idea, the body's metabolic processes are overwhelmed by normal byproducts. These byproducts, called "toxins", are said to build up in the cells and cause cancer and other diseases through a process sometimes called autointoxication or autotoxemia . Treatments following this approach are usually aimed at detoxification or body cleansing , such as enemas.
This claim asserts that if only the body's immune system were strong enough, it would kill the "invading" or "foreign" cancer. Unfortunately, most cancer cells retain normal cell characteristics, making them appear to the immune system to be a normal part of the body. Cancerous tumors also actively induce immune tolerance , which prevents the immune system from attacking them. [ 51 ]
This claim uses research into the mechanism of epigenetics to understand how mutations in the epigenetic machinery of cells will alter histone acetylation patterns to create cancer epigenetics . DNA damage appears to be the primary underlying cause of cancer. [ 53 ] [ 54 ] If DNA repair is deficient, DNA damage tends to accumulate. Such excess DNA damage can increase mutational errors during DNA replication due to error-prone translesion synthesis . Excess DNA damage can also increase epigenetic alterations due to errors during DNA repair. Such mutations and epigenetic alterations can give rise to cancer . [ citation needed ]
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Alternative medicine degrees include academic degrees , first professional degrees , qualifications or diplomas issued by accredited and legally recognised academic institutions in alternative medicine or related areas, either human or animal.
Examples of alternative medicine degrees include:
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Aluminium oxide (or aluminium(III) oxide ) is a chemical compound of aluminium and oxygen with the chemical formula Al 2 O 3 . It is the most commonly occurring of several aluminium oxides , and specifically identified as aluminium oxide . It is commonly called alumina and may also be called aloxide , aloxite , ALOX or alundum in various forms and applications and alumina is refined from bauxite . [ 7 ] It occurs naturally in its crystalline polymorphic phase α-Al 2 O 3 as the mineral corundum , varieties of which form the precious gemstones ruby and sapphire ,which have an alumina content approaching 100%. [ 7 ] Al 2 O 3 is used as feedstock to produce aluminium metal, as an abrasive owing to its hardness , and as a refractory material owing to its high melting point. [ 8 ]
Corundum is the most common naturally occurring crystalline form of aluminium oxide. [ 9 ] Rubies and sapphires are gem-quality forms of corundum, which owe their characteristic colours to trace impurities. Rubies are given their characteristic deep red colour and their laser qualities by traces of chromium . Sapphires come in different colours given by various other impurities, such as iron and titanium. An extremely rare delta form occurs as the mineral deltalumite. [ 10 ] [ 11 ] Although aluminum is the most abundant metal in the earth’s crust, it must be extracted from bauxite as alumina to produce aluminum metal. [ 7 ]
The field of aluminium oxide ceramics has a long history. Aluminium salts were widely used in ancient and medieval alchemy . Several vintage textbooks cover the history of the field. [ 12 ] [ 13 ] A 2019 textbook by Andrew Ruys contains a detailed timeline on the
history of aluminium oxide from ancient times to the 21st century. [ 14 ]
Al 2 O 3 is an electrical insulator but has a relatively high thermal conductivity ( 30 Wm −1 K −1 ) [ 2 ] for a ceramic material. Aluminium oxide is insoluble in water. In its most commonly occurring crystalline form, called corundum or α-aluminium oxide, its hardness makes it suitable for use as an abrasive and as a component in cutting tools . [ 8 ]
Aluminium oxide is responsible for the resistance of metallic aluminium to weathering . Metallic aluminium is very reactive with atmospheric oxygen, and a thin passivation layer of aluminium oxide (4 nm thickness) forms on any exposed aluminium surface in a matter of hundreds of picoseconds. [ better source needed ] [ 15 ] This layer protects the metal from further oxidation. The thickness and properties of this oxide layer can be enhanced using a process called anodising . A number of alloys , such as aluminium bronzes , exploit this property by including a proportion of aluminium in the alloy to enhance corrosion resistance. The aluminium oxide generated by anodising is typically amorphous , but discharge-assisted oxidation processes such as plasma electrolytic oxidation result in a significant proportion of crystalline aluminium oxide in the coating, enhancing its hardness .
Aluminium oxide was taken off the United States Environmental Protection Agency 's chemicals lists in 1988. Aluminium oxide is on the EPA's Toxics Release Inventory list if it is a fibrous form. [ 16 ]
Aluminium oxide is an amphoteric substance, meaning it can react with both acids and bases , such as hydrofluoric acid and sodium hydroxide , acting as an acid with a base and a base with an acid, neutralising the other and producing a salt.
The most common form of crystalline aluminium oxide is known as corundum , which is the thermodynamically stable form. [ 17 ] The oxygen ions form a nearly hexagonal close-packed structure with the aluminium ions filling two-thirds of the octahedral interstices. Each Al 3+ center is octahedral . In terms of its crystallography , corundum adopts a trigonal Bravais lattice with a space group of R 3 c (number 167 in the International Tables). The primitive cell contains two formula units of aluminium oxide.
Aluminium oxide also exists in other metastable phases, including the cubic γ and η phases, the monoclinic θ phase, the hexagonal χ phase, the orthorhombic κ phase and the δ phase that can be tetragonal or orthorhombic. [ 17 ] [ 18 ] Each has a unique crystal structure and properties. Cubic γ-Al 2 O 3 has important technical applications. The so-called β-Al 2 O 3 proved to be NaAl 11 O 17 . [ 19 ]
Molten aluminium oxide near the melting temperature is roughly 2/3 tetrahedral (i.e. 2/3 of the Al are surrounded by 4 oxygen neighbors), and 1/3 5-coordinated, with very little (<5%) octahedral Al-O present. [ 20 ] Around 80% of the oxygen atoms are shared among three or more Al-O polyhedra, and the majority of inter-polyhedral connections are corner-sharing, with the remaining 10–20% being edge-sharing. [ 20 ] The breakdown of octahedra upon melting is accompanied by a relatively large volume increase (~33%), the density of the liquid close to its melting point is 2.93 g/cm 3 . [ 21 ] The structure of molten alumina is temperature dependent and the fraction of 5- and 6-fold aluminium increases during cooling (and supercooling), at the expense of tetrahedral AlO 4 units, approaching the local structural arrangements found in amorphous alumina. [ 22 ]
Aluminium hydroxide minerals are the main component of bauxite , the principal ore of aluminium . A mixture of the minerals comprise bauxite ore, including gibbsite (Al(OH) 3 ), boehmite (γ-AlO(OH)), and diaspore (α-AlO(OH)), along with impurities of iron oxides and hydroxides, quartz and clay minerals . [ 23 ] Bauxites are found in laterites . Bauxite is typically purified using the Bayer process :
Except for SiO 2 , the other components of bauxite do not dissolve in base. Upon filtering the basic mixture, Fe 2 O 3 is removed. When the Bayer liquor is cooled, Al(OH) 3 precipitates, leaving the silicates in solution.
The solid Al(OH) 3 Gibbsite is then calcined (heated to over 1100 °C) to give aluminium oxide: [ 8 ]
The product aluminium oxide tends to be multi-phase, i.e., consisting of several phases of aluminium oxide rather than solely corundum . [ 18 ] The production process can therefore be optimized to produce a tailored product. The type of phases present affects, for example, the solubility and pore structure of the aluminium oxide product which, in turn, affects the cost of aluminium production and pollution control. [ 18 ]
The Sintering Process is a high-temperature method primarily used when the Bayer Process is not suitable, especially for ores with high silica content or when a more controlled product morphology is required. [ 24 ] Firstly, Bauxite is mixed with additives like limestone and soda ash, then heating the mixture at high temperatures (1200 °C to 1500 °C) to form sodium aluminate and calcium silicate . [ 25 ] After sintering, the material is leached with water to dissolve the sodium aluminate , leaving behind impurities. Sodium aluminate is then precipitated from the solution and calcined at around 1000 °C to produce alumina. [ 26 ] This method is useful for the production of complex shapes and can be used to create porous or dense materials. [ 27 ]
Known as alpha alumina in materials science , and as alundum (in fused form) or aloxite [ 28 ] in mining and ceramic communities, aluminium oxide finds wide use. Annual global production of aluminium oxide in 2015 was approximately 115 million tonnes , over 90% of which was used in the manufacture of aluminium metal. [ 8 ] The major uses of speciality aluminium oxides are in refractories, ceramics, polishing and abrasive applications. Large tonnages of aluminium hydroxide, from which alumina is derived, are used in the manufacture of zeolites , coating titania pigments, and as a fire retardant/smoke suppressant.
Over 90% of aluminium oxide, termed smelter grade alumina (SGA), is consumed for the production of aluminium, usually by the Hall–Héroult process . The remainder, termed specialty alumina , is used in a wide variety of applications which take advantage of its inertness, temperature resistance and electrical resistance. [ 29 ]
Being fairly chemically inert and white, aluminium oxide is commonly used as a filler for plastics. Aluminium oxide is a common ingredient in sunscreen [ 30 ] and is often also present in cosmetics such as blush, lipstick, and nail polish. [ 31 ]
Many formulations of glass have aluminium oxide as an ingredient. [ 32 ] Aluminosilicate glass is a commonly used type of glass that often contains 5% to 10% alumina.
Aluminium oxide catalyses a variety of reactions that are useful industrially. In its largest scale application, aluminium oxide is the catalyst in the Claus process for converting hydrogen sulfide waste gases into elemental sulfur in refineries. It is also useful for dehydration of alcohols to alkenes .
Aluminium oxide serves as a catalyst support for many industrial catalysts, such as those used in hydrodesulfurization and some Ziegler–Natta polymerizations.
Aluminium oxide is widely used to remove water from gas streams. [ 33 ]
Aluminium oxide is used for its hardness and strength. Its naturally occurring form, corundum , is a 9 on the Mohs scale of mineral hardness (just below diamond). It is widely used as an abrasive , including as a much less expensive substitute for industrial diamond . Many types of sandpaper use aluminium oxide crystals. In addition, its low heat retention and low specific heat make it widely used in grinding operations, particularly cutoff tools. As the powdery abrasive mineral aloxite , it is a major component, along with silica , of the cue tip "chalk" used in billiards . Aluminium oxide powder is used in some CD / DVD polishing and scratch-repair kits. Its polishing qualities are also behind its use in toothpaste. It is also used in microdermabrasion , both in the machine process available through dermatologists and estheticians, and as a manual dermal abrasive used according to manufacturer directions.
Aluminium oxide flakes are used in paint for reflective decorative effects, such as in the automotive or cosmetic industries. [ citation needed ]
Aluminium oxide is a representative of bioinert ceramics. [ 34 ] Due to its excellent biocompatibility, high strength, and wear resistance, alumina ceramics are used in medical applications to manufacture artificial bones and joints. [ 35 ] In this case, aluminium oxide is used to coat the surfaces of medical implants to give biocompatibility and corrosion resistance. [ 36 ] It is also used for manufacturing dental implants, joint replacements, and other medical devices. [ 37 ]
Aluminium oxide has been used in a few experimental and commercial fiber materials for high-performance applications (e.g., Fiber FP, Nextel 610, Nextel 720). [ 38 ] Alumina nanofibers in particular have become a research field of interest.
Some body armors utilize alumina ceramic plates, usually in combination with aramid or UHMWPE backing to achieve effectiveness against most rifle threats. Alumina ceramic armor is readily available to most civilians in jurisdictions where it is legal, but is not considered military grade. [ 39 ]
An aluminium oxide layer can be grown as a protective coating on aluminium by anodizing or by plasma electrolytic oxidation (see the "Properties" above). Both the hardness and abrasion-resistant characteristics of the coating originate from the high strength of aluminium oxide, yet the porous coating layer produced with conventional direct current anodizing procedures is within a 60–70 Rockwell hardness C range [ 40 ] which is comparable only to hardened carbon steel alloys, but considerably inferior to the hardness of natural and synthetic corundum. Instead, with plasma electrolytic oxidation , the coating is porous only on the surface oxide layer while the lower oxide layers are much more compact than with standard DC anodizing procedures and present a higher crystallinity due to the oxide layers being remelted and densified to obtain α-Al2O3 clusters with much higher coating hardness values circa 2000 Vickers hardness. [ citation needed ]
Alumina is used to manufacture tiles which are attached inside pulverized fuel lines and flue gas ducting on coal fired power stations to protect high wear areas. They are not suitable for areas with high impact forces as these tiles are brittle and susceptible to breakage.
Aluminium oxide is an electrical insulator used as a substrate ( silicon on sapphire ) for integrated circuits , [ 41 ] but also as a tunnel barrier for the fabrication of superconducting devices such as single-electron transistors , superconducting quantum interference devices ( SQUIDs ) and superconducting qubits . [ 42 ] [ 43 ]
For its application as an electrical insulator in integrated circuits, where the conformal growth of a thin film is a prerequisite and the preferred growth mode is atomic layer deposition , Al 2 O 3 films can be prepared by the chemical exchange between trimethylaluminium (Al(CH 3 ) 3 ) and H 2 O: [ 44 ]
H 2 O in the above reaction can be replaced by ozone (O 3 ) as the active oxidant and the following reaction then takes place: [ 45 ] [ 46 ]
The Al 2 O 3 films prepared using O 3 show 10–100 times lower leakage current density compared with those prepared by H 2 O.
Aluminium oxide, being a dielectric with relatively large band gap , is used as an insulating barrier in capacitors . [ 47 ]
Before the advent of domestic plastics aluminium ice cream scoops would with wear and tear leave aluminium residue. [ 48 ] [ 49 ]
In lighting, translucent aluminium oxide is used in some sodium vapor lamps . [ 50 ] Aluminium oxide is also used in preparation of coating suspensions in compact fluorescent lamps .
In chemistry laboratories, aluminium oxide is a medium for chromatography , available in basic (pH 9.5), acidic (pH 4.5 when in water) and neutral formulations. Additionally, small pieces of aluminium oxide are often used as boiling chips .
Health and medical applications include it as a material in hip replacements [ 8 ] and birth control pills . [ 51 ]
It is used as a scintillator [ 52 ] and dosimeter for radiation protection and therapy applications for its optically stimulated luminescence properties. [ citation needed ]
Insulation for high-temperature furnaces is often manufactured from aluminium oxide. Sometimes the insulation contains a percentage of silica depending on the temperature rating of the material. The insulation can be made in blanket, board, brick and loose fiber forms for various application requirements.
It is also used to make spark plug insulators . [ 53 ]
Using a plasma spray process and mixed with titania , it is coated onto the braking surface of some bicycle rims to provide abrasion and wear resistance. [ citation needed ]
Most ceramic eyes on fishing rods are circular rings made from aluminium oxide. [ citation needed ]
In its finest powdered (white) form, called Diamantine, aluminium oxide is used as a superior polishing abrasive in watchmaking and clockmaking. [ 54 ]
Aluminium oxide is also used in the coating of stanchions in the motocross and mountain bike industries.
This coating is combined with molybdenum disulfide to provide long term lubrication of the surface. [ 55 ]
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Amaurosis (Greek meaning darkening , dark , or obscure ) is vision loss or weakness that occurs without an apparent lesion affecting the eye . [ 1 ] It may result from either a medical condition or excess acceleration, as in flight. The term is the same as the Latin gutta serena , which means, in Latin, clear drop (or bright drop ). Gutta serena is a condition of partial or complete blindness with a transparent, clear pupil. This term contrasts with suffusio nigra which means, in Latin, dark suffusion , indicating partial or complete blindness with a dark pupil, e.g., a cataract. Milton, already totally blind for twelve years (some scholars think from retinal detachment; others have diagnosed glaucoma) by the time he published Paradise Lost , refers to these terms in Book 3, lines 25–26. [ 2 ]
Leber's congenital amaurosis (LCA) is the most severe and earliest of the inherited retinal dystrophies that cause congenital blindness. It has an incidence of 2-3 per 100,000 births and accounts for 10-18% of cases of congenital blindness among children in blind institutes and 5% of all retinal dystrophies, a figure that is likely to be greater in countries with a greater percentage of consanguinity. [ 3 ]
In most cases, LCA is inherited in an autosomal recessive pattern, as established by Alström and Olson in 1957. Some patients only have retinal blindness, whereas others have multi-systemic involvement that includes renal, cardiac, skeletal, and, most notably, central nervous system anomalies. [ 3 ]
Theodor von Leber, a German ophthalmologist, described LCA in 1869 as a disorder characterized by profound visual loss present at or shortly after birth, nystagmus, sluggish pupillary reactions, and pigmentary retinopathy. [ 3 ]
Amaurosis fugax, also known as transient monocular blindness, is caused by a sudden, temporary decrease in blood flow to one eye. The loss of vision is abrupt, lasting only seconds or minutes. Blindness is total, though it is sometimes limited to a specific area of vision. Blindness frequently develops as if a shade was drawn upward or downward over the eye, rarely sideward. Single or multiple attacks are possible. Some patients experience hundreds, if not thousands, of episodes. Pain, scintillations, and diplopia are usually not present. The prognosis for retinal recovery is good in most patients; retinal infarction occurs in a few. [ 4 ]
Although amaurosis caused by quinine poisoning is now uncommon, it does occur on occasion. When quinine is used as an abortifacient, the initial history may be deceptive, but the presence of characteristic changes in the fundi usually allows certainty of a diagnosis. [ 5 ]
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An ambe , in anatomy , is a superficial jutting out of a bone .
Ambe is also the name of an old surgical instrument, made famous by Hippocrates , for reducing dislocations of the shoulder , so called because its extremity projects like the prominence of a rock. It was described in the Philosophical Transactions of the Royal Society as making a sufficient extension and counter-extension to guide the dislocated bone back into joint. [ 1 ]
This article incorporates text from a publication now in the public domain : Chambers, Ephraim , ed. (1728). "Ambe" . Cyclopædia, or an Universal Dictionary of Arts and Sciences . Vol. Alguazil– anagram (1st ed.). James and John Knapton, et al. p. 74.
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Ambesh maneuver is a technique that involves the simple external compression of internal jugular vein in supraclavicular fossa to prevent [ 1 ] and diagnose [ 2 ] misplacement of the subclavian vein catheter into the internal jugular vein (IJV). The subclavian vein is a big vessel that drains the blood from the hand, forearm and the upper arm into the right side of the heart through superior vena cava. The subclavian veins lie just behind the clavicle on each side and therefore known as subclavian vein. [ citation needed ]
Catheter placement in one of the big veins (Subclavian vein, Internal jugular vein or femoral vein) is routinely done to monitor central venous pressure (CVP), to administer long term intravenous medication and parenteral nutrition in critically sick patients. The subclavian vein is the preferred choice for this purpose because it is most comfortable to the patient and has less chances of infection. However, there is a significant risk of misplacement of subclavian vein catheter into the internal jugular vein of same side. Misplaced catheter enhances the risk of clot formation , thrombophlebitis , catheter erosion and inappropriate delivery of drugs in addition to erroneous CVP value. Chest skiagram is performed to identify misplacement, however, it is time-consuming, requires exposure to radiation and may not be feasible in emergency situations. [ citation needed ]
Ambesh maneuver not only prevents misplacement of subclavian vein catheter into the IJV but also provides instant diagnosis of misplaced catheter. Following successful puncture of subclavian vein with a cannula /needle, same side of IJV is compressed externally by placing a sterile finger in supraclavicular fossa . The guidewire is threaded through the cannula into the subclavian vein keeping the compression on. If the operator notices resistance while inserting the guidewire, it means the guidewire is going north into the IJV. The guidewire is removed gently and re-threaded maintaining the pressure in the supraclavicular fossa. After successful insertion of the guidewire, pressure in fossa is released and the subclavian vein catheter is railroaded over the guidewire up to the desired length. The guidewire is removed and the catheter is now connected to the transducer and the monitor. The CVP waveform pattern as well as its value is noted. The ipsilateral supraclavicular fossa is compressed again and any change in CVP value and/or its waveform pattern is noted. If the waveform pattern is lost (becomes straight line) and or CVP value increased by more than 2 cm H 2 O then it is surely a misplaced subclavian vein catheter into the same side IJV. If no change occurs then this catheter is fine and can be used for CVP monitoring and drug administration. The Ambesh maneuver is quite simple, handy, inexpensive, and instant bedside technique that prevents and diagnoses misplacement of subclavian vein catheter into the IJV [ 3 ] The maneuver is now routinely used and recommended by others to avoid the most common misplacement of subclavian vein catheter. [ 4 ]
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Amblyaudia (amblyos- blunt; audia-hearing) is a term coined by Dr. Deborah Moncrieff to characterize a specific pattern of performance from dichotic listening tests. Dichotic listening tests are widely used to assess individuals for binaural integration, a type of auditory processing skill. During the tests, individuals are asked to identify different words presented simultaneously to the two ears. Normal listeners can identify the words fairly well and show a small difference between the two ears with one ear slightly dominant over the other. For the majority of listeners, this small difference is referred to as a "right-ear advantage" because their right ear performs slightly better than their left ear. But some normal individuals produce a "left-ear advantage" during dichotic tests and others perform at equal levels in the two ears. Amblyaudia is diagnosed when the scores from the two ears are significantly different with the individual's dominant ear score much higher than the score in the non-dominant ear [ 1 ] Researchers interested in understanding the neurophysiological underpinnings of amblyaudia consider it to be a brain based hearing disorder that may be inherited or that may result from auditory deprivation during critical periods of brain development. [ 2 ] Individuals with amblyaudia have normal hearing sensitivity (in other words they hear soft sounds) but have difficulty hearing in noisy environments like restaurants or classrooms. Even in quiet environments, individuals with amblyaudia may fail to understand what they are hearing, especially if the information is new or complicated. Amblyaudia can be conceptualized as the auditory analog of the better known central visual disorder amblyopia . The term “lazy ear” has been used to describe amblyaudia although it is currently not known whether it stems from deficits in the auditory periphery (middle ear or cochlea) or from other parts of the auditory system in the brain, or both. A characteristic of amblyaudia is suppression of activity in the non-dominant auditory pathway by activity in the dominant pathway which may be genetically determined [ 3 ] and which could also be exacerbated by conditions throughout early development.
Children with amblyaudia experience difficulties in speech perception, [ 4 ] particularly in noisy environments, sound localization, [ 5 ] and binaural unmasking [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] (using interaural cues to hear better in noise) despite having normal hearing sensitivity (as indexed through pure tone audiometry). These symptoms may lead to difficulty attending to auditory information causing many to speculate that language acquisition and academic achievement may be deleteriously affected in children with amblyaudia. A significant deficit in a child's ability to use and comprehend expressive language may be seen in children who lacked auditory stimulation throughout the critical periods of auditory system development. A child suffering from amblyaudia may have trouble in appropriate vocabulary comprehension and production and the use of past, present and future tenses. Amblyaudia has been diagnosed in many children with reported difficulties understanding and learning from listening [ 11 ] [ 12 ] [ 13 ] and adjudicated adolescents are at a significantly high risk for amblyaudia (Moncrieff, et al., 2013, Seminars in Hearing).
Families report the presence of amblyaudia in several individuals, suggesting that it may be genetic in nature. It is possible that abnormal auditory input during the first two years of life may increase a child's risk for amblyaudia, although the precise relationship between deprivation timing and development of amblyaudia is still unclear. Recurrent ear infections ( otitis media ) are the leading cause of temporary auditory deprivation in young children. [ 14 ] [ 15 ] [ 16 ] During ear infection bouts , the quality of the signal that reaches the auditory regions of the brains of a subset of children with OM is degraded in both timing and magnitude. [ 17 ] [ 18 ] When this degradation is asymmetric (worse in one ear than the other) the binaural cues associated with sound localization can also be degraded. Aural atresia (a closed external auditory canal) also causes temporary auditory deprivation in young children. Hearing can be restored to children with ear infections and aural atresia through surgical intervention (although ear infections will also resolve spontaneously). Nevertheless, children with histories of auditory deprivation secondary to these diseases can experience amblyaudia for years after their hearing has been restored. [ 6 ] [ 19 ]
Amblyaudia is a deficit in binaural integration of environmental information entering the auditory system. It is a disorder related to brain organization and function rather than what is typically considered a “hearing loss” (damage to the cochlea). It may be genetic or developmentally acquired or both. When animals are temporarily deprived of hearing from an early age, profound changes occur in the brain. Specifically, cell sizes in brainstem nuclei are reduced, [ 20 ] [ 21 ] [ 22 ] [ 23 ] the configuration of brainstem dendrites are altered [ 24 ] [ 25 ] [ 26 ] and neurons respond in different ways to sounds presented to both the deprived and non-deprived ears. [ 27 ] [ 28 ] [ 29 ] [ 30 ]
An electrophysiologic study demonstrated that children with amblyaudia (referred to then as a "left-ear deficit") were less able to process information from their non-dominant ears when competing information is arriving at their dominant ears. The N400-P800 complex [ 31 ] showed a strong and highly correlated response from the dominant and non-dominant ears among normal children while the response from children with amblyaudia was uncorrelated and indicated an inability to separate information arriving at the non-dominant ear from the information arriving at the dominant ear. The same children also produced weaker fMRI responses from their non-dominant left ears when processing dichotic material in the scanner. [ 32 ]
A clinical diagnosis of amblyaudia is made following dichotic listening testing as part of an auditory processing evaluation. Clinicians are advised to use newly developed dichotic listening tests that provide normative cut-off scores for the listener's dominant and non-dominant ears. These are the Randomized Dichotic Digits Test [ 33 ] and the Dichotic Words Test. [ 34 ] Older dichotic listening tests that provide normative information for the right and left ears can be used to supplement these two tests for support of the diagnosis ( [ 1 ] ). If performance across two or more dichotic listening tests is normal in the dominant ear and significantly below normal in the non-dominant ear, a diagnosis of amblyaudia can be made. [ 35 ]
A number of computer-based auditory training programs exist for children with generalized Auditory Processing Disorders (APD) . In the visual system, it has been proven that adults with amblyopia can improve their visual acuity with targeted brain training programs ( perceptual learning ). [ 36 ] A focused perceptual training protocol for children with amblyaudia called Auditory Rehabilitation for Interaural Asymmetry (ARIA) was developed in 2001 [ 37 ] which has been found to improve dichotic listening performance in the non-dominant ear and enhance general listening skills.
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The ambulatory ( Latin : ambulatorium 'walking place') is the covered passage around a cloister or the processional way around the east end of a cathedral or large church and behind the high altar . [ 1 ] [ 2 ] The first ambulatory was in France in the 11th century but by the 13th century ambulatories had been introduced in England and many English cathedrals were extended to provide an ambulatory. [ 3 ]
The same feature is often found in Indian architecture and Buddhist architecture generally, especially in older periods. Ritual circumambulation or parikrama around a stupa or cult image is important in Buddhism and Hinduism . Often the whole building was circumambulated, often many times. The Buddhist chaitya hall always allowed a path for this, and the Durga temple, Aihole (7th or 8th century) is a famous Hindu example.
The term is also used to describe a garden feature in the grounds of a country house. A typical example is the one shown, which stands in the grounds of Horton Court in Gloucestershire , England. [ 4 ]
Ambulatory is also an adjective used to describe
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Ambulatory Patient Group ( APG ) is a classification system for outpatient services reimbursement developed for the American Medicare service by the Health Care Financing Administration . [ 1 ] It classifies patients into nearly 300 pathology groups rather than the 14,000 of the International Classification of Diseases .
The APG system is similar to the diagnosis-related groups (DRG), which apply to inpatient care rendered by a hospital.
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Ameloblastic carcinoma is a rare form of malignant odontogenic tumor , that develops in the jawbones from the epithelial cells that generate the tooth enamel . It is usually treated with surgery; chemotherapy has not been proven to be effective. [ 1 ] [ 2 ]
Common symptoms of ameloblastic carcinomas are pain and swelling either localized in the jaw or throughout the entire face, dysphagia, and trismus . Less common symptoms include ulceration, loosening of the teeth, chronic epistaxis , facial pressure, and nasal dyspnea. [ 3 ] [ 4 ]
It is speculated that some cases of ameloblastic carcinoma arise from remnants of epithelial tissue left behind after the development of the teeth and related structures. Other times, it may be caused by a benign odontogenic cyst becoming malignant, or a pre-existing ameloblastoma. [ 5 ] [ 2 ]
Chemotherapy has not proven effective in treating ameloblastic carcinoma, leaving surgical removal of the tumor one of the only options. [ 6 ] Surgical resection with wide margins is the main treatment. [ 7 ]
Followup after surgery is important, as over 50% of recurrences occur within 5 years. [ 6 ]
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Amenomania (compound of Latin amoenus , "cheerful"; and Greek μανία, "madness") [ 1 ] is a disused psychiatric diagnosis that originally designated patients with delusional disorders which do not paralyse them, but who may have fixed bizarre delusions. In some cases, religious delusion might accompany, causing individuals to believe themselves to have peculiar spiritual powers, or to even be God , often characterising outlines which might be diagnosed by modern psychiatry as paranoid schizophrenia or bipolar disorder . [ 2 ] [ 3 ]
According to Benjamin Rush , amenomania would be a higher form of hypochondriasis , in which the patient, instead of having anxiety upon non-existent diseases, would deny any imperfection in his health , being not melancholic about his mental abnormalities, but rather cheerful (hence the name of the condition). [ 4 ]
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The American Academy of Cardiovascular Perfusion (AACP) is a professional association located in Fogelsville, PA, that aims to increase knowledge of cardiovascular perfusion by providing educational resources to its members. [ 1 ] The organization was founded in 1979. [ 1 ] The AACP was organized in 1979 by Earl Lawrence, who was encouraged to establish the organization by Thomas Wharton. [ 1 ] [ 2 ]
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The American Academy of Neurology ( AAN ) is a professional society representing over 40,000 neurologists and neuroscientists . [ 1 ] As a medical specialty society it was established in 1948 by A.B. Baker of the University of Minnesota to advance the art and science of neurology , and thereby promote the best possible care for patients with neurological disorders . It is headquartered in Minneapolis and maintains a health policy office in Washington, D.C.
In April 2012, the academy relocated its headquarters to a new 63,000-square-foot building in downtown Minneapolis. [ 2 ] The five-story facility cost $20 million to build. [ 2 ]
The annual meeting of the AAN is attended by more than 15,000 neurologists and neuroscientists from the US and abroad.
The American Academy of Neurology has formal policies for avoiding conflicts of interest with pharmaceutical and device industries, and meets or exceeds all recommendations of the Council of Medical Specialty Societies Code. [ 3 ]
The AAN partnered with the American Board of Internal Medicine Foundation and Consumer Reports to provide their top 5 recommendations for neurologists. Out of 178 nominations from AAN members, these 5 guidelines were selected by a panel of 4 AAN Staff and 10 experienced AAN members who voted according to a modified Delphi method . [ 4 ] The guidelines were published in Neurology on February 20, 2013.
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American Association of Neuropathologists, Inc. was established in the 1930s as a professional and educational organization representing American neuropathologists . It was incorporated in the State of Pennsylvania in May 1960. Currently, the membership consists of 800 scientists and physicians, many of whom are international members. The AANP's expressed purpose is to advance the science and practice of neuropathology. [ 1 ] Its official journal is the Journal of Neuropathology & Experimental Neurology .
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The American Association of Nurse Anesthesiology ( AANA ), previously named the American Association of Nurse Anesthetists , is a professional association for nurse anesthetists in the United States . The organization states that it has a membership of more than 62,000 and represents approximately 90% of CRNAs in the United States. [ 1 ] The AANA headquarters is currently located in Rosemont, Illinois , a suburb of Chicago .
On June 17, 1931, 48 nurse anesthetists, led by Agatha Hodgins, met in a classroom at the University Hospital of Cleveland Lakeside in Cleveland, Ohio . During this meeting, they founded the National Association of Nurse Anesthetists (NANA). [ 2 ] [ 3 ] The association held its first annual meeting in Milwaukee, Wisconsin , from September 13 to 15, 1933. The meeting drew 120 attendees and saw Agatha Hodgins elected as the inaugural president. [ 2 ] [ 4 ] As a new organization, it had two main objectives: establish a national qualifying exam, and establish an accreditation program for nurse anesthetist schools. The first national certification exam was held in June 1945, with 90 candidates sitting for the exam. [ 2 ] [ 5 ]
The AANA began accrediting nurse anesthetist programs in 1952 [ 6 ] and was recognized as an accrediting body by the U.S. Department of Education in 1955. [ 2 ] In 1975, the accreditation of nurse anesthesia educational programs transitioned from the AANA to the autonomous Council on Accreditation of Nurse Anesthesia Educational Programs (COA). [ 6 ]
In August 2021, the organization changed its name from "American Association of Nurse Anesthetists" to "American Association of Nurse Anesthesiology" as part of a rebranding effort. [ 7 ] This name change, along with the organization's endorsement of the descriptor "nurse anesthesiologist", was subsequently condemned by many physicians ' groups, including the American Medical Association (AMA), American Society of Anesthesiologists (ASA), American Board of Medical Specialties , American Osteopathic Association , American Board of Anesthesiology , and American Osteopathic Board of Anesthesiology . [ 8 ] These organizations state that the name change is misappropriating the anesthesiologist title, and that it is deceptive, misleading to patients, and causes confusion in care settings. [ 9 ] [ 10 ]
The Journal of the American Association of Nurse Anesthesiology ( AANA Journal ) is a peer-reviewed, bimonthly academic journal serving as the official publication of the American Association of Nurse Anesthesiology. [ 11 ] First published in 1933, [ 2 ] [ 12 ] it focuses on disseminating scholarly articles relevant to the practice of nurse anesthesiology. [ 11 ]
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The American Association of Pathologists' Assistants ( AAPA ) is a professional association for laboratory pathologists' assistants (PA).
AAPA was founded in 1972 by the first 5 PA graduates from Duke University Hospital . [ 1 ]
Official website
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The American Board of Anesthesiology sets standards and exams for the accreditation of Board certified anesthesiologists coming to the end of their residency . It is one of the 24 medical specialty boards that constitutes the American Board of Medical Specialties .
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The American Board of Endodontics is the US certifying body for the specialty of endodontics , It was founded in 1956, and is sponsored by the American Association of Endodontists . The board is one of the nine dental specialty boards recognized by the American Dental Association . [ 1 ]
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The American Board of Periodontology is an organization which serves the public and the dental profession by administering the board certification process for experts in the dental specialty of periodontics . The board was formed in 1939 by the American Academy of Periodontology to maintain a high standard of care and advance the science and art of periodontology . It is one of the nine specialty boards recognized by the American Dental Association .
Periodontists who have achieved board certification are awarded the title "Diplomate of the American Board of Periodontology", to demonstrate to the public that their knowledge and skills have passed this rigorous peer review process. [ 1 ]
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The American Board of Psychiatry and Neurology, Inc. ( ABPN ) is a not-for-profit corporation founded in 1934 following conferences of committees appointed by the American Psychiatric Association , the American Neurological Association , and the then "Section on Nervous and Mental Diseases" of the American Medical Association . This action was taken as a method of identifying qualified specialists in psychiatry and neurology . [ 1 ] The ABPN is one of 24 member boards of the American Board of Medical Specialties .
The Board of Directors consists of sixteen voting members. Elections to fill the places of members whose terms have expired take place annually. Neurology and psychiatry are represented on the board. It is independently incorporated. [ 2 ]
In addition to the specialties of psychiatry, neurology, and neurology with a special qualification in child neurology, [ 3 ] the ABPN (sometimes in collaboration with other member boards) has sought from the ABMS and gained approval for recognition of 15 sub-specialties, as listed below: [ 4 ]
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The American College of Cardiology ( ACC ), based in Washington, D.C. , is a nonprofit medical association established in 1949. It bestows credentials upon cardiovascular specialists who meet its qualifications. Education is a core component of the college, which is also active in the formulation of health policy and the support of cardiovascular research.
The American College of Cardiology was chartered and incorporated as a teaching institution in 1949, and established its headquarters, called Heart House, in Bethesda, Maryland , in 1977. [ citation needed ] In 2006, the college relocated to Washington, D.C. 's West End neighborhood.
Past papers for the institution are held at the National Library of Medicine in Bethesda, Maryland. [ 1 ]
The college is governed by its officers, including the president, president-elect, vice president, secretary, treasurer, chief executive officer and board of trustees (BOT). The current ACC Board of Trustees consists of 14 college members. The president of ACC leads the board of trustees for a one-year term. Members of the board of governors serve as grassroots liaisons between the local chapters and the college's national headquarters. Athena Poppas, MD, FACC, was the president for 2020–2021. In July 2023, the college announced that Cathleen Biga, MSN, RN, FACC, would assume the role as president for 2024–2025. [ 2 ]
The American College of Cardiology has approximately 54,000 members, including physicians, registered nurses, clinical nurse specialists, nurse practitioners, physician assistants, doctors of pharmacology and practice administrators, specializing in cardiovascular care. Becoming a fellow of the American College of Cardiology, associate fellow or affiliate member is based on training, specialty board certification, scientific and professional accomplishments and duration of active participation in a cardiovascular related field. At least 75 percent of professional activities must be devoted to the field of cardiovascular disease. Those who have long exposure in field of academics, research and patient care are eligible for the fellowship of this college. The website of ACC has eligibility calculator from which one can find their eligibility score which should be more than 100. Those achieving highest distinction in the field are awarded the title Master of the American College of Cardiology, which is bestowed upon a maximum of three practicing cardiologists each year.
The college maintains 48 chapters in the U.S. and Puerto Rico. Chapters are legally distinct entities from national organization and do not share budgets or staffing. Since 2008, national members have automatically become members of a local chapter.
As early as the 1980s, the college partnered with the American Heart Association to develop the first clinical practice guidelines for cardiovascular practice. In the 1990s, the college used the guidelines to lay the groundwork for studies documenting discrepancies best and actual cardiovascular practices. The college works with national organizations such as the National Heart, Lung and Blood Institute to continually develop and update these guidelines.
In 2000, the college partnered with the American Heart Association to begin development and publication of national performance measurement standards and data standards for both inpatient and outpatient care based on the guidelines. Measurement sets include: coronary artery disease , hypertension , heart failure , atrial fibrillation , cardiac rehabilitation , myocardial infarction , primary prevention and peripheral arterial disease . In addition, the college has submitted its measures to the National Quality Forum , with the majority of its measures receiving endorsement as national standards.
The college has also collaborated with specialty societies to undertake the task of developing and publishing clinical data standards. Clinical data standards developed include those for acute coronary syndrome, atrial fibrillation, heart failure and electrophysiology .
The college has published criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI), computed tomography of the heart and cardiac magnetic resonance imaging , resting transthoracic and transesophageal echocardiography , and coronary revascularization.
The college's National Cardiovascular Data Registry is a source for measuring and quantifying outcomes and identifying gaps in the delivery of quality care. Its data are used in select pay-for-reporting and/or performance programs to demonstrate the benefits and challenges of such incentive programs. To date, the college has developed five hospital-based cardiovascular registries. In addition, the PINNACLE Registry is the nation's first and largest practice-based cardiovascular registry. In 2011, the college and The Society of Thoracic Surgeons launched the STS/ACC TVT Registry, which tracks transcatheter valve therapy procedures.
Currently several key quality initiatives are underway to help translate science into practice and improve outcomes for cardiovascular patients. These projects include the Door to Balloon Alliance, Hospital to Home and Imaging in FOCUS.
Launched in November 2006, the Door to Balloon Alliance is focused on helping hospital not only reduce, but successfully sustain the guideline-recommended time of 90 minutes or less from the time a patient with chest pain arrives at an emergency room until they have a balloon dilatation procedure. The alliance provides hospitals with the evidence-based strategies and resources to focus on process improvement, interdisciplinary cooperation and coordination to substantially impact their door-to-balloon times, and thus, improve patient outcomes.
The hospital to Home initiative, led by both the American College of Cardiology and the Institute for Healthcare Improvement , is a national quality improvement campaign to reduce cardiovascular-related hospital rehospitalizations and improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease. Launched in 2009, it seeks to examine and address readmission problems.
Imaging in FOCUS is a community designed to guide implementation of appropriate use criteria and ensure patients are receiving the right care at the right time; the initiative has produced innovations such as pocket cards and mobile applications; access to an online community; and access to webinars, educational programs and performance improvement tools.
The American College of Cardiology Foundation offers a variety of educational programs and products tailored to the needs of clinicians in a variety of specialty areas at all stages of their careers.
The college also advocates for health policies that allow cardiovascular professionals to provide quality, appropriate and cost-effective care on such issues as Medicare physician payment, medical imaging, health care reform implementation, medical liability reform and funding for prevention and research. The college is also active on policies that address non-communicable diseases.
The college also publishes a peer reviewed scientific journal Journal of the American College of Cardiology with a high Impact factor .
The College organizes an annual conference for each year for sharing the latest research in the field of Cardiology . The college cancelled its flagship conference for the first time since inception of the college for the year 2020 in light of the COVID-19 pandemic . [ 3 ]
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Founded in 1961, the American College of Neuropsychopharmacology (ACNP) is a professional organization of leading brain and behavior scientists. [ 1 ] The principal functions of the College are research and education. Their goals in research are to offer investigators an opportunity for cross-disciplinary communication and to promote the application of various scientific disciplines to the study of the brain's effect on behavior, with a focus on mental illness of all forms. Their educational goals are to encourage young scientists to enter research careers in neuropsychopharmacology and to develop and provide accurate information about behavioral disorders and their pharmacological treatment.
The college is an honorary society. Members are selected primarily on the basis of their original research contributions to the broad field of neuroscience . [ 2 ] The membership of the college is drawn from scientists in multiple fields including behavioral pharmacology , neuroimaging , chronobiology , clinical psychopharmacology , epidemiology , genetics , molecular biology , neurochemistry , neuroendocrinology , neuroimmunology , neurology , neurophysiology , psychiatry , and psychology . [ 3 ]
The annual meeting of the College is a closed meeting; only the ACNP members and their invited guests may attend. [ 4 ] Because of the College's intense concern with, and involvement in, the education and training of tomorrow's brain scientists, the College selects a number of young scientists to be invited to the annual meeting through a competitive process open to all early career researchers. This meeting, a mix of foremost brain and behavior research world-wide, is designed to encourage dialogue, discussion, and synergy by those attending.
The ACNP offers the following awards. [ 5 ]
The Springer-Nature Publishing Group journals Neuropsychopharmacology and NPP-Digital Psychiatry and Neuroscience are their official publications. Neuropsychopharmacology [ 6 ] was first published in 1987 and NPP-Digital Psychiatry and Neuroscience is an Open Access journal that started in 2023.
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The American College of Psychiatrists is an American association of psychiatrists based in Chicago, Illinois . It operates annual meetings, publishes a newsletter, presents awards and organizes the PRITE exam for psychiatric residents and the PIPE exam for practicing psychiatrists. Membership is decided by current members. It was founded in 1963. [ 1 ]
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The American Dental Education Association ( ADEA ) is a non-profit organization that works to further the education of dental professionals and the advancement of academic dental programs in Canada and the United States. Founded in 1923 as the American Association of Dental Schools, [ 1 ] ADEA is based in Washington, D.C.
The ADEA membership includes:
Nancy Goorey became the first female president of ADEA in 1977. [ 2 ] In 2006, ADEA instituted open membership, which increased the number of ADEA member institutions .
ADEA has 38 sections: academic affairs, anatomical sciences, behavioral science , biochemistry, nutrition, and microbiology, business and financial administration, cariology , clinic administration, community and preventative dentistry, comprehensive care and general dentistry, continuing education , dental anatomy and occlusion, dental assisting education, dental hygiene education, dental informatics , dental school admissions officers, development, alumni affairs, and public relations, educational research/development and curriculum, endodontics , gay-straight alliance , gerontology and geriatrics education, graduate and postgraduate education, minority affairs, operative dentistry and biomaterials, oral biology, oral diagnosis/oral medicine, oral and maxillofacial radiology , orthodontics, pediatric dentistry , periodontics , physiology, pharmacology, and therapeutics, postdoctoral general dentistry, practice management , prosthodontics , student affairs and financial aid, and substance abuse, addiction and tobacco dependence education
ADEA has ten special interest groups : career development for the new educator, dental hygiene clinic coordinators, foreign-educated dental professionals, graduate dental hygiene education programs, implant dentistry, lasers in dentistry, professional, ethical, and legal issues in dentistry, scholarship of teaching and learning , and teaching and learning with emerging technologies.
The ADEA Division of Educational Pathways supports four application services for dental students:
ADEA helps students from diverse backgrounds to learn about careers in dentistry as early as elementary school with the following programs:
For dental educators, the ADEA Leadership Institute and the ADEA Allied Dental Faculty Leadership Development Program cultivate leadership skills. Webinars , fellowship programs and numerous meetings (including the ADEA Annual Session & Exhibition) offer educational programming and networking .
ADEA determines best practices for dental education and encourages advancements in dental education programs and institutions. The ADEA Commission on Change and Innovation in Dental Education (ADEA CCI) has engaged representatives from each U.S. dental school specifically to examine dental school curricula .
ADEA provides financial support for dental education, research, and leadership through the Gies Foundation, named after Dr. William J. Gies . The Gies Awards for vision, innovation and achievement in oral health and dental education are distributed annually at the ADEA Annual Session & Exhibition.
ADEA publishes the peer-reviewed Journal of Dental Education , the Bulletin of Dental Education , the ADEA Official Guide to Dental Schools , surveys and reports on the state of dental education and policy briefs.
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The American Heart Association ( AHA ) is a nonprofit organization in the United States that funds cardiovascular medical research , educates consumers on healthy living and fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke . They are known for publishing guidelines on cardiovascular disease and prevention, standards on basic life support , advanced cardiac life support (ACLS), pediatric advanced life support (PALS), and in 2014 issued the first guidelines for preventing strokes in women. [ 1 ] The American Heart Association is also known for operating a number of highly visible public service campaigns starting in the 1970s, and also operates several fundraising events.
Originally formed in Chicago in 1924, [ 2 ] [ 3 ] the American Heart Association is currently headquartered in Dallas , Texas. It was originally headquartered in New York City . [ 2 ] [ 3 ] The American Heart Association is a national voluntary health agency. [ 4 ] The mission of the organization, updated in 2018, is "To be a relentless force for a world of longer, healthier lives." [ 5 ] The organization's work can be divided into five key areas: research; heart and brain health; health equity; advocacy; and professional education and development.
In 1924, cardiologists Paul Dudley White , Hugh D. McCulloch, Joseph Sailer, Robert H. Halsey, James B. Herrick, and Lewis A. Conner, [ 6 ] formed the Association for the Prevention and Relief of Heart Disease as a professional society for doctors. In 1948, the organization transitioned into a nationwide voluntary health organization. [ 7 ] Since 1949, it has funded over $5 billion in cardiovascular, cerebrovascular, and brain health research. [ 8 ] The organization, now known as the American Heart Association, consists of over 33 million volunteers who are dedicated to improving heart health and reducing deaths from cardiovascular diseases. [ 7 ]
In the 1950s and 1960s, the American Heart Association published several reports and guidelines focused on recommended lifestyles to improve cardiovascular health. This included a 1957 report that said: (1) Diet may play an important role in the pathogenesis of atherosclerosis, (2) The fat content and total calories in the diet are probably important factors, (3) The ratio between saturated and unsaturated fat may be the basic determinant, and (4) A wide variety of other factors besides fat, both dietary and non-dietary, may be important. [ 9 ]
By 1961, these findings had been strengthened, leading to the new 1961 American Heart Association recommendations: (1) Maintain a correct body weight, (2) Engage in moderate exercise, e.g., walking to aid in weight reduction, (3) Reduce intake of total fat, saturated fat, and cholesterol. Increase intake of polyunsaturated fat, (4) Men with a strong family history of atherosclerosis should pay particular attention to diet modification, and (5) Dietary changes should be carried out under medical supervision. These recommendations continued to become more precise from 1957 to 1980, but there maintained "a general coherence among them". [ 9 ]
In 1994, the Chronicle of Philanthropy , an industry publication, released the results of the largest study of charitable and non-profit organization popularity and credibility. The study showed that the American Heart Association was ranked as the fifth "most popular charity/non-profit in America" of over 100 charities researched, with 95 percent of Americans over the age of 12 choosing the Love and Like A lot description categories. [ 10 ]
In 1998, the AHA created the American Stroke Association to help prevent strokes, improve treatments, and maximize recoveries. In 2003, the two organizations created the Get With the Guidelines (GWTG)-Stroke program. [ 11 ] It is a voluntary registry that hospitals can use to receive the latest scientific treatment guidelines. [ 12 ] The program also collects data on patient characteristics, hospital adherence to guidelines, and patient outcomes. [ 11 ]
In 2004 the American Heart Association launched the " Go Red for Women " campaign [ 13 ] specifically targeting women, with information about risks and action they can take to protect their health. [ 14 ] All revenues from the local and national campaigns go to support awareness, research, education and community programs to benefit women. [ 15 ] [ 14 ]
In 2008, the AHA recommended “hands only” CPR as an option for bystanders who want to help keep a cardiac arrest victim alive. [ 16 ] [ 17 ] This method removes the practice of performing rescue breaths and depends solely on chest compressions. [ 16 ]
On November 30, 2009, The American Heart Association announced a new cardiac arrest awareness campaign called Be the Beat. [ 18 ] The campaign's aim is to teach 12- to 15-year-olds fun ways to learn the basics of cardiopulmonary resuscitation and how to use an automated external defibrillator .
In 2012, the AHA renewed its focus on hands-only CPR by carrying out a national campaign to educate more people on how to perform this method. Jennifer Coolidge was a spokesperson for the campaign. [ 19 ] [ 20 ]
It also carried out a campaign in 2012 to educate more people on how to carry out hands-only CPR. [ 19 ] [ 20 ] [ 21 ] The 2012 campaign, which began in New York City , had Jennifer Coolidge as the spokesperson. [ 22 ]
In 2013, the American Heart Association issued a joint guideline recognizing obesity as a disease and recommending its treatment by weight loss. [ 23 ]
In 2014, the American Heart Association issued its first guidelines for preventing strokes in women. [ 1 ] Just as heart attack systems differ between men and women, men and women also face different stroke risks. For women, the guidelines for preventing strokes focus on factors such as birth control, pregnancy, and depression. [ 1 ]
In 2015, the American Heart Association officially endorsed the Tobacco 21 campaign, urging local, state and national governments to raise the tobacco and nicotine sales age from 18 to 21. [ 24 ]
In 2016, the American Heart Association, Verily Life Sciences, and AstraZeneca invested $75 million in the One Brave Idea program. The money was awarded to institutions researching new biomarkers, such as genetic and molecular factors, that put individuals at risk for atherosclerosis. [ 25 ] [ 26 ] It was hoped that the research would help the AHA reach its goals of increasing cardiovascular health by 20% and reducing cardiovascular mortality by 20% by 2020. [ 26 ]
In 2017, the American Heart Association, the American College of Cardiology, and nine other groups redefined high blood pressure for the first time in fourteen years. [ 27 ] Under the new guidelines, the high blood pressure reading is 130 over 80, a change from the old 140 over 80. The change was made in recognition of the risk of heart disease, disability, and death faced by those with blood pressures at 130 over 80. [ 27 ] The organization said that they hoped by identifying cardiovascular risks earlier, more people would be able to address the health risks by lifestyle changes instead of medication. [ 27 ]
In 2018, the American Heart Association and American College of Cardiology issued new guidelines for clinicians on the management of cholesterol as a way to reduce risk for heart attack and stroke . Newly included in the guidelines is a recommendation to use coronary artery calcium score if healthcare providers are having difficulty deciding if a patient could benefit from statin medications or should focus solely on lifestyle modifications. The cholesterol guidelines were last updated in 2013. [ 28 ]
In 2020 and 2021, the annual flagship meeting of the organization was held virtually owing to the COVID-19 pandemic and resumed as an in-person conference in 2022. [ 29 ]
In June 2024, the American Heart Association celebrated its 100 year anniversary of its founding. [ 30 ] With the official celebration of its founding, the association was recognized as the nation’s oldest and largest voluntary organization dedicated to fighting heart disease and stroke. [ 31 ] The association held CPR training, where in many places the first hundred or so people to participate in the 5-minute training were given take-home CPR kits. [ 32 ]
Some of the American Heart Association's research, campaigns, and other work is included here.
Since 1949, the association has funded over $5 billion in cardiovascular, cerebrovascular, and brain health research. [ 33 ]
In 2014, the American Heart Association announced the Strategically Focused Research Network initiative to address "key strategic issues as determined by the AHA Board of Directors." Some of the topics focused on by SFRNs include hypertension, heart failure, heart disease, and health technologies and innovation. [ 34 ] [ 35 ]
The Go Red for Women campaign started in 2004 to raise awareness that women, and not only men, are vulnerable to heart disease. [ 36 ] Between 2016 and 2021, the American Heart Association invested $20 million in the Go Red for Women Strategically Focused Research Network. The SFRN also received $52 million from the National Institutes of Health. [ 36 ]
In 2017, the Go Red National Leadership Council was started to engage female executives in the campaign. Additional projects associated with the campaign include Research Goes Red and National Wear Red Day. [ 36 ]
As of 2023, over 900,000 women have joined the campaign and receive updates on what they can do to improve their heart health. The campaign's social media channels had audiences of over 5.3 million in 2022. [ 36 ]
Also in 2023, Miss America’s Scholarship Foundation, a 501(c)(3), announced a 3-year commitment supporting American Heart Association’s women’s initiative, Go Red for Women®. This initiative raises funds and awareness of women’s heart health and bringing fitness initiatives back to the national Miss America competition stage after the swimsuit portion was scrapped in 2018. [ 37 ]
The "Be the Beat" challenge encourages people to learn CPR. [ 36 ]
The CEO Roundtable was formed in 2013 and focuses on implementing evidence-based approaches to workplace health. In 2020, the CEOs of CVS Health, Walgreens Boots Alliance, and US Foods joined the association. [ 38 ] In 2023, there were almost 50 Fortune 100 CEOs in the association. [ 39 ]
In 1998, the association created the American Stroke Association to help prevent strokes, improve treatments, and maximize recoveries. In 2003, the two organizations created the Get With the Guidelines (GWTG)-Stroke program. [ 40 ] It is a voluntary registry that hospitals can use to receive the latest scientific treatment guidelines. [ 41 ] The program also collects data on patient characteristics, hospital adherence to guidelines, and patient outcomes. [ 40 ]
The American Heart Association announced in October of 2024 a grant aimed at improving heart health in rural communities by funding initiatives that address healthcare access and education. This support is expected to enhance resources for prevention and treatment of heart disease in underserved areas. [ 42 ]
This 2023 Spanish-language campaign works to raise awareness among Hispanic Americans about stroke symptoms. The acronym stands for: [ 43 ] [ 44 ]
The American Stroke Association has launched a new Spanish-language website , to educate Hispanic and Latino communities about stroke recognition, prevention, and recovery. [ 45 ]
This is a joint campaign from the American heart Association and the American Diabetes Association. It works to raise awareness about the connection between diabetes and heart disease. [ 46 ] [ 47 ] The AHA reports that adults with diabetes are 2-4 times more likely to die from heart disease than adults without diabetes. [ 46 ]
The "Check. Change. Control." program is an evidence-based hypertension management program that encourages blood pressure self-monitoring. In 2019 it was used by more than 315,000 people. [ 48 ]
This program was started in 2023 to “educate and prepare teens and adults to be confident to save life in a cardiac emergency.” More than 350,000 people have out-of-hospital cardiac arrests each year, and this program wants to help improve their survival rate. [ 49 ]
As part of National Wear Red Day, Buffalo Bills NFL player Damar Hamlin joined the American Heart Association at the Empire State Building to raise awareness about heart health. [ 50 ] Hamlin, who survived a cardiac arrest on the field during a January 2023 game versus the Cincinnati Bengals, shared his experience of how a direct hit caused his heart to stop and emphasized the importance of heart health and emergency response. Cardiologist Dr. Joseph Puma highlighted that timely medical attention, including heart scans, can prevent life-threatening events, urging individuals to seek care if experiencing chest pain, shortness of breath, or other warning signs of heart issues. [ 50 ] [ 51 ]
Life’s Essential 8 (LE8) are cardiovascular health measurements shared by the AHA. Previously the measurements were known as the LE7, but in 2022 the AHA added sleep health as an additional behavioral metric. The other metrics look at body weight, blood pressure, cholesterol, blood sugar, smoking, physical activity, and diet. [ 52 ] [ 53 ]
The American Heart Association’s 2024 Impact Goal states, "Every person deserves the opportunity for a full, healthy life. By 2024, as champions for health equity, the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality." [ 54 ]
The AHA partnered with the Deloitte Health Equity Institute and the Society for Human Resource Management Foundation on the Health Equity in the Workforce initiative. The initiative provides tools to help employers improve health equity in the workplace. [ 55 ]
The AHA's Social Impact Fund is a nationwide fund that provides financial resources for "evidence-based, community driven entrepreneurial solutions that help remove the social and economic barriers to health equity and drive economic empowerment, healthy food access, affordable housing, access to quality healthcare, transportation, educational opportunities, and reduce recidivism." [ 56 ]
Organizations that have received funding include:
The HSI scholarship program is for students who identify as Hispanic/Latino who are enrolled in public health and healthcare focused programs at 18 Hispanic-serving colleges and universities. [ 59 ] [ 60 ] The program's goal is to increase representation in health care. [ 61 ] Students in the program are paired with volunteer mentors. They develop and present a research project that addresses basic, clinical, and educational science, receive a stipend, and participate in professional development workshops. [ 60 ]
The HBCU Scholars program pairs students with a local American Heart Association researcher and was created to " support the development of minority scientists and healthcare professionals ," and increase the number of minority students who apply and are accepted into biomedical and health science programs. [ 62 ] [ 63 ] Students and researchers study the impact of cardiovascular disease in their community, learn the factors affecting vulnerable populations, and sample areas of scientific inquiry. [ 63 ] Students also receive financial stipends. [ 64 ]
HeartCorps is the American Heart Association's Public Health AmeriCorps program and is designed to drive health equity in rural America. As of November 2022, twenty-six states participated in the program. [ 65 ]
The American Heart Association supports legislation that creates smoke-free workplaces and public spaces. [ 66 ] Starting in 2014, the AHA called for regulations for e-cigarettes to prevent young people from becoming addicted to nicotine, referencing studies that suggest the e-cigarettes can be a gateway drug. [ 67 ]
The American Heart Association supports the No Surprises Act, stating it will keep costs and premiums down and encourage more people to seek care from healthcare professionals. [ 68 ]
In 2022, the American Heart Association, the Rockefeller Foundation, Kroger, and other partners announced a plan to build a national Food is Medicine Research Initiative to help provide concrete evidence that food-as-medicine programs improve health. [ 55 ]
In September 2023, the AHA partnered with the National Association of Chain Drug Stores, the American Cancer Society, the American Diabetes Association, and the Food is Medicine Institute at the Friedman School of Nutrition Science and Policy at Tufts University to launch Nourish My Health . It is a national public education campaign that promotes the protective health benefits of nutritious food. [ 69 ]
You're the Cure is the national grassroots network of the American Heart Association. [ 70 ]
The American Heart Association publishes healthcare guidelines, statements, and performance measures.A small sample of these professional education and development resources include:
The AHA also holds an annual Scientific Sessions meeting, which covers several days and a number of medical/healthcare topics; and hosts an International Stroke Conference. [ 76 ] [ 77 ] [ 78 ]
The Second Century of Science Initiative was announced in 2023 as part of the AHA’s plans to celebrate its first 100 years. Under the Initiative, the AHA awarded $20 million in grants to over 100 scientists in the U.S. The grants were awarded in three categories: the Second Century Implementation Science Award, the Second Century Early Faculty Independence Award, and the Clinical Fellow Research Education Program [ 33 ]
In 2003, the AHA and the American Stroke Association created the Get With the Guidelines (GWTG)-Stroke program. [ 79 ] It is a voluntary registry that hospitals can use to receive the latest scientific treatment guidelines. [ 80 ] The program also collects data on patient characteristics, hospital adherence to guidelines, and patient outcomes. [ 79 ]
Fellowship is open to wide-ranged medical professionals (physicians, scientists, etc.) who demonstrate a major and productive interest in cardiovascular diseases and stroke. The association has 16 different councils. Members (at the Premium Professional or Premium Professional Plus level) of one of these councils can apply for Fellowship. All applicants from all councils will be evaluated against the same criteria. Fellows are entitled to use the post-nominal designation FAmerican Heart Association (Fellow of the American Heart Association), which reflects not only the professional stature of the Fellow but also their record of valuable service to the association and the council. In addition, American Heart Association fellowship offers several benefits; e.g., reduced subscription rates for all American Heart Association print journals and reduced registration fees for American Heart Association Scientific Sessions. [ 81 ] [ 82 ]
Nancy Brown has been the CEO of the American Heart Association since 2009. [ 83 ] [ 84 ] Keith B. Churchwell became the volunteer president in 2024. [ 85 ]
The following journals are published by the American Heart Association:
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The American Institute for Stuttering is an American nonprofit organization that provides universally affordable speech therapy to people who stutter . The organization, legally known as The American Institute for Stuttering Treatment and Professional Training (AIS), was founded in 1998 by speech-language pathologist Catherine Otto Montgomery in New York, New York. The current clinical director is speech-language pathologist Heather Grossman, PhD. AIS currently has offices in New York City, Atlanta, GA, and Los Angeles, CA.
The organization provides stuttering therapy to children and adults, [ 1 ] financial assistance to help make therapy affordable, and clinical training to speech-language pathologists seeking specialized knowledge in the treatment of stuttering.
The members of the board of directors are: [ 2 ]
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The American Journal of Cancer Research is a medical journal established in 2011. [ 3 ] It covers all areas of clinical oncology and experimental cancer research and publishes review articles , original articles, and editorials . It is published by e-Century Publishing Corporation . The editor-in-chief is Dr. Mien-Chie Hung. [ 1 ] [ 2 ] The journal is abstracted and indexed in the Science Citation Index Expanded . [ 4 ] According to the Journal Citation Reports , the journal has a 2021 impact factor of 6.166. [ 5 ]
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The American Journal of Clinical Oncology is a bimonthly, peer-reviewed , scientific, oncology journal , published by Lippincott Williams & Wilkins . The editor in chief is David E. Wazer ( Tufts University ). The journal was formerly entitled Cancer Clinical Trials . [ 1 ] [ 2 ] [ 3 ] [ 4 ]
The focus of this journal is loco-regional management of cancer. Topical coverage include subjects related to the management of cancer for cancer surgeons, radiation oncologists, medical oncologists, gynecological oncologists, and pediatric oncologists. [ 5 ]
The following services abstract and index the journal:
According to the Journal Citation Reports , the journal has a 2014 impact factor of 3.062, ranking it 93rd out of 211 journals in the category "Oncology".
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The American Journal of Clinical Pathology is a monthly peer-reviewed medical journal covering clinical pathology . It was established in 1931 and is published by Oxford University Press . It is the official journal of the American Society for Clinical Pathology and the Academy of Clinical Laboratory Physicians and Scientists . The editor-in-chief is Steven H. Kroft ( Medical College of Wisconsin ). According to the Journal Citation Reports , the journal has a 2020 impact factor of 2.493. [ 1 ]
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The American Medical Women's Association ( AMWA ) is a professional advocacy and educational organization of women physicians and medical students.
The Woman's Medical Journal began publication in the 1893. [ 1 ]
As World War I broke out, medial women, though already 6% of the medical profession, faced severe discrimination, as they were barred from the American Medical Association and from the Army Medical Reserve Corps , effectively barring them from military participation as equals to medical men. [ 2 ]
In response [ 2 ] , the Medical Women’s National Association was founded in 1915 by Bertha Van Hoosen , MD, with the established journal as its official organ. In 1917, the association formed the War Service Committee, later renamed the American Women’s Hospitals Service (AWHS). It was later renamed the American Medical Women's Association. The AMWA works to advance women in medicine and to serve as a voice for women's health.
The association used to publish the Journal of the American Medical Women's Association ; the Journal of Women's Health is now the official journal of the AMWA. [ 3 ] [ 4 ] [ 5 ] [ 6 ]
The AMWA honors women physicians each year with four awards. [ 7 ]
The AMWA also established the International Women in Medicine Hall of Fame to recognize contributions made by women in the medical profession. The more than two dozen inductees include the first woman physician, Elizabeth Blackwell; and two former Surgeon Generals of the United States Antonia Novello and Joycelyn Elders . In 2010, the inductees were Linda A. Randolph , president and CEO of the Developing Families Center, an innovative model for healthcare delivery to poor families; and Diana Zuckerman , a health policy expert who is president of the National Research Center for Women & Families. The latter is the first non-physician inducted. [ 8 ]
The AMWA has published a number of books, primarily in the field of women's health.
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https://en.wikipedia.org/wiki/American_Medical_Women's_Association
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The American Neurological Association ( ANA ) is a professional society of academic neurologists and neuroscientists devoted to advancing the goals of academic neurology; to training and educating neurologists and other physicians in the neurologic sciences; and to expanding both our understanding of diseases of the nervous system and our ability to treat them. [ 1 ] It was founded in June 1875. [ 2 ]
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The American Phytopathological Society ( APS ) is an international scientific organization devoted to the study of plant diseases (phytopathology). APS promotes the advancement of modern concepts in the science of plant pathology and in plant health management in agricultural , urban and forest settings.
The Society has nearly 5,000 plant pathologists and scientists worldwide. It is the oldest and largest organization of its type in the world. [ 1 ] It is also a member of the International Society for Plant Pathology . [ 2 ]
APS provides information on the latest developments and research advances in plant health science through its journals and its publishing arm, APS Press.
APS advocates and participates in the exchange of plant health information with public policy makers and the larger scientific community, and it provides advice on education and training. [ 3 ]
The society was founded in December 1908 by a group led by Cornelius Lott Shear . [ 4 ] The first regular meeting was held in December 1909. [ 1 ] It was the first scientific organization in the world to be devoted exclusively to phytopathology. [ 1 ]
In 1929, its Canadian Phytopathological division was spun off into an independent organization, the Canadian Phytopathological Society . [ 1 ]
The society began publishing scientific peer-reviewed research in 1911 and today publishes five journals in the area of plant pathology:
The society gives a number of awards, designated by the National Research Council (United States) as "prestigious." [ 5 ]
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https://en.wikipedia.org/wiki/American_Phytopathological_Society
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American Society for Artificial Internal Organs (ASAIO) is an organization of individuals and groups that are interested in artificial internal organs and their development. [ 1 ]
It supports research into artificial internal organs and holds an annual meeting, which attracts industry, researchers and government officials. [ 2 ] ASAIO's most heavily represented areas are nephrology , cardiopulmonary devices ( artificial hearts , heart-lung machines ) and biomaterials . It publishes a peer-reviewed publication, the ASAIO Journal , 10 times a year. [ 3 ]
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The American Society for Clinical Pathology ( ASCP ), formerly known as the American Society of Clinical Pathologists , is a professional association based in Chicago , Illinois , encompassing 130,000 pathologists and laboratory professionals .
Founded in 1922, the ASCP provides programs in education, certification and advocacy on behalf of patients, pathologists and lab professionals. [ 1 ] In addition, the ASCP publishes numerous textbooks, newsletters and other manuals, and publishes two industry journals: American Journal of Clinical Pathology (AJCP) and LabMedicine . [ 2 ]
The current CEO since 2010 is Ervin Blair Holladay, Ph.D., MASCP, SCT(ASCP) CM who collects an annual salary of US$1 million.
In February 2006, ASCP acquired the cytology product line of the Midwest Institute for Medical Education (MIME). [ 3 ] At the time, it was the only national cytology proficiency testing provider. [ 4 ]
In 2009, ASCP acquired the medical technologist led National Credentialing Agency for Laboratory Personnel (NCA). [ 5 ] The baccalaureate-level certification designations Medical Technologist (MT) and Clinical Laboratory Scientist (CLS) were replaced by Medical Laboratory Scientist, MLS(ASCP) CM . [ 5 ] The BOC Board of Governors will be composed of five ASCP Fellows (pathologists), five ASCP laboratory professionals, four representatives of ASCLS, two representatives of the Association of Genetic Technologists, eight representatives from the eight participating societies respectively, and one public representative. [ 5 ] The acquisition was criticized by AMT as doing little to further the standing of laboratory professionals. [ 6 ]
In 2021, ASCP acquired the Clinical Laboratory Management Association (CMLA). [ 7 ] CMLA had advocated against laboratory personnel licensure as an unnecessary cost.
[MT ASCP] is becoming increasingly important and will serve in to place trained laboratory technicians in a more secure competition with those whose training has been more superficial.
The ASCP Board of Registry (BOR) was established in 1928 as the "Registration Bureau for Technicians" as the first certification agency for clinical laboratory personnel in the US. [ 9 ] [ 10 ] ASCP was the first professional medical organization to set standards for laboratory professionals, which initially only required a recommendation from a member. [ 10 ] Those recommended were subsequently registered with ASCP, hence name the Board of Registry . [ 10 ] In 1931, there were two classifications for registrants: Laboratory Technician (L.T.) and Medical Technologist (M.T.). [ 11 ] [ 9 ] The L.T. designation was granted to all technicians who met the minimum requirements without the examination. [ 11 ] The M.T. designations was issued to applicants who met rigid requirement of the Board and were individually elected at each annual meeting. [ 11 ] The first certification was issued in 1930 to Paul H. Adams of Fort Wayne, Indiana . [ 11 ] [ 9 ] In 1933, ASCP began to assess individuals for academic and clinical prerequisites, and those who passed a board examination were granted certification. [ 10 ] The initial certifications included a written and practical component. [ 11 ] In 1935 the title Medical Technologist (MT) automatically to those certified Laboratory Technicians with college degrees. [ 9 ] In 1936, the "Laboratory Technician" designation is retired and subsequent registrants are designated Medical Technologists and the academic requirements were raised to two years of college. [ 9 ] In 1938, the Registry was renamed from the Registry of Technicians to the Registry of Medical Technologists. [ 11 ] As Canadian pathology society did not have a registry, interested Canadian medical technologists sat for the Amereican ASCP MT certification instead. [ 8 ] In 1939, the BOR publishes the first book outlining the educational curriculum for medical technologists entitled Curriculum for Schools of Medical Technology. [ 10 ] [ 9 ] In 1940, as other organizations began using the same designations, the initials MT(ASCP) were used. [ 9 ] [ 11 ] In 1944, due to travel wartime restrictions from World War II , the practical component of the certification was discontinued. [ 11 ] In 1948, the written essay portion of the certification was deemed too cumbersome to assess, and the certification was switched to a multiple choice and true-false assessment that could be graded on a machine and provide exam statistics. [ 9 ] [ 11 ] In 1949, the BOR changed the exam format to a 200 multiple choice question exam as the multiple choice questions were found to be a more reliable indicator than true-false questions. [ 12 ] In 1949, the BOR also created the Board of Schools (BOS) for registering schools. [ 12 ] In 1958, BoR and ASMT assisted with the reclassification of medical technologists, putting them at the professional level in the Civil Service and allowing medical technologists to gain commission status in the US military. [ 11 ]
In 1962, the BoR began requiring 3 years of college for the MT certification. [ 11 ] [ 12 ] In 1972, the BoR began requiring a Bachelor's degree for the MT certification. [ 12 ]
There were 100,000 certificates issued by 1975, 200,000 by 1980, 300,000 by 1991, 400,000 by 2005, and 500,000 by 2014. [ 9 ]
In July 1991, BOR administered their first Computer adaptive tests the ASCP headquarters for the Medical Technologist (MT), Medical Laboratory Technician (MLT), Phlebotomy Technician (PBT), Cytotechnologist (CT), and Histologic Technician (HT) certification examinations. [ 13 ]
In 1994, BOR changed their examination format to Computerized adaptive testing (CAT). [ 9 ]
In 2004, the BOR implemented the Certification Maintenance Program (CMP) requiring continuing education every three years to remain certified. [ 9 ]
Through its efforts to standardize the training of medical technologists, the Registry has come to be recognized by the leading medical and hospital groups as the only authoritative qualifying body for this field...The Registry, therefore, while purely voluntary and non-coercive, is universally accepted as the authoritative organization for qualifying the medical technologists in the United States.
In the 1960s, the BOR Code of Ethics and Standards of Conduct placed professional limitations on medical technologists requiring "A medical technologist will work at all times under the direction or supervision of a pathologist or other duly qualified and licensed doctor of medicine, such qualifications being determined on the basis of accepted medical ethics" and that "A medical technologist will not act as owner, co-owner, advisor or employee, or by means of any subterfuge, participate in an arrangement whereby an individual not regularly licensed to practice medicine is enabled to own or operate a laboratory of clinical pathology." [ 14 ] In 1965, Janet Higgins, an ASCP certified medical technologist, was removed from the Board of Registry (BOR) because she was employed at a New Jersey laboratory where the director was a state-licensed bio-analytical laboratory director, but not a physician. [ 14 ] Though New Jersey has never required the certification for employment, the technologist successfully sued ASCP under monopolistic restraint of trade to be reinstated to the registry with the Supreme Court of New Jersey finding that the "professional status conferred on plaintiff by her certificate is an interest of sufficient substance to warrant the protection of the court." [ 14 ] [ 15 ] [ 16 ] [ 17 ] The lawsuit, and the focus on pathologists over medical technologists spurred other medical technologist societies, such as the American Society for Medical Technology (ASMT) to promote the creation of their own certifying boards. [ 15 ]
The BOR bylaws were updated following the transition from the American Society of Clinical Pathologists to American Society for Clinical Pathology.
In 1949, ASCP stablished the Board of Schools (BOS) for accrediting medical technologist programs and published the Essentials of an Acceptable MT School. [ 10 ] In 1973, following antitrust litigation by the United States Department of Education , the ASCP Board of Schools became the independent National Accrediting Agency for Clinical Laboratory Sciences . [ 10 ] [ 12 ]
In 2022 ASCP received a multi-year grant over $1M to promote the CDC OneLab initiative, a network of laboratory professionals and testers to support rapid, large-scale responses to public health emergencies. [ 18 ] [ 19 ]
ASCP offers a number of certifications. [ 20 ] International certifications taken outside the United States are denoted as ASCP i . [ 21 ] As of 2022, there were 580,000 ASCP and 20,800 ASCP i certificates awarded. [ 22 ] [ 23 ] In 2023, the number of MLS ASCPi applicants exceeded the number of MLS ASCP applicants.
Outside the US, the Philippines is largest ASCP i market with a third of eligible Filipino graduates applying for the MLS (ASCP i ) certification annually. [ 24 ] The credential is not required for practice in the Philippines, but is appealing for its international work eligibility, primarily immigration to the United States . [ 24 ] [ 25 ]
The following lists the eligible programs under accreditation agencies [ 27 ]
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https://en.wikipedia.org/wiki/American_Society_for_Clinical_Pathology
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Founded in 1979, the American Society for Cytotechnology is a professional organization dedicated to the field of cytotechnology . [ 1 ] The ASCT promotes cytotechnology through the development of practice standards, [ 2 ] and by staying up to date regarding emerging technologies and the legislative and regulatory issues within the field. As well, the Society offers Cytotechnology related educational opportunities. [ 3 ]
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The American Society for Investigative Pathology ( ASIP ) is a society of biomedical scientists who investigate mechanisms of disease . [ 1 ] ASIP membership includes scientists in the academic, government, hospital, and pharmaceutical arenas that focus their research on the pathogenesis, classification, diagnosis and manifestations of disease. Research findings are ultimately used in the understanding, diagnosis and treatment of human diseases. The word pathology is derived from the Greek word "pathos" meaning "disease."
ASIP traces its earliest beginnings to the Boston Society of Medical Sciences that was begun in 1869 by a group of faculty from Harvard Medical School . In 1901 the American Association of Pathologists and Bacteriologists (AAPB) was established. In 1976 the AAPB and the American Society for Experimental Pathology (ASEP) joined to form the American Association of Pathologists (AAP), which in 1992 became ASIP. [ 2 ]
ASIP is a member of the Federation of American Societies for Experimental Biology (FASEB), a coalition of 27 independent societies that includes over 125,000 biomedical scientists from around the world. FASEB plays an active role in lobbying for the interests of its constituents.
The oldest award and most meritorious award of this society is the "gold-headed cane award", which was first granted in 1919 to Harold C. Ernst . It is presented each year at the annual meeting of the ASIP. [ 3 ] [ 4 ]
Scientific Interest Groups (SIGs) represent the specialty interests of the membership, and include Biobanking, Breast Cancer , Cell Injury, Digital and Computational Pathology, Environmental and Toxicologic Pathology, Gene Expression , Immunohistochemistry and Microscopy, Inflammation / Immunopathology , Informatics , Liver Pathobiology, Molecular Diagnostic Pathology, Neoplasia /Growth Regulation, Neuropathology , Pulmonary Pathobiology, Regenerative Medicine and Stem Cells, Tumor Microenvironment and Metastasis, Vascular and Mucosal Pathobiology, and Veterinary Pathology [ citation needed ]
The American Journal of Pathology ( AJP ), [ 5 ] official journal of the American Society for Investigative Pathology, publishes articles on the cellular and molecular biology of disease.
The Journal of Molecular Diagnostics ( JMD ), [ 6 ] co-owned by the American Society for Investigative Pathology and the Association for Molecular Pathology, publishes articles on scientific advances in the translation and validation of molecular discoveries in medicine into the clinical diagnostic setting, and the description and application of technological advances in the field of molecular diagnostic medicine. [ citation needed ]
The ASIP Annual Meeting at Experimental Biology features current topics in disease pathogenesis, including both mechanistic and translational aspects of pathology research. Programming includes several major symposia, workshops, educational sessions, award lectures, and other special sessions that feature nationally and internationally recognized investigators and speakers. Various aspects of professional growth and advancement are presented in career development workshops that specifically address the needs of MD, MD/PhD, PhD, and other trainees. Additional sessions are programmed from abstract submissions to the ASIP topic categories covering a wide variety of subjects related to pathogenesis research. [ citation needed ]
The Pathobiology for Investigators, Students, and Academicians (PISA) Meeting features lectures presented by the leading scientists in their field. Abstract-driven sessions and poster discussions offer a cordial, collegial and contemporary environment for learning and networking as well as an intimate setting for intellectual exchange and constructive criticism, especially for trainees and junior faculty. [ citation needed ]
Satdarshan P. Monga
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https://en.wikipedia.org/wiki/American_Society_for_Investigative_Pathology
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The American Society for Preventive Cardiology [ a ] (ASPC) is a non-profit membership-based organization dedicated to educating health care professionals and patients about the prevention of cardiovascular disease .
The American Society for Preventive Cardiology was established in 1985 under the guidance of Joseph Stokes III (1924–1989), a cardiologist who served as coprincipal investigator of the Framingham Heart Study . [ 2 ] The organization was founded through a working group of scientists from the National Heart, Lung, and Blood Institute who recommended curricula to facilitate medical school research aimed at preventing cardiovascular disease. [ 2 ] The ASPC disseminated the National Institutes of Health Preventive Cardiology Academic Awards, which funded teaching preventive cardiology across 60 medical schools over a 17 year period. [ 3 ] The ASPC has close connection with the American Heart Association (AHA) including its Council on Epidemiology and Prevention. [ 3 ] Since 1994, the ASPC has presented annual debates at the American Heart Association Council on Epidemiology and Prevention scientific sessions. [ 4 ] Members of the ASPC and AHA collaborated on the Women's Agenda Targeting Cholesterol in Heart Disease program. [ 5 ]
In 2010, the ASPC attended the Great Wall International Congress of Cardiology in Beijing and the World Congress on Heart Disease sponsored by the International Academy of Cardiology. [ 4 ] The ASPC has hosted an annual congress on cardiovascular disease prevention since 2012. [ 3 ] The Stokes Award is issued to individuals by the ASPC who have demonstrated a lifetime achievement in preventive cardiology. [ 4 ] In 2015 at the ASPC annual meeting in Boca Raton the first ASPC Experts Course in Preventive Cardiology was offered. A year later the ASPC accepted applications for its inaugural class of fellows which provided the first official fellowship certification in preventive cardiology for those who have a record of accomplishment and dedication in the field. [ 4 ]
The ASPC describes its mission as "to promote the prevention of cardiovascular disease, advocate for the preservation of cardiovascular health, and disseminate high‐quality, evidence‐based information through the education of health care clinicians and their patients." [ 6 ] It was granted 501(c)(3) status in 2007. [ 7 ]
In 2023, the ASPC collaborated with ten other organizations including the American Heart Association and American Society of Echocardiography on new appropriate use criteria to evaluate chronic coronary disease. [ 8 ] The ASPC and National Lipid Association have supported low-density lipoprotein (LDL-c) measurement as a performance metric to improve population-wide lipid control. [ 9 ]
In 2007, the ASPC adopted Preventive Cardiology as their official journal. [ 2 ] Since 2011, the ASPC has published Clinical Cardiology by Wiley as their official journal. [ 4 ] As of 2020 the ASPC also publishes The American Journal of Preventive Cardiology which has been credited with increasing the validation and use of coronary artery calcium scoring. [ 3 ] [ 10 ] It is published quarterly by Elsevier and is one of the only journals dedicated solely to preventive cardiology. [ 11 ] [ 12 ]
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https://en.wikipedia.org/wiki/American_Society_for_Preventive_Cardiology
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The American Society of Cytopathology ( ASC ), founded in 1951, is a national professional society of physicians , cytotechnologists and scientists who are dedicated to cytopathology , which involves the cytologic method of diagnostic pathology . They have more than 3000 members including representatives for other countries. The ASC provides a forum where physicians and cytotechnologists can interact with one another. Although this society is involved with guidelines for cytotechnologists [ 1 ] and admits certain qualified cytotechnologists, it should not be confused with the American Society for Cytotechnology (ASCT).
The official journal of the ASC is the Journal of the American Society of Cytopathology (JASC) published bimonthly. [ 2 ]
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The American Society of Transplantation ( AST ) is an international organization of over 4,000 transplant professionals dedicated to advancing the field of transplantation through the promotion of research , education , advocacy , organ donation , and service to the community through a lens of equity and inclusion. It is the largest professional transplantation society in North America. [ 1 ]
The history of the AST begins in 1981, when the charter members of the society met at the annual meeting of the American Society of Nephrology (ASN). It was at this meeting where a new society, known as the American Society of Transplant Physicians (ASTP), was created to meet the professional needs of a burgeoning group of transplant physicians . The ASTP was founded on May 10, 1982, with membership open to physicians and certain other health professionals who shared an interest in transplantation medicine and biology . In 1998, the ASTP changed its name to the American Society of Transplantation (AST) and opened its membership to additional health professionals working in the area of transplantation. [ 2 ]
The society's first annual meeting (as the ASTP) took place on June 3, 1982, in Chicago. In 2000, the AST returned to Chicago in conjunction with the American Society of Transplant Surgeons (ASTS) and held the first American Transplant Congress (ATC). Since that time, the ATC has met annually in a variety of North American cities, and is currently the largest annual meeting of transplant professionals. [ 3 ]
The first Fellows Symposium on Transplant Medicine was held July 27–28, 1996 in St. Louis, Missouri. Renamed the Fellows Symposium on Transplantation in 2015, this meeting gives clinical fellows and residents, surgical fellows, research fellows, pharmacists, and other trainees the opportunity to participate in specialized scientific sessions and meet one-on-one with senior transplant specialists. [ 2 ]
The first AST Winter Symposium was held February 13–17, 1997, in Phoenix, Arizona. The AST's winter meeting has been designated as the Cutting Edge of Transplantation (CEOT) meeting. [ 2 ]
The AST held its first Transplant Patient Summit in October 2017. The meeting was held in Washington, DC and was the society's first patient-focused meeting. The society later changed the name of this summit to the Transplant Community Summit. The second was held during the Transplant Games of America in August 2018.
In 2007, the Transplant Nephrology Core Curriculum (TNCC) was launched as an online program provided jointly by the ASN and the AST. The TNCC focuses on key information needed to prepare for the American Board of Internal Medicine Nephrology Board Certification and Maintenance of Certification examinations. [ 4 ]
In 2011, the AST launched the Timely Topics in Transplantation (T3) webinar series. The T3 webinars can be viewed live or on-demand, and span all transplant topics. [ 5 ]
In 2017, the AST launched the Comprehensive Trainee Curriculum, an educational resource that helps young transplant professional expand their broad understanding of the field. [ citation needed ]
The Society also launched its Transplant in 10 resource in 2017. Transplant in 10 aims to educate busy transplant professionals with videos that are 10 minutes or less.
The AST Communities of Practice (COPs) are specialty-area focused groups within the larger society. The AST currently has 16 COPs:
The American Journal of Transplantation is the joint monthly peer-reviewed medical journal of the AST and ASTS, published by Wiley-Blackwell. [ 6 ]
Additional publications:
The AST Research Network is the AST's mechanism for identifying, funding, and providing ongoing support to the most innovative research in transplantation and immunology.
Power2Save (P2S) is an initiative developed by the AST dedicated to increasing public awareness around the importance of donating organs, advocating for patient health, and funding transplant research. [ 11 ]
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https://en.wikipedia.org/wiki/American_Society_of_Transplantation
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The American Speech–Language–Hearing Association ( ASHA ) is a professional association for speech–language pathologists , audiologists , and speech , language , and hearing scientists in the United States and internationally. The association reported over 234,000 members and affiliates in its 2023 report. [ 1 ]
The association's national office is located at 2200 Research Boulevard, Rockville, Maryland . The organization also has an office on Capitol Hill.
As of January 2022, Vicki R. Deal-Williams serves as the association's chief executive officer.
ASHA was founded in 1925 as the American Academy of Speech Correction in the home of Lee Edward Travis in Iowa City, Iowa . [ 2 ] [ 3 ]
The charter members were Margaret Gray Blanton, Smiley Blanton, Richard Carmen Borden, Frederick Warner Brown, Mary A Brownell, Alvin Clayton Busse, Pauline Beatrice Camp, Jane Dorsey (Zimmerman), Eudora Porter Estabrook, Mabel Farrington Gifford , Max Aaron Goldstein , Ruth Green, Laura Heilman, Elmer Lawton Kenyon, Mabel V Lacey, Elizabeth Dickinson McDowell, Thyrza Nichols, Samuel Dowse Robbins, Sara Mae Stinchfield (Hawk) , Jane Bliss Taylor, Charles Kenneth Thomas, Lee Edward Travis , Lavilla Amelia Ward, Sina Fladeland Waterhouse, and Robert William West. [ 4 ]
In 1927, they changed their name to American Society for the Study of Disorders of Speech, in 1934 to the American Speech Correction Association, in 1947 to the American Speech and Hearing Association.
The current name was adopted in 1978. [ 5 ]
The Council for Academic Accreditation in Audiology and Speech–Language Pathology (CAA) is the accreditation unit of the ASHA. Founded over 100 years ago by American universities and secondary schools, CAA established standards for graduate program accreditation that meet entry-level preparation in the speech and hearing field. [ 6 ] Accreditation is available for graduate programs with a master's degree in Speech–Language Pathology or clinical doctoral program in audiology . [ 7 ]
Professionals of Communication Sciences and Disorders (CSD) can become members of ASHA. These professionals include audiologists, speech-language pathologists, and speech-language-hearing scientists. As of December 31, 2023, the organization reports more than 234,000 members and affiliates. [ 1 ] ASHA also sponsors various special interest groups for its members. [ citation needed ]
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https://en.wikipedia.org/wiki/American_Speech–Language–Hearing_Association
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The American Thyroid Association ( ATA ) is a professional organization of over 1700 medical specialists devoted to thyroid biology and to the prevention and treatment of thyroid disease through excellence in research, clinical care, education, and public health. The ATA publishes the journals Clinical Thyroidology for the Public and Signal . The peer-reviewed journals Thyroid , Clinical Thyroidology and VideoEndocrinology are published through Mary Ann Liebert, Inc., publishers .
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The American Women's Hospitals Service (AWHS) is a charitable organization that promotes the relief of suffering worldwide by supporting independent clinics to provide care to high risk populations and by providing travel grants to medical students and residents to perform clinical projects abroad in under-served areas. They are partnered with the American Medical Women's Association (AMWA) - an organization of women physicians, medical students and others seeking the advancement of women in medicine .
In 1917 the Medical Women's National Association (which was later renamed AMWA) established a war service committee in order to create a census of the medical women in the country and to plan how to apply their resources to the war effort. World War I had already entered into its third year, women at that time were not accepted by military branches of the government, and the government had no plan to organize them for war service. The war service committee, adopting the name American Women's Hospitals, decided that they wanted to provide individual medical service abroad and also establish military hospitals overseas. [ 1 ]
In its first year, AWH partnered with the Red Cross and civilian medical organizations to send abroad 62 AWH volunteer doctors as well as 30 technicians and lay workers to France , Serbia , Palestine and Greece . [ 1 ] AWH also established its first hospital in Neufmoutiers-en-Brie , France, in July 1918. [ 2 ] This hospital, financed entirely by AWH, had 25 beds, a staff of 15 women including 3 dentists. [ 3 ] In the US, AWH arranged for hospitals for convalescent soldiers, for care for soldiers' dependents, and for laboratory training courses in order to address the critical shortage at that time of skilled lab workers. [ 1 ]
Although the armistice was signed a year later, the ensuing local wars, revolutions , earthquakes , famine and millions of destitute refugees meant that medical assistance remained urgently needed around the world. AWH expanded its service at home and multiple countries abroad in order to address the thousands who looked for help. [ 4 ]
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https://en.wikipedia.org/wiki/American_Women's_Hospitals_Service
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Amine fluorides are dental drugs.
Amine fluorides were developed in the 1950s by GABA in collaboration with the Institute of Dentistry of the University of Zurich (Switzerland).
For the first time, in 1954, Wainwright showed in his study the high permeability of tooth enamel to organic molecules like urea . This aspect made him ask himself if it was not possible to enrich the contents of the enamel with fluoride by using organic molecules as carrier, which were chemically bonded to amino fluoride. [ 1 ]
In 1957, Mühlemann, Schmid and König published the results of their studies in vitro, in which they demonstrated that some compounds with amino fluoride were obviously superior to those with inorganic fluoride in reducing the solubility of the enamel. [ 2 ]
In the same year, Irwin, Leaver and Walsh published the results of their experiments in vitro, which demonstrated that monoamine-aliphatic compounds offered protection to the enamel against acid decalcification. [ 3 ]
In 1967, Muhleman demonstrated the superiority of organic fluoride compared to inorganic fluoride in preventing dental decay. He observed that amine fluoride had a pronounced affinity regarding enamel, by raising the quantity of fluoride in the enamel and also having an antienzyme effect on the microbial activity of dental plaque . His conclusions were the following:
In this way amine fluorides were born in GABA S.A.-BASEL laboratory.
The commercial products, which contain amine fluoride or compounds of this with tin-fluoride in their formula, are present under different
forms:
- gels,
- fluids,
- dentifrice,
- mouth rinse.
The unique position of the amine fluoride is based on their special molecular structure: the fluoride ion is bound to an organic fatty acid amine fragment. This is not the case for the inorganics fluorides such as sodium fluoride and sodium monofluorophosphate.
Amine fluorides have a hydrophobic molecular moiety, the non-polar tail, with a hydrophilic component, the polar amine head. For this reason, they act like surfactants , reducing the surface tension of saliva, and forming a homogeneous film on all oral surfaces.
Due to their surface activity the amine fluorides are rapidly dispersed in the oral cavity and wet all surfaces. In contrast, in the case of inorganic fluorides the counter ion (e.g. sodium) has no transport function; the fluoride is statistically distributed in the oral cavity. Amine fluoride covers the tooth surfaces with a homogeneous molecular layer. This continuous film prevents rapid rinsing off by the saliva. The amine fluorides are thus available as an active agent for a longer period.
Amine fluorides have a slightly acidic pH . For this reason, fluoride ions can combine rapidly with the calcium in dental enamel to form calcium fluoride. This acts as a fluoride depot over a longer period:
Under cariogenic conditions fluoride ions are made available stimulating the remineralisation of dental enamel and thus prevent acid attacks.
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https://en.wikipedia.org/wiki/Amine_fluoride
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An amorphus globosus (from Greek : αμορφή (amorphē) 'formless' and Latin : globus 'sphere') , also known as a globosus amorphus , [ 1 ] or an amorphous globosus monster , [ 1 ] is a malformation occurring in veterinary medicine , especially in domestic cattle . Instead of a normally developed fetus , it results in the formation of a more or less spherical structure covered with hairy skin, which contains parts of all three germ layers ; the differentiation of its contents can vary greatly. An amorphus globosus is not viable due to the lack of functional organs . [ 2 ]
The teratological reasons for the development of amorphus globosus are not fully understood, but it is believed that the malformation is generally associated with twin gestation , [ 3 ] in which one embryo does not develop normally. In two cases, the karyotype of the amorphus was identical to its normally developing twin, [ 4 ] [ 5 ] while in another case, the karyotype deviated from the normal twin, [ 6 ] so an emergence from fraternal twins also seems possible.
Amorphus globosus is more common in livestock than generally assumed. [ 2 ] It occurs most commonly in cattle, but there are also case reports in goats [ 2 ] and horses . [ 7 ] A case of amorphus globosus has also been described in human medicine , where it was also a twin pregnancy. [ 8 ]
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https://en.wikipedia.org/wiki/Amorphous_globosus
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In enzymology , a 3-mercaptopyruvate sulfurtransferase ( EC 2.8.1.2 ) is an enzyme that catalyzes the chemical reactions of 3-mercaptopyruvate . This enzyme belongs to the family of transferases , specifically the sulfurtransferases. [ 1 ] This enzyme participates in cysteine metabolism . It is encoded by the MPST gene . [ 2 ]
The enzyme is of interest because it provides a pathway for detoxification of cyanide , especially since it occurs widely in the cytosol and distributed broadly. [ 3 ]
The systematic name of this enzyme class is 3-mercaptopyruvate:cyanide sulfurtransferase. This enzyme is also called beta-mercaptopyruvate sulfurtransferase and in the older literature, human liver rhodanese. [ 4 ]
The MPST gene lies on the chromosome location of 22q12.3 and consists of 6 exons . Alternatively spliced transcript variants encoding the same protein have been identified. [ 2 ] [ 5 ]
The encoded cytoplasmic protein is a member of the rhodanese family but is not rhodanese itself, which is found only in mitochondria. MPST protein consists of 317 amino acid residues and weighs 35250Da. MPST contains two rhodanese domains with similar secondary structures suggesting a common evolutionary origin. The catalytic cysteine residue only exists in the C-terminal rhodanese domain. The protein can function as a monomer or as a disulfide-linked homodimer.
The biological function of MPST remains unclear. It may be involved in cyanide detoxification, biosynthesis of thiosulfate, production of the signalling molecule hydrogen sulfide, or the degradation of cysteine.
MPST reacts with 3-MP to convert a cysteinyl residue to the persulfide-containing intermediate: [ 3 ]
The persulfide group is labile, and can transfer S to other groups, such as cyanide. It is also susceptible to reduction to release hydrogen sulfide .
H 2 S is produced from l-cysteine by cystathionine-γ-lyase (CSE) and MPST. l-cysteine-dependent production of H 2 S by MPST is a two-step reaction. In the first step, cysteine transaminase converts l-cysteine along with α-ketoglutarate into 3-mercaptopyruvate (3-MP). Subsequently, MPST converts 3-MP into H 2 S. [ 6 ] MPST catalyzes the transfer of a sulfur atom from mercaptopyruvate to sulfur acceptors like cyanides or thiol compounds. [ 7 ] Thus it is also considered to participate in cysteine degradation. [ 5 ] MPST generates H 2 S in coronary artery , mediating its effects through direct modulation of NO , namely vasodilation. This has important implications for H 2 S-based therapy in healthy and diseased coronary arteries. [ 8 ]
MPST is expressed in a number of tissues, including kidney, liver, lung, heart, muscle, spleen , and brain. [ 9 ] [ 10 ] [ 11 ]
3- Mercaptopyruvate (3-MP), along with α-ketoglutarate , is derived from cysteine by the action of an aminotransferase . Thus MPST may participate in cysteine degradation.
H 2 S is produced from MPST (as well as by cystathionine-γ-lyase ). [ 6 ] [ 1 ] MPST generates H 2 S in coronary artery , mediating its effects through direct modulation of NO , namely vasodilation. This has important implications for H 2 S-based therapy in healthy and diseased coronary arteries. [ 8 ]
Deficiency in MPST has been found related to mercaptolactate-cysteine disulfiduria (or Ampola syndrome ), a rare inheritable disorder associated with oversecretion of mercaptolactate-cysteine disulfide in urine. [ 12 ] Fewer than 1,000 people have this rare disorder in the United States . [ 13 ] Symptoms and signs include: high forehead, seizures, arachnodactyly , genu valgum , hypolasia of the ear cartilage and
umbilical hernia.
Immunoreactivity for MPST was detected in malignant uroepithelium and muscular layer of bladder cancer samples. Protein levels and catalytic activities of MPST increased with the increase of malignant degrees in human bladder tissues and human urothelial cell carcinoma of bladder (UCB) cell lines and this may promote the application of MPST novel enzymes to UCB diagnosis or treatment. [ 14 ]
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Physical medicine and rehabilitation
Amputation is the removal of a limb or other body part by trauma , medical illness , or surgery . As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene . In some cases, it is carried out on individuals as a preventive surgery for such problems. A special case is that of congenital amputation , a congenital disorder , where fetal limbs have been cut off by constrictive bands. In some countries, judicial amputation is currently used to punish people who commit crimes. [ 1 ] [ 2 ] [ 3 ] [ 4 ] Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment. [ 5 ] [ 6 ] [ 7 ] When done by a person, the person executing the amputation is an amputator. [ 8 ] [ 9 ] The oldest evidence of this practice comes from a skeleton found buried in Liang Tebo cave, East Kalimantan , Indonesian Borneo dating back to at least 31,000 years ago, where it was done when the amputee was a young child. [ 10 ] A prosthesis or a bioelectric replantation restores sensation of the amputated limb.
Lower limb amputations can be divided into two broad categories: minor and major amputations. Minor amputations generally refer to the amputation of digits . Major amputations are commonly below-knee- or above-knee amputations. Common partial foot amputations include the Chopart , Lisfranc , and ray amputations.
Common forms of ankle disarticulations include Pyrogoff, Boyd, and Syme amputations. [ 11 ] A less common major amputation is the Van Nes rotation , or rotationplasty, i.e. the turning around and reattachment of the foot to allow the ankle joint to take over the function of the knee.
Types of amputations include:
Types of upper extremity amputations include:
A variant of the trans-radial amputation is the Krukenberg procedure in which the radius and ulna are used to create a stump capable of a pincer action.
Genital modification and mutilation may involve amputating tissue, although not necessarily as a result of injury or disease.
Laryngectomy is the amputation of the larynx.
In some rare cases when a person has become trapped in a deserted place, with no means of communication or hope of rescue, the victim has amputated their own limb. The most notable case of this is Aron Ralston , a hiker who had amputated his own right forearm after it was pinned by a boulder in a hiking accident and he was unable to free himself for over five days. [ 12 ]
Body integrity identity disorder is a psychological condition in which an individual feels compelled to remove one or more of their body parts, usually a limb. In some cases, that individual may take drastic measures to remove the offending appendages, either by causing irreparable damage to the limb so that medical intervention cannot save the limb, or by causing the limb to be severed. [ 13 ]
In surgery , a guillotine amputation is an amputation performed without closure of the skin in an urgent setting. [ 14 ] Typical indications include catastrophic trauma or infection control in the setting of infected gangrene . [ 14 ] A guillotine amputation is typically followed by a more time-consuming, definitive amputation such as an above or below knee amputation . [ 14 ]
Frostbite is a cold-related injury occurring when an area (typically a limb or other extremity) [ 17 ] is exposed to extreme low temperatures, causing the freezing of the skin or other tissues. [ 18 ] Its pathophysiology involves the formation of ice crystals upon freezing and blood clots upon thawing, leading to cell damage and cell death . [ 18 ] Treatment of severe frostbite may require surgical amputation of the affected tissue or limb; [ 19 ] if there is deep injury autoamputation may occur. [ 20 ]
Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance.
The punishment of those who wage war against Allah and His Messenger, and strive with might for mischief through the land is execution or crucifixion, or cutting of hands and feet from opposite sides, or exile from the land. As for the thief, male or female, cut off their hands and feet from opposite ends in recompense for what they have committed. [ 33 ]
Surgeons performing an amputation have to first ligate the supplying artery and vein , so as to prevent hemorrhage (bleeding). The muscles are transected, and finally, the bone is sawed through with an oscillating saw . Sharp and rough edges of bones are filed, skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a prosthesis .
Distal stabilisation of muscles is often performed. This allows effective muscle contraction which reduces atrophy, allows functional use of the stump and maintains soft tissue coverage of the remnant bone. The preferred stabilisation technique is myodesis where the muscle is attached to the bone or its periosteum. In joint disarticulation amputations tenodesis may be used where the muscle tendon is attached to the bone. Muscles are attached under similar tension to normal physiological conditions. [ 48 ]
An experimental technique known as the "Ewing amputation" aims to improve post-amputation proprioception . [ 49 ] [ 50 ] Another technique with similar goals, which has been tested in a clinical trial, [ 51 ] is Agonist-antagonist Myoneural Interface (AMI). [ 52 ]
In 1920, Dr. Janos Ertl Sr. of Hungary , developed the Ertl procedure in order to return a high number of amputees to the workforce. [ 53 ] The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques. [ 54 ]
A 2019 Cochrane systematic review aimed to determine whether rigid dressings were more effective than soft dressings in helping wounds heal following transtibial (below the knee) amputations. Due to the limited and very low certainty of evidence available, the authors concluded that it was uncertain what the benefits and harms were for each dressing type. They recommended that clinicians consider the pros and cons of each dressing type on a case-by-case basis: rigid dressings may potentially benefit patients who have a high risk of falls; soft dressings may potentially benefit patients who have poor skin integrity. [ 55 ]
A 2017 review found that the use of rigid removable dressings (RRD's) in trans-tibial amputations, rather than soft bandaging, improved healing time, reduced edema, prevented knee flexion contractures and reduced complications, including further amputation, from external trauma such as falls onto the stump. [ 56 ]
Post-operative management, in addition to wound healing, considers maintenance of limb strength, joint range, edema management, preservation of the intact limb (if applicable) and stump desensitization.
Traumatic amputation is the partial or total avulsion of a part of a body during a serious accident, like traffic, labor, or combat. [ 57 ] [ 58 ]
Traumatic amputation of a human limb, either partial or total, creates the immediate danger of death from blood loss. [ 59 ]
Orthopedic surgeons often assess the severity of different injuries using the Mangled Extremity Severity Score. Given different clinical and situational factors, they can predict the likelihood of amputation. This is especially useful for emergency physicians to quickly evaluate patients and decide on consultations. [ 60 ]
Traumatic amputation is uncommon in humans (1 per 20,804 population per year). Loss of limb usually happens immediately during the accident, but sometimes a few days later after medical complications. Statistically, the most common causes of traumatic amputations are: [ 61 ]
The development of the science of microsurgery over the last 40 years has provided several treatment options for a traumatic amputation, depending on the patient's specific trauma and clinical situation: [ 64 ]
Methods in preventing amputation, limb-sparing techniques , depend on the problems that might cause amputations to be necessary. Chronic infections, often caused by diabetes or decubitus ulcers in bedridden patients, are common causes of infections that lead to gangrene, which, when widespread, necessitates amputation. [ 71 ]
There are two key challenges: first, many patients have impaired circulation in their extremities, and second, they have difficulty curing infections in limbs with poor blood circulation. [ 72 ] [ 73 ]
Crush injuries where there is extensive tissue damage and poor circulation also benefit from hyperbaric oxygen therapy (HBOT). The high level of oxygenation and revascularization speed up recovery times and prevent infections. [ 74 ]
A study found that the patented method called Circulator Boot achieved significant results in prevention of amputation in patients with diabetes and arteriosclerosis. [ 75 ] [ 76 ] Another study found it also effective for healing limb ulcers caused by peripheral vascular disease. [ 77 ] The boot checks the heart rhythm and compresses the limb between heartbeats; the compression helps cure the wounds in the walls of veins and arteries, and helps to push the blood back to the heart. [ 78 ]
For victims of trauma, advances in microsurgery in the 1970s have made replantation of severed body parts possible.
The establishment of laws, rules, and guidelines, and the employment of modern equipment help protect people from traumatic amputations. [ 79 ]
The individual may experience psychological trauma and emotional discomfort. The stump will remain an area of reduced mechanical stability. Limb loss can present significant or even drastic practical limitations. [ 80 ]
A large proportion of amputees (from 50 to 80% to 80-100%, according to different studies) experience the phenomenon of phantom limbs ; [ 81 ] [ 82 ] they feel body parts that are no longer there. These limbs can itch, ache, burn, feel tense, dry or wet, locked in or trapped or they can feel as if they are moving. Some scientists believe it has to do with a kind of neural map that the brain has of the body, which sends information to the rest of the brain about limbs regardless of their existence. Phantom sensations and phantom pain may also occur after the removal of body parts other than the limbs, e.g. after amputation of the breast, extraction of a tooth (phantom tooth pain) or removal of an eye ( phantom eye syndrome ).
A similar phenomenon is an unexplained sensation in a body part unrelated to the amputated limb. It has been hypothesized that the portion of the brain responsible for processing stimulation from amputated limbs, being deprived of input, expands into the surrounding brain, ( Phantoms in the Brain : V.S. Ramachandran and Sandra Blakeslee ) such that an individual who has had an arm amputated will experience unexplained pressure or movement on his face or head. [ 83 ]
In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb. To support improved resistance or usability, comfort or healing, some types of stump socks may be worn instead of or as part of wearing a prosthesis. [ 80 ]
Another side effect can be heterotopic ossification , especially when a bone injury is combined with a head injury. The brain signals the bone to grow instead of scar tissue to form, and nodules and other growth can interfere with prosthetics and sometimes require further operations. This type of injury has been especially common among soldiers wounded by improvised explosive devices in the Iraq War . [ 84 ]
Due to technological advances in prosthetics, many amputees live active lives with little restriction. Organizations such as the Challenged Athletes Foundation have been developed to give amputees the opportunity to be involved in athletics and adaptive sports such as amputee soccer . [ 85 ]
Nearly half of the individuals who have an amputation due to vascular disease will die within 5 years, usually secondary to the extensive co-morbidities rather than due to direct consequences of an amputation. This is higher than the five year mortality rates for breast cancer, colon cancer, and prostate cancer. [ 86 ] Of persons with diabetes who have a lower extremity amputation, up to 55% will require amputation of the second leg within two to three years. [ 87 ]
The word amputation is borrowed from Latin amputātus, past participle of amputāre "to prune back (a plant), prune away, remove by cutting (unwanted parts or features), cut off (a branch, limb, body part)," from am-, assimilated variant of amb- "about, around" + putāre "to prune, make clean or tidy, scour (wool)". The English word "Poes" was first applied to surgery in the 17th century, possibly first in Peter Lowe's A discourse of the Whole Art of Chirurgerie (published in either 1597 or 1612); his work was derived from 16th-century French texts and early English writers also used the words "extirpation" (16th-century French texts tended to use extirper ), " disarticulation ", and " dismemberment " (from the Old French desmembrer and a more common term before the 17th century for limb loss or removal), or simply "cutting", but by the end of the 17th century "amputation" had come to dominate as the accepted medical term. [ 88 ]
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The Amsterdam criteria are a set of diagnostic criteria used by doctors to help identify families which are likely to have Lynch syndrome , also known as hereditary nonpolyposis colorectal cancer (HNPCC) . [ 1 ] [ 2 ] [ 3 ] [ 4 ]
The Amsterdam criteria arose as a result of a meeting of the International Collaborative Group on Hereditary Non-Polyposis Colon Cancer in Amsterdam, in 1990. [ 5 ] Following this, some of the genetic mechanisms underlying Lynch syndrome were elucidated during the 1990s and the significance of tumours outside the colon , such as those of the endometrium , small intestine and ureter , became clearer. These changes in the knowledge of the syndrome lead to a revision of the Amsterdam criteria and were published in Gastroenterology journal in 1999. [ 4 ] [ 5 ]
The initial Amsterdam criteria were a series of clinical criteria that were colloquially known as the 3-2-1 rule. They were formulated to serve as a common starting point for future research into the genetics underlying the disease. The criteria were as follows:
These criteria were found to be too strict and were expanded to include the associated non-colorectal cancers in 1998. These were called the Amsterdam II clinical criteria for families with Lynch syndrome. [ 4 ] [ 6 ]
Each of the following criteria must be fulfilled:
In 1997, the National Cancer Institute published a set of recommendations called the Bethesda guidelines for the identification of individuals who should receive genetic testing for Lynch syndrome related tumors. [ 6 ] The NCI revisited and revised these criteria in 2004. [ 7 ]
The Revised Bethesda Guidelines are as follows:
The Revised Bethesda Guidelines have been reported as being more sensitive than the Amsterdam II Criteria in detecting individuals and families at risk of Lynch syndrome. [ 6 ]
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In the United Kingdom , an anaesthesia associate (AA) is a healthcare worker who provides anaesthesia under the medical direction and supervision of a consultant anaesthetist (who is a medical doctor ). [ 1 ] Anaesthesia associates complete a 27-month full-time training programme which leads to the award of a postgraduate diploma, or alternatively a 24-month training programme via University College London leading to a master's degree. [ 2 ] It is classed as a medical associate profession . To be eligible, a candidate must have a previous degree in a biomedical or science subject, or recognised previous healthcare experience in another role. [ 3 ]
The role was introduced into the UK National Health Service in 2004, under the title of Anaesthesia Practitioner. This was later changed to physicians' assistant (anaesthesia), abbreviated to PA(A). The Association of Physicians' Assistants Anaesthesia changed the name of their role to Anaesthesia Associates in July 2019. [ 4 ] In July 2019, the UK government announced its intention to request that the General Medical Council (GMC) would in future regulate anaesthesia associates as a distinct profession. [ 5 ] The GMC started regulation of the profession in December 2024 and also provided quality assurance of all three of the AA courses in the UK in April 2025. [ 6 ] [ 7 ]
Serious concerns about the lack of regulation, transparency of professional background, and scope of practise, of anaesthesia associates have been raised by Anaesthetists United, a grass-roots group of anaesthetists, triggering an Extraordinary General Meeting of the Royal College of Anaesthetists (RCoA) on 17 October 2023. All six motions were passes with significant majorities including on a call to pause recruitment of AAs until the RCoA consultation had been completed and the professional standard to inform patients clearly when AAs are involved in their care and their role. [ 8 ] [ 9 ]
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Anal dysplasia is a pre-cancerous condition which occurs when the lining of the anal canal undergoes abnormal changes. It can be classified as low grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL). [ 1 ] Most cases are not associated with symptoms, but people may notice lumps in and around the anus . [ 2 ]
Anal dysplasia is most commonly linked to human papillomavirus (HPV), a usually sexually-transmitted infection . [ 3 ] HPV is the most common sexually transmitted infection in the United States [ 4 ] while genital herpes ( HSV ) was the most common sexually transmitted infection globally. [ 5 ]
This oncology article is a stub . You can help Wikipedia by expanding it .
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Analytical psychology ( German : analytische Psychologie , sometimes translated as analytic psychology ; also Jungian analysis ) is a term referring to the psychological practices of Carl Jung . It was designed to distinguish it from Freud's psychoanalytic theories as their seven-year collaboration on psychoanalysis was drawing to an end between 1912 and 1913. [ 1 ] [ 2 ] [ 3 ] The evolution of his science is contained in his monumental opus , the Collected Works , written over sixty years of his lifetime. [ 4 ]
The history of analytical psychology is intimately linked with the biography of Jung. At the start, it was known as the "Zurich school", whose chief figures were Eugen Bleuler , Franz Riklin , Alphonse Maeder and Jung, all centred in the Burghölzli hospital in Zurich. It was initially a theory concerning psychological complexes until Jung, upon breaking with Sigmund Freud , turned it into a generalised method of investigating archetypes and the unconscious , as well as into a specialised psychotherapy .
Analytical psychology, or "complex psychology", from the German : Komplexe Psychologie , is the foundation of many developments in the study and practice of psychology as of other disciplines. Jung has many followers, and some of them are members of national societies around the world. They collaborate professionally on an international level through the International Association of Analytical Psychologists (IAAP) and the International Association for Jungian Studies (IAJS). Jung's propositions have given rise to a multidisciplinary literature in numerous languages.
Among widely used concepts specific to analytical psychology are anima and animus , archetypes , the collective unconscious , complexes , extraversion and introversion , individuation , the Self , the shadow and synchronicity . [ 5 ] [ 6 ] The Myers–Briggs Type Indicator (MBTI) is loosely based on another of Jung's theories on psychological types . [ 5 ] [ 7 ] [ 8 ] A lesser known idea was Jung's notion of the Psychoid to denote a hypothesised immanent plane beyond consciousness, distinct from the collective unconscious, and a potential locus of synchronicity. [ 9 ]
The approximately "three schools" of post-Jungian analytical psychology that are current, the classical , archetypal and developmental , can be said to correspond to the developing yet overlapping aspects of Jung's lifelong explorations, even if he expressly did not want to start a school of "Jungians". [ 5 ] : 50–53 [ 10 ] Hence as Jung proceeded from a clinical practice which was mainly traditionally science-based and steeped in rationalist philosophy , anthropology and ethnography , his enquiring mind simultaneously took him into more esoteric spheres such as alchemy , astrology , gnosticism , metaphysics , myth and the paranormal , without ever abandoning his allegiance to science as his long-lasting collaboration with Wolfgang Pauli attests. [ 11 ] His wide-ranging progression suggests to some commentators that, over time, his analytical psychotherapy, informed by his intuition and teleological investigations, became more of an "art". [ 5 ]
The findings of Jungian analysis and the application of analytical psychology to [ 12 ] contemporary preoccupations such as social and family relationships, [ 13 ] [ page needed ] dreams and nightmares, work–life balance , [ 14 ] architecture and urban planning, [ 15 ] [ page needed ] politics and economics, conflict and warfare, [ 16 ] [ page needed ] and climate change are illustrated in several publications and films. [ 17 ] [ 18 ] [ page needed ] [ 19 ] [ 20 ] [ page needed ]
Jung began his career as a psychiatrist in Zürich , Switzerland. Already employed at the Burghölzli hospital in 1901, in his academic dissertation for the medical faculty of the University of Zurich he took the risk of using his experiments on somnambulism and the visions of his mediumistic cousin, Helly Preiswerk. The work was entitled, "On the Psychology and Pathology of So-Called Occult Phenomena". [ 21 ] It was accepted but caused great upset among his mother's family. [ 22 ] Under the direction of psychiatrist Eugen Bleuler , he also conducted research with his colleagues using a galvanometer to evaluate the emotional sensitivities of patients to lists of words during word association . [ 22 ] [ 23 ] [ 24 ] [ 25 ] Jung has left a description of his use of the device in treatment. [ 26 ] [ 27 ] [ 28 ] His research earned him a worldwide reputation and numerous honours, including honorary Doctorates from Clark and Fordham Universities in 1909 and 1910 respectively. Other honours followed later. [ 29 ] [ 30 ]
In 1907, Jung travelled to meet Sigmund Freud in Vienna, Austria; they had begun corresponding a year earlier. At that stage, Jung, aged thirty-two, had a much greater international renown than the forty-nine-year-old neurologist . [ 22 ] For a further six years, the two scholars worked and travelled to the United States together. In 1911, they founded the International Psychoanalytical Association , of which Jung was the first president. [ 22 ] However, early in the collaboration, Jung had already observed that Freud would not tolerate ideas that were different from his own. [ 22 ]
Unlike most modern psychologists, Jung did not believe in restricting himself to the scientific method as a means to understanding the human psyche. He saw dreams, myths, coincidence , and folklore as empirical evidence to further understanding and meaning. So although the unconscious cannot be studied by using direct methods, it acts as a useful working hypothesis, according to Jung. [ 31 ] As he said, "The beauty about the unconscious is that it is really unconscious." [ 32 ] Hence, the unconscious is 'untouchable' by experimental researches, or indeed any possible kind of scientific or philosophical reach, precisely because it is unconscious. [ 33 ] [ 34 ]
It was the publication of a book by Jung which provoked the break with psychoanalysis and led to the founding of analytical psychology. In 1912 Jung met "Miss Miller", brought to his notice by the work of Théodore Flournoy and whose case gave further substance to his theory of the collective unconscious . [ 35 ] : 213–215 The study of her visions supplied the material which would go on to furnish his reasoning which he developed in Psychology of the Unconscious ( Wandlungen und Symbole der Libido ) (re-published as Symbols of Transformation in 1952) (C.W. Vol. 5). At this, Freud muttered about "heresy". [ 36 ] It was the second part of the work that brought the divergence to light. Freud mentioned to Ernest Jones that it was on page 174 of the original German edition, that Jung, according to him, had "lost his way". [ 35 ] : 215 It is the extract where Jung enlarged on his conception of the libido . The sanction was immediate: Jung was officially banned from the Vienna psychoanalytic circle from August 1912. From that date the psychoanalytic movement split into two obediences, with Freud's partisans on one side, Karl Abraham being delegated to write a critical notice about Jung, [ 37 ] and with Ernest Jones as defender of Freudian orthodoxy; while on the other side, were Jung's partisans, including Leonhard Seif, Franz Riklin , Johan van Ophuijsen and Alphonse Maeder . [ 35 ] : 260
Jung's innovative ideas with a new formulation of psychology and lack of contrition sealed the end of the Jung-Freud friendship in 1913. From then, the two scholars worked independently on personality development: Jung had already termed his approach analytical psychology (1912), while the approach Freud had founded is referred to as the Psychoanalytic School ( psychoanalytische Schule ). [ 1 ]
Jung's postulated unconscious was quite different from the model proposed by Freud, despite the great influence that the founder of psychoanalysis had had on him. In particular, tensions manifested between him and Freud because of various disagreements, including those concerning the nature of the libido . [ 38 ] Jung de-emphasized the importance of sexual development as an instinctual drive and focused on the collective unconscious: the part of the unconscious that contains memories and ideas which Jung believed were inherited from generations of ancestors. While he accepted that libido was an important source for personal growth, unlike Freud, Jung did not consider that libido alone was responsible for the formation of the core personality. [ 39 ] Due to the particular hardships Jung had endured growing up, he believed his personal development and that of everyone was influenced by factors unrelated to sexuality. [ 38 ]
The overarching aim in life, according to Jungian psychology, is the fullest possible actualisation of the "Self" through individuation . [ 40 ] [ 6 ] Jung defines the "self" as "not only the centre but also the whole circumference which embraces both conscious and unconscious; it is the centre of this totality, just as the ego is the centre of the conscious mind". [ 41 ] Central to this process of individuation is the individual's continual encounter with the elements of the psyche by bringing them into consciousness. [ 6 ] People experience the unconscious through symbols encountered in all aspects of life: in dreams, art, religion, and the symbolic dramas enacted in relationships and life pursuits. [ 6 ] Essential to the process is the merging of the individual's consciousness with the collective unconscious through a huge range of symbols. By bringing conscious awareness to bear on what is unconscious, such elements can be integrated with consciousness when they "surface". [ 6 ] To proceed with the individuation process, individuals need to be open to the parts of themselves beyond their own ego, which is the "organ" of consciousness. [ 6 ] In a famous dictum, Jung said, "the Self, like the unconscious is an a priori existent out of which the ego evolves. It is ... an unconscious prefiguration of the ego. It is not I who create myself, rather I happen to myself'. [ 42 ]
It follows that the aim of (Jungian) psychotherapy is to assist the individual to establish a healthy relationship with the unconscious so that it is neither excessively out of balance in relation to it, as in neurosis, a state that can result in depression , anxiety , and personality disorders or so flooded by it that it risks psychosis resulting in mental breakdown . One method Jung applied to his patients between 1913 and 1916 was active imagination , a way of encouraging them to give themselves over to a form of meditation to release apparently random images from the mind to bridge unconscious contents into awareness. [ 43 ]
" Neurosis " in Jung's view results from the build up of psychological defences the individual unconsciously musters in an effort to cope with perceived attacks from the outside world, a process he called a "complex", although complexes are not merely defensive in character. [ 6 ] The psyche is a self-regulating adaptive system . [ 6 ] People are energetic systems, and if the energy is blocked, the psyche becomes sick. If adaptation is thwarted, the psychic energy stops flowing and becomes rigid. This process manifests in neurosis and psychosis. Jung proposed that this occurs through maladaptation of one's internal realities to external ones. The principles of adaptation, projection, and compensation are central processes in Jung's view of psyche's attempts to adapt.
Jung was an adept principally of the American philosopher William James , founder of pragmatism , whom he met during his trip to the United States in 1909. [ 22 ] : 255 He also encountered other figures associated with James, such as John Dewey and the anthropologist, Franz Boas . [ 22 ] : 165 Pragmatism was Jung's favoured route to base his psychology on a sound scientific basis according to historian Sonu Shamdasani. [ 44 ] His theories consist of observations of phenomena, and according to Jung, it is phenomenology . In his view psychologism was suspect. [ 38 ]
Displacement into the conceptual deprives experience of its substance and the possibility of being simply named.
Throughout his writings, Jung sees in empirical observation not only a precondition of an objective method but also respect for an ethical code which should guide the psychologist, as he stated in a letter to Joseph Goldbrunner:
I consider it a moral obligation not to make assertions about things one cannot see or whose existence cannot be proved, and I consider it an abuse of epistemological power to do so regardless. These rules apply to all experimental science. Other rules apply to metaphysics. I regard myself as answerable to the rules of experimental science. As a result nowhere in my work are there any metaphysical assertions nor – nota bene – any negations of a metaphysical nature. [ 45 ]
According to the Italo-French psychoanalyst Luigi Aurigemma, Jung's reasoning is also marked by Immanuel Kant , and more generally by German rationalist philosophy . His lectures are evidence of his assimilation of Kantian thought, especially the Critique of Pure Reason and Critique of Practical Reason . [ 46 ] Aurigemma characterises Jung's thinking as " epistemological relativism " because it does not postulate any belief in the metaphysical. [ 46 ] : 19 In fact, Jung uses Kant's teleology to bridle his thinking and to guard himself from straying into any metaphysical excursions. [ 46 ] : 21 On the other hand, for French historian of psychology, Françoise Parot, contrary to the alleged rationalist vein, Jung is " heir " to mystics ( Meister Eckhart , Hildegard of Bingen , or Augustine of Hippo [ 46 ] : 96 ) and to the romantics be they scientists, such as Carl Gustav Carus or Gotthilf Heinrich von Schubert in particular, or to philosophers and writers, along the lines of Nietzsche , Goethe , and Schopenhauer , in the way he conceptualised the unconscious in particular. Whereas his typology is profoundly dependent on Carl Spitteler . [ 22 ] : 255
As a trained psychiatrist, Jung had a grounding in the state of science in his day. He regularly refers to the experimental psychology of Wilhelm Wundt . His Word Association Test designed with Franz Riklin is actually the direct application of Wundt's theory. Notwithstanding the great debt of analytical psychology to Sigmund Freud , Jung borrowed concepts from other theories of his time. For instance, the expression " abaissement du niveau mental " ("lowering of the mental level") comes directly from the French psychologist Pierre Janet whose courses Jung attended during his studies in France in 1901. Jung had always acknowledged how much Janet had influenced his career.
Jung's use of the concept of " participation mystique " is owed to the French ethnologist Lucien Lévy-Bruhl :
PARTICIPATION MYSTIQUE is a term derived from Lévy-Bruhl. It denotes a peculiar kind of psychological connection with objects, and consists in the fact that the subject cannot clearly distinguish himself from the object but is bound to it by a direct relationship which amounts to partial identity. [ 47 ] : paragraph 781
Jung used the concept to illustrate the case of men of a South American tribe fantasizing they are macaw birds.
Finally, his use of the English expression, "pattern of behaviour", which is synonymous with the term archetype , is drawn from British studies in ethology .
The principal contribution to analytical psychology, nevertheless, remains that of Freud's psychoanalysis , from which Jung took a number of concepts, especially the method of inquiring into the unconscious through free association . Individual analysts' thinking was also integrated into his project, among whom are Sándor Ferenczi (Jung refers to his notion of " affect ") or Ludwig Binswanger and his Daseinsanalysis ( Daseinsanalyse ). Jung also affirms Freud's contribution to our knowledge of the psyche as being, without doubt, of the highest importance. It reveals penetrating information about the dark corners of the soul and of the human personality, which is of the same order as Nietzsche's On the Genealogy of Morality (1887). In this context, Freud was, according to Jung, one of the great cultural critics of the 19th century. [ 48 ]
Jungian analysis is, like psychoanalysis, a method to access, experience and integrate unconscious material into awareness. It is a search for the meaning of behaviours, feelings and events. Many are the channels to extend knowledge of the self: the analysis of dreams is one important avenue. Others may include expressing feelings about and through art, poetry or other expressions of creativity, the examination of conflicts and repeating patterns in a person's life. A comprehensive description of the process of dream interpretation is complex, in that it is highly specific to the person who undertakes it. Most succinctly, it relies on the associations which the particular dream symbols suggest to the dreamer, which at times may be deemed "archetypal" insofar as they are supposed to be common to many people throughout history. Examples could be a hero, an old man or woman, situations of pursuit, flying or falling.
Whereas Freudian psychoanalysis relies entirely on the development of the transference in the analysand (the person under treatment) to the analyst, Jung initially used the transference and later concentrated more on a dialectical and didactic approach to the symbolic and archetypal material presented by the patient. Moreover, his attitude towards patients departed from what he had observed in Freud's method. Anthony Stevens has explained it thus:
In place of Freud's "surgical detachment", Jung demonstrated a more relaxed and warmer welcome in the consulting room. [ 51 ] He remained aware nonetheless that exposure to a patient's unconscious contents always posed a certain risk of contagion (he calls it "psychic infection") to the analyst, as experienced in the countertransference . [ 52 ] The process of contemporary Jungian analysis depends on the type of "school of analytical psychology" to which the therapist adheres. The "Zurich School" would reflect the approach Jung himself taught, while those influenced by Michael Fordham and associates in London, would be significantly closer to a Kleinian approach and therefore, concerned with analysis of the transference and countertransference as indicators of repressed material along with the attendant symbols and patterns. [ 53 ]
Jung's preoccupation with dreams can be dated from 1902. [ 54 ] It was only after the break with Freud that he published in 1916 his "Psychology of the Unconscious" where he elaborated his view of dreams, which contrasts sharply with Freud's conceptualisation. [ 55 ] While he agrees that dreams are a highway into the unconscious, he enlarges on their functions further than psychoanalysis did. One of the salient differences is the compensatory function they perform by reinstating psychic equilibrium in respect of judgments made during waking life: thus a man consumed by ambition and arrogance may, for example, dream about himself as small and vulnerable person. [ 56 ] [ 57 ]
According to Jung, this demonstrates that the man's attitude is excessively self-assured and thereby refuses to integrate the inferior aspects of his personality, which are denied by his defensive arrogance. Jung calls this a compensation mechanism , necessary for the maintenance of a healthy mental balance. Shortly before his death in 1961, he wrote:
To secure mental and even physiological stability, it is necessary that the conscious and unconscious should be integrated one with the other. This is so that they evolve in parallel. (Pour sauvegarder la stabilité mentale, et même physiologique, il faut que la conscience et l'inconscient soient intégralement reliés, afin d'évoluer parallèlement) [ 58 ]
Unconscious material is expressed in images through the deployment of symbolism which, in Jungian terms, means it has an affective role (in that it can sometimes give rise to a numinous feeling, when associated with an archetypal force) and an intellectual role. [ 59 ] Some dreams are personal to the dreamer, others may be collective in origin or "transpersonal" in so far as they relate to existential events. [ 60 ] They can be taken to express phases of the individuation process and may be inspired by literature, art, alchemy or mythology .
Analytical psychology is recognized for its historical and geographical study of myths as a means to deconstruct, with the aid of symbols, the unconscious manifestations of the psyche. Myths are said to represent directly the elements and phenomena arising from the collective unconscious and though they may be subject to alteration in their detail through time, their significance remains similar. While Jung relies predominantly on Christian or on Western pagan mythology (Ancient Greece and Rome), he holds that the unconscious is driven by mythologies derived from all cultures. He evinced an interest in Hinduism , in Zoroastrianism and Taoism , which all share fundamental images reflected in the psyche. Thus analytical psychology focusses on meaning, based on the hypothesis that human beings are potentially in constant touch with universal and symbolic aspects common to humankind. In the words of André Nataf:
Jung opens psychoanalysis to a dimension currently obscured by the prevailing scientism : spirituality. His contribution, though questionable in certain respects, remains unique. His explorations of the unconscious carried out both as a scientist and a poet, indicate that it is structured as a language but one which is in a mythical mode. (Jung ouvre la psychanalyse à une dimension cachée par le scientisme ambiant : la spiritualité. Son apport, quoique contestable sur certains points, reste unique. Explorant l'inconscient en scientifique et poète, il montre que celui-ci se structure non-comme une langue mais sur le mode du mythe) [ 61 ]
In analytical psychology two distinct types of psychological process may be identified: that deriving from the individual, characterised as "personal", belonging to a subjective psyche, and that deriving from the collective, linked to the structure of an objective psyche, which may be termed "transpersonal". [ 62 ] These processes are both said to be archetypal . Some of these processes are regarded as specifically linked to consciousness, such as the animus or anima, the persona or the shadow. Others pertain more to the collective sphere. Jung tended to personify the anima and animus as they are, according to him, always attached to a person and represent an aspect of his or her psyche. [ 62 ]
Jung identified the archetypal anima as being the unconscious feminine component of men and the archetypal animus as the unconscious masculine component in women. [ 63 ] These are shaped by the contents of the collective unconscious, by others, and by the larger society. [ 63 ] However, many modern-day Jungian practitioners do not ascribe to a literal definition, citing that the Jungian concept points to every person having both an anima and an animus. [ 64 ] Jung considered, for instance, an "animus of the anima" in men, in his work Aion and in an interview in which he says:
Yes, if a man realizes the animus of his anima, then the animus is a substitute for the old wise man. You see, his ego is in relation to the unconscious, and the unconscious is personified by a female figure, the anima. But in the unconscious is also a masculine figure, the wise old man. And that figure is in connection with the anima as her animus, because she is a woman. So, one could say the wise old man was in exactly the same position as the animus to a woman. [ 65 ]
Jung stated that the anima and animus act as guides to the unconscious unified Self, and that forming an awareness and a connection with the anima or animus is one of the most difficult and rewarding steps in psychological growth. Jung reported that he identified his anima as she spoke to him, as an inner voice, unexpectedly one day.
In cases where the anima or animus complexes are ignored, they vie for attention by projecting itself on others. [ 66 ] This explains, according to Jung, why we are sometimes immediately attracted to certain strangers: we see our anima or animus in them. Love at first sight is an example of anima and animus projection. Moreover, people who strongly identify with their gender role (e.g. a man who acts aggressively and never cries) have not actively recognized or engaged their anima or animus.
Jung attributes human rational thought to be the male nature, while the irrational aspect is considered to be natural female (rational being defined as involving judgment, irrational being defined as involving perceptions). Consequently, irrational moods are the progenies of the male anima shadow and irrational opinions of the female animus shadow.
The use of archetypes in psychology was advanced by Jung in an essay entitled "Instinct and the Unconscious" in 1919. [ 43 ] The first element in Greek 'arche' signifies 'beginning, origin, cause, primal source principle', by extension it can signify 'position of a leader, supreme rule and government'. The second element 'type' means 'blow or what is produced by a blow, the imprint of a coin ...form, image, prototype, model, order, and norm', ...in the figurative, modern sense, 'pattern underlying form, primordial form'. [ 67 ] In his psychological framework, archetypes are innate, universal or personal prototypes for ideas and may be used to interpret observations. The method he favoured was hermeneutics which was central in his practice of psychology from the start. He made explicit references to hermeneutics in the Collected Works and during his theoretical development of the notion of archetypes. Although he lacks consistency in his formulations, his theoretical development of archetypes is rich in hermeneutic implications. As noted by Smythe and Baydala (2012),
his notion of the archetype as such can be understood hermeneutically as a form of non-conceptual background understanding. [ 68 ] [ page needed ]
A group of memories and attitudes associated with an archetype can become a complex, e.g. a mother complex may be associated with a particular mother archetype. Jung treated the archetypes as psychological organs, analogous to physical ones in that both are morphological givens which probably arose through evolution .
Archetypes have been regarded as collective as well as individual, and identifiable in a variety of creative ways. As an example, in his book Memories, Dreams, Reflections , Jung states that he began to see and talk to a manifestation of anima and that she taught him how to interpret dreams. As soon as he could interpret on his own, Jung said that she ceased talking to him because she was no longer needed. [ 69 ] However, the essentialism inherent in archetypal theory in general and concerning the anima, in particular, has called for a re-evaluation of Jung's theory in terms of emergence theory. This would emphasise the role of symbols in the construction of affect in the midst of collective human action. In such a reconfiguration, the visceral energy of a numinous experience can be retained while the problematic theory of archetypes has outlived its usefulness. [ 70 ]
Jung's concept of the collective unconscious has undergone re-interpretation over time. The term "collective unconscious" first appeared in Jung's 1916 essay, "The Structure of the Unconscious". [ 71 ] This essay distinguishes between the "personal", Freudian unconscious, filled with fantasies (e. g. sexual) and repressed images, and the "collective" unconscious encompassing the soul of humanity at large. [ 72 ]
In "The Significance of Constitution and Heredity in Psychology" (November 1929), Jung wrote:
And the essential thing, psychologically, is that in dreams, fantasies, and other exceptional states of mind the most far-fetched mythological motifs and symbols can appear autochthonously at any time, often, apparently, as the result of particular influences, traditions, and excitations working on the individual, but more often without any sign of them. These "primordial images" or "archetypes," as I have called them, belong to the basic stock of the unconscious psyche and cannot be explained as personal acquisitions. Together they make up that psychic stratum which has been called the collective unconscious.
The existence of the collective unconscious means that individual consciousness is anything but a tabula rasa and is not immune to predetermining influences. On the contrary, it is in the highest degree influenced by inherited presuppositions, quite apart from the unavoidable influences exerted upon it by the environment. The collective unconscious comprises in itself the psychic life of our ancestors right back to the earliest beginnings. It is the matrix of all conscious psychic occurrences, and hence it exerts an influence that compromises the freedom of consciousness in the highest degree, since it is continually striving to lead all conscious processes back into the old paths. [ 73 ]
Given that in his day he lacked the advances of complexity theory and especially complex adaptive systems (CAS), it has been argued that his vision of archetypes as a stratum in the collective unconscious, corresponds to nodal patterns in the collective unconscious which go on to shape the characteristic patterns of human imagination and experience and in that sense, "seems a remarkable, intuitive articulation of the CAS model". [ 74 ]
Individuation is a complex process that involves going through different stages of growing awareness through the progressive confrontation and integration of personal unconscious elements. This is the central concept of analytical psychology first introduced in 1916. [ 75 ] [ 76 ] It is the objective of Jungian psychotherapy to the extent that it enables the realisation of the Self. [ 77 ] As Jung stated:
The aim of individuation is nothing less than to divest the self of the false wrappings of the persona, on the one hand and the suggestive power of primordial images on the other. [ 78 ]
Jung started experimenting with individuation after his split with Freud as he confronted what was described as eruptions from the collective unconscious driven by a contemporary malaise of spiritual alienation. [ 79 ] According to Jung, individuation means becoming an individual and implies becoming one's own self. [ 80 ] Unlike individuality, which emphasizes some supposed peculiarity, Jung described individuation as a better and more complete fulfillment of the collective qualities of the human being. [ 80 ] In his experience, Jung explained that individuation helped him, "from the therapeutic point of view, to find the particular images that lie behind emotions". [ 79 ]
Individuation is from the first what the analysand must undergo, to integrate the other elements of the psyche. [ 46 ] : 35 This pursuit of wholeness aims to establish the Self, which include both the rational conscious mind of the ego and the irrational contents of the unconscious, as the new personality center. [ 81 ] Prior to individuation, the analysand is carefully assessed to determine if the ego is strong enough to take the intensity of this process. [ 82 ] The elements to be integrated include the persona which acts as the representative of the person in her/his role in society, the shadow which contains all that is personally unknown and what the person considers morally reprehensible and, the anima or the animus, which respectively carry their feminine and masculine values. [ 83 ] For Jung many unconscious conflicts at the root of neurosis are caused by the difficulty to accept that such a dynamic can unbalance the subject from his habitual position and confronts her/him with aspects of the self they were accustomed to ignore. Once individuation is completed the ego is no longer at the centre of the personality. [ 84 ] The process, however, does not lead to a complete self-realization and that individuation can never be a fixed state due to the unfathomable nature of the depths of the collective unconscious. [ 85 ]
The shadow is an unconscious complex defined as the repressed, suppressed or disowned qualities of the conscious self. [ 86 ] According to Jung, the human being deals with the reality of the shadow in four ways: denial, projection, integration and/or transmutation. Jung himself asserted that "the result of the Freudian method of elucidation is a minute elaboration of man's shadow-side unexampled in any previous age." [ 87 ] : 63 According to analytical psychology, a person's shadow may have both constructive and destructive aspects. In its more destructive aspects, the shadow can represent those things people do not accept about themselves. For instance, the shadow of someone who identifies as being kind may be harsh or unkind. Conversely, the shadow of a person who perceives himself to be brutal may be gentle. In its more constructive aspects, a person's shadow may represent hidden positive qualities. This has been referred to as the "gold in the shadow". Jung emphasized the importance of being aware of shadow material and incorporating it into conscious awareness to avoid projecting shadow qualities on others.
The shadow in dreams is often represented by dark figures of the same gender as the dreamer. [ 88 ]
The shadow may also concern great figures in the history of human thought or even spiritual masters, who became great because of their shadows or because of their ability to live their shadows (namely, their unconscious faults) in full without repressing them.
Just like the anima and animus , the persona (derived from the Latin term for a mask, as would have been worn by actors) is another key concept in analytical psychology. It is the part of the personality which manages an individual's relations with society in the outside world and works the same way for both sexes. [ 89 ]
The persona ... is the individual's system of adaptation to, or the manner assumed in dealing with the world. Every calling or profession, for example, has its own characteristic persona [...] Only the danger is that (people) become identical with their personas: thus the professor with his textbook, the tenor with his voice. One could say with little exaggeration, that the persona is that which in reality one is not, but which oneself as well as others think one is. [ 38 ] : 415–416
The persona, which is at the heart of the psyche, is contrary to the shadow which is actually the true personality but denied by the self. The conscious self identifies primarily with the persona during development in childhood as the individual develops a psychological framework for dealing with others. [ 90 ] Identifications with diplomas, social roles, with honours and awards, with a career, all contribute to the apparent constitution of the persona and which do not lead to knowledge of the self. For Jung, the persona has nothing real about it. [ 91 ] It can only be a compromise between the individual and society, yielding an illusion of individuality . [ 92 ] Individuation consists, in the first instance, of discarding the individual's mask, but not too quickly as often, it is all the patient has as a means of identification. [ 93 ] The persona is implicated in a number of symptoms such as compulsive disorders, phobias, shifting moods, and addictions, among others. [ 94 ]
Analytical psychology distinguishes several psychological types or temperaments.
According to Jung, the psyche is an apparatus for adaptation and orientation, and consists of a number of different psychic functions. Among these he distinguishes four basic functions: [ 95 ]
Early in Jung's career he coined the term and described the concept of the " complex ". Jung claims to have discovered the concept during his free association and galvanic skin response experiments. Freud obviously took up this concept in his Oedipus complex amongst others. Jung seemed to see complexes as quite autonomous parts of psychological life. It is almost as if Jung were describing separate personalities within what is considered a single individual, but to equate Jung's use of complexes with something along the lines of multiple personality disorder would be a step out of bounds.
Jung saw an archetype as always being the central organizing structure of a complex. For instance, in a "negative mother complex", the archetype of the "negative mother" would be seen to be central to the identity of that complex. This is to say, our psychological lives are patterned on common human experiences. Jung saw the Ego (which Freud wrote about in German literally as the "I", one's conscious experience of oneself) as a complex. If the "I" is a complex, what might be the archetype that structures it? Jung, and many Jungians, might say "the hero ", one who separates from the community to ultimately carry the community further.
Jung first officially used the term synchronicity during a conference held in memory of his sinologist friend, Richard Wilhelm in 1930. [ 96 ] It was part of his explanation of the modus operandi of the I Ching . [ 96 ] The second reference was made in 1935 in his Tavistock Lectures.
For an overview of the origins of the concept, see Joseph Cambray: "Synchronicity as emergence". [ 97 ] It was used to denote the simultaneous occurrence of two events with no causal physical connection, but whose association evokes a meaning for the person experiencing or observing it. The often cited example of the phenomenon is Jung's own account of a beetle (the common rose-chafer, Cetonia aurata ) flying into his consulting room directly following on from his patient telling him a dream featuring a golden scarab. [ 98 ] The concept only makes sense psychologically and cannot be reduced to a verified or scientific fact. For Jung it constitutes a working hypothesis which has subsequently given rise to many ambiguities.
I chose this term because the simultaneous occurrence of two meaningfully but not causally connected events seemed to me an essential criterion. I am therefore using the general concept of synchronicity in the special sense of a coincidence in time of two or more causally unrelated events which have the same or a similar meaning, in contrast to synchronism , which simply means the simultaneous occurrence of two events.
Synchronicity therefore means the simultaneous occurrence of a certain psychic state with one or more external events which appear as meaningful parallels to the momentary subjective state -and, in certain cases, vice versa. [ 99 ] [ 100 ]
According to Jung, an archetype which has been constellated in the psyche can, under certain circumstances, transgress the boundary between substance and psyche.
Jung had studied such phenomena with the physicist and Nobel Prize winner, Wolfgang Pauli , who did not always agree with Jung, and with whom he carried on an extensive correspondence, enriched by the contributions of both specialists in their own fields. [ 101 ] Pauli had given a series of lectures to the C. G. Jung Institute, Zürich whose member and patron he had been since 1947. [ 35 ] It gave rise to a joint essay: Synchronicity, an a-causal principle (1952) [ 102 ] [ 103 ] The two men saw in the idea of synchronicity a potential way of explaining a particular relationship between "incontrovertible facts", whose occurrence is tied to unconscious and archetypal manifestations,
The psyche and matter are ordered according to principles which are common, neutral, and incontrovertible. [ 104 ]
Borrowing the notion from Arthur Schopenhauer , Jung calls it Unus mundus , a state where neither matter nor the psyche are distinguishable. [ 35 ] whereas for Pauli it was a limiting concept, in two senses, in that it is at once scientific and symbolic. According to him, the phenomenon is dependent on the observer. [ 105 ] Nevertheless, both men were in accord that there existed the possibility of a conjunction between physics and psychology. Jung wrote in a letter to Pauli:
These researches (Jung's research into alchemy), have shown me that modern physics can symbolically represent psychological processes down to the minutest detail. [ 106 ]
Marie-Louise von Franz also had a lengthy exchange of letters with Wolfgang Pauli. On Pauli's death in 1958, his widow, Franca, deliberately destroyed all the letters von Franz had sent to her husband, and which he had kept locked inside his writing desk. However, the letters from Pauli to von Franz were all saved and were later made available to researchers and published. [ 107 ]
Synchronicity is among the most developed ideas by Jung's followers, notably by Michel Cazenave [ fr ] , James Hillman , Roderick Main, [ 108 ] Carl Alfred Meier and by the British developmental clinician, George Bright. [ 109 ] It has been explored also in a range of spiritual currents who have sought in it a scientific rigour. [ 110 ]
Although Synchronicity as conceived by Jung within the bounds of the science available in his day, has been categorised as pseudoscience , recent developments in complex adaptive systems argue for a revision of such a view. [ 74 ] Critics cite that Jung's experiments that sought to provide statistical proof for this theory did not yield satisfactory result. [ 111 ] His experiment was also faulted for not using a true random sampling method as well as for the use of dubious statistics and astrological material. [ 111 ]
Andrew Samuels (1985) has distinguished three distinct traditions or approaches of "post-Jungian" psychology – classical, developmental and archetypal. Today there are more developments.
The classical approach tries to remain faithful to Jung's proposed model, his teachings and the substance of his 20 volume Collected Works, together with recently published works, such as the Liber Novus , [ 112 ] and the Black Books . [ 113 ] Prominent advocates of this approach, according to Samuels (1985), include Emma Jung , Jung's wife, an analyst in her own right, Marie-Louise von Franz , Joseph L. Henderson , Aniela Jaffé , Erich Neumann , Gerhard Adler and Jolande Jacobi . Jung credited Neumann, author of "Origins of Conscious" and "Origins of the Child", as his principal student to advance his (Jung's) theory into a mythology -based approach. [ 114 ] He is associated with developing the symbolism and archetypal significance of several myths: the Child, Creation, the Hero, the Great Mother and Transcendence . [ 10 ]
One archetypal approach, sometimes called "the imaginal school" by James Hillman , was written about by him in the late 1960s and early 1970s. Its adherents, according to Samuels (1985), include Gerhard Adler , Irene Claremont de Castillejo , Adolf Guggenbühl-Craig , Murray Stein, Rafael López-Pedraza [ es ] and Wolfgang Giegerich . Thomas Moore also was influenced by some of Hillman's work. Developed independently, other psychoanalysts have created strong approaches to archetypal psychology. Mythopoeticists and psychoanalysts such as Clarissa Pinkola Estés who believes that ethnic and aboriginal people are the originators of archetypal psychology and have long carried the maps for the journey of the soul in their songs, tales, dream-telling, art and rituals; Marion Woodman who proposes a feminist viewpoint regarding archetypal psychology. Some of the mythopoetic/archetypal psychology creators either imagine the Self not to be the main archetype of the collective unconscious as Jung thought, but rather assign each archetype equal value. [ citation needed ] Others, who are modern progenitors of archetypal psychology (such as Estés), think of the Self as the thing that contains and yet is suffused by all other archetypes, each giving life to the other.
Robert L. Moore has explored the archetypal level of the human psyche in a series of five books co-authored with Douglas Gillette, which have played an important role in the men's movement in the United States. Moore studies computerese so he uses a computer's hard wiring (its fixed physical components) as a metaphor for the archetypal level of the human psyche. Personal experiences influence the access to the archetypal level of the human psyche, but personalized ego consciousness can be likened to computer software. [ citation needed ]
In the 21st century, Jordan Peterson is a prominent Jungian psychologist whose extensive work Maps of Meaning is centered around the theories of Jungian archetypes. [ 115 ] [ 116 ]
A major expansion of Jungian theory is credited to Michael Fordham and his wife, Frieda Fordham . It can be considered a bridge between traditional Jungian analysis and Melanie Klein 's object relations theory . Judith Hubback and William Goodheart MD are also included in this group. [ 117 ] Andrew Samuels (1985) considers J.W.T. Redfearn , Richard Carvalho and himself as representatives of the developmental approach. Samuels notes how this approach differs from the classical by giving less emphasis to the Self and more emphasis to the development of personality; he also notes how, in terms of practice in therapy, it gives more attention to transference and counter-transference than either the classical or the archetypal approaches.
Sandplay is a non-directive, creative form of therapy using the imagination, originally used with children and adolescents, later also with adults. Jung had stressed the importance of finding the image behind the emotion. The use of sand in a suitable tray with figurines and other small toys, farm animals, trees, fences and cars enables a narrative to develop through a series of scenarios. This is said to express an ongoing dialogue between the conscious and the unconscious aspects of the psyche, which in turn activates a healing process whereby the patient and therapist can together view the evolving sense of self. [ 118 ]
Jungian Sandplay started as a therapeutic method in the 1950s. Although its origin has been credited to a Swiss Jungian analyst, Dora Kalff it was in fact, her mentor and trainer, Dr. Margaret Lowenfeld , a British paediatrician, who had developed the Lowenfeld World Technique inspired by the writer H. G. Wells in her work with children, [ 119 ] using a sand tray and figurines in the 1930s. [ 120 ] Jung had witnessed a demonstration of the technique while on a visit to the UK in 1937. Kalff saw in it potential as a further application of analytical psychology. Encouraged by Jung, Kalff developed the new application over a number of years and called it Sandplay . [ 121 ] From 1962 she began to train Jungian Analysts in the method including in the United States, Europe and Japan. Both Kalff and Jung believed an image can offer greater therapeutic engagement and insight than words alone. Through the sensory experience of working with sand and objects, and their symbolic resonance new areas of awareness can be brought into consciousness, as in dreams, which through their frames and storyline can bring material into consciousness as part of an integrating and healing process. The historian of psychology, Sonu Shamdasani has commented:
Historical reflection suggests the spirit of Jung's practice of the image, his engagement with his own figures, is indeed more alive in Sandplay than in other Jungian conclaves. [ 122 ]
One of Dora Kalff's trainees was the American concert pianist, Joel Ryce-Menuhin , whose music career was ended by illness and who retrained as a Jungian analyst and exponent of sandplay. [ 123 ]
Process-oriented psychology (also called Process work) is associated with the Zurich-trained Jungian analyst Arnold Mindell . Process work developed in the late 1970s and early 1980s and was originally identified as a "daughter of Jungian psychology". [ 124 ] Process work stresses awareness of the "unconscious" as an ongoing flow of experience. This approach expands Jung's work beyond verbal individual therapy to include body experience, altered and comatose states as well as multicultural group work.
Formally Jungian analysis differs little from psychoanalysis . However, variants of each school have developed overlaps and specific divergences through the century, or more, of their existence. They share a " frame " consisting of regular spatio-temporal meetings, one or more times a week, focusing on patient material, using dialogue which may consist of elaboration, amplification and abreaction and which may last on average three years (sometimes more briefly or far longer). The spatial arrangement between analyst and analysand may differ: seated face to face or the patient may use the couch with the analyst seated behind. [ 125 ]
In some approaches alternative elements of expression can take place, such as active imagination , sandplay , [ 126 ] drawing or painting, even music. The session may at times become semi-directed (in contrast to psychoanalytic treatment which is essentially a non-directive encounter). [ 125 ] : 738 The patient is at the heart of the therapy, as Marie Louise von Franz has it in her work, "Psychotherapy: the practitioner's experience", where she recounts Jung's thinking on that point. [ 127 ] The transference is sought out (contrary to psychoanalytic treatment which distinguishes positive and negative transferences) and, the interpretation of dreams is one of the central pillars of Jungian psychotherapy. In all other respects, the rules correspond to those of classical psychoanalysis: the analyst examines free associations and tries to be objective and ethical, meaning respectful of the patient's pace and rhythm of unfolding progress. In fact, the task of Jungian analysis is not merely to explore the patient's past, but to connect conscious awareness with the unconscious such that a better adaptation to their emotional and social life may ensue.
Neurosis is not a symptom of the re-emergence of a repressed past, but is regarded as the functional, sometimes somatic, incapacity to face certain aspects of lived reality. In Jungian analysis the unconscious is the motivator whose task it is to bring into awareness the patient's shadow, in alliance with the analyst, the more so since unconscious processes enacted in the transference provoke a dependent relationship by the analysand on the analyst, leading to a falling away of the usual defences and references. This requires that the analyst guarantee the safety of the transference. [ 128 ] The responsibilities and accountability of individual analysts and their membership organisations, matters of clinical confidentiality and codes of ethics and professional relations with the public sphere are explored in a volume edited by Solomon and Twyman, with contributions from Jungian analysts and psychoanalysts. [ 129 ] Solomon has characterised the nature of the patient – analyst relationship as one where the analytic attitude is an ethical attitude since:
The ethical attitude presupposes special responsibilities that we choose to adopt in relation to another. Thus, a parallel situation pertains between caregiver and child and between analyst and patient: they are not equal partners, but nevertheless are in a situation of mutuality, shared subjectivity, and reciprocal influence. [ 130 ]
Analytical psychology has inspired a number of contemporary academic researchers to revisit some of Jung's own preoccupations with the role of women in society, with philosophy and with literary and art criticism. [ 131 ] [ 132 ] Leading figures to explore these fields include the British-American, Susan Rowland, who produced the first feminist revision of Jung and the fundamental contributions made to his work by the creative women who surrounded him. [ 133 ] She has continued to mine his work by evaluating his influence on modern literary criticism and as a writer. [ 134 ] Leslie Gardner has devoted a series of volumes to analytical psychology in 21st century life, one of which concentrates on the "Feminine Self". [ 135 ] Paul Bishop , a British German scholar, has placed analytical psychology in the context of precursors such as, Goethe , Schiller and Nietzsche. [ 136 ] [ 137 ]
The Franco-Swiss art historian and analytical psychologist Christian Gaillard has examined Jung's place as an artist and art critic in his series of Fay lectures at the Texas A&M University . [ 138 ] These scholars draw from Jung's works that apply analytical psychology to literature such as the lecture " On the Relation of Analytical Psychology to Poetry ". [ 139 ] In this presentation, which was delivered in 1922, Jung stated that the psychologist cannot replace the art critic. [ 140 ] He rejected the Freudian art criticism for reducing complex works of art to Oedipal fantasies of their creators, stressing the danger of simplifying literature to causes found outside of the actual work. [ 140 ]
Since its inception, analytical psychology has been the object of criticism, emanating from the psychoanalytic sphere. Freud himself characterised Jung as a "mystic and a snob". [ 141 ] In his introduction to the 2011 edition of Jung's "Lectures on the Theory of Psychoanalysis", given in New York City in 1912, Sonu Shamdasani contends that Freud orchestrated a round of critical reviews of Jung's writings from Karl Abraham , Jung's former colleague at the Burghölzli hospital, and from the early Welsh Freudian, Ernest Jones . [ 142 ] [ 143 ] [ 144 ] Such criticisms multiplied during the 20th century, focusing primarily on the "mysticism" in Jung's writings. Other psychoanalysts, including Jungian analysts, objected to the cult of personality around the Swiss psychiatrist. [ 145 ] It reached a crescendo with Jung's perceived collusion with Nazism in the build-up and during World War II and is still a recurrent theme. Thomas Kirsch writes: "Successive generations of Jungian analysts and analysands have wrestled with the question of Jung's complex relations to Germany." [ 110 ] Other considered evaluations come from Andrew Samuels and from Robert Withers. [ 146 ] [ 147 ]
The French philosopher, Yvon Brès [ fr ] , considers that the concept of the collective unconscious, "shows also how easily one can slip from the psychological unconscious into perspectives from a universe of thought, quite alien from traditional philosophy and science, where this idea arose." ("Le concept jungien d'inconscient collectif "témoigne également de la facilité avec laquelle on peut glisser du concept d'inconscient psychologique vers des perspectives relevant d'un univers de pensée étranger à la tradition philosophique et scientifique dans laquelle ce concept est né'"). [ 148 ]
In his Le Livre Rouge de la psychanalyse ("Red Book of psychoanalysis"), the French psychoanalyst, Alain Amselek [ fr ] , criticizes Jung's tendency to be fascinated by the image and to reduce the human to an archetype. He contends that Jung dwells in a world of ideas and abstractions, in a world of books and old secrets lost in ancient books of spells (fr: grimoires ). While claiming to be an empiricist, Amselek finds Jung to be an idealist, a pure thinker who has unquestionably demonstrated his intellectual talent for speculation and the invention of ideas. While he considers his epistemology to be in advance of that of Freud, Jung remains stuck in his intellectualism and in his narrow provincial outlook. [ clarification needed ] In fact, his hypotheses are determined by the concept of his postulated pre-existing world and he has constantly sought to find confirmations of it in the old traditions of Western Medieval Europe. [ 149 ]
Perhaps the most prominent critic of Analytical Psychology has been American clinical psychologist and historian of medicine Richard Noll , who claims that Analytical Psychology "was constructed deliberately, and somewhat deceptively, by Jung to make his own magical, polytheist, pagan worldview more palatable to a secularized world conditioned to respect only those ideas that seem to have a scientific air to them. I make this judgment about Jung without being either Christian or Jew or Moslem--or Freudian". [ 150 ]
He argues in his books "The Jung Cult: Origins of a Charismatic Movement" and "The Aryan Christ: The Secret Life of Carl Jung" that Jung secretly founded a mystery cult based on pre-Christian Germanic pagan ideals, influenced by the late 19th and early 20th century Völkisch movement . [ 151 ]
Noll's work was received critically by the Jungian community. Sonu Shamdasani , who originally corresponded with Noll prior to his publication of "The Jung Cult", wrote a rebuttal titled "Cult Fictions", in which he claims "some of Jung’s followers were responsible for attempting to turn analytical psychology into a quasi-religious cult, but not Jung himself. This distinction is critical." [ 152 ]
French psychoanalyst Élisabeth Roudinesco , another critic of Noll, stated in a review: "Even if Noll's theses are based on a solid familiarity with the Jungian corpus [...], they deserve to be re-examined, such is the detestation of the author for the object of his study that it diminishes the credibility of the arguments." ("Même si les thèses de Noll sont étayées par une solide connaissance du corpus jungien [...], elles méritent être réexaminées, tant la détestation de l'auteur vis-à-vis de son objet d'étude diminue la crédibilité de l'argumentation.") [ 153 ]
French ethnographer and anthropologist Jean-Loïc Le Quellec [ fr ] criticized Jung over his alleged misuse of the term archetype and his "suspect motives" in dealings with some of his colleagues. [ 154 ]
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Anaphia , also known as tactile anesthesia , is a medical symptom in which there is a total or partial absence of the sense of touch. [ 1 ] Anaphia is a common symptom of spinal cord injury and neuropathy . [ citation needed ]
This medical symptom article is a stub . You can help Wikipedia by expanding it .
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Anaplastic astrocytoma is a rare WHO grade III type of astrocytoma , which is a type of cancer of the brain. In the United States, the annual incidence rate for anaplastic astrocytoma is 0.44 per 100,000 people. [ 1 ]
Initial presenting symptoms most commonly are headache, depressed mental status, focal neurological deficits, and/or seizures. [ 2 ] The growth rate and mean interval between onset of symptoms and diagnosis is approximately 1.5–2 years but is highly variable, [ 2 ] being intermediate between that of low-grade astrocytomas and glioblastomas. [ 2 ] Seizures are less common among patients with anaplastic astrocytomas compared to low-grade lesions. [ 2 ]
The best-known risk factor is exposure to ionizing radiation, and CT scan radiation is an important cause. [ 3 ] [ 4 ] The dose-response for the relationship between low-dose ionising radiation and anaplastic astrocytoma risk is a risk increase of 115% per 100 milligray of radiation.
Most high-grade gliomas occur sporadically or without identifiable cause. [ 5 ] However, a small proportion (less than 5%) of persons with malignant astrocytoma have a definite or suspected hereditary predisposition. [ 6 ] The main hereditary predispositions are mainly neurofibromatosis type I , Li-Fraumeni syndrome , hereditary nonpolyposis colorectal cancer and tuberous sclerosis . [ 5 ] Anaplastic astrocytomas have also been associated with previous exposure to vinyl chloride and to high doses of radiation therapy to the brain. [ 5 ]
Anaplastic astrocytomas fall under the category of high grade gliomas (WHO grade III-IV), which are pathologically undifferentiated gliomas that carry a poor clinical prognosis. Unlike glioblastomas (WHO grade IV), anaplastic astrocytomas lack vascular proliferation and necrosis on pathologic evaluation. [ 7 ] Compared to grade II tumors, anaplastic astrocytomas are more cellular, demonstrate more atypia, and mitoses are seen. [ citation needed ]
The standard initial treatment is to remove as much of the tumor as possible without worsening neurologic deficits. Radiation therapy has been shown to prolong survival and is a standard component of treatment. There is no proven benefit to adjuvant chemotherapy or supplementing other treatments for this kind of tumor. Although temozolomide is effective for treating recurrent anaplastic astrocytoma, its role as an adjuvant to radiation therapy has not been fully tested. [ 8 ]
Quality of life after treatment depends heavily on the area of the brain that housed the tumor. In many cases, patients with anaplastic astrocytoma may experience various types of paralysis, speech impediments, difficulties planning and skewed sensory perception. Most cases of paralysis and speech difficulties can be rehabilitated with speech, occupational, physical, and vision therapy. [ citation needed ]
The age-standardized 5-year relative survival rate is 23.6%. [ 9 ] Patients with this tumor are 46 times more likely to die than matched members of the general population. [ 9 ] It is important to note that prognosis across age groups is different especially during the first three years post-diagnosis. When the elderly population is compared with young adults, the excess hazard ratio (a hazard ratio that is corrected for differences in mortality across age groups) decreases from 10.15 to 1.85 at 1 to 3 years, meaning that the elderly population are much more likely to die in the first year post-diagnosis when compared to young adults (aged 15 to 40), but after three years, this difference is reduced markedly. [ 9 ] Typical median survival for anaplastic astrocytoma is 2–3 years. Secondary progression to glioblastoma multiforme is common. Radiation, younger age, female sex, treatment after 2000, and surgery were associated with improved survival in AA patients. [ 10 ]
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Anaplastic oligodendroglioma is a neuroepithelial tumor which is believed to originate from oligodendrocytes , a cell type of the glia . In the World Health Organization (WHO) classification of brain tumors, anaplastic oligodendrogliomas are classified as grade III. [ 2 ] In the course of the disease, it can degenerate into highly malignant oligodendroglioma, grade IV. [ 3 ] The vast majority of oligodendrogliomas occur sporadically, without a confirmed cause and without inheritance within a family.
Symptoms of anaplastic oligodendroglioma may include: [ 4 ]
The ( malignant ) anaplastic oligodendroglioma belongs to the group of diffuse glioma and arises in the central nervous system ( brain and spinal cord ) from precursor stem cells of the oligodendrocytes . This tumor occurs primarily in middle adulthood with a frequency peak in the 4th and 5th decade of life. [ 3 ]
The most important diagnostic procedure is magnetic resonance imaging (MRI). Occasionally, outside of routine diagnostics, the metabolism in the tissue is shown using positron emission tomography (PET). The diagnosis is confirmed by a fine tissue examination following an operation . Anaplastic oligodendrogliomas often show a loss of genetic material. About 50 to 70% [ 5 ] of WHO grade III anaplastic oligodendrogliomas have combined allele losses on the short arm of chromosome 1 (1p) and the long arm of chromosome 19 (19q).
This change is mostly referred to as "1p / 19q Co Deletion". It can be seen as favorable for the patient and makes a response to radiation or chemotherapy more likely. The designation of grade III oligodendroglioma (high grade) generally subsumes the previous diagnoses of anaplastic or malignant oligodendroglioma. [ 2 ]
Surgery can help reduce symptoms caused by the tumor. As complete as possible removal of the tumor visible on the MRI is preferred, provided the location of the tumor allows this. Since typically the cells of an anaplastic oligodendroglioma have already migrated into the surrounding healthy brain tissue at the time of diagnosis, a complete surgical removal of all tumor cells is not possible. The "1p / 19q Codeletion" marker plays an increasingly important role in the selection of therapy and therapy combinations.
Because this tumor is an "indolent condition" (a slowly progressive medical condition associated with little or no pain) and the potential morbidity associated with neurosurgery , chemotherapy and radiation therapy , most neuro-oncologists will initially pursue a course of watchful waiting and treat patients symptomatically. Symptomatic treatment often includes the use of anticonvulsants for seizures and steroids for brain swelling . For further treatment, radiation or chemotherapy with temozolomide or a chemotherapy with Procarbazine , CCNU and Vincristine (PCV) has been shown to be effective and was the most commonly used chemotherapy regimen used for treating anaplastic oligodendrogliomas. [ 3 ] [ 6 ]
5–Year relative survival rate: Age 20–44, 76%. Age 45–54, 67%. Age 55–64, 45%. [ 7 ] [ 8 ] Procarbazine, lomustine and vincristine have been used since May 1975. For 48 years, new therapeutic options have been regularly tested as part of therapy studies to improve the treatment of anaplastic oligodendroglioma. [ 9 ]
As of 2022 [update] , a definitive cure is not possible with anaplastic oligodendrogliomas of WHO grade III. A retrospective study on 1054 patients with anaplastic oligodendroglioma, presented during the 2009 ASCO Annual Meeting, suggests that PCV therapy may be effective. Median time to progression for patients with 1p19q co-deletion was longer following PCV alone (7.6 years) than with temozolomide alone (3.3 years); median overall survival was also longer with PCV treatment versus temozolomide treatment (not reached, vs. 7.1 years). [ 10 ] A recent long-term study does affirm that radiation combined with adjuvant chemotherapy is significantly more efficacious for anaplastic oligodendroglioma patients with 1p 19q co-deleted tumors and has become the new standard of care. [ 11 ] It is possible that radiotherapy may prolong the overall time to progression for non-deleted tumors. If the tumor mass compresses adjacent brain structures, a neurosurgeon will typically remove as much of the tumor as he or she can without damaging other critical, healthy brain structures. Recent studies suggest that radiation does not improve overall survival (even when age, clinical data, histological grading , and type of surgery are considered). [ 12 ] [ 13 ]
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Anatomical pathology ( Commonwealth ) or anatomic pathology ( U.S. ) is a medical specialty that is concerned with the diagnosis of disease based on the macroscopic , microscopic , biochemical, immunologic and molecular examination of organs and tissues . Over the 20th century, surgical pathology has evolved tremendously: from historical examination of whole bodies ( autopsy ) to a more modernized practice, centered on the diagnosis and prognosis of cancer to guide treatment decision-making in oncology. Its modern founder was the Italian scientist Giovanni Battista Morgagni from Forlì . [ 1 ]
Anatomical pathology is one of two branches of pathology , the other being clinical pathology , the diagnosis of disease through the laboratory analysis of bodily fluids or tissues. Often, pathologists practice both anatomical and clinical pathology, a combination known as general pathology . [ 2 ] Similar specialties exist in veterinary pathology .
Anatomic pathology relates to the processing, examination, and diagnosis of surgical specimens by a physician trained in pathological diagnosis. Clinical pathology involves the laboratory analysis of tissue samples and bodily fluids; procedures may include blood sample analysis, urinalysis , stool sample analysis, and analysis of spinal fluid. Clinical pathologists may specialize in a number of areas, including blood banking, clinical chemistry, microbiology, and hematology. [ 3 ]
The procedures used in anatomic pathology include:
Surgical pathology is the most significant and time-consuming area of practice for most anatomical pathologists. Surgical pathology involves the gross and microscopic examination of surgical specimens, as well as biopsies submitted by non- surgeons such as general internists , medical subspecialists , dermatologists , and interventional radiologists . Surgical pathology increasingly requires technologies and skills traditionally associated with clinical pathology such as molecular diagnostics.
In the United States, subspecialty-trained doctors of dentistry , rather than medical doctors, can be certified by a professional board to practice Oral and Maxillofacial Pathology.
Cytopathology is a sub-discipline of anatomical pathology concerned with the microscopic examination of whole, individual cells obtained from exfoliation or fine-needle aspirates . Cytopathologists are trained to perform fine-needle aspirates of superficially located organs, masses, or cysts and are often able to render an immediate diagnosis in the presence of the patient and consulting physician. In the case of screening tests such as the Papanicolaou smear , non-physician cytotechnologists are often employed to perform initial reviews, with only positive or uncertain cases examined by the pathologist. Cytopathology is a board-certifiable subspecialty in the U.S.
Molecular pathology is an emerging discipline within anatomical and clinical pathology that is focused on the use of nucleic acid-based techniques such as in-situ hybridization, reverse-transcriptase polymerase chain reaction, and nucleic acid microarrays for specialized studies of disease in tissues and cells. Molecular pathology shares some aspects of practice with both anatomic and clinical pathology, and is sometimes considered a "crossover" discipline.
Forensic pathologists receive specialized training in determining the cause of death and other legally relevant information from the bodies of persons who died suddenly with no known medical condition, those who die from non-natural causes, as well as those dying as a result of homicide, or other criminally suspicious deaths. A majority of the forensic pathologists cases are due to natural causes. Often, additional tests such as toxicology, histology, and genetic testing will be used to help the pathologist determine the cause of death. Forensic pathologists will often testify in courts regarding their findings in cases of homicide and suspicious death. They also play a large role in public health, such as investigating deaths in the workplace, deaths in custody, as well as sudden and unexpected deaths in children.
Forensic pathologists often have special areas of interest within their practice, such as sudden death due to cardiac pathology, deaths due to drugs, or Sudden Infant Death (SIDS), and various others.
Anatomical Pathology is one of the specialty training programs offered by the Royal College of Pathologists of Australasia (RCPA). The RCPA . To qualify as a Fellow of the RCPA in Anatomical Pathology, the candidate must complete a recognised undergraduate or postgraduate medical qualification and then complete a minimum of 2 years of clinical medical experience as a prerequisite to selection as a training registrar. The training program is a minimum of 5 years, served in at least two laboratories, and candidates must pass a Basic Pathological Sciences examination (usually in first year), the Part 1 examinations (not before 3rd year) and the Part 2 examinations (not before 5th year). Fellows may then continue into subspecialty training.
Anatomical Pathology (AP) is one of the specialist certificates granted by the Royal College of Physicians and Surgeons of Canada. Other certificates related to pathology include general pathology (GP), hematopathology, and neuropathology. Candidates for any of these must have completed four years of medical school and five years of residency training.
Anatomic Pathology (AP) is one of the two primary certifications offered by the American Board of Pathology (the other is Clinical Pathology (CP)) [ 4 ] and one of three primary certifications offered by the American Osteopathic Board of Pathology. [ 5 ] To be certified in anatomic pathology, the trainee must complete four years of medical school followed by three years of residency training. Many U.S. pathologists are certified in both AP and CP, which requires a total of four years of residency. After completing residency, many pathologists enroll in further years of fellowship training to gain expertise in a subspecialty of AP or CP. Pathologists' Assistants are highly trained medical professionals with specialized training in Anatomic and Forensic pathology. To become a Pathologists' Assistant one must enter and successfully complete a NAACLS accredited program and pass the ASCP Board of Certification Exam.
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An anatomical theatre ( Latin : Theatrum Anatomicum ) was a specialised building or room, resembling a theatre , used in teaching anatomy at early modern universities. They were typically constructed with a tiered structure surrounding a central table, allowing a larger audience to see the dissection of cadavers more closely than would have been possible in a non-specialized setting.
An anatomical theatre was usually a room of roughly amphitheatrical shape, in the centre of which would stand a table on which the dissection of human or animal bodies took place. Around this table were several circular, elliptic or octagonal tiers with railings, steeply tiered so that observers (typically students) could stand and observe the dissection below, without spectators in the front-most rows blocking their view. It was common to display skeletons in some location within the theatre.
The first anatomical theatre, the Anatomical Theatre of Padua , was built at the University of Padua in 1594, and has been preserved into the modern day. Other early examples include the Theatrum Anatomicum of Leiden University , built in 1596 and reconstructed in 1988, and the Anatomical Theatre of the Archiginnasio in Bologna (whose building dates from 1563 and the anatomical theatre from 1637).
The anatomical theatre of the University of Uppsala is well-known, having been completed in 1663 by medical profession and amateur architect Olaus Rudbeck (1630-1702). The theatre is housed in the idiosyncratic cupola constructed on the top of the Gustavianum building, one of the older buildings of the university. Rudbeck had spent time in the Dutch city of Leiden , and the construction of both the anatomical theatre and the botanical garden he founded in Uppsala in 1655 were influenced by his experiences there. The anatomical theatre is now preserved as part of the Gustavianum, now preserved as a museum for the general public under the name Museum Gustavianum .
Thomas Jefferson built an anatomical theatre for the University of Virginia . It was completed in 1827, but demolished in 1939 after the construction of Alderman Library nearby.
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Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America is a book by Robert Whitaker published in 2010 by Crown . [ 1 ] [ 2 ] [ 3 ] Whitaker asks why the number of Americans who receive government disability for mental illness approximately doubled since 1987. [ 4 ]
In the book, Whitaker tries to answer that question and examines the long-term outcomes for the mentally ill in the U.S.
Whitaker begins by reviewing the discovery of antipsychotics , benzodiazepines and antidepressants . These were discovered as side effects during research for antihistamines (specifically promethazine ), gram negative antibiotics (specifically mephenesin ) and the anti-tuberculosis agents isoniazid and iproniazid respectively. The psychiatric mechanisms of action of these drugs were not known at the time and these were initially called major tranquilizers (now typical antipsychotics) due to their induction of "euphoric quietude"; minor tranquilizers (now benzodiazepines) and psychic energizers (now antidepressants) due to patients "dancing in the wards." [ 5 ] These compounds were developed during a period of growth for the pharmaceutical industry bolstered by the 1951 Durham-Humphrey Amendment , giving physicians monopolistic prescribing rights thus aligning the interests of physicians and pharmaceutical companies. This also followed the industry's development of "magic bullets" that treat people with, for example, diabetes , which according to Whitaker provided an analogy to sell the idea of these drugs to the public. It was not until many years later, after the mechanisms of these drugs were determined, that the serotonergic hypothesis of depression and dopaminergic hypothesis of schizophrenia were developed to fall in line with the drug's mechanisms. According to Whitaker's analysis of the primary literature, lower levels of serotonin and higher levels of dopamine "have proved to be true in patients WITH prior exposure to antidepressants or antipsychotics (ie as homeostatic mechanisms) but NOT in patients without prior exposure."
Whitaker further criticizes the magic bullet theory by attacking the historical notion that the "invention of the antipsychotic Thorazine " emptied the asylums. [ 6 ] His case begins by showing that during the late 1940s and 1950s ~75% of cases admitted for first episode schizophrenia recovered to the community by approximately 3 years (Thorazine was not released until 1955). [ 7 ] [ 8 ] [ 9 ] He then notes that the arrival of Thorazine did not improve discharge rates in the 1950s for people newly diagnosed with schizophrenia. In fact, based on the only large scale first episode schizophrenia study of this era, 88% of those who were not treated were discharged within eighteen months compared to 74% of neuroleptic treated. [ 10 ] This is additionally evidenced by the fact that when Thorazine was introduced in 1955 there were 267 thousand schizophrenia patients in state and county mental hospitals, and eight years later, there were 253 thousand, thus indicating that the advent of neuroleptics barely budged the number of hospitalized patients. [ 11 ] What he argues actually cleared the asylums was the beginning of Medicare and Medicaid in 1965. These programs provided federal subsidies for nursing home care but no such subsidy for care in state mental hospitals, and so the states, seeking to save money, began sending their chronic patients to nursing homes.
Whitaker acknowledges that psychiatric medications do sometimes work but believes that they must be used in a "selective, cautious manner. It should be understood that they’re not fixing any chemical imbalances. And honestly, they should be used on a short-term basis." [ 12 ]
Whitaker traces the effects of what looks like an iatrogenic epidemic: [ 13 ] the drugs that patients receive can perturb their normal brain function. [ 14 ]
Whitaker suggests that the "wonder drug" glow around the second generation psychotropics has long since disappeared. He views the "hyping" of the top-selling atypical antipsychotics as "one of the more embarrassing episodes in psychiatry's history, as one government study after another failed to find that they were any better than the first-generation anti-psychotics." [ 15 ]
Whitaker speaks warmly of Open Dialogue , an organisation of care documented by professor psychologist Jaakko Seikkula at Keropudas Hospital in Tornio in Lapland where drugs are given to patients only on a limited basis. According to Whitaker, the district has [ when? ] the lowest per capita spending on mental health of all health districts in Finland . [ 16 ]
Whitaker sees that children are vulnerable to being prescribed a lifetime of drugs. As the author says, a psychiatrist and parents may give a child a "cocktail" to force him or her to behave. Then when this child reaches the age of eighteen, Whitaker says the child often becomes a disabled adult. [ 17 ]
Whitaker spent a year and a half researching for this book, [ 14 ] and maintains a website listing some relevant studies. [ 18 ]
Whitaker did interviews with Salon and The Boston Globe during the release of this book. [ 12 ] [ 19 ] He also did a book tour, and he spoke for an hour and a half on C-SPAN where there is an archived video. [ 20 ]
A review by sleep researcher Dennis Rosen for The Boston Globe concludes that "although extensively researched and drawing upon hundreds of sources, the gaps in his theory remain too large for him to succeed in making a convincing argument", and compares Whitaker to Thabo Mbeki and AIDS denialism . [ 21 ] The book received positive reviews from New Scientist , [ 2 ] The Record , [ 3 ] Time magazine, [ 1 ] and Salon . [ 12 ]
Over a year after the book was published, Marcia Angell , former editor of The New England Journal of Medicine , published a two-part review of Whitaker's and other books in The New York Review of Books [ 22 ]
Whitaker presented his views at a psychiatric Grand Rounds at Massachusetts General Hospital on January 13, 2011, where his data and approach were critiqued by psychiatrist Andrew Nierenberg. [ 23 ] Additional criticism has come from psychiatrist and author Daniel Carlat . Whitaker has responded to critics on his website. [ 24 ]
In April 2011, Investigative Reporters and Editors (IRE) announced that the book had won its award as the best investigative journalism book of 2010 stating, "this book provides an in-depth exploration of medical studies and science and intersperses compelling anecdotal examples. In the end, Whitaker rejects the conventional wisdom of treatment of mental illness with drugs." [ 25 ]
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Andrew Howard Eric Eder (born 21 April 1964) is a British dentist , clinical academic, strategic board adviser, and charity trustee. He is Emeritus Professor of Restorative Dentistry and Dental Education at the UCL Eastman Dental Institute , [ 1 ] and a specialist in restorative dentistry and prosthodontics at the Harley Street Dental and Implant Clinic. [ 2 ] He was appointed Chair of the Board at the Academy of Medical Royal Colleges for a three-year term in April 2022. [ 3 ] [ 4 ]
He co-edited Tooth Surface Loss in 2000 [ 5 ] and Tooth Wear in 2022, [ 6 ] both published by the British Dental Journal , and has contributed to textbooks and authored over 100 articles. He also served as president of the Royal Society of Medicine 's Odontological Section from 2001 to 2002 and the British Society for Restorative Dentistry from 2005 to 2006. [ 7 ]
He is the younger brother of The Hon Sir Bernard Eder , an English lawyer and a former High Court judge.
Eder was educated at North Bridge House School and St Paul's School, London . He completed his Bachelor of Dental Surgery from King's College London School of Medicine and Dentistry in 1986 and his masters in conservative dentistry from the UCL Eastman Dental Institute in 1990.
He achieved his Membership in Restorative Dentistry from the Royal College of Surgeons of England and the Royal College of Physicians and Surgeons of Glasgow in 1994. In 2002, he was elected to Fellowship of the Higher Education Academy and was awarded an Honorary Fellowship in Dental Surgery from the Royal College of Surgeons of Edinburgh in 2003, both in recognition of his contribution to dental education. Eder was elected to Fellowship of the College of General Dentistry and Fellowship in Dental Surgery by the Royal College of Surgeons of England, both in 2021. [ 8 ]
Eder has been associated with the UCL Eastman Dental Institute, the postgraduate dental school of University College London , since 1989. In 2002, he was appointed honorary consultant in restorative dentistry at UCLH NHS Foundation Trust and, in 2008, to a chair in restorative dentistry and dental education at the UCL Eastman Dental Institute.
He served as director of continuing professional development at the UCL Eastman Dental Institute from 2002 to 2012, [ 9 ] director of education at the UCL Eastman Dental Institute from 2005 to 2012, associate dean for continuing education at the UCL School of Life and Medical Sciences from 2008 [ 10 ] to 2012, and Pro-Vice-Provost at UCL from 2013 [ 11 ] [ 12 ] to 2017.
In March 2018, he was appointed emeritus professor of restorative dentistry and dental education at the UCL Eastman Dental Institute. [ 13 ]
Eder was elected Chair of the Membership in Restorative Dentistry Examination at the Royal College of Surgeons of England and Royal College of Physicians and Surgeons of Glasgow in 2016, having served as an examiner since 2009. He led development of the new Restorative Specialty Membership Examinations and oversaw successful implementation as Chair of the Examination Board until 2022.
He also served on the editorial boards of the British Dental Journal from 2005 to 2017, the European Journal of Prosthodontics and Restorative Dentistry from 1995 to 2014, and the Faculty Dental Journal at the Royal College of Surgeons of England where he has been the AI and Digital Innovation Lead since 2023. [ 14 ]
Since 2003, he has been chair of the charitable trust of Alpha Omega , the oldest international dental fraternity. In June 2017, Eder was elected to the Board of the Faculty of Dental Surgery at the Royal College of Surgeons of England for a six-year term. In July of that year, he was elected a trustee of the United Synagogue for a six-year term. [ 15 ] Since 2023, he has been a Specialist List Assessor and Appeals Panel Member for the General Dental Council .
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Andreas (Andrew) Margioris ( Greek : Ανδρέας Μαργιωρής) is a Greek internist and endocrinologist , Professor of Clinical Chemistry Emeritus in the University of Crete . [ 1 ]
Andrew Margioris was born in Alexandria , Egypt from Greek parents. His father was the esoteric philosopher Nikolaos Margioris . Margioris attended the University of Athens Medical School; and finished in 1971. He completed his doctorate thesis at the University of Athens in 1975, where he was also teaching as an assistant at the Department of Biochemistry , School of Medicine.
Margioris was enrolled as intern in Internal Medicine in 1976 at the Brooklyn Cumberland Medical Center in Downtown Brooklyn . He continued his Internal Medicine training as junior, senior and chief resident at the Medical Center of the Downstate University of New York . Margioris started residency in Endocrinology at the Mount Sinai Medical Center, City University of New York , from 1980 till 1984. Following that, he was promoted as an instructor in Medicine at the same medical center (1985-1988).
In 1985, he was awarded a KO8, Clinical Research award ( NIH ). [ 2 ] Following the untimely death of the Chief of the Department of Endocrinology at the Mount Sinai Medical Center, professor Dorothy T. Krieger , Margioris moved his research base at the NICHD , National Institutes of Health (NIH). Margioris was awarded a senior research grant from the National Research Council in 1988.
In 1989, Margioris was unanimously elected as an associate professor and head of the Department of Clinical Chemistry at the Medical School, of the University of Crete , and few years later he was promoted as a full professor. In 2010 he was elected as Chief of the Medical Service and interim Chairman of the Board at the University Hospital of Heraklion , Crete . [ 3 ] [ 4 ] Margioris was elected as Dean of the School of Medicine in the University of Crete, from 2011 to 2014. [ 5 ]
Margioris retired in 2014 and he has since be elected as a professor Emeritus . He was also member of the Standing Committee of the European Medical Research Council (2009-2014) and member of the Greek Health Task Force of the Ministry of Health of Greece from 2011 to 2012. Margioris was Editor in Chief of the scientific journal Hormones , published by Springer-Nature , from 2010 to 2022. Hormones is the official journal of the Greek Endocrine Society and is on PubMed since 2002. [ 6 ]
Margioris has 170 publications sited in PubMed, and 65 publications in textbooks . [ 7 ]
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Andrew T. Scull (born 1947) is a British-born sociologist who researches the social history of medicine and the history of psychiatry . He is a distinguished professor of sociology and science studies at University of California, San Diego , and recipient of the Roy Porter Medal for lifetime contributions to the history of medicine. [ 1 ] His books include Madhouse: A Tragic Tale of Megalomania and Modern Medicine , Madness in Civilization: A Cultural History of Insanity , and Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness .
Scull was born in Edinburgh , Scotland, the son of Allan Edward Scull, a civil engineer and Marjorie née Corrigan, a college teacher. He received his BA with first-class honors from Balliol College, Oxford . He then studied at Princeton University , receiving his MA in sociology in 1971 and his Ph.D. in 1974. He was a postdoc at University College London in 1976–77. [ 2 ]
Scull taught at the University of Pennsylvania from 1973 until 1978, when he was appointed to the sociology faculty at University of California, San Diego, as an associate professor. He was appointed a full professor in 1982, and distinguished professor in 1994. [ 2 ]
Scull's first book, Decarceration: Community Treatment and the Deviant – A Radical View was published in 1977 by Prentice-Hall . [ 3 ] A revised version of his Princeton doctoral dissertation, Museums of Madness: The Social Organization of Insanity in 19th Century England , was published in 1979 by Allen Lane (London) and St. Martin's Press (New York). [ 4 ] Scull's later books include Madhouse: A Tragic Tale of Megalomania and Modern Medicine (Yale University Press, 2005); Hysteria: The Biography (Oxford University Press, 2009); [ a ] Madness in Civilization: A Cultural History of Insanity (Princeton
University Press, 2015). [ 5 ] [ 6 ] [ 7 ] [ 8 ] Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness (The Belknap Press, 2022).
In the summer of 2009, Scull authored a letter to the University of California Regents that called for reallocation of funding from the Riverside, Santa Cruz, and Merced campuses to make up for budget shortfalls at what he deemed "higher tiered" campuses, stating that rather than being research heavy institutions and thus draws for grant and philanthropic moneys, "UCSC, UCR and UC Merced are in substantial measure teaching institutions" [ 9 ] and that "[i]f we don't do this, we will end up with a bunch of mediocre U.C.'s instead of great U.C.'s." Then UC President Mark Yudoff dismissed the proposal outright in a statement released to all UC campus chancellors, but not before critics noted the demographic differences between UCSD and the campuses Scull and his 22 co-signatories targeted. [ 10 ]
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Androgen deprivation therapy ( ADT ), also called androgen ablation therapy or androgen suppression therapy , is an antihormone therapy whose main use is in treating prostate cancer . Prostate cancer cells usually require androgen hormones , such as testosterone , to grow. ADT reduces the levels of androgen hormones, with drugs or surgery , to prevent the prostate cancer cells from growing. [ 1 ] The pharmaceutical approaches include antiandrogens and chemical castration .
Several studies have concluded that ADT has demonstrated benefit in patients with metastatic disease, and as an adjunct to radiation therapy in patients with locally advanced disease, as well as those with unfavorable intermediate-risk or high-risk localized disease. However, in patients with low-risk prostate cancer, ADT has demonstrated no survival advantage, and significant harm, such as impotence, diabetes and bone loss. [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ]
The therapy can also eliminate cancer cells by inducing androgen deprivation-induced senescence . [ 7 ] Lowering androgen levels or stopping them from getting into prostate cancer cells often makes prostate cancer shrink or grow more slowly for a time. However, this treatment needs to be combined with radiation therapy (RT) [ 8 ] because ADT itself does not eradicate the cancer ; it just decreases its aggressiveness. [ 9 ]
Normal male sexuality seems to depend upon very specific and complicated hormonal patterns that are not completely understood. [ 12 ] One study suggests that ADT can alter the hormonal balance necessary for male sexual activity. As men age, testosterone levels decrease by about 1% a year after age 30; however, it is important to determine whether low testosterone is due to normal aging, or to a disease, such as hypogonadism. [ 13 ] Testosterone plays a significant role in sexual functioning; therefore, naturally declining levels of testosterone can lead to reduction in normal sexual functioning. Further decreases in serum testosterone can have a negative impact on normal sexual function, leading to a decline in quality of life. [ 14 ]
Erectile dysfunction is not uncommon after radical prostatectomy and men who undergo ADT in addition to this are likely to show further decline in their ability to engage in penetrative intercourse, as well as their desire to do so. [ 13 ] A study looking at the differences of using GnRH-A (and androgen suppressant) or an orchiectomy report differences in sexual interest, the experience of erections, and the prevalence of participating in sexual activity. Men reporting no sexual interest increased from 27.6% to 63.6% after orchiectomy, and from 31.7% to 58.0% after GnRH-A; men who experienced no erections increased from 35.0% to 78.6%; and men who did not report engaging in sexual activity increased from 47.9% to 82.8% after orchiectomy and 45.0% to 80.2%. [ 14 ] This study suggests that the GnRH-A and orchiectomy had similar effects on sexual functioning. A vicious cycle whereby lowering testosterone levels leads to decreased sexual activity, which in turn cause both free and total testosterone levels to decline even further. [ 12 ] This demonstrates the importance of androgens for maintaining sexual structures and functions. [ 12 ] [ 15 ]
Although targeting the androgen axis has clear therapeutic benefit, its effectiveness is temporary, as prostate tumor cells adapt to survive and grow. The removal of androgens has been shown to activate epithelial–mesenchymal transition (EMT), neuroendocrine transdifferentiation (NEtD) and cancer stem cell -like gene programs. [ 16 ]
Thus, activation of these programs via inhibition of the androgen axis provides a mechanism by which tumor cells can adapt to promote disease recurrence and progression. [ 11 ]
Orchiectomy, LHRH analogs and LHRH antagonists can all cause similar side effects, due to changes in the levels of sex hormones (testosterone). [ 17 ]
A program has been developed for patients and their partners to recognize and manage the more burdensome side effects of androgen deprivation therapy. One program is built around the 2014 book "Androgen Deprivation Therapy: An Essential Guide for Prostate Cancer Patients and Their Loved Ones", which is endorsed by the Canadian Urological Association. [ 18 ]
Recent studies have shown ADT may increase the risk of Alzheimer's disease or dementia. [ 19 ] The increase in risk may be associated with duration of ADT. [ 20 ] While some studies report a decline in certain areas of cognitive function such as spatial abilities , attention , and verbal memory associated with ADT, evidence as a whole remains contradictory. [ 21 ] [ 22 ] [ 23 ] Useful preventative interventions may include social interaction , physical exercise and a " Mediterranean diet ", among others. [ 21 ] There is an additional small risk of cardiac arrhythmias.
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Androgen replacement therapy ( ART ), often referred to as testosterone replacement therapy ( TRT ), is a form of hormone therapy in which androgens , often testosterone , are supplemented or replaced. It typically involves the administration of testosterone through injections, skin creams, patches, gels, pills, or subcutaneous pellets. ART is often prescribed to counter the effects of male hypogonadism .
ART is also prescribed to lessen the effects or delay the onset of normal male aging. However, this is controversial and is the subject of ongoing clinical trials. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ]
As men enter middle age they may notice changes caused by a relative decline in testosterone: fewer erections, fatigue, thinning skin, declining muscle mass and strength, and/or more body fat. Dissatisfaction with these changes causes some middle age men to seek ART. Androgen deficiencies in women have also, as of 2001, been recognized as a medical disorder that can be treated with ART. [ 8 ] As with men, symptoms associated with androgen deficiency are most prevalent with age, and androgen replacement therapy has been shown to help with symptoms of menopause . [ 9 ]
Androgen replacement is the classic treatment of hypogonadism . [ 10 ] It is also used in men who have lost the ability to produce androgens due to disease or its treatment. [ 11 ] [ 12 ]
The risks of diabetes and of testosterone deficiency in men over 45 (i.e., hypogonadism, specifically hypoandrogenism) are strongly correlated. Testosterone replacement therapies have been shown to improve blood glucose management. [ 13 ] [ 14 ] Still, "it is prudent not to start testosterone therapy in men with diabetes solely for the purpose of improving metabolic control if they show no signs and symptoms of hypogonadism." [ 15 ]
Androgen replacement is used in postmenopausal women: the indications are to increase sexual desire ; and to prevent or treat osteoporosis . [ 16 ] Other symptoms of androgen deficiency are similar in both sexes, such as muscle loss and physical fatigue. [ 8 ] The androgens used for androgen replacement in women include testosterone (and esters ), prasterone (dehydroepiandrosterone; DHEA) (and the ester prasterone enanthate ), methyltestosterone , nandrolone decanoate , and tibolone , among others. [ 16 ]
The Food and Drug Administration (FDA) stated in 2015 that neither the benefits nor the safety of testosterone have been established for low testosterone levels due to aging . [ 17 ] The FDA has required that testosterone labels include warning information about the possibility of an increased risk of heart attacks and stroke. [ 17 ]
On January 31, 2014, reports of strokes , heart attacks , and deaths in men taking testosterone-replacement led the FDA to announce that it would be investigating this issue. [ 18 ] The FDA's action followed three peer-reviewed studies of increased cardiovascular events and deaths. [ 19 ] Due to an increased rate of adverse cardiovascular events compared to a placebo group , a randomized trial stopped early. [ 20 ] Also, in November 2013, a study reported an increase in deaths and heart attacks in older men. [ 21 ] Concerns have been raised that testosterone was being widely marketed without the benefit of data on efficacy and safety from large randomized controlled trials. [ 22 ] As a result of the "potential for adverse cardiovascular outcomes", the FDA announced, in September 2014, a review of the appropriateness and safety of testosterone replacement therapy. [ 23 ] [ 24 ] [ 25 ] However, when given to men with hypogonadism in the short- and medium-term, testosterone replacement therapy does not increase the risk of cardiovascular events (including strokes and heart attacks and other heart diseases). [ 2 ] The long-term safety of the therapy is not known yet. [ 26 ] [ 27 ]
Other significant adverse effects of testosterone supplementation include acceleration of pre-existing prostate cancer growth in individuals who have undergone androgen deprivation; increased hematocrit , which can require venipuncture in order to treat; and, exacerbation of sleep apnea . [ 28 ] A 2014 review said there was some evidence men with certain comorbidities may be at risk of adverse effects including sleep apnoea , metabolic syndrome and cardiovascular disease. [ 29 ] Exogenous testosterone may also cause suppression of spermatogenesis , leading to, in some cases, infertility. [ 30 ] It is recommended that physicians screen for prostate cancer with a digital rectal exam and prostate-specific antigen (PSA) level before starting therapy, and monitor PSA and hematocrit levels closely during therapy. [ 31 ]
Some studies argue that ART increases the risk of prostate cancer, although the results are not conclusive. [ 32 ]
There are several artificial androgens , many of which are manipulations of the testosterone molecule referred to as anabolic-androgenic steroids . Androgen replacement is administered by patch, tablet, capsule, cream or gel; or depot injections given into fat or muscle. [ 18 ]
Some UFC fighters used TRT until 2014 when the Nevada State Athletic Commission banned its use. [ 33 ]
As of September 2014, testosterone replacement therapy has been under review for appropriateness and safety by the Food and Drug Administration due to the "potential for adverse cardiovascular outcomes". [ 23 ] [ 24 ] [ 25 ]
In the United States usage increased from 0.5% in 2002 to 3.2% in 2013 and have since decreased to 1.7% in 2016. [ 34 ]
A UK study in 2013 showed that prescriptions for testosterone replacement, particularly transdermal products, almost doubled between 2000 and 2010. [ 35 ]
Testosterone is being investigated as therapy for the following conditions:
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Androgen suppression , also known as testosterone suppression , is a medical treatment to suppress or block the production or action of male sex hormones , typically used against certain cancers that rely on male growth hormones. This a done by castration (sometimes chemical castration ) or by prescribing female sex hormones and drugs called antiandrogens . It is employed in androgen deprivation therapy for prostate cancer , feminizing hormone therapy for transgender women and against other androgen-dependent conditions .
This article incorporates public domain material from Dictionary of Cancer Terms . U.S. National Cancer Institute .
This oncology article is a stub . You can help Wikipedia by expanding it .
This sexuality -related article is a stub . You can help Wikipedia by expanding it .
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Androniki Drakou (born 1965), also known as Nina Drakou , is a Greek doctor descended from Komotini , Greece [ 1 ] specialized in orthopedic surgery . [ 2 ] She is currently the Director of the Orthopaedics Clinic of Laiko General Hospital . [ 3 ]
Drakou graduated from the Medical School of the Aristotle University of Thessaloniki in 1991. She also holds a MPhil from the University of Sheffield (2008)and a postgraduate diploma in Principles of Computer-Assisted Knee Arthroplasty from the University of Glasgow (2011). [ 2 ]
Nina Drakou is known for pioneering complex operations in orthopaedic surgery. In 2018 she led a team of orthopaedic surgeons in applying limb-lengthening intramedullary nails activated by an external electromagnetic field on a young patient with achondroplasia . The operation took place at Laiko General and it was the first of its kind to be performed in a Greek public hospital. [ 4 ] At the same hospital, in 2020 she performed the first operation using computer-aided simulation and 3-D printing to reconstruct the deformed thigh bone of a patient with a rare bone disease . The surgical procedure was developed by a team of researchers, engineers and orthopaedic surgeons from Balgrist University (Zurich) and the Orthopaedic team of Laiko General under the direction of Drakou. [ 5 ]
Her research interests include limb reconstruction by distraction osteogenesis , complex trauma, bone infection , rare skeletal diseases as well as computer assisted and minimally invasive arthroplasty of the hip & knee, [ 2 ] while she has presented her work at related medical seminars and conferences. [ 6 ] [ 7 ]
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Awareness under anesthesia , also referred to as intraoperative awareness or accidental awareness during general anesthesia ( AAGA ), is a rare complication of general anesthesia where patients regain varying levels of consciousness during their surgical procedures. While anesthesia awareness is possible without resulting in any long-term memory of the experience, it is also possible for victims to have awareness with explicit recall , where they can remember the events related to their surgery ( intraoperative awareness with explicit recall ). [ 1 ] [ 2 ]
Intraoperative awareness with explicit recall is an infrequent condition with potentially devastating psychological consequences. [ 3 ] While it has gained popular recognition in media, research shows that it only occurs at an incidence rate of 0.1–0.2%. Patients report a variety of experiences, ranging from vague, dreamlike states to being fully awake, immobilized, and in pain from the surgery. Intraoperative awareness is usually caused by the delivery of inadequate anesthetics relative to the patient's requirements. Risk factors can be anesthetic (e.g., use of neuromuscular blockade drugs , use of intravenous anesthetics, technical/mechanical errors), surgical (e.g., cardiac surgery , trauma/emergency, C-sections ), or patient-related (e.g., reduced cardiovascular reserve, history of substance use , history of awareness under anesthesia). [ 4 ]
Currently, the mechanism behind consciousness and memory under anesthesia is unknown, although there are many working hypotheses. However, intraoperative monitoring of anesthetic level with bispectral index (BIS) or end-tidal anesthetic concentration (ETAC) may help to reduce the incidence of intraoperative awareness, although clinical trials have yet to show a decreased incidence of AAGA with the BIS monitor. [ 5 ]
There are also many preventative techniques considered for high-risk patients, such as pre-medicating with benzodiazepines , avoiding complete muscle paralysis, and managing patients' expectations. Diagnosis is made postoperatively by asking patients about potential awareness episodes and can be aided by the modified Brice interview questionnaire. A common but devastating complication of intraoperative awareness with recall is the development of post-traumatic stress disorder (PTSD) from the events experienced during surgery. Prompt diagnosis and referral to counseling and psychiatric treatment are crucial to the treatment of intraoperative awareness and the prevention of PTSD. [ 2 ]
Intraoperative awareness can present with a variety of signs and symptoms. A large proportion of patients report vague, dreamlike experiences, while others report specific intraoperative events, such as: [ 6 ] [ 7 ] [ 8 ]
Intraoperative signs that may indicate patient awareness include: [ 8 ]
Patients under anesthesia are paralyzed if a neuromuscular blockade drug , a type of muscle relaxant , has been given as part of general anesthesia. When paralyzed, patients may not be able to communicate their distress or alert the operating room staff of their consciousness until the paralytic wears off. After surgery, recognition of the symptoms of an awareness event may be delayed. [ 10 ] One review showed that only about 35% of patients are able to report an awareness event immediately after the surgery, with the rest remembering the experience from weeks to months afterward. [ 11 ] Depending on the awareness experience, patients may have postoperative psychological problems that range from mild anxiety to post-traumatic stress disorder (PTSD) . [ 6 ] [ 12 ] PTSD is characterized by recurrent anxiety, irritability, flashbacks or nightmares, avoidance of triggers related to the trauma, and sleep disturbances. [ 13 ]
The biggest risk factor is anesthesia performed by unsupervised trainees and the use of a medication that induces muscle paralysis, such as suxamethonium ( succinylcholine ) or non-depolarizing neuromuscular blocking drugs (muscle relaxants). During general anesthesia , the patient's muscles may be paralyzed in order to facilitate tracheal intubation or surgical exposure (abdominal and thoracic surgery can be performed only with adequate muscle relaxation). Because the patient cannot breathe for themselves, mechanical ventilation must be used. The paralyzing agent does not cause unconsciousness or take away the patient's ability to feel pain, but does prevent the patient from breathing, so the airway (trachea) must be protected and the lungs ventilated to ensure adequate oxygenation of the blood and removal of carbon dioxide.
A fully paralyzed patient is unable to move, speak, blink the eyes, or otherwise respond to the pain. If neuromuscular blocking drugs are used, this causes skeletal muscle paralysis but does not interfere with cardiac or smooth muscle or the functioning of the autonomic nervous system , so heart rate, blood pressure, intestinal peristalsis, sweating and lacrimation are unaffected. The patient cannot signal distress and may not exhibit the signs of awareness that would be expected to be detectable by clinical vigilance, because other drugs used during anaesthesia may block or obtund these.
Many types of surgery do not require the patient to be paralyzed. A patient who is anesthetized but not paralyzed can move in response to a painful stimulus if the analgesia is inadequate. This may serve as a warning sign that the anesthetic depth is inadequate. Movement under general anesthesia does not imply full awareness but is a sign that the anesthesia is light. Even without the use of neuromuscular blocking drugs the absence of movement does not necessarily imply amnesia.
For certain operations, such as caesarean section , or in hypovolemic patients or patients with minimal cardiac reserve , the anesthesia provider may aim to provide "light anesthesia" and should discuss this with patients to warn them. During such circumstances, consciousness and recall may occur because judgments of depth of anesthesia are not precise. The anesthesia provider must weigh the need to keep the patient safe and stable with the goal of preventing awareness. Sometimes, it is necessary to provide lighter anesthesia in order to preserve the life of the patient. "Light" anesthesia means less drugs by the intravenous route or via inhalational means, leading to less cardiovascular depression ( hypotension ) but permitting "awareness" in the anesthetized subject. [ 14 ]
Human errors include repeated attempts at intubation during which the short-acting anesthetic may wear off but the paralyzing drug does not; esophageal intubation; inadequate drug dose; a drug given by the wrong route or a wrong drug given; drugs given in the wrong sequence; inadequate monitoring; patient abandonment; disconnections and kinks in tubes from the ventilator; and failure to refill the anesthetic machine 's vaporizers with volatile anesthetic . Other causes include unfamiliarity with techniques used, e.g. intravenous anesthetic regimes, and inexperience. Most cases of awareness are caused by inexperience and poor anesthetic technique, which can be any of the above, but also includes techniques that could be described as outside the boundaries of "normal" practice. The American Society of Anesthesiologists in 2007 released a Practice Advisory outlining the steps that anesthesia professionals and hospitals should take to minimize these risks. Other societies have released their own versions of these guidelines, including the Australian and New Zealand College of Anaesthetists . [ 15 ]
To reduce the likelihood of awareness, anesthetists must be adequately trained, and supervised while still in training. Equipment that monitors depth of anesthesia, such as bispectral index monitoring, should not be used in isolation.
Current research attributes the incidence of AAGA to a combination of the risks mentioned above, together with ineffective practice from ODPs, anesthetic nurses, HCAs and anesthetists. [ 3 ] The main failures include:
Machine malfunction or misuse may result in an inadequate delivery of anesthetic. Many Boyle's machines in hospitals have the oxygen regulator serving as a slave to the pressure in the nitrous oxide regulator, to enable the nitrous oxide cut-off safety feature. If nitrous oxide delivery suffers due to a leak in its regulator or tubing, an 'inadequate' mixture can be delivered to the patient, causing awareness. Many World War II-vintage Boyle 'F' models are still functional and used in UK hospitals. Their emergency oxygen flush valves have a tendency to release oxygen into the breathing system, which, when added to the mixture set by the anesthesiologist, can lead to awareness. This may also be caused by an empty vaporizer (or nitrous oxide cylinder ) or a malfunctioning intravenous pump or disconnection of its delivery tubing. Patient abandonment (when the anesthesiologist is no longer present) causes some cases of awareness and death.
Very rare causes of awareness include drug tolerance , or a tolerance induced by the interaction of other drugs . Some patients may be more resistant to the effects of anesthetics than others; factors such as younger age, obesity, tobacco smoking, or long-term use of certain drugs ( alcohol , opioids , or amphetamines ) may increase the anesthetic dose needed to produce unconsciousness. There may be genetic variations that cause differences in how quickly patients clear anesthetics, and there may be differences in how the sexes react to anesthetics as well. In addition, anesthetic requirement is increased in persons with naturally red hair . [ 16 ] Marked anxiety prior to the surgery can increase the amount of anesthesia required to prevent recall.
There are various levels of consciousness. Full wakefulness and general anesthesia are the two extremes of the spectrum. Conscious sedation and monitored anesthesia care (MAC) refer to an awareness somewhere in the middle of the spectrum, depending on the degree to which a patient is sedated. Monitored anesthesia care involves titration of local anesthesia along with sedation and analgesia. [ 17 ] Awareness/wakefulness does not necessarily imply pain or discomfort. The aim of conscious sedation or MAC is to provide a safe and comfortable anesthetic while maintaining the patient's ability to follow commands.
Under certain circumstances, a general anesthetic, whereby the patient is completely unconscious, may be unnecessary or undesirable. For instance, with a caesarean delivery , the goal is to provide comfort with neuraxial anesthetic yet maintain consciousness [ 18 ] so that the mother can participate in the birth of the child. Other circumstances may include, but are not limited to, procedures that are minimally invasive or purely diagnostic (and thus not uncomfortable). Sometimes, the patient's health may not tolerate the stress of general anesthesia. The decision to provide MAC versus general anesthesia can be complex, involving careful consideration of individual circumstances and discussion with the patient about their preferences.
Patients who undergo conscious sedation or monitored anesthesia care are never meant to be without recall. [ 19 ] Whether a patient remembers the procedure depends on the type of anesthetic, dosages, patient physiology, and other factors. Many patients undergoing monitored anesthesia may go through profound amnesia, depending on the amount of anesthetic used. [ 20 ]
Some patients undergo sedation for smaller procedures such as biopsies and colonoscopies and are told they will be asleep, although in fact they are getting a sedation that may allow some level of awareness as opposed to a general anesthetic.
New research has been carried out to test what people can remember after a general anesthetic, in an effort to understand anesthesia awareness more clearly and help to protect patients from experiencing it. A memory is not one simple entity; it is a system of many intricate details and networks.
Memory is currently classified under two main subsections.
Some researchers are now formally interviewing patients postoperatively to calculate the incidence of anesthesia awareness. It is good practice for the anesthesiologist to visit the patient after the operation and check that the patient was not aware. Most patients who were not unduly disturbed by their experiences do not necessarily report cases of awareness unless directly asked. Many who are greatly disturbed report their awareness but anesthesiologists and hospitals deny that it has happened. It has been found that some patients may not recall experiencing awareness until one to two weeks after undergoing surgery. It was also found that some patients require a more detailed interview to jog their memories for intraoperative experiences but these are only untraumatic cases. Some researchers have found that while anesthesia awareness does not commonly occur in minor surgeries, it may occur more frequently in more serious surgeries, and that it is good practice to warn of the possibility of awareness in those cases where it may be more likely.
The risk of awareness is reduced by avoidance of paralytics unless necessary; careful checking of drugs, doses and equipment; good monitoring, and careful vigilance during the case. The Isolated Forearm Technique (IFT) can be used to monitor consciousness; the technique involves applying a tourniquet to the patient's upper arm before the administration of muscle relaxants, so that the forearm can still be moved consciously. [ 23 ] [ 24 ] The technique is considered a reference standard by which other means of monitoring consciousness can be assessed. [ 25 ] [ 26 ]
Because the medical staff may not know if a person is unconscious or not, it has been suggested that the staff maintain the professional conduct that would be appropriate for a conscious patient. [ 27 ]
Recent advances have led to the manufacture of monitors of awareness. Typically these monitor the EEG , which represents the electrical activity of the cerebral cortex , which is active when awake but quiescent under anesthesia (or in natural sleep ). The monitors usually process the EEG signal down to a single number, where 100 corresponds to a patient who is fully alert, and zero corresponds to electrical silence. General anesthesia is usually signified by a number between 60 and 40 (this varies with the specific system used). There are several monitors now commercially available. These newer technologies include the bispectral index (BIS), [ 28 ] EEG entropy monitoring , auditory evoked potentials , and several other systems such as the SNAP monitor and the Narcotrend monitor.
None of these systems are perfect. For example, they are unreliable at extremes of age (e.g., neonates , infants or the very elderly). Secondly, certain agents, such as nitrous oxide , may produce anesthesia without reducing the value of the depth monitor. [ 29 ] This is because the molecular action of these agents ( NMDA receptor antagonists) differs from that of more conventional agents, and they suppress cortical EEG activity less. Third, they are prone to interference from other biological potentials (such as EMG ), or external electrical signals (such as electrosurgery ). This means that the technology that will reliably monitor depth of anesthesia for every patient and every anesthetic does not yet exist. This may in part explain why a 2016 systematic review and meta analysis concluded that depth-of-anesthesia monitors had a similar effect to standard clinical monitoring on the risk of awareness during surgery. [ 30 ]
The incidence of anesthesia awareness is variable; it seems to affect 0.2% to 0.4% of patients. This variation reflects the surgical setting as well as the physiological state of the patient; the incidence is 0.2% in general surgery, about 0.4% during caesarean section, between 1% and 2% during cardiac surgery and between 10% and 40% for anesthesia of the traumatized. [ 31 ] [ 32 ] [ 33 ] [ 34 ] [ 35 ] [ 36 ] [ 37 ] [ 38 ] [ 39 ] The majority of these do not feel pain, although around one-third did, in a range of experience from a sore throat caused by the endotracheal tube, to traumatic pain at the incision site. The incidence is halved in the absence of neuromuscular blockade. [ 39 ]
The quoted incidences are controversial as many cases of "awareness" are open to interpretation.
The incidence is higher and has more serious sequelae when muscle relaxants or neuromuscular-blocking drugs are used. [ 40 ] This is because without relaxant the patient will move and the anesthesiologist will then deepen the anesthesia.
One study has indicated that this phenomenon occurs in 0.13% of patients, or between 1 and 2 per 1000. [ 41 ] There are conflicting data, however, as another study suggested it is a rarer phenomenon, with an incidence of 0.0068%, after review of data from a population of 211,842 patients. [ 42 ]
Postoperative interview by an anesthetist is common practice to elucidate whether awareness occurred in the case. If awareness is reported, a case review is immediately performed to identify machine, medication, or operator error. [ citation needed ]
Patients who experience full awareness with explicit recall may have suffered an enormous trauma due to the extreme pain of surgery. Some patients experience post-traumatic stress disorder (PTSD), leading to long-lasting after-effects such as nightmares , night terrors , flashbacks , insomnia , and in some cases even suicide . [ 43 ] Some cases of awareness alert the patient to intra-operative errors. [ citation needed ]
A study from Sweden in 2002 attempted to follow up 18 patients for approximately 2 years after having been previously diagnosed with awareness under anesthesia. [ 44 ] Four of the nine interviewed patients were still severely disabled due to psychiatric/psychological after-effects. All of these patients had experienced anxiety during the period of awareness, but only one had stated feeling pain. Another three patients had less severe, transient mental symptoms, although they could cope with these in daily life. Two patients denied any lasting effects from their awareness episode. [ citation needed ]
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Ocular surgery may be performed under topical , local or general anesthesia . Local anaesthesia is more preferred because it is economical, easy to perform and the risk involved is less. Local anaesthesia has a rapid onset of action and provides a dilated pupil with low intraocular pressure .
Susruta Samhita has evidences of use of anaesthesia for ocular surgeries. Inhalational anaesthesia was used for this purpose. [ citation needed ] Egyptian surgeons used carotid compression to produce transient ischemia during eye surgery to reduce the perception of pain. [ citation needed ] In 1884, Karl Koller used cocaine for ocular surgery. [ citation needed ] The same year, Herman Knapp used cocaine for retrobulbar block. [ citation needed ] In 1914, van Lint achieved orbicularis akinesia by local injection. [ citation needed ]
Surface anaesthesia is given by instillation of 2.5 ml xylocaine . One drop of xylocaine instilled four times after every 4 minutes will produce conjunctival and corneal anaesthesia. Paracaine , tetracaine , bupivacaine , lidocaine etc. may also be used in place of xylocaine. [ 1 ] Cataract surgery by phacoemulsification is frequently performed under surface anaesthesia. Facial nerve , which supplies the orbicularis oculi muscle, is blocked in addition for intraocular surgeries. Topical anaesthesia is known to cause endothelial and epithelial toxicity, allergy and surface keratopathy. [ citation needed ]
There are four types of facial block : van Lint's block, Atkinson block, O' Brien block and Nadbath block.
This technique was first practiced by Herman Knapp in 1884. Here, 2% xylocaine is introduced into the muscle cone behind the eyeball. The injection is usually given through the inferior fornix of the skin of the outer part of the lower lid when the eye is in primary gaze. The ciliary nerves , ciliary ganglion , oculomotor nerve and abducens nerve are anesthetized in retrobulbar block. [ 2 ] As a result, global akinesia, anaesthesia and analgesia are produced. The superior oblique muscle , which is outside the muscle cone, is not usually paralyzed. The complications of retrobulbar block are globe perforation, optic nerve injury, retrobulbar haemorrhage and extraocular muscle palsy. Retrobulbar anaesthesia is contraindicated in posterior staphyloma , high axial myopia and enophthalmos . [ 4 ]
This technique was first applied by Davis. In peribulbar block, local anaesthetic is injected to the peripheral spaces of the orbit. The anaesthetic diffuses into the muscle cone and eyelids , causing global and orbicularis akinesia and anaesthesia. After injection, orbital compression is applied for around 15 minutes. [ clarification needed ] [ 4 ]
Nearly all ocular surgeries viz keratoplasty , cataract extraction , glaucoma surgery , iridectomy , strabismus , [ 5 ] retinal detachment surgery etc. can be done under regional anaesthesia. Conjunctiva , globe and orbicularis can be paralysed using a combination of surface anaesthesia, facial anaesthesia and retrobulbar block. [ 1 ] The advantage is that it produces less post-operative restlessness. It has less post-operative lung complications and less bleeding. [ 2 ]
General anaesthesia is preferred for ocular surgeries in anxious adults, psychiatric patients, infants and children. [ 5 ] It is also indicated in perforating ocular injuries and major surgeries like exenteration. During the surgery, it has to be ensured that no carbon dioxide retention occurs. If this occurs, the choroid swells up and ocular contents may prolapse as soon as the eye is opened. The advantages of general anaesthesia is that it produces complete akinesia, controlled intraocular pressure and safe operating environment. It is the safest option for bilateral surgery. The complications of general anaesthesia are laryngospasm , hypotension , hypercarbia , respiratory depression and cardiac arrhythmia .
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In the United States , anesthesia can be administered by physician anesthesiologists , an anesthesiologist assistant , or nurse anesthetist .
Anesthesiologists are physicians (MD/DO) specializing in the practice of anesthesiology.
The training of a physician anesthesiologist typically consists of four years of college, four years of medical school, one year of internship, and three years of residency optionally followed by a one-year fellowship in a sub-specialty. It is the highest training level for all practitioners delivering anesthesia in the United States. While most physicians practicing anesthesiology in the United States
pass a comprehensive board exam, board certification is not required in order to practice anesthesiology. Physicians who have successfully completed training in an ACGME accredited program become board eligible at the time of graduation and may practice anesthesiology until board certification is attained, commonly within one year post graduation. According to an American Society of Anesthesiologists (ASA) press release Anesthesiologists provide or participate in more than 90 percent of the 40 million anesthetics delivered annually. [ 1 ]
Other specialties within medicine are closely affiliated to anesthesiology. These include intensive care medicine and pain medicine . Specialists in these disciplines have completed training in anesthesia including a three-year residency in anesthesia with an additional year in an accredited fellowship in a sub specialty of anesthesia (e.g. Pain, Critical Care Medicine, Obstetric Anesthesia, Pediatric Anesthesia). Anesthesiology is not limited to the operating room. Physician anesthesiologists are termed "peri-operative physicians", and are involved in optimizing the patient's health before surgery, performing the anesthetic and associated procedures (e.g. neuraxial anesthesia, specialized intravascular access), following up the patient in the post-anesthesia care unit and post-operative wards, and ensuring optimal analgesia throughout. Some sub-specialty physician anesthesiologists are an integral member of the critical care team in Surgical Intensive Care Units (SICU) and manage complex surgical patients throughout their hospitalization. [ citation needed ]
Certified Registered Nurse Anesthetists are advanced practice registered nurses specializing in the provision of anesthesia care. As of 2018, CRNAs represent more than 50% of the anesthesia workforce in the United States, with 52,000 providers, according to the American Association of Nurse Anesthetists, and administer more than 40 million anesthetics each year. Thirty-four percent of nurse anesthetists practice in communities of less than 50,000 due to the rural pass-through program where "eligible hospitals may use reasonable-costs based Part A payments in lieu of the conventional Part B payments as a rural practice inducement for nurse anesthetists to practice in small, underserved rural hospitals. [ citation needed ]
CRNAs begin their education with a four-year Bachelor of Science degree, followed by at least one year of critical care nursing experience (most trainees enter with 3-6 years of critical care nursing experience), and completion of the CCRN certification. After 3 years of intensive didactic and clinical anesthesia training, they obtain a doctorate of nursing degree and they must then pass the NBCRNA national certification exam. [ 2 ]
CRNAs care for patients pre-, intra-, and postoperatively and practice in all facets of anesthesia care. They may care for patients independently but also work collaboratively as part of the healthcare teams. Some choose to narrow the focus of care to sub-specialize in the provision of cardiac, pediatric, pain, or obstetrical care. CRNAs administer anesthesia in all types of surgical cases, and are able to apply all of the accepted anesthetic techniques—general, regional, local, or sedation independently without supervision of a physician anesthesiologist. [ 3 ]
As of 2022, 19 governors opted out of the CRNA supervision requirement of the Centers of Medicare and Medicaid Services (CMS).
Anesthesiologist assistants are advanced non-physician anesthesia providers qualified by graduate medical education and clinical training to work under the direction of an anesthesiologist in developing and implementing the anesthesia care plan. The anesthesiologist assistant is a nonphysician anesthesist in the Anesthesia Care Team (ACT) with an identical scope of practice of certified registered nurse anesthetist (CRNA). Anesthesiologist assistants obtain pre-anesthetic health histories, perform preoperative physical exams, establish non-invasive and invasive monitors, perform all types of intubations and airway management techniques, administer medications/IV fluids/blood products, evaluate and treat life-threatening situations, and execute all forms of anesthesia including the induction, maintenance, emergence and recovery of general, local, sedation and regional anesthetic techniques. [ citation needed ]
Anesthesiologist assistants generally work in the hospital setting but can work at any location including pain clinics, dental offices and surgical care centers. Anesthesiologist assistants work under the medical direction of physician anesthesiologists in surgical environments such as cardiac surgery, neurosurgery, transplant surgery, and trauma surgery centers. The incorporation of anesthesiologist assistants into ACT teams across the country is a dynamic process, and currently there are sixteen states, as well as Washington, D.C., and the Veteran's Affairs Medical System. In each of these states, the anesthesiologist assistant falls under the regulatory authority of the State Board of Medicine.
As of 2017 there are twelve anesthesiologist assistant training programs in the United States all of which offer degrees at the Master's level. [ citation needed ] Approximately 97% of currently practicing anesthesiologist assistants hold a master's degree (some early anesthesiologist assistant graduates held bachelor's degrees). All newly credentialed and future anesthesiologist assistants must complete an accredited Master's program for anesthesiologist assistants. Upon completion of the educational program, graduates must sit for a credentialing exam that is co-validated by the National Board of Medical Examiners and National Commission for Certification of Anesthesiologist Assistants. All anesthesiologist assistant programs are credentialed by the Commission on Accreditation of Allied Health Educational Programs (CAAHEP)
Effective November 13, 2001, CMS established an exemption for Certified Registered Nurse Anesthetists (CRNAs) from the physician supervision requirement. This exemption recognized a Governor's written request to CMS attesting that he or she is aware of the state's right to an exemption of the requirement for CRNA to be supervised by a physician. The attestation recognizes that it is in the best interests of the State's citizens to exercise this option in order to provide safe, cost-effective, valuable anesthesia services and especially helps assure the provision of those services to all citizens. [ citation needed ]
Requirements for “Opt-Out” Of Federal Supervision Requirement
• The federal requirement has been that CRNAs must be supervised by a physician. The November 13,
2001 rule allows states to "opt-out" or be "exempted" (the terms are used synonymously in the November
13 rule) from the federal supervision requirement.
• For a state to "opt-out" of the federal supervision requirement, the state's governor must send a letter of
attestation to CMS. The letter must attest that:
a. The state's governor has consulted with the state's boards of medicine and nursing about issues
related to access to and the quality of anesthesia services in the state; and
b. That it is in the best interests of the state's citizens to opt-out of the current federal physician
supervision requirement; and
c. That the opt-out is consistent with state law.
As of March 2020, nineteen states have chosen to opt-out of the CRNA physician supervision regulation. The states are: Alaska, Arizona, Colorado, California, Idaho, Iowa, Kansas, Kentucky, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, Oklahoma, South Dakota, Washington, and Wisconsin.
According to the ASA statement on the Anesthesia Care Team, anesthesia care personally performed or medically directed by an anesthesiologist constitutes the practice of medicine. According to the American Association of Nurse Anesthetists and state law in all fifty states, anesthesia care provided by a Certified Registered Nurse Anesthesiologist is considered the practice of nursing. Certain aspects of physician directed anesthesia care may be delegated to other trained and credentialed professionals, including anesthesiologist assistants and CRNAs. [ 4 ]
It has been established that, under US law , anesthesia is practice of both medicine and nursing. Frank v. South , [ 5 ] Chalmers-Francis v. Nelson [ 6 ] [ 7 ] and other court decisions determined that anesthesia was the practice of Nursing as well as Medicine. [ 8 ] As such, the practice of anesthesia in the US may be delivered by a physician anesthesiologist, an anesthesiologist assistant or a Certified Registered Nurse Anesthesist. The decisions have not been challenged since the Dagmar Nelson case. [ 9 ] In addition to legal decisions, individual hospital and surgical facility policies also regulate the granting of anesthesia clinical privileges and are often based on contractual agreements with provider groups.
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https://en.wikipedia.org/wiki/Anesthesia_provision_in_the_United_States
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Anesthesiology , anaesthesiology or anaesthesia is the medical specialty concerned with the total perioperative care of patients before, during and after surgery . [ 1 ] It encompasses anesthesia , intensive care medicine , critical emergency medicine , and pain medicine . [ 2 ] A physician specialized in anesthesiology is called an anesthesiologist , anaesthesiologist , or anaesthetist , depending on the country . [ 3 ] [ 4 ] [ 5 ] [ 6 ] In some countries, the terms are synonymous, while in other countries, they refer to different positions and anesthetist is only used for non-physicians, such as nurse anesthetists .
The core element of the specialty is the prevention and mitigation of pain and distress using various anesthetic agents, as well as the monitoring and maintenance of a patient's vital functions throughout the perioperative period. [ 7 ] Since the 19th century, anesthesiology has developed from an experimental area with non-specialist practitioners using novel, untested drugs and techniques into what is now a highly refined, safe and effective field of medicine. In some countries anesthesiologists comprise the largest single cohort of doctors in hospitals, [ 8 ] [ 9 ] and their role can extend far beyond the traditional role of anesthesia care in the operating room , including fields such as providing pre-hospital emergency medicine , running intensive care units , transporting critically ill patients between facilities, management of hospice and palliative care units, and prehabilitation programs to optimize patients for surgery. [ 7 ] [ 8 ]
As a specialty, the core element of anesthesiology is the practice of anesthesia . This comprises the use of various injected and inhaled medications to produce a loss of sensation in patients, making it possible to carry out procedures that would otherwise cause intolerable pain or be technically unfeasible. [ 10 ] Safe anesthesia requires in-depth knowledge of various invasive and non-invasive organ support techniques that are used to control patients' vital functions while under the effects of anaesthetic drugs; these include advanced airway management , invasive and non-invasive hemodynamic monitors, and diagnostic techniques like ultrasonography and echocardiography . Anesthesiologists are expected to have expert knowledge of human physiology , medical physics , and pharmacology as well as a broad general knowledge of all areas of medicine and surgery in all ages of patients, with a particular focus on those aspects which may impact on a surgical procedure. In recent decades, the role of anesthesiologists has broadened to focus not just on administering anesthetics during the surgical procedure itself, but also beforehand in order to identify high-risk patients and optimize their fitness, during the procedure to maintain situational awareness of the surgery itself so as to improve safety, and afterwards to promote and enhance recovery. This has been termed " perioperative medicine ".
The concept of intensive care medicine arose in the 1950s and 1960s, with anesthesiologists taking organ support techniques that had traditionally been used only for short periods during surgical procedures (such as positive pressure ventilation ) and applying these therapies to patients with organ failure , who might require vital function support for extended periods until the effects of the illness could be reversed. The first intensive care unit was opened by Bjørn Aage Ibsen in Copenhagen in 1953, prompted by a polio epidemic during which many patients required prolonged artificial ventilation. In many countries, intensive care medicine is considered to be a subspecialty of anesthesiology, and anesthesiologists often rotate between duties in the operating room and the intensive care unit. This allows continuity of care when patients are admitted to the ICU after their surgery, and it also means that anesthesiologists can maintain their expertise at invasive procedures and vital function support in the controlled setting of the operating room, while then applying those skills in the more dangerous setting of the critically ill patient. In other countries, intensive care medicine has evolved further to become a separate medical specialty in its own right, or has become a "supra-specialty" which may be practiced by doctors from various base specialties such as anesthesiology, emergency medicine , general medicine , surgery or neurology .
Anesthesiologists have key roles in major trauma , resuscitation , airway management , and caring for other patients outside the operating theatre who have critical emergencies that pose an immediate threat to life, again reflecting transferable skills from the operating room, and allowing continuity of care when patients are brought for surgery or intensive care. This branch of anesthesiology is collectively termed critical emergency medicine , and includes provision of pre-hospital emergency medicine as part of air ambulance or emergency medical services , as well as safe transfer of critically ill patients from one part of a hospital to another, or between healthcare facilities. Anesthesiologists commonly form part of cardiac arrest teams and rapid response teams composed of senior clinicians that are immediately summoned when a patient's heart stops beating, or when they deteriorate acutely while in hospital. Different models for emergency medicine exist internationally: in the Anglo-American model, the patient is rapidly transported by non-physician providers to definitive care such as an emergency department in a hospital. Conversely, the Franco-German approach has a physician, often an anesthesiologist, come to the patient and provide stabilizing care in the field. The patient is then triaged directly to the appropriate department of a hospital.
The role of anesthesiologists in ensuring adequate pain relief for patients in the immediate postoperative period as well as their expertise in regional anesthesia and nerve blocks has led to the development of pain medicine as a subspecialty in its own right. The field comprises individualized strategies for all forms of analgesia , including pain management during childbirth , neuromodulatory technological methods such as transcutaneous electrical nerve stimulation or implanted spinal cord stimulators , and specialized pharmacological regimens.
Anesthesiologists often perform interhospital transfers of critically ill patients, both on short range helicopter [ 11 ] [ 12 ] or ground based missions, [ 13 ] as well as longer range national transports [ 14 ] to specialized centra or international missions to retrieve citizens injured abroad. [ 15 ] [ 16 ] Ambulance services employ units staffed by anesthesiologists that can be called out to provide advanced airway management , blood transfusion , thoracotomy , ECMO , and ultrasound capabilities outside the hospital. [ 17 ] Anesthesiologists often (along with general surgeons and orthopedic surgeons ) make up part of military medical teams to provide anesthesia and intensive care to trauma victims during armed conflicts . [ 18 ]
Various names and spellings are used to describe this specialty and the individuals who practice it in different parts of the world. [ 19 ] In North America, the specialty is referred to as anesthesiology (omitting the "ae" diphthong ), and a physician of that specialty is therefore called an anesthesiologist . [ 1 ] [ 2 ] In these countries, the term anesthestist is used to refer to non-physician providers of anesthesia services such as certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants (AAs). [ 20 ] In other countries – such as United Kingdom, Australia, New Zealand, and South Africa – the medical specialty is referred to as anaesthesia or anaesthetics , with the "ae" diphthong. [ 1 ] [ 2 ] Contrary to the terminology in North America, anaesthetist is used only to refer to a physician practicing in the field; non-physicians use other titles such as physician assistant . [ 3 ] At this time, the spelling anaesthesiology is most commonly used in written English, and a physician practicing in the field is termed an anaesthesiologist. [ 1 ] This is the spelling adopted by the World Federation of Societies of Anaesthesiologists and the European Society of Anaesthesiology , as well as the majority of their member societies. [ 21 ] [ 22 ] It is the also the most commonly used spelling found in the titles of medical journals. [ 1 ] In fact, many countries, such as Ireland and Hong Kong, which formerly used anaesthesia and anaesthetist have now transitioned to anaesthesiology and anaesthesiologist . [ 4 ] [ 5 ]
Throughout human history, efforts have been made by almost every civilization to mitigate pain associated with surgical procedures, ranging from techniques such as acupuncture or phlebotomy to administration of substances such as mandrake, opium, or alcohol. [ 23 ] [ 24 ] [ 25 ] However, by the mid-nineteenth century the study and administration of anesthesia had become far more complex as physicians began experimenting with compounds such as chloroform and nitrous oxide , albeit with mixed results. [ 25 ] On October 16, 1846, a day that would thereafter be referred to as "Ether Day", in the Bullfinch Auditorium at Massachusetts General Hospital, which would later be nicknamed the "Ether Dome", New England Dentist William Morton successfully demonstrated the use of diethyl ether using an inhaler of his own design to induce general anesthesia for a patient undergoing removal of a neck tumor. [ 23 ] Reportedly, following the quick procedure, operating surgeon John Warren affirmed to the audience that had gathered to watch the exhibition, "Gentlemen, this is no humbug!", although this report has been disputed. [ 26 ]
The term Anaesthesia was first used by the Greek philosopher Dioscorides, derived from the Ancient Greek roots ἀν- an- , "not", αἴσθησις aísthēsis , "sensation" to describe the insensibility that accompanied the narcotic-like effect produced by the mandrake plant. [ 25 ] However, following Morton's successful exhibition, Oliver Wendell Holmes Sr. sent a letter to Morton in which he first to suggested anesthesia to denote the medically induced state of amnesia, insensibility, and stupor that enabled physicians to operate with minimal pain or trauma to the patient. [ 25 ] [ 23 ] The original term had simply been "etherization" because at the time this was the only agent discovered that was capable of inducing such a state. [ 27 ]
Over the next one hundred-plus years the specialty of anesthesiology developed rapidly as further scientific advancements meant that physicians' means of controlling peri-operative pain and monitoring patients' vital functions grew more sophisticated. [ 28 ] With the isolation of cocaine in the mid-nineteenth century there began to be drugs available for local anesthesia. By the end of the nineteenth century, the number of pharmacological options had increased and had begun to be applied both peripherally and neuraxially . Then in the twentieth century neuromuscular blockade allowed the anesthesiologist to completely paralyze the patient pharmacologically and breathe for him or her via mechanical ventilation. With these new tools, the anesthetist could intensively manage the patient's physiology, bringing about critical care medicine , which, in many countries, is intimately connected to anesthesiology.
Historically anesthesia providers were almost solely utilized during surgery to administer general anesthesia in which a person is placed in a pharmacologic coma . This is performed to permit surgery without the individual responding to pain ( analgesia ) during surgery or remembering ( amnesia ) the surgery.
Effective practice of anesthesiology requires several areas of knowledge by the practitioner, some of which are:
Many procedures or diagnostic tests do not require "general anesthesia" and can be performed using various forms of sedation or regional anesthesia , which can be performed to induce analgesia in a region of the body. For example, epidural administration of a local anesthetic is commonly performed on the mother during childbirth to reduce labor pain while permitting the mother to be awake and active in labor and delivery.
In the United States, anesthesiologists may also perform non-surgical pain management (termed pain medicine ) and provide care for patients in intensive care units (termed critical care medicine ).
International standards for the safe practice of anesthesia, jointly endorsed by the World Health Organization and the World Federation of Societies of Anaesthesiologists , define anesthesiologist as a graduate of a medical school who has completed a nationally recognized specialist anesthesia training program. [ 29 ] The length and format of anesthesiology training programs varies from country to country, as noted below. A candidate must first have completed medical school training to be awarded a medical degree , before embarking on a program of postgraduate specialist training or residency which can range from four to nine years. [ 30 ] Anesthesiologists in training spend this time gaining experience in various different subspecialties of anesthesiology and undertake various advanced postgraduate examinations and skill assessments. These lead to the award of a specialist qualification at the end of their training indicating that they are an expert in the field and may be licensed to practice independently.
In Argentina, specialized training in the field of anesthesiology is overseen by the Argentine Federation of Associations of Anaesthesia, Analgesia and Reanimation (in Spanish, Federación Argentina de Asociaciones de Anestesia, Analgesia y Reanimación or FAAAAR). [ 31 ] Residency programs are four [ 32 ] [ 33 ] to five [ 34 ] years long.
In Australia and New Zealand, the medical specialty is referred to as anaesthesia or anaesthetics ; note the extra "a" (or diphthong). [ 35 ] [ 36 ] Specialist training is supervised by the Australian and New Zealand College of Anaesthetists (ANZCA), while anaesthetists are represented by the Australian Society of Anaesthetists and the New Zealand Society of Anaesthetists. The ANZCA-approved training course encompasses an initial two-year long Pre-vocational Medical Education and Training (PMET), which may include up to 12 months training in anaesthesia or ICU medicine, plus at least five years of supervised clinical training at approved training sites. [ 37 ] [ 38 ] Trainees must pass both the primary and final examinations which consist of both written (multiple choice questions and short-answer questions) and, if successful in the written exams, oral examinations ( viva voce ). [ citation needed ]
In the final written examination, there are many questions of clinical scenarios (including interpretation of radiological exams, EKGs and other special investigations). [ 39 ] There are also two cases of real patients with complex medical conditions – for clinical examination and a following discussion. [ 39 ] The course has a program of 12 modules such as obstetric anaesthesia, pediatric anaesthesia, cardiothoracic and vascular anaesthesia, neurosurgical anaesthesia and pain management. [ 40 ] Trainees also have to complete an advanced project, such as a research publication or paper. They also undergo an EMAC (Effective Management of Anaesthetic Crises) or EMST ( Early Management of Severe Trauma ) course. [ 40 ] On completion of training, the trainees are awarded the Diploma of Fellowship and are entitled to use the qualification of FANZCA – Fellow of the Australian and New Zealand College of Anaesthetists. [ 41 ] [ 40 ]
In Brazil, anesthesiology training is overseen by the National Commission for Medical Residency (CNRM) and the Brazilian Society of Anesthesiology (SBA). [ 42 ] Approximately 650 physicians [ citation needed ] are admitted yearly to a three-year specialization program with a duty hour limit of 60 hours per week. [ 42 ] [ 30 ] The residency programs can take place at training centers in university hospitals. These training centers are accredited by the Brazilian Society of Anesthesiology (SBA), or other referral hospitals accredited by the Ministry of Health. Most of the residents are trained in different areas, including ICU, pain management, and anesthesiology sub-specialties, including transplants and pediatrics. [ 30 ] Residents may elect to pursue further specialization via a fellowship post-residency, but this is optional and only offered at few training centers. [ 42 ] In order to be a certified anesthesiologist in Brazil, the residents must undergo exams (conducted by the SBA) throughout the residency program and at the end of the program. [ 43 ] In order to be an instructor of a residency program certified by the SBA, the anesthesiologists must have the superior title in anaesthesia, in which the specialist undergoes a multiple choice test followed by an oral examination conducted by a board assigned by the national society. [ citation needed ]
In Canada, training is supervised by 17 universities approved by the Royal College of Physicians and Surgeons of Canada . [ 44 ] Residency programs are typically five years long, consisting of 1.5 years of general medicine training followed by 3.5 years of anesthesia specific training. [ 30 ] Canada, like the United States, uses a competency-based curriculum along with an evaluation method called "Entrustable Professional Activities" or "EPA" in which a resident is assessed based on their ability to perform certain tasks that are specific to the field of anesthesiology. [ 43 ] Upon completion of a residency program, the candidate is required to pass a comprehensive objective examination consisting of a written component (two three-hour papers: one featuring 'multiple choice' questions, and the other featuring 'short-answer' questions) and an oral component (a two-hour session relating to topics on the clinical aspects of anesthesiology). [ 45 ] The examination of a patient is not required. [ 45 ] Upon completion of training, the anaesthesia graduate is then entitled to become a "Fellow of the Royal College of Physicians of Canada" and to use the post-nominal letters "FRCPC". [ 46 ] [ 47 ]
In Germany, after earning the right to practice medicine ( German : Approbation ), [ 48 ] German physicians who want to become anaesthesiologists must undergo five years of additional training as outlined by the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, or DGAI). [ 49 ] This specialist training consists of anaesthesiology, emergency medicine, intensive care and pain medicine, and also palliative care medicine. [ 49 ] Similar to many other countries, the training includes rotations serving in the operation theatres to perform anaesthesia on a variety of patients being treated by various surgical subspecialties (e.g. general surgery , neurosurgery , invasive urological and gynecological procedures), followed by a rotation through various intensive-care units. [ 50 ] Many German anaesthesiologists choose to complete an additional curriculum in emergency medicine, which once completed, enables them to be referred to as Notarzt [ de ] , an emergency physician working pre-clinically with the emergency medical service . [ 51 ] [ 52 ] In pre-clinical settings the emergency physician is assisted by paramedics . [ 53 ]
In the Netherlands, anaesthesiologists must complete medical school training, which takes six years. After successfully completing medical school training, they start a five-year residency training in anaesthesiology. In their fifth year they can choose to spend the year doing research, or to specialize in a certain area, including general anaesthesiology, critical care medicine, pain and palliative medicine, paediatric anaesthesiology, cardiothoracic anaesthesiology, neuroanaesthesiology or obstetric anaesthesiology.
In Guatemala, a student with a medical degree must complete a residency of 4 years. This consists of 3 years in residency and one year of supervised practice with an expert anaesthesiologist. [ 54 ]
After residency, students take a board examination conducted by the college of medicine of Guatemala, the Universidad de San Carlos de Guatemala (Medicine Faculty Examination Board), and a chief physician who represents the health care ministry of the government of Guatemala. The examination includes a written section, an oral section, and a special examination of skills and knowledge relating to anaesthetic instruments, emergency treatment, pre-operative care, post-operative care, intensive care units, and pain medicine. After passing the examination, the college of medicine of Guatemala, Universidad de San Carlos de Guatemala and the health care ministry of the government of Guatemala grants the candidate a special license to practice anaesthesia as well as a diploma issued by the Universidad de San Carlos de Guatemala granting the degree of physician with specialization in anaesthesia. Anaesthetists in Guatemala are also subject to yearly examinations and mandatory participation in yearly seminars on the latest developments in anaesthetic practice.
To be qualified as an anesthesiologist in Hong Kong, medical practitioners must undergo a minimum of six years of postgraduate training and pass three professional examinations. Upon completion of training, the Fellowship of Hong Kong College of Anesthesiologists and subsequently the Fellowship of Hong Kong Academy of Medicine is awarded. Practicing anesthesiologists are required to register in the Specialist register of the Medical Council of Hong Kong and hence are under the regulation of the Medical Council. [ 55 ]
In Italy, a medical school graduate must complete an accredited five-year residency in anesthesiology. [ citation needed ] Anesthesia training is overseen by the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI). [ 56 ]
In Denmark, Finland, Iceland, Norway, and Sweden, anesthesiologists' training is supervised by the respective national societies of anesthesiology as well as the Scandinavian Society of Anaesthesiology and Intensive Care Medicine . In the Nordic countries, anesthesiology is the medical specialty that is engaged in the fields of anesthesia, intensive care medicine, pain control medicine, pre-hospital and in-hospital emergency medicine. Medical school graduates must complete a twelve-month internship, followed by a five-year residency program. SSAI currently hosts six training programs for anesthesiologists in the Nordics. These are Intensive care, Pediatric anesthesiology and intensive care, Advanced pain medicine, Critical care medicine, Critical emergency medicine, and Advanced obstetric anesthesiology.
In Sweden one speciality entails both anesthesiology and intensive care, i.e. one cannot become and anesthetist without also becoming an intensivist and vice versa. The Swedish Board of Health and Welfare regulates specialization for medical doctors in the country and defines the speciality of anesthesiology and intensive care as being:
"[…] characterized by a cross-professional approach and entailing
A medical doctor can enter training as a resident in anesthesiology and intensive care after obtaining a license to practice medicine, following an 18–24 month internship. The residency program then lasts at least five years, not including the internship. See also Residency (medicine), Sweden .
In the United Kingdom, training is supervised by the Royal College of Anaesthetists . Following the completion of medical school training, doctors enter a two-year foundation program that consists of at least six, four-month rotations in various medical specialties. It is mandatory for all physicians to complete a minimum of three months of general medicine and general surgery training during this time. Following the foundation program, physicians compete for specialist training.
The training program in the United Kingdom currently consists of three years of core training and four years of higher training. Before the end of core training, all trainees must have passed the primary examination for the diploma of Fellowship of the Royal College of Anaesthetists (FRCA). Trainees wishing to hold dual accreditation in anaesthesia and intensive care medicine may enter anaesthesia training via the Acute Care Common Stem (ACCS) program which lasts four years and consists of experience in anaesthesia, emergency medicine, acute medicine and intensive care. Trainees in anaesthesia are called Specialty Registrars (StR) or Specialist Registrars (SpR).
The Certificate of Completion of Training (CCT) in anaesthesia is divided into three levels: Basic, intermediate and advanced. During this time, physicians learn anaesthesia as applicable to all surgical specialties. The curriculum focuses on a modular format, with trainees primarily working in one special area during one module, for example: cardiac anaesthesia, neuroanaesthesia , ENT, maxillofacial, pain medicine, intensive care, and trauma. Traditionally (before the advent of the foundation program), trainees entered anaesthesia from other specialties, such as medicine or accidents and emergencies . Specialist training takes at least seven years. On completion of specialist training, physicians are awarded CCT and are eligible for entry on the GMC Specialist register and are also able to work as consultant anaesthetist. A new consultant in anaesthetics must have completed a minimum of 14 years of training (including: five to six years of medical school training, two years of foundation training, and seven years of anaesthesia training).
Those wishing for dual accreditation (in Intensive care and anaesthesia) are required to undergo approximately an additional year of training and also complete the fellowship of the Faculty of Intensive Care Medicine (FFICM). Pain specialists give the Fellowship of the Faculty of Pain Medicine of the Royal College of Anaesthetists (FFPMRCA) examination.
Following medical school training, anesthesiology residency programs in the United States require successful completion of an intern year plus three years of advanced residency training at an ACGME approved program (for a total of four years) for board certification eligibility in the specialty of anesthesiology. [ 58 ] Anesthesiology residents face multiple examinations during their residency, including exams encompassing physiology, pathophysiology, pharmacology, and other medical sciences addressed in medical school, along with multiple anesthesia knowledge tests which assess progress during residency. Successful completion of both a written and oral board exam after completion of residency is required for board certification.
Residency training in the U.S. encompasses the full scope of perioperative medicine, including pre-operative medical evaluation, management of pre-existing disease in the surgical patient, intraoperative life support, intraoperative pain control, intraoperative ventilation, post-operative recovery, intensive care medicine, and chronic and acute pain management. After residency, many anesthesiologists complete an additional fellowship year of sub-specialty training in areas such as pain management, sleep medicine, cardiothoracic anesthesiology , pediatric anesthesiology, neuroanesthesiology , regional anesthesiology/ambulatory anesthesiology, obstetric anesthesiology , or critical care medicine . [ 59 ]
The majority of anesthesiologists in the United States are board-certified, either by the American Board of Anesthesiology (ABA) or the American Osteopathic Board of Anesthesiology (AOBA). Osteopathic physician anesthesiologists can be certified by the ABA. The ABA is a member of the American Board of Medical Specialties, while the AOBA falls under the American Osteopathic Association . Both Boards are recognized by the major insurance underwriters in the U.S. as well as by all branches of the U.S. Uniformed Services. Board certification by the ABA involves both a written and an oral examination. AOBA certification requires the same exams, in addition to a practical examination with examining physicians observing the applicant actually administering anesthetics in the operating room. [ 60 ]
There are several non-physician anesthesia providers practicing in the United States. These include certified registered nurse anesthetists (CRNAs), anesthesiologist assistants (AAs), and dental anesthesiologists. CRNAs are the only type of non-physician anesthesia provider that have successfully lobbied for the ability to provide all types of anesthesia for any surgery or procedure independently in some states. [ citation needed ] AAs must work under the supervision of an anesthesiologist, and dental anesthesiologists are limited to dental cases.
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An anesthetic technician is a healthcare professional who performs a patient care role predominantly with the administration and monitoring of anesthesia and has an extensive knowledge of anesthesia techniques, instruments, supplies and technology.
Anesthetic technicians are mainly employed by anesthetic departments or operating theatre suites, but can be found in other areas of clinical practice including emergency departments , intensive care units (ICU) and day surgery clinics. [ citation needed ]
Anesthetic technicians are involved with all aspects of the delivery of a patient's perioperative anesthetic care, [ 1 ] taking into account the patients' religious and cultural beliefs and respecting their right to medical privacy and dignity at all times. Anesthetic Technicians’ also provide a key role in the emergency resuscitation of patients. [ citation needed ]
Anesthetic technicians prepare equipment needed for the patient to safely undergo anesthesia . This involves: [ citation needed ]
The anesthetic technicians role includes assisting with: [ citation needed ]
Anesthetic technicians assist the anesthetic with: [ citation needed ]
Regional variations exist, but anesthetic technicians may also be involved with: [ citation needed ]
American Society of Anesthesia Technologists & Technicians ( ASATT ), acknowledges the scope of practice for the Anesthesia technical personnel. The commitment of ASATT is to ensure that efficient, safe, competent, and ethical practices are provided to society and maintaining professional standards of practice. ASATT acknowledges that the Anesthesia technical personnel are a part of the Anesthesia care team as listed in the practice guidelines of the American Society of Anesthesiologists ( ASA ). [ 2 ] This position should not be confused with that of an anesthesiologist assistant who actively participates as a licensed anesthesia provider.
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Angellift is a brand of noninvasive, removable perioral ( mouth ) implant or prosthetic marketed by Medical Matrix, LLC used to lift and tighten the lower facial dermis . Angellift came about when a California surgeon wanted to provide his patients with a preview of their new appearance, but the concept is believed to date back more than 25 years in use by European actors. [ 1 ] In the United States they are just one aspect of a growing trend in cosmetic dentistry . [ 2 ] [ 3 ] The first ones in the United States were made in 2003, and are still in use. [ 4 ] [ 5 ] It was featured in the fifth season of Shark Tank . [ 6 ]
The American Dental Association and Canadian Dental Association have not been invited to participate in the development of this device as it does not affect teeth or occlusion ; although the device is fit within the mouth, it affects the skin surface and not the perioral cavity. The Angellift devices are cleaned in similar fashion as retainers or dentures .
In 2008 Angellift introduced an over-the-counter version of the original prescriptive model which could only be fit by dentists. The over-the-counter version does not require a dental visit as it does not attach to the teeth. Also in 2008, Angellift applied to the Food and Drug Administration for administration approval for general physicians and dermatologists . [ 1 ]
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Angelman syndrome ( AS ) is a genetic disorder that affects approximately 1 in 15,000 individuals. [ 9 ] AS impairs the function of the nervous system , producing symptoms, such as severe intellectual disability , developmental disability , limited to no functional speech, balance and movement problems, seizures, hyperactivity, and sleep problems. [ 10 ] Physical symptoms include a small head and a specific facial appearance. [ 10 ] Additionally, those affected usually have a happy personality and have a particular interest in water. [ 10 ] Angelman syndrome involves genes that have also been linked to 1–2% of autism spectrum disorder cases. [ 9 ]
Though the prevalence of Angelman syndrome is not precisely known, there are some estimates. The best data available are from studies of school age children, ages 6–13 years, living in Sweden and from Denmark where the diagnosis of AS children in medical clinics was compared to an 8-year period of about 45,000 births. The Swedish study showed an AS prevalence of about 1/20,000, [ 11 ] and the Danish study showed a minimum AS prevalence of about 1/10,000. [ 12 ] AS rates are similar between males and females. [ 13 ]
Harry Angelman , a pediatrician working in Warrington , England, first reported three children with this condition in 1965. [ 15 ] Angelman later described his choice of the title "Puppet Children" to describe these cases as being related to an oil painting he had seen while vacationing in Italy:
The history of medicine is full of interesting stories about the discovery of illnesses. The saga of Angelman's syndrome is one such story. It was purely by chance that nearly thirty years ago (e.g. [ sic ], circa 1964) three handicapped children were admitted at various times to my children's ward in England. They had a variety of disabilities and although at first sight they seemed to be suffering from different conditions I felt that there was a common cause for their illness. The diagnosis was purely a clinical one because in spite of technical investigations which today are more refined I was unable to establish scientific proof that the three children all had the same handicap. In view of this I hesitated to write about them in the medical journals. However, when on holiday in Italy I happened to see an oil painting in the Castelvecchio Museum in Verona called ... a Boy with a Puppet. The boy's laughing face and the fact that my patients exhibited jerky movements gave me the idea of writing an article about the three children with a title of Puppet Children. It was not a name that pleased all parents but it served as a means of combining the three little patients into a single group. Later the name was changed to Angelman syndrome. This article was published in 1965 and after some initial interest lay almost forgotten until the early eighties.
Case reports from the United States first began appearing in the medical literature in the early 1980s. [ 17 ] [ 18 ] Specifically, in 1982, Dr. Charles Williams and Dr Jaime Frias saw their first patients they believed has "happy puppet syndrome". [ 19 ] In 1987, Ellen Magenis, a physician, discovered a genetic marker of AS. [ 19 ] Specifically, it was noted that around half of the children with AS have a small piece of chromosome 15 missing. [ 20 ] In 1992, the AS foundation was created to further research for treatments and a cure for Angelman syndrome. [ 19 ] In 1997, Dr Arthur Beaudet discovered the cause of AS was mutation of the Ube3a gene. [ 19 ]
The signs and symptoms of AS and their relative frequency in patients are listed below.
100% of AS diagnoses have the following symptoms
80% of AS diagnoses have the following symptoms
20-80% of AS diagnoses have the following symptoms
Diagnostic criteria for the disorder were initially established in 1995 in collaboration with the Angelman syndrome Foundation (US); these criteria underwent revision in 2005. [ 22 ]
Angelman syndrome is caused by mutations in the UBE3A gene. [ 23 ] This gene is located within a region of chromosome 15 known as 15q11-q13. UBE3A is implicated in the ubiquitin pathway, which tags proteins to be degraded by a proteasome . Specifically, UBE3A codes for a very selective E6-AP ubiquitin ligase which targets MAPK1 , PRMT5 , CDK1 , CDK4 , β-catenin , and UBXD8 for ubiquitination. Alternative splicing of UBE3A results in three isoforms or variants of UBE3A with varying N-terminus . [ 24 ]
Typically, a fetus inherits a maternal copy of UBE3A and a paternal copy of UBE3A . In certain areas of the developing brain, the paternal copy of UBE3A is inactivated through a process known as imprinting , and the fetus relies soly on the functioning maternal copy of UBE3A in order to develop normally. In an individual with AS, the maternal UBE3A copy is absent or not functioning normally, which negatively impacts fetal brain development. There are four main maternal UBE3A geneotypes which make up a majority of the AS cases which are listed below
Deletion Positive (70% of AS cases): The most common genetic defect leading to Angelman syndrome is a 5- to 7-Mb (megabase) maternal deletion in chromosomal region 15q11.2-q13. [ 25 ] Essentially, the maternal copy of the UBE3A allele is completely deleted, and only the paternal copy of the UBE3A gene is present.
Mutation (11% of AS cases): This genotype of AS entails a mutation of the maternal UBE3A which prevents the expression of maternal UBE3A or alters its function. [ 26 ]
Imprinting Center Defect (6% of AS cases): Individuals with an imprinting center defect have an abnormality in the imprinting center of the maternal copy of the UBE3A gene. The imprinting center is an area on the chromosome that regulates whether genes are turned on or turned off. Therefore, the maternal copy of the UBE3A gene may be present in an individual with AS; however, if the AS patient has an imprinting center defect the maternal UBE3A gene is unavailable in the brain. [ 26 ]
Paternal Uniparental Disomy (UPD) (3% of AS cases): This genotype occurs when there are two paternal copies of UBE3A and no maternal copy. [ 26 ] Since the paternal copy of UBE3A is silent in the brain and the maternal copy is still absent, this genotype is still problematic for CNS development.
Importantly, the genotypes are predictive of the severity of symptoms. For example, the most common genotype of AS, deletion positive, is associated with more severe symptoms such as microcephaly, seizures, hypopigmentation, less weight gain, while the more rare genetic causes of AS, paternal uniparental disomy is associated with less severe symptoms. [ 26 ]
The presence of the consistent features of AS is required for the diagnosis of AS. However, additional genetic testing can be performed to confirm a proper diagnosis of AS.
Methylation studies: In 80% of AS patients, the maternal copy of UBE3A is methylated . Therefore, methylation studies can be done to confirm AS in patients. [ 13 ]
Fluorescence in Situ Hybridization (FISH ) : is conducted following methylation studies to detect if there is a maternal deletion of UBE3A on chromosome 15 [ 13 ]
DNA marker analysis: Inprinting defects or paternal disomy must also be considered using other molecular tests or DNA marker analysis, respectively. [ 13 ] Myethylation studies can miss a mutation of UBE3A. [ 13 ] Therefore, DNA sequencing can be done.
Electroencephalograms : Lastly, electroencephalograms can indicate characteristic patterns of AS brain activity and also reveal epileptic activity, a common symptom in AS. [ 13 ]
Other conditions that can appear similar include: [ 27 ]
There is currently no approved cure available. The epilepsy can be controlled by the use of one or more types of anticonvulsant medications. However, there are difficulties in ascertaining the levels and types of anticonvulsant medications needed to establish control, because people with AS often have multiple types of seizures. [ 29 ] Many families use melatonin [ 30 ] to promote sleep in a condition which often affects sleep patterns. Mild laxatives are also used frequently to encourage regular bowel movements. Additionally, among a cohort of 163 individuals with AS, ranitidine was shown to be the most frequently prescribed medication for treating gastroesophageal reflux disease (GERD). [ 30 ] Early intervention with physiotherapy is sometimes used to encourage joint mobility and prevent stiffening of the joints. [ citation needed ]
Occupational therapists can contribute to the development and augmentation of non-verbal communication skills by addressing the foundational skills such as finger isolation, motor planning, hand-eye coordination, spatial awareness, and refining gestures. [ 31 ] This is important because individuals with Angelman Syndrome who already possess some form of non-verbal communication have a much harder time adapting to changes in a new or existing AAC device because they can communicate their needs much faster nonverbally. [ 31 ]
Occupational therapists can assist individuals with Angelman syndrome with many other skills as well. [ 32 ] Many individuals with Angelman syndrome also have difficulty processing sensory information and responding appropriately to sensory stimuli. [ 33 ] Occupational therapists can work together with these individuals to improve their visual perceptual skills and increase their sensory awareness. [ 33 ]
Expressive verbal communication is limited by AS, but many people with the disorder are able to learn non-verbal communication skills to express their needs. Deictic gesturing (i.e., pointing to an object) is the most commonly used form of non-symbolic communication in AS, followed by physically manipulating others (such as moving a caregiver's hand to a specific object or guiding a person to a new location) and non-speech vocalizations. [ 32 ] Some are able to use symbolic communication such as signing, though the prevalence of this ability is related to both genetic etiology and epilepsy status, with non-deletion etiologies without epilepsy showing the highest prevalence of symbolic communication skills. [ 34 ] People with AS tend to have much higher receptive language abilities than expressive; recent studies have shown that patients with AS have typical auditory brain region responses to speech but atypical memory responses, suggesting that word meaning recall is delayed or processed differently in AS. [ 35 ] This may be caused by the altered cortical morphology seen in AS [ 36 ] in the precuneus , a region of the brain involved in self-reflection and memory. Similarly, both adults and children with AS show a delay in processing speed in speech processing, [ 37 ] and this should be accounted for during communication.
An experimental treatment, currently in clinical development by Roche , targets the GABAA α5 receptor . Alogabat is a small molecule that acts as a positive allosteric modulator ( PAMs ) of the receptor. It does not involve replacing or activating the UBE3A gene, instead it is a mechanism aimed at improving various symptoms of AS such as learning, sleep, and seizure control. [ 38 ] [ 39 ] [ 40 ] [ 41 ]
Several models have been developed to study the neuropathology of AS, including neuron cultures, animal models, human post-mortem brain tissue samples, and induced pluripotent stem cells from AS patients. [ 42 ] The UBE3A maternal-deficient mouse model (UBE3A m-/p+) is one of the most commonly used models to study AS. [ 42 ] This genetically modified mouse line is a valuable model for AS, since these mice present multiple symptoms of AS, such as ataxia, seizures, and sleep alterations. [ 42 ] However, there are multiple mouse models of AS. Between mouse models, their genetic modification of the UBE3A gene and translatability to clinical AS symptoms vary. [ 42 ] Recent advancements have been made to restore UBE3A levels in AS mice by activating the normally silenced paternal UBE3A allele in neurons. [ 42 ] [ 43 ] The paternal UBE3A allel is inactive in neurons because the UBE3A-ATS RNA transcript silences it. [ 13 ] The topoisomerase inhibitor topotecan is effective at unsilencing paternal UBE3A throughout the rodent brain. [ 13 ]
Clinical trials are conducted to test the effectiveness of drugs for the treatment of AS. Below are the recent, ongoing, or upcoming clinical trials for AS in order of clinical phase.
Tangelo (phase 1) : Roche is testing the safety of an antisense oligonucleotide , RO7248824, administered via intrathecal injection. [ 44 ] This drug works to unsilence paternal UBE3A. [ 44 ]
Aldebran (phase 2): Roche is testing the safety of Alogobat, which is administered as a once daily oral tablet. Alogobat targets the GABAA α5 receptor . Alogabat is a small molecule that acts as a positive allosteric modulator ( PAM ) of the receptor. It does not involve replacing or activating the UBE3A gene. Instead, it is a mechanism aimed at improving various symptoms of AS, such as learning, sleep, and seizure control. [ 44 ]
Angelman syndrome Study (phase 2): Neuren Pharmaceuticals is testing the safety of NNZ-2591, an oral medication which has been shown to improve impaired connection and signaling in brain cells. [ 44 ]
Aspire (phase 3): Aspire is researching GTX-102, an antisense oligonucleotide that attempts to unsilence the paternal copy of UBE3A. [ 44 ] This drug is administered via intrathecal injection. [ 44 ]
Reveal (phase 3): Ionis is investigating ION582, which is an antisense oligonucleotide designed to increase UBE3A production. [ 44 ]
In humans with AS, electroencephalogram (EEG) activity appears often abnormal. [ 45 ] This EEG facilitates the differential diagnosis of AS, but is not pathognomonic . [ 45 ] Three distinct interictal patterns are seen in these patients. The most common pattern is a very large amplitude 2–3 Hz rhythm most prominent in prefrontal leads. Next most common is a symmetrical 4–6 Hz high voltage rhythm. The third pattern, 3–6 Hz activity punctuated by spikes and sharp waves in occipital leads, is associated with eye closure. Paroxysms of laughter have no relation to the EEG, ruling out this feature as a gelastic phenomenon [ 45 ]
EEG anomalies may be used as a quantitative biomarkers to "chart progression of AS and as clinical outcome measures". [ 46 ] Slow delta activity (~3 Hz) is greatly increased in AS relative to typically developing children, yet more pronounced in children with partial 15q deletions as opposed to those with etiologies principally affecting UBE3A . [ 47 ] Theta activity (~5 Hz) is much greater in children with partial 15q deletions. [ 47 ] Thus, delta activity appears to be chiefly reflective of UBE3A dysfunction with some modulation from other 15q genes, whereas theta activity may be an electrophysiological readout of genes beyond UBE3A such as GABRA5 , GABRB3 , and GABRG3 [ 47 ] .
Brain regions
The paternal copy of UBE3A is silenced within the hippocampus, cortex, thalamus, olfactory bulb, and cerebellum. Therefore, a functioning maternal copy of UBE3A is essential for proper development in these brain regions. Of the areas of the brain implicated in AS, the hippocampus , cortex , and cerebellum have been extensively studied. Findings from these three brain regions are outlined below.
Hippocampus: The hippocampus is responsible for learning and memory processes. In AS models, hippocampal cell function is impaired. [ 42 ] Specifically, AS models display an increase in the alpha 1 subunit of the sodium potassium pump , the NaV1.6 sodium channel, and the anchoring protein ankyrin-G . [ 42 ] Ultimately, these proteins can alter the activity of hippocampal cells and result in dysfunction of synaptic plasticity , and, in return, learning and memory deficits. [ 42 ] During normal hippocampal function, UBE3A marks the protein ARC for degradation. Lack of maternal UBE3A leads to ARC accumulation and excessive endocytosis of the excitatory AMPA receptor in hippocampal neuron dendrites. In mice with a UBE3A and ARC knockout, seizure symptoms are reduced. [ 42 ] Interestingly, sleep disturbances are a common symptom of AS, which can have a serious impact on the well-being of individuals with AS. Circadian rhythm , the body's biological clock, influences hippocampal cell function. [ 48 ] UBE3A mutation decreases BMAL1 , a protein that influences circadian rhythm, and weakens the interaction between mGluR5 and HOMER1A, which are proteins involved in neurotransmission . The changes in BMAL1 and mGluR5 were found to impair sleep wake cycle and produce sleep deprivation. [ 48 ]
Cortex: The cortex is involved in a variety of brain functions. Importantly, cortical impairment is a hallmark of many neuropsychiatric disorders. In the cortex of AS mice, there is an imbalance of cortical activity. Specifically, AS mice display an overexcitable cortex. [ 42 ] This increase in cortical brain activity is produced by changes in dendritic spines and synaptic vesicle cycling. [ 42 ] Increased cortical activity in AS mice may be responsible for producing seizures, which are a common symptom of AS. [ 42 ] Additionally, microRNAs in the cortex of AS mice display impaired function. For example, in AS mice, microRNAs increase intracellular Ca2+, which leads to maladaptive phosphorylation of CaMKII in primary cortical neurons. [ 42 ] CamKII plays a primary role in learning and memory. Therefore, dysfunction of CaMKII signaling in the cortex may be responsible for memory deficits present in AS. [ 42 ]
Cerebellum: The cerebellum plays a central role in motor function. Therefore, motor impairments in AS may arise from cerebellum dysfunction. [ 42 ] In AS mice, granule cells , a major cell type in the cerebellum, display decreased tonic inhibition. [ 42 ] Additionally, in granule cells of AS mice, the GABA transporter 1 is upregulated. [ 42 ] This results in decreased activation of GABA receptors on granule cells, suggesting granule cell activity is not being properly regulated in AS mice. [ 42 ] Interestingly, reducing granule cell activity in the cerebellum of AS mice decreases ataxia symptoms. [ 42 ] Additionally, the mTOR pathway plays a role in AS pathology. [ 42 ] Specifically in AS mice, Purkinje cells, which are another main cell type in the cerebellum, have an mTOR1 and mTOR2 imbalance. [ 42 ] This imbalance has been shown to produce motor dysfunction. [ 42 ]
The severity of the symptoms associated with Angelman syndrome varies significantly across the population of those affected. Some speech and a greater degree of self-care are possible among the least profoundly affected. Walking and the use of simple sign language may be beyond the reach of the more profoundly affected. Early and continued participation in physical, occupational (related to the development of fine-motor control skills), and communication (speech) therapies are believed to significantly improve the prognosis (in the areas of cognition and communication) of individuals affected by AS. Further, the specific genetic mechanism underlying the condition is thought to correlate to the general prognosis of the affected person. On one end of the spectrum, a mutation to the UBE3A gene is thought to correlate to the least affected, whereas larger deletions on chromosome 15 are thought to correspond to the most affected. [ citation needed ]
The clinical features of Angelman syndrome alter with age. As adulthood approaches, hyperactivity and poor sleep patterns improve. The seizures decrease in frequency and often cease altogether and the EEG abnormalities are less obvious. Medication is typically advisable to those with seizure disorders. Often overlooked is the contribution of the poor sleep patterns to the frequency and/or severity of the seizures. Medication may be worthwhile to help deal with this issue and improve the prognosis with respect to seizures and sleep. Also noteworthy are the reports that the frequency and severity of seizures temporarily escalate in pubescent Angelman syndrome girls, but do not seem to affect long-term health. [ citation needed ] The facial features remain recognizable with age, but many adults with AS look remarkably youthful for their age. [ citation needed ]
Puberty and menstruation begin at around the average age. Sexual development is thought to be unaffected, as evidenced by a single reported case of a woman with Angelman syndrome conceiving a female child who also had Angelman syndrome. [ 49 ]
The majority of those with AS achieve continence by day and some by night. Angelman syndrome is not a degenerative syndrome, and thus people with AS may improve their living skills with support. [ citation needed ]
Dressing skills are variable and usually limited to items of clothing without buttons or zippers. Most adults can eat with a knife or spoon and fork, and can learn to perform simple household tasks. Particular problems which have arisen in adults are a tendency to obesity (more in females), and worsening of scoliosis [ 50 ] if it is present. The affectionate nature may also persist into adult life where it can pose a problem socially, but this problem is not insurmountable. People with Angelman syndrome appear to have a reduced but near-normal life expectancy, dying on average 10 to 15 years earlier than the general population. [ 51 ]
Many poems in Richard Price 's poetry collections Hand Held (1997), Lucky Day (2005), and Small World (2012) reflect on his daughter, who has Angelman syndrome. In October 2007, actor Colin Farrell publicly announced that his son has Angelman syndrome. [ 52 ] In the 2011 Philippine drama series Budoy , the titular character and main protagonist Budoy Maniego (played by Filipino actor Gerald Anderson ) is diagnosed with Angelman syndrome.
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An anginal equivalent is a symptom such as shortness of breath ( dyspnea ), diaphoresis (sweating), extreme fatigue, or pain at a site other than the chest, occurring in a patient at high cardiac risk. Anginal equivalents are considered to be symptoms of myocardial ischemia . Anginal equivalents are considered to have the same importance as angina pectoris in patients presenting with elevation of cardiac enzymes or certain EKG changes which are diagnostic of myocardial ischemia. [ 1 ]
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Angiolathyrism is a form of lathyrism disease. It is mainly caused the consumption of Lathyrus sativus (also known as grass pea ) and to a lesser degree by Lathyrus cicera , Lathyrus ochrus and Lathyrus clymenum [ 1 ] containing the toxin ODAP . [ 2 ] The main chemical responsible is β- Aminopropionitrile , which prevents collagen cross-linking, thus making the blood vessel, especially the tunica media , weak. This can result in Cystic medial necrosis or a picture similar to Marfan syndrome . The damaged vessels are at an increased risk of dissection . [ citation needed ]
Unlike osteolathyrism , the blood vessels are affected instead of bone. However it is caused by similar action and is typically associated with the other forms of lathyrism. [ citation needed ]
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Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue cancer that affects children and young adults.
It is characterized by cystic blood-filled spaces and composed of histiocyte -like cells. A lymphocytic cuff is common. It often simulates a vascular lesion, and was initially described as doing this. [ 1 ]
AFH typically has a chromosomal translocation involving the ATF1 gene -- t(12;16) FUS/ATF1 or t(12;22) EWS/ATF1. [ 2 ]
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Angioscopy is a medical technique for visualizing the interior of blood vessels . In this technique, a flexible fibre bundle endoscope catheter is inserted directly into an artery. [ 1 ] It can be helpful in diagnosing (e.g., arterial embolism ). [ 2 ] Angioscopy is also used as an adjunctive procedure during vascular bypass to visualize valves within venous conduits. The instrument used to perform angioscopy is called an angioscope. Scanning Fiber Endoscope (SFE) is an emerging technology which provides much higher resolution imaging, whilst maintaining a small form factor and flexibility. [ 1 ]
Coronary artery angioscopy, which first was used to reveal the presence of a blood clot in the coronary arteries of patients with unstable angina and myocardial infarction , [ 3 ] is now widely used in catherization laboratories to visualize stents .
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2WXW , 2X0B , 4APH ,%%s 1N9U , 1N9V ,%%s 1N9V , 1N9U , 3CK0 , 4AA1 , 4APH , 5E2Q
183
11606
ENSG00000135744
ENSMUSG00000031980
P01019
P11859 Q3UTR7
NM_000029 NM_001382817 NM_001384479
NM_007428
NP_000020 NP_001369746
NP_031454
Angiotensin is a peptide hormone that causes vasoconstriction and an increase in blood pressure . It is part of the renin–angiotensin system , which regulates blood pressure. Angiotensin also stimulates the release of aldosterone from the adrenal cortex to promote sodium retention by the kidneys.
An oligopeptide , angiotensin is a hormone and a dipsogen . It is derived from the precursor molecule angiotensinogen, a serum globulin produced in the liver . Angiotensin was isolated in the late 1930s (first named 'angiotonin' or 'hypertensin', later renamed 'angiotensin' as a consensus by the 2 groups that independently discovered it [ 5 ] ) and subsequently characterized and synthesized by groups at the Cleveland Clinic and Ciba laboratories. [ 6 ]
Angiotensinogen is an α-2-globulin synthesized in the liver [ 7 ] and is a precursor for angiotensin, but has also been indicated as having many other roles not related to angiotensin peptides. [ 8 ] It is a member of the serpin family of proteins, leading to another name: Serpin A8, [ 9 ] although it is not known to inhibit other enzymes like most serpins. In addition, a generalized crystal structure can be estimated by examining other proteins of the serpin family, but angiotensinogen has an elongated N-terminus compared to other serpin family proteins. [ 10 ] Obtaining actual crystals for X-ray diffractometric analysis is difficult in part due to the variability of glycosylation that angiotensinogen exhibits. The non-glycosylated and fully glycosylated states of angiotensinogen also vary in molecular weight, the former weighing 53 kDa and the latter weighing 75 kDa, with a plethora of partially glycosylated states weighing in between these two values. [ 8 ]
Angiotensinogen is also known as renin substrate. It is cleaved at the N-terminus by renin to result in angiotensin I, which will later be modified to become angiotensin II. [ 8 ] [ 10 ] This peptide is 485 amino acids long, and 10 N-terminus amino acids are cleaved when renin acts on it. [ 8 ] The first 12 amino acids are the most important for activity.
Plasma angiotensinogen levels are increased by plasma corticosteroid , estrogen , thyroid hormone , and angiotensin II levels. In mice with a full body deficit of angiotensinogen, the effects observed were low newborn survival rate, stunted body weight gain, stunted growth, and abnormal renal development. [ 8 ]
Angiotensin I ( CAS # 11128-99-7), officially called proangiotensin , is formed by the action of renin on angiotensinogen . Renin cleaves the peptide bond between the leucine (Leu) and valine (Val) residues on angiotensinogen, creating the decapeptide (ten amino acid) (des-Asp) angiotensin I. Renin is produced in the kidneys in response to renal sympathetic activity, decreased intrarenal blood pressure (<90mmHg systolic blood pressure [ 11 ] ) at the juxtaglomerular cells , dehydration or decreased delivery of Na+ and Cl- to the macula densa . [ 12 ] If a reduced NaCl concentration [ 13 ] in the distal tubule is sensed by the macula densa, renin release by juxtaglomerular cells is increased. This sensing mechanism for macula densa-mediated renin secretion appears to have a specific dependency on chloride ions rather than sodium ions. Studies using isolated preparations of thick ascending limb with glomerulus attached in low NaCl perfusate were unable to inhibit renin secretion when various sodium salts were added but could inhibit renin secretion with the addition of chloride salts. [ 14 ] This, and similar findings obtained in vivo, [ 15 ] has led some to believe that perhaps "the initiating signal for MD control of renin secretion is a change in the rate of NaCl uptake predominantly via a luminal Na,K,2Cl co-transporter whose physiological activity is determined by a change in luminal Cl concentration." [ 16 ]
Angiotensin I appears to have no direct biological activity and exists solely as a precursor to angiotensin II.
Angiotensin I is converted to angiotensin II (AII) through removal of two C-terminal residues by the enzyme angiotensin-converting enzyme (ACE), primarily through ACE within the lung (but also present in endothelial cells , kidney epithelial cells, and the brain). [ citation needed ]
Angiotensin II is degraded to angiotensin III by angiotensinases located in red blood cells and the vascular beds of most tissues. Angiotensin II has a half-life in circulation of around 30 seconds, [ 17 ] whereas, in tissue, it may be as long as 15–30 minutes. Other cleavage products of ACE, seven or nine amino acids long, are also known; they have differential affinity for angiotensin receptors , although their exact role is still unclear.
Angiotensin II exhibits endocrine , autocrine / paracrine , and intracrine functions.
It promotes aldosterone release from the adrenal cortex , as well as arginine vasopressin release from the posterior pituitary . [ citation needed ]
It acts directly upon the proximal tubules of the kidney to regulate water and Na+ reabsorption, promoting reabsorption at very low concentrations while increasingly inhibiting reabsorption with increasing concentrations. [ 18 ] In the proximal tubule, it promotes Na + reabsorption and H + excretion (which is coupled to bicarbonate reabsorption) by the Na + /H + exchanger . [ 19 ]
It causes venous and arterial [ citation needed ] vasoconstriction by a Gq alpha subunit -coupled receptor upon vascular smooth muscle cells (with downstream IP3-dependent mechanism causing a rise in intracellular Ca 2+ to effect smooth muscle excitation-contraction coupling ), thus acting to increase blood pressure. [ 19 ]
ACE is a pharmaceutical target of ACE inhibitor drugs, which decrease the rate of conversion of angiotensin I to angiotensin II, [ 19 ] and of angiotensin II receptor antagonists which block angiotensin II AT 1 receptors .
Angiotensin II results in increased inotropy , chronotropy , catecholamine and sensitivity, aldosterone levels, vasopressin levels, and cardiac remodeling and vasoconstriction through AT 1 receptors on peripheral vessels (conversely, AT 2 receptors impair cardiac remodeling). This is why ACE inhibitors and ARBs help to prevent remodeling that occurs secondary to angiotensin II and are beneficial in congestive heart failure . [ 16 ] [ further explanation needed ]
Angiotensin III, along with angiotensin II, is considered an active peptide derived from angiotensinogen. [ 20 ]
Angiotensin III has 40% of the pressor activity of angiotensin II, but 100% of the aldosterone-producing activity. Increases mean arterial pressure . It is a peptide that is formed by removing an amino acid from angiotensin II by glutamyl aminopeptidase A, which cleaves the N-terminal Asp residue. [ 21 ]
Activation of the AT2 receptor by angiotensin III triggers natriuresis , while AT2 activation via angiotensin II does not. This natriuretic response via angiotensin III occurs when the AT1 receptor is blocked. [ 22 ]
Angiotensin IV is a hexapeptide that, like angiotensin III, has some lesser activity. Angiotensin IV has a wide range of activities in the central nervous system. [ 23 ] [ 24 ]
The exact identity of AT4 receptors has not been established. There is evidence that the AT4 receptor is insulin-regulated aminopeptidase (IRAP). [ 25 ] There is also evidence that angiotensin IV interacts with the HGF system through the c-Met receptor. [ 26 ] [ 27 ]
Synthetic small molecule analogues of angiotensin IV with the ability to penetrate through blood brain barrier have been developed. [ 27 ]
The AT4 site may be involved in memory acquisition and recall, as well as blood flow regulation. [ 28 ] Angiotensin IV and its analogs may also benefit spatial memory tasks such as object recognition and avoidance (conditioned and passive avoidance). [ 29 ] Studies have also shown that the usual biological effects of angiotensin IV on the body are not affected by common AT2 receptor antagonists such as the hypertension medication Losartan . [ 29 ]
Angiotensins II, III and IV have a number of effects throughout the body:
Angiotensins "modulate fat mass expansion through upregulation of adipose tissue lipogenesis ... and downregulation of lipolysis." [ 30 ]
Angiotensins are potent direct vasoconstrictors , constricting arteries and increasing blood pressure. This effect is achieved through activation of the GPCR AT 1 , which signals through a Gq protein to activate phospholipase C, and subsequently increase intracellular calcium. [ 31 ]
Angiotensin II has prothrombotic potential through adhesion and aggregation of platelets and stimulation of PAI-1 and PAI-2 . [ 32 ] [ 33 ]
Angiotensin II increases thirst sensation ( dipsogen ) through the area postrema and subfornical organ of the brain, [ 34 ] [ 35 ] [ 36 ] decreases the response of the baroreceptor reflex , increases the desire for salt , increases secretion of ADH from the posterior pituitary , and increases secretion of ACTH from the anterior pituitary . [ 34 ] Some evidence suggests that it acts on the organum vasculosum of the lamina terminalis (OVLT) as well. [ 37 ]
Angiotensin II acts on the adrenal cortex , causing it to release aldosterone , a hormone that causes the kidneys to retain sodium and lose potassium. Elevated plasma angiotensin II levels are responsible for the elevated aldosterone levels present during the luteal phase of the menstrual cycle .
Angiotensin II has a direct effect on the proximal tubules to increase Na + reabsorption . It has a complex and variable effect on glomerular filtration and renal blood flow depending on the setting. Increases in systemic blood pressure will maintain renal perfusion pressure; however, constriction of the afferent and efferent glomerular arterioles will tend to restrict renal blood flow. The effect on the efferent arteriolar resistance is, however, markedly greater, in part due to its smaller basal diameter; this tends to increase glomerular capillary hydrostatic pressure and maintain glomerular filtration rate . A number of other mechanisms can affect renal blood flow and GFR. High concentrations of Angiotensin II can constrict the glomerular mesangium, reducing the area for glomerular filtration. Angiotensin II is a sensitizer to tubuloglomerular feedback , preventing an excessive rise in GFR. Angiotensin II causes the local release of prostaglandins, which, in turn, antagonize renal vasoconstriction. The net effect of these competing mechanisms on glomerular filtration will vary with the physiological and pharmacological environment.
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https://en.wikipedia.org/wiki/Angiotensin
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Angiotensin (1-7) ( C 41 H 62 N 12 O 11 ; Molecular weight = 899.02 g/mol; H- Asp - Arg - Val - Tyr - Ile - His - Pro -OH) is an active heptapeptide of the renin–angiotensin system (RAS). [ 1 ] It also known by the generic name talfirastide (development name TXA127 ). [ 2 ]
In 1988, Santos et al demonstrated that angiotensin (1-7) was a main product of the incubation of angiotensin I with brain micropunch biopsies [ 3 ] and Schiavone et al reported the first biological effect of this heptapeptide. [ 4 ]
Benter et al were the first to report that Ang-(1-7) behaves in a way opposite to that of Ang II and that intavenous administration of Ang-(1-7) produces blood pressure lowering effects by activating its own receptor [ 5 ] Angiotensin (1-7) is a vasodilator agent affecting cardiovascular organs, such as heart, blood vessels and kidneys, with functions frequently opposed to those attributed to the major effector component of the RAS, angiotensin II (Ang II). [ 6 ]
The polypeptide Ang I can be converted into Ang (1-7) by the actions of neprilysin (NEP) [ 7 ] and thimet oligopeptidase (TOP) [ 8 ] enzymes. Also, Ang II can be hydrolyzed into Ang (1-7) through the actions of angiotensin-converting enzyme 2 (ACE2). Ang (1-7) binds and activates the G-protein coupled receptor Mas receptor [ 9 ] leading to opposite effects of those of Ang II.
Ang (1-7) has been shown to have anti-oxidant and anti-inflammatory effects. [ 10 ] [ 11 ] It helps protect cardiomyocytes of spontaneously hypertensive rats by increasing the expression of endothelial and neuronal nitric oxide synthase enzymes, augmenting production of nitric oxide. [ 12 ]
Ang (1-7) contributes to the beneficial effects of ACE inhibitors and angiotensin II receptor type 1 antagonists. [ 13 ]
Talfirastide has been tested in people with COVID-19 [ 14 ] and stroke. [ 15 ]
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https://en.wikipedia.org/wiki/Angiotensin_(1-7)
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Angiozyme is an anti-angiogenic ribozyme. [ 1 ] It is largely being studied in the treatment of kidney cancer . It may prevent the growth of blood vessels from surrounding tissue to the tumor , i.e., angiogenesis. It belongs to the families of drugs called VEGF receptor and angiogenesis inhibitors . Preliminary tests have demonstrated that Angiogenesis has no significant side effects. [ 2 ] It is also known as RPI.4610.
This article incorporates public domain material from Dictionary of Cancer Terms . U.S. National Cancer Institute .
This oncology article is a stub . You can help Wikipedia by expanding it .
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https://en.wikipedia.org/wiki/Angiozyme
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An animal bite is a wound , usually a puncture or laceration, caused by the teeth. An animal bite usually results in a break in the skin but also includes contusions from the excessive pressure on body tissue from the bite. The contusions can occur without a break in the skin. Bites can be provoked or unprovoked. Other bite attacks may be apparently unprovoked. Biting is a physical action not only describing an attack but it is a normal response in an animal as it eats, carries objects, softens and prepares food for its young, removes ectoparasites from its body surface, removes plant seeds attached to its fur or hair, scratching itself, and grooming other animals. Animal bites often result in serious infections and mortality. Animal bites not only include injuries from the teeth of reptiles, mammals, but fish, and amphibians. Arthropods can also bite and leave injuries.
Bite wounds can cause a number of signs and symptoms
Bites are usually classified by the type of animal causing the wound.
Many different animals are known to bite humans.
Involuntary biting injuries due to closed-fist injuries from fists striking teeth (referred to as reverse bite injuries) are a common consequence of fist fights . These have been termed "fight bites". Injuries in which the knuckle joints or tendons of the hand are bitten into tend to be the most serious.
Teething infants are known to bite objects to relieve pressure on their growing teeth, and may inadvertently bite people's hands or arms while doing so. Young children may also bite people out of anger or misbehaviour, although this is usually corrected early in the child's life.
A reverse bite injury (also called a clenched fist injury, closed fist injury, or fight bite) results when a person punches another person in the face, and the skin (and sometimes tendons) of their knuckles are cut against the teeth of the person they are punching. [ 2 ] The proximity of the wound is often located over the metacarpophalangeal joint resulting in tendon injury. [ 3 ]
The medical treatment of this injury is similar to those of a human bite , but may also involve damage of the underlying tendons. [ 4 ]
These injuries should be managed as other human bites: wound irrigation and antibiotics are essential as human saliva can contain a number of bacteria. [ 5 ] The nature of these injuries is such that even if the injury is optimally managed, poor outcomes may still occur. [ 2 ]
The bites of arthropods have some of the most serious health consequences known. Mosquito bites transmit serious disease and result in millions of deaths and illnesses in the world. Ticks also transmit many diseases such as Lyme disease .
A natural consequence of a bite is tissue trauma at the site. Trauma may consist of scratching, tearing, punture or laceration of the skin, hematoma (bruising), embedding of foreign objects, for example a tooth or hair, damage to or severing of underlying structures such as connective tissue or muscle, amputations, and the ripping off of skin and hair. If major blood vessels are damaged, severe blood loss can occur. [ 6 ]
Pathogen organisms can be introduced into the bite. Some of the pathogens can originate from the mouth of the 'biter', the substrate onto which the injured person or animal can fall or from the naturally occurring microorganisms that are present on the skin or hair of the animal. The advent of antibiotics improved the outcome of bite wound infections. [ 6 ]
Animal bites where skin has been penetrated, most commonly by dogs and bats , transmit rabies to humans. [ 7 ] Rabies from other animals is rare. [ 7 ] If the animal is caught alive or dead with its head preserved, the head can be analyzed to detect the disease. Signs of rabies include foaming at the mouth, growling, self-mutilation, jerky behavior, red eyes, and hydrophobia .
If the animal cannot be captured, preventative rabies treatment is recommended in many places. Several countries are known not to have native rabies, see the Wikipedia page for prevalence of rabies .
The first step in treatment includes washing the bite wound. [ 8 ] If there is a low risk of infection the wound may be sutured. [ 8 ] Debridement and drainage of bite wounds was practiced in the pre-antibiotic era, but high rates of infection still occurred. A 2019 Cochrane systematic review aimed to evaluate the healing and infection rates in bite wounds based on if/when they were stitched closed. The review authors looked for studies that compared stitching wounds closed straight away, leaving them open for a short time or not stitching them at all. Due to a lack of high-certainty evidence, the review authors concluded that more robust randomised controlled trials were needed to fully answer this question. [ 9 ]
Antibiotics to prevent infection are recommended for dog and cat bites of the hand, [ 10 ] and human bites if they are more than superficial. [ 11 ] They are also recommended in those who have poor immune function . [ 8 ] Evidence for antibiotics to prevent infection in bites in other areas is not clear. [ 12 ]
The first choice is amoxicillin with clavulanic acid , and if the person is penicillin-allergic, doxycycline and metronidazole . [ 11 ] The antistaphylococcal penicillins (e.g., cloxacillin , nafcillin , flucloxacillin ) and the macrolides (e.g., erythromycin , clarithromycin ) are not used for empirical therapy, because they do not cover Pasteurella species. [ 11 ]
Rabies prevention is generally available in North America and the Northern European states.
Tetanus toxoid treatment is recommended in those whose vaccinations are not up to date and have a bite that punctures the skin. [ 8 ] Tetanus immune globulin is indicated in people with more than 10 years since prior vaccination. Tetanus boosters (Td) should be given every ten years.
TT = tetanus toxoid; TIG: tetanus immune globulin
Antihistamines are effective treatment for the symptoms from bites. [ 13 ] Many diseases such as malaria and dengue are transmitted by mosquitoes .
Human bites are the third most frequent type of bite after dog and cat bites. [ 6 ] Dog bites are commonplace, with children the most commonly bitten and the face and scalp the most common target. [ 14 ] About 4.7 million dog bites are reported annually in the United States . [ 15 ] The US estimated annual count of animal bites is 250,000 human bites, 1 to 2 million dog bites, 400,000 cat bites, and 45,000 bites from snakes. Bites from skunks, horses, squirrels, rats, rabbits, pigs, and monkeys may be up to 1 percent of bite injuries. Pet ferrets attacks that were unprovoked have caused serious facial injuries. Non-domesticated animals though assumed to be more common especially as a cause of rabies infection, make up less than one percent of reported bite wounds. When a person is bitten, it is more likely to occur on the right arm, most likely due to defensive reactions when the person uses their dominant arm. Estimates are that three-quarters of bites are located on the arms or legs of humans. Bites to the face of humans constitute only 10 percent of the total. Two-thirds of bite injuries in humans are suffered by children aged ten and younger. [ 6 ]
Up to three-fourths of dog bites happen to those younger than 20 years-old. In the United States, the costs associated with dog bites are estimated to be more than $1 billion annually. The age groups that suffer most from dog bites are children 5 to 9 years-old. Often, bites go unreported and no medical treatment given - these bites go unreported. As many as one percent of pediatric emergency room visits are for treatment for animal bites. This is more frequent during the summer months. Up to five percent of children receiving emergency care for dog bites are then admitted to the hospital. Bites typically occur in the late afternoon and early evening. Girls are bitten more frequently by cats than they are by dogs. Boys are bitten by dogs two times more often than girls are bitten by dogs. [ 6 ]
The bites of humans are recorded during the biblical era. Reports of secondary infection occurring after a human bite in children have been noted in the United States since at least 1910. Morbidity and mortality rates improved with the use of antibiotics. [ 6 ]
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https://en.wikipedia.org/wiki/Animal_bite
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Animal psychopathology is the study of mental or behavioral disorders in non-human animals.
Historically, there has been an anthropocentric tendency to emphasize the study of animal psychopathologies as models for human mental illnesses. [ 1 ] But animal psychopathologies can, from an evolutionary point of view, be more properly regarded as non-adaptive behaviors due to some sort of a cognitive disability , emotional impairment or distress. This article provides a non-exhaustive list of animal psychopathologies.
Animals in the wild appear to be relatively free from eating disorders although their body composition fluctuates depending on seasonal and reproductive cycles . However, domesticated animals including farm , laboratory , and pet animals are prone to disorders. Evolutionary fitness drives feeding behavior in wild animals . The expectation is that farm animals also display this behavior, but questions arise if the same principles apply to laboratory and pet animals.
Activity anorexia (AA) is a condition where rats begin to exercise excessively while simultaneously cutting down on their food intake, similar to human anorexia nervosa or hypergymnasia . When given free access to food and an exercise wheel, rats normally develop a balanced routine between exercise and food intake, which turns them into fit rats. However, if food intake is restricted and wheel access is unrestricted, rats begin to exercise more and eat less, resulting in excessive weight loss and, ultimately, death. The running cycles shift so that most of the running is done in hours before feeding is scheduled. In other conditions, AA does not develop. Unrestricted food access and restricted wheel access will not cause any significant change in either feeding or exercise routine. Also, if rats are restricted both in food intake and wheel access, they will adjust accordingly. In fact, if rats are first trained to the feeding schedule and then given unrestricted access to a running wheel, they will not develop AA behavior. Results support the notion that the running interferes with adaptation to the new feeding schedule and is associated with the reward system in the brain . [ 2 ] One theory is that running simulates foraging , a natural behavior in wild rats. Laboratory rats therefore run (forage) more in response to food shortages. The effect of semi- starvation on activity has also been studied in primates . Rhesus macaque males become hyperactive in response to long-term chronic food restriction. [ 3 ]
Thin sow syndrome (TSS) is a behavior observed in stalled sows that is similar to AA where some sows after early pregnancy are extremely active, eat little, and waste away, resulting very often in death. They experience emaciation , hypothermia , a depraved appetite, restlessness, and hyperactivity. [ 3 ] The syndrome may mainly be related to social and environmental stressors . Stress in stalled sows is often perceived as the consequence of the restraint of animals that happens in intensive production units . The sows that experience the most restraining conditions are those lactating or pregnant as they have very little room to move around because they are kept in barred gestation crates or tethered for the 16 weeks of pregnancy which prevents natural and social behaviors. [ 4 ] However, increased movement and freedom is also stressful for adult sows, which is usually the case after weaning . When placed into groups they fight vigorously, with one dominant sow emerging that eats voraciously. It is also likely that two subordinate sows make up part of the group who actively avoid competitive feeding situations and are bullied by the dominant sow. Affected sows have poor appetite but often show pica, excessive water intake (polydipsia) and are anemic. [ 1 ]
Studies on the effects of overcrowding were conducted in the 1940s by placing pregnant Norway rats in a room with plenty of water and food and observing the population growth . The population reached a number of individuals and did not grow thereafter; overcrowding produced stress and psychopathologies. Even though there was plenty of water and food, the rats stopped eating and reproducing. [ 5 ]
Similar effects have also been observed in dense populations of beetles . When overcrowding occurs, female beetles destroy their eggs and turn cannibalistic , eating each other. Male beetles lose interest in the females and although there is plenty of water and food, there is no population growth. Similar effects have been observed in overcrowded situations in jack rabbits and deer . [ 6 ]
Pica is the ingestion of non-nutritive substances and has so far been poorly documented. In non-human animals in the laboratory it has been examined through the ingestion of kaolin (a clay mineral) by rats. Rats were induced to intake kaolin by administering various emetic stimuli such as copper sulfate , apomorphine , cisplatin , and motion. Rats are unable to vomit when they ingest a substance that is harmful thus pica in rats is analogous to vomiting in other species; it is a way for rats to relieve digestive distress. [ 7 ] In some animals pica seems to be an adaptive trait but in others it seems to be a true psychopathology like in the case of some chickens . Chickens can display a type of pica when they are feed-deprived (feeding restriction has been adopted by the egg industry to induce molting ). They increase their non-nutritive pecking, such as pecking structural features of their environment like wood or wire on fences or the feathers of other birds. It is a typical response that occurs when feeding is restricted or is completely withdrawn. Some of the non-nutritive pecking may be due to a redirection of foraging related behavior. [ 8 ] Another animal that has displayed a more complex pica example are cattle . Cattle eat bones when they have a phosphorus deficiency . However, in some cases they persist on eating bones even after their phosphorus levels have stabilized and they are getting adequate doses of phosphorus in their diet. In this case evidence supports both a physical and psychological adaptive response. Cattle that continue to eat bones after their phosphorus levels are adequate do it because of a psychological reinforcer . "The persistence of pica in the seeming absence of a physiological cause might be due to the fortuitous acquisition of a conditioned illness during the period of physiological insult." [ 9 ]
Cats also display pica behavior in their natural environments and there is evidence to support that this behavior has a psychological aspect to it. Some breeds (such as the Siamese cat ) are more predisposed to showing this type of behavior than other breeds, but several types of breeds have been documented to show pica. Cats have been observed to start by chewing and sucking on non-nutritive substances like wool, cotton, rubber, plastic and even cardboard and then progress into ingestion of these substances. This type of behavior occurs through the first four years of a cat's life but it is primarily observed during the first two months of life when cats are introduced into new homes is most common. [ 10 ] Theories explaining why this behavior becomes active during this time suggest that early weaning and stress as a consequence of separation from the mother and litter-mates and exposure to a new environment are to blame. Eating wool or other substances may be a soothing mechanism that cats develops to cope with the changes. Pica is also observed predominately during 6–8 months of a cat's life when territorial and sexual behaviors emerge. Pica may be induced by these social stressors . [ 10 ] Other theories contemplated include pica as a redirection of prey-catching/ingestion behavior as a result of indoor confinement, especially common among oriental breeds due to risk of theft. [ 10 ] In natural environments pica has been observed in parrots (such as macaws ) and other birds and mammals. Charles Munn has been studying Amazon macaws lick clay from riverbeds in the Amazon to detoxify the seeds they eat. Amazon macaws spend two to three hours a day licking clay. [ 11 ] Munn has found that clay helps counter the tannins and alkaloids in the seeds the macaws ingest, a strategy that is also used by native cultures in the Andes Mountains in Peru .
Pica also affects domesticated animals. While drugs like Prozac are often able to diminish troublesome behaviors in pet dogs , they don't seem to help with this eating disorder. The following story about Bumbley, a wire fox terrier who appeared on the TV show 20/20 as a result of his eating disorder, is taken from a book by Dr. Nicholas Dodman: [ 12 ]
This dog's presenting problem was light chasing (otherwise known as shadow chasing). It chased shadows for hours on end, even excavating through plasterboard walls to pursue its will-o'-the-wisp illusions ... The one thing that didn't come across clearly in the show was that Bumbley ate everything in sight and the house had to be "Bumbley-proofed" against his relentless ingestion of anything his owners left around ... He had already had surgery to relieve intestinal obstructions resulting from his habit and, each day, his owners reentered their house with trepidation after work, fearing that Bumbley might have eaten something else.
Dodman talks about new research relating bulimia and compulsive overeating to seizural behavior in human patients. He suggests that anti-epileptic medication might be a possible treatment for some cases of pica in animals.
Behavioral disorders are difficult to study in animal models because it is difficult to know what animals are thinking and because animal models used to assess psychopathologies are experimental preparations developed to study a condition. Lacking the ability to use language to study behavioral disorders like depression and stress questions the validity of those studies conducted. It can be difficult to attribute human conditions to non-human animals. [ 13 ]
Obsessive-compulsive behavior in animals, often called " stereotypy " or "stereotypical behavior" can be defined as a specific, unnecessary action (or series of actions) repeated more often than would normally be expected. It is unknown whether animals are able to 'obsess' in the same way as humans, and because the motivation for compulsive acts in non-human animals is unknown, the term "abnormal repetitive behavior" is less misleading.
A wide variety of animals exhibit behaviors that can be considered abnormally repetitive.
Though obsessive-compulsive behaviors are often considered to be pathological or maladaptive , some ritualized and stereotyped behaviors are beneficial. These are usually known as " fixed action patterns ". These behaviors sometimes share characteristics with obsessive-compulsive behavior, including a high degree of similarity in form and use among many individuals and a repetitive dimension.
There are many observable animal behaviors with characteristic, highly conserved patterns. One example is grooming behavior in rats. This behavior is defined by a specific sequence of actions that does not normally differ between individual rats. The rat first begins by stroking its whiskers , then expands the stroking motion to include the eyes and the ears, finally moving on to lick both sides of its body. [ 14 ] Other behaviors may be added to the end of this chain, but these four actions themselves are fixed. Its ubiquity and high degree of stereotypy suggest that this is a beneficial behavior pattern which has been maintained throughout evolutionary history.
Although humans and animals both have pathological stereotyped behaviors, they do not necessarily provide a similar model of OCD. [ 15 ] Feather picking in orange-winged amazon parrots has both a genetic component, with the behavior being more likely in one sibling if the other does it, and more common in parrots close to a door when they were housed in groups. [ 16 ] The same study found that feather picking was more common in females and that there was no social transmission of the behavior; neighbors of feather picking birds were only more likely to show the behavior as well if they were related.
Some researchers believe that disadvantageous obsessive compulsive behaviors can be thought of as a normally beneficial process gone too far. Brüne (2006) suggests that change of various origin in striatal and frontal brain circuits , which play a role in predicting needs and threats that may arise in the future, may result in a hyperactive cognitive harm avoidance system, in which a person becomes consciously and unreasonably fearful of an unlikely or impossible event. [ 13 ] [ 17 ] This may also be true in other animals.
Canine compulsions are more common in some breeds and behavioral dispositions are often shared within the same litter. This suggests that there is a genetic factor to the disorder. A questionnaire to dog owners and a blood sample of 181 dogs from four breeds, miniature and standard bull terriers, German shepherds , and Staffordshire bull terriers showed these to be more susceptible to compulsive and repetitive behaviors. [ 18 ] Advances in the study of canine compulsive disorder pathology could lead to advances in the understanding of the genetic and hereditary factors leading to human obsessive disorders. [ 19 ] A chromosome has been located in dogs that confers a high risk of susceptibility to OCD. [ 20 ] Canine chromosome 7 has been found to be most significantly associated with obsessive compulsive disorder in dogs, or more specifically, canine compulsive disorder (CCD). This breakthrough helped further relate OCD in humans to CCD in canines. Canine chromosome 7 is expressed in the hippocampus of the brain, the same area that Obsessive Compulsive Disorder is expressed in human patients. Similar pathways are involved in drug treatment responses for both humans and dogs, offering more research that the two creatures exhibit symptoms and respond to treatment in similar ways. This data can help scientists to discover more effective and efficient ways to treat OCD in humans through the information they find by studying CCD in dogs.
Animals exhibiting obsessive and compulsive behaviors that resemble OCD in humans have been used as a tool for elucidating possible genetic influences on the disease, potential treatments, and to better understand the pathology of this behavior in general. While such models are useful, they are also limited; it is unclear whether the behavior is ego dystonic in animals. That is, it is difficult to evaluate whether an animal is aware that its behavior is excessive and unreasonable and whether this awareness is a source of anxiety.
One study done by Simon Vermeier used neuroimaging to investigate serotonergic and dopaminergic neurotransmission in 9 dogs with Canine Compulsive Disorder (CCD) to measure the serotonin 2A receptor availability. When compared to the 15 non-compulsive dogs used as a control group, the dogs with CCD were found to have lower receptor availability as well as lower subcortical perfusion and hypothalamic availability. The results of this study provide evidence that there are imbalanced serotonergic and dopaminergic pathways in dogs. Similarities between other studies about human OCD provide construct validity for this study, which suggests that the research will be valid and useful in continuing to investigate brain activity and drug treatment in Obsessive Compulsive Disorder. [ 21 ]
Some treatment has been given to dogs with CCD to observe their reactions and how they are similar or different from how humans would react to the same pharmaceutical or behavioral treatment. A combination of the two approaches has been found to be most effective in lowering the intensity and regularity of OCD in both canines and humans. [ 22 ] Pharmaceutically, clomipramine was found to be more effective than an alternative chemical, amitriptyline , in treatments for dogs. One study by Karen Overall discovered that by combining behavioral therapy with the more effective clomipramine, the symptoms of Canine Compulsive Disorder decreased by over 50% for all of the dogs involved in the study. [ 22 ] The treatment outcomes mirror the prognosis for human compulsive disorders in achieving substantial improvement but maintaining a moderate degree of residual symptoms. [ 23 ]
Alicia Graef's article [ 24 ] makes several bold claims that dogs are the future in understanding how to better diagnose, recognize, and treat Obsessive Compulsive Disorder in humans. There is evidence supporting her statements, but the connection between CCD and OCD is not clearly understood. So far, studies have proved that effective treatments in dogs are similarly effective for humans, but there are still so many things unknown. Obsessive Compulsive Disorder is a unique mental disorder that cannot be fully cured. It can be controlled and understood, and one possible way of better doing that might be through studying CCD in canines. Studying dogs that exhibit compulsive behaviors has led scientists to genetic breakthroughs in understanding more how biology and genetics factor into Obsessive Compulsive Disorder. By observing and studying how CCD manifests in the brain activity, behaviors, and genes of diagnosed canines, scientists have been able to use their newfound information to develop better diagnostic tests and more readily recognize symptoms and susceptible humans. The similar brain functions and behaviors of dogs with CCD and humans with OCD suggests they have a connection, not only in behavior and symptoms, but in reacting to treatments. Understanding Canine Compulsive Disorder in dogs has helped scientists to better understand and apply their learning to developing new and more effective ways to treat Obsessive Compulsive Disorder in humans.
Some examples of ways in which rats and mice, two of the most common animal models, have been used to represent human OCD are provided below.
Lever pressing in rats
Certain laboratory rat strains that have been created by controlled breeding for many generations show a higher tendency towards compulsive behaviors than other strains. Lewis rats show more compulsive lever pressing behavior than Sprague Dawley or Wistar rats and are less responsive to the anti-compulsive drug paroxetine . [ 25 ] In this study, rats were taught to press a lever to receive food in an operant conditioning task. Once food was no longer provided when they pressed the lever, rats were expected to stop pressing it. Lewis rats pressed the lever more often than the other two types, even though they had presumably learned that they would not receive food, and continued to press it more often even after treatment with the drug. An analysis of the genetic differences between the three rat strains might help to identify genes that might be responsible for the compulsive behavior.
Rats have also been used to test the possibility of a problem with dopamine levels in the brains of animals that exhibit compulsive checking behavior. After treating rats with quinpirole , a chemical that specifically blocks dopamine D2/D3 receptors , compulsive checking of certain locations in an open field increased. [ 26 ] Some components of the checking behavior, such as the level of stereotypy in the path animals took to checked locations, the number of checks, and the length of the checks indicated an increase in compulsivity as doses of quinpirole increased; other components, such as the time taken to return from the checked location to the starting point and the time taken to make that trip remained constant after the initial injection throughout the experiment. This means that there might be both an all-or-none and a sensitization aspect in the biology of the dopamine deficiency model of OCD. In addition, quinpirole might reduce a sense of satisfaction in the rats after they check a location, causing them to return to that location again and again.
Estrogen deficiency in male mice
Based on findings of changes in OCD symptoms in menstruating women and differences in the development of the disease between men and women, Hill and colleagues set out to research the effect of estrogen deprivation on the development of compulsive behavior in mice. [ 27 ] Male mice with an aromatase gene knockout who were unable to produce estrogen showed excessive grooming and wheel running behaviors, but female mice did not. When treated with 17β-estradiol , which replaced estrogen in these mice, the behaviors disappeared. This study also found that COMT protein levels decreased in mice that did not produce estrogen and increased in the hypothalamus after estrogen-replacement treatment. Briefly, the COMT protein is involved in degrading some neurotransmitters, including dopamine, norepinephrine and epinephrine . This data suggests that there may be a hormonal component and a hormone-gene interaction effect that may contribute to obsessive behaviors.
Pets
Dr. Nicholas Dodman describes a wide variety of OCD-like behaviors in his book Dogs Behaving Badly. [ 28 ] Such behaviors typically appear when the dog is placed in a stressful situation, including an environment that is not very stimulating, or in dogs with a history of abuse. Different breeds of dog seem to display different compulsions. Lick granuloma , or licking repeatedly until ulcers form on the skin, affects more large dogs, like Labradors , golden retrievers , Great Danes , and Dobermans , while bull terriers , German shepherds , Old English sheepdogs , Rottweilers , and wire-haired fox terriers , and springer spaniels are more likely to snap at imaginary flies or chase light and shadows. These associations probably have an evolutionary basis, although Dodman does not clearly explain that aspect of the behaviors.
Louis Shuster and Nicholas Dodman noticed that dogs often demonstrate obsessive and compulsive behaviors similar to humans. [ 29 ] Canine Compulsive Disorder (CCD) is not only specific to certain breeds of dogs, but the breed may affect the specific types of compulsions. For example, bull terriers frequently exhibit obsessively predatory or aggressive behaviors. [ 30 ] Breed may factor into the types of compulsions, but some behaviors are more common across the canine spectrum. Most commonly, CCD is seen in canines as they repeat behaviors such as chasing their tails, compulsively chewing on objects, or licking their paws excessively, similar to the common hand-washing compulsion many people with Obsessive Compulsive Disorder have. [ 19 ] Hallucinating and attacking the air around their head, as if there were a bug there, is another compulsion that has been seen in some dogs. Circling, hair biting, staring, and sometimes even barking are other examples of behaviors that are considered compulsions in dogs when taken to extreme, repetitive actions. [ 30 ]
Dodman advocates the use of exercise, an enriched environment (like providing noises for dogs to listen to while owners are at work), and often Prozac (an SSRI used to treat OCD in humans) as treatments.
Shuster and Dodman tested pharmaceutical treatment on canines with CCD to see if it would work as effectively as it does in humans. They used glutamate receptor blockers ( memantine ) and fluoxetine , commonly known as the antidepressant Prozac, to treat and observe the reactions of 11 dogs with compulsions. Seven of the 11 dogs significantly reduced their compulsions in intensity and frequency after receiving medication. [ 29 ]
Dodman includes a story about Hogan, a castrated deaf male Dalmatian , and his compulsive behavior. Hogan had a history of neglect and abuse before he was adopted by Connie and Jim, who attempted to improve his behavior by teaching him to respond to American Sign Language. The following are some excerpts from Hogan's file: [ 31 ]
All was well for a year and a half when suddenly, one March morning, he woke up and started pawing everything in sight, and just wouldn't stop. He pawed rugs and blankets, hardwood floors and linoleum, grass and dirt surfaces ... The similarity between what he was doing and prey-seeking behavior was remarkable.
I do believe ... that Hogan was under some kind of psychological pressure at the time the compulsive pawing behavior developed. ... Connie and Jim were compelled to leave him for some eight hours a day while they went to work. ... The pendulum was set and ready to swing. The actual compulsion that develops under such circumstances is less relevant than the fact that one "does" develop.
The "three R's" of rehabilitation are exercise, nutrition, and communication. First, I advised Connie to step up Hogan's exercise to a minimum of thirty minutes of aerobic activity a day. In addition, I advised that Hogan should be fed a low-protein, preservative-free diet. Completing the rehabilitation checklist, I exhorted Connie to work even harder with the sign-language and instructed her on a new sign to use when Hogan started digging. The sign was a piece of card with the letter "H" written on it in thick black pen. Connie was to show Hogan this sign as soon as possible after he engaged in a bout of unwanted pawing and then leave the room. The idea was to let him know that the behavior was not wanted by signaling to him that Connie was about to leave the room. ... Call me a coward, but I didn't think that alone would cut it because of previous experiences with canine compulsive disorders so, employing a belt-and-suspenders strategy, I also advised medicating Hogan with the tricyclic antidepressant Elavil . Theoretically, Elavil wouldn't be that good in obsessive-compulsive behavior but, limited for reasons of expense, and bearing in mind the possible contribution of separation anxiety, Elavil was my best shot.
It took six months before Hogan was over the hump of treatment success. ... At this time Hogan only engaged in occasional pawing of significantly reduced intensity, and the pawing only occurred in moments of stress. Connie reported that stresses particularly likely to induce pawing included being unable to find her and sensing that he was about to be left alone. ... Hogan continued to improve and reached a point at which he was almost pawing-free - but not quite. That seems to be the way with compulsive disorders in man and beast. They can be reduced to the level of permitting affectees to lead relatively normal lives, but there are occasional relapses.
Sugar addiction has been examined in laboratory rats and it develops in the same way that drug addiction develops. Eating sugary foods causes the brain to release natural chemicals called opioids and dopamine in the limbic system . Tasty food can activate opioid receptors in the ventral tegmental area and thereby stimulate cells that release dopamine in the nucleus accumbens (NAc). The brain recognizes the intense pleasure derived from the dopamine and opioids release and learns to crave more sugar. Dependence is created through these natural rewards, the sugary treats, and the opioid and dopamine released into the synapses of the mesolimbic system . The hippocampus, the insula and the caudate activate when rats crave sugar, which are the same areas that become active when drug addicts crave the drug. Sugar is good because it provides energy, but if the nervous system goes through a change and the body becomes dependent on the sugar intake, somatic signs of withdrawal begin to appear like chattering teeth, forepaw tremors and head shakes when sugar is not ingested. [ 32 ] Morphine tolerance, a measure of addiction, was observed in rats and their tolerance on Morphine was attributed to environmental cues and the systemic effects of the drug. Morphine tolerance does not depend merely on the frequency of pharmacological stimulation, but rather on both the number of pairings of a drug-predictive cue with the systemic effects of the drug. Rats became significantly more tolerant to morphine when they had been exposed to a paired administration than those rats that were not administered a drug-predictive cue along with the morphine. [ 5 ]
Using dogs, Martin Seligman and his colleagues pioneered the study of depression in the animal model of learned helplessness at the University of Pennsylvania . Dogs were separated into three groups, the control group, group A had control over when they were being shocked and group B had no control over when they were being electrocuted. After the shocking condition, the dogs were tested in a shuttle box where they could escape shock by jumping over a partition. To eliminate an interference effect – that the dogs did not learn responses while being shocked that would interfere with their normal escape behavior – the dogs were immobilized using curare , a paralyzing drug while they were being shocked. Both the control group and group A tended to jump over the partition to escape shock while group B dogs did not jump and would passively take the shock. The dogs in group B perceived that the outcome was not related to their efforts. [ 33 ] Consequently, a theory emerged that attributed the behavior of the animals to the effects of the shock as a stressor so extreme that it depleted a neurochemical needed by the animals for movement. [ 33 ] After the dogs study the effects of helplessness have been tested in species from fish to cats. [ 33 ] Most recently learned helplessness has been studied in rhesus macaques using inescapable shock, evoked through stress situations like forced swimming , behavioral despair tasks, tails suspension and pinch induced catalepsy ; situations that render the monkey incapable of controlling the environment. [ 34 ]
Depression and low mood were found to be of a communicative nature. They signal yielding in a hierarchy conflict or a need for help. [ 35 ] Low mood or extreme low mood (also known as depression) can regulate a pattern of engagement and foster disengagement from unattainable goals. "Low mood increases an organism's ability to cope with the adaptive challenges characteristic of unpropitious situations in which effort to pursue a major goal will likely result in danger, loss, bodily damage, or wasted effort." [ 35 ] Being apathetic can have a fitness advantage for the organism. Depression has also been studied as a behavioral strategy used by vertebrates to increase their personal or inclusive fitness in the threat of parasites and pathogens . [ 36 ]
The lack of neurogenesis has been linked to depression. Animals with stress (isolated, cortisol levels) show a decrease in neurogenesis and antidepressants have been discovered to promote neurogenesis. Rene Hen and his colleagues at Columbia University ran a study on rats in which they blocked neurogenesis by applying radiation to the hippocampal area to test the efficacy of antidepressants. Results suggested that antidepressants failed to work when neurogenesis was inhibited.
Robert Sapolsky has extensively studied baboons in their natural environment in the Serengeti in Africa . He noticed that baboons have very similar hierarchies in their society as do humans . They spend very few hours searching for food and fulfilling their primary needs, leaving them with time to develop their social network. In primates, mental stresses show up in the body. Primates experience psychological stresses that can elicit physiological responses that, over time, can make them sick. Sapolsky observed the baboons' ranks, personalities and social affiliations, then collected blood samples of the baboons to control the cortisol (stress hormone) levels of the baboons, then matched social position to cortisol levels. Most of the data have been collected from male baboons, because at any given time 80 percent of the females were pregnant. [ 37 ] Three factors influenced a baboon's cortisol levels: friendships, perspective, and rank. Baboons had lower levels of cortisol if they 1. played with infants and cultivated friendships, 2. could tell if a situation was a real threat and could tell if they were going to win or lose, and 3. were top ranking.
Cortisol levels rise with age and hippocampal cells express fewer hormone receptors on their surface to protect themselves from excess, making it harder to control stress levels. [ 37 ] Cortisol levels are elevated in half of people with major depression, it is the hippocampal region that is affected by both. Stress can have negative effects on gastrointestinal function causing ulcers, and it can also decrease sex drive , affect sleeping patterns and elevate blood pressure but it can also stimulate and motivate. When animals experience stress, they are generally more alert than when they are not stressed. It may help them be better aware of unfamiliar environments and possible threats to their life in these environments. [ 38 ] Yerkes and Dodson developed a law that explains the empirical relationship between arousal and performance illustrated by an inverted U-shape graph. [ 39 ] According to the Yerkes-Dodson Law, performance increases, as does cognitive arousal, but only to a certain point. The downward part of the U-shape is caused by stress and as stress increases so does efficiency and performance, but only to a certain point. [ 39 ] When stress becomes too great, performance and efficiency decline.
Sapolsky has also studied stress in rats and his results indicate that early experiences in young rats have strong, lasting effects. Rats that were exposed to human handling (a stressful situation) had finely-tuned stress responses that may have lowered their lifetime exposure to stress hormones compared to those that were not handled. In short: stress can be adaptive. The more exposure to stressful situations, the better the rat can handle that situation. [ 37 ]
Stereotypies are repetitive, sometimes abnormal behaviors like pacing on the perch for birds. There are adaptive stereotypic behaviors such as grooming in cats and preening in birds. Captive parrots commonly perform a range of stereotypies. These behaviors are repeated identically and lack any function or goal. Captive parrots perform striking oral and locomotor stereotypies like pacing on the perch or repetitive play with a certain toy. Feather picking and loud vocalizations can be stereotypies but are not as rigid and may be reactions to confinement, stress, boredom and loneliness as studies have shown that parrots that are in cages closest to the door are the most prone to feather pick or scream. Feather picking is not a true stereotypy and is more like hair pulling in humans. Loud vocalizations or screaming can be a stereotypy but vocalization is part of a parrot's natural behavior. Captive parrots lack sufficient stimulation. Presumably they suffer from lack of companionship and opportunities to forage. [ 40 ] Stereotypies can evolve from the social environment for example the presence or absence of certain social stimuli, social isolation, low feeder space and high stocking density (especially for tail biting in pigs). These behaviors can also be transmitted through social learning. Bank voles , pigeons and pigs when housed next to animals that show stereotypies, pick them up as well as through stimulus enhancement which is what happens in tail biting in pigs and feather pecking by hens. [ 41 ]
Stereotypies may be coping mechanisms as results suggest from study on tethered and stalled sows. Sows that are tethered and stalled exhibited more stereotypies like licking and rubbing than sows that are in groups outdoors. This abnormal behavior seems to be related to opioid (related to the reward system) receptor density. [ 42 ] In sows, prolonged confinement, being tethered or being in gestation crates, results in abnormal behaviors and stereotypies. Mu and kappa receptors are associated with aversion behaviors and mu receptor density is greater in tethered sows than sows that are in groups outdoors. However, sows with stereotypy behaviors experienced a decrease both in Mu and Kappa receptor density in the brain suggesting that inactivity increases Mu receptor density and stereotypy development decrease both kappa and Mu receptor density. It is suggested that captive environment design can help prevent the existence of stereotypies, by creating an enclosure as similar as possible to the animal's natural environment and providing enrichments to stimulate their natural behavior. [ 43 ]
Rhesus macaques have been observed to display self-aggression (SA) including self-biting, self-clasping, self-slapping, self-rubbing and threatening of body parts. The rhesus macaques observed were individually caged and free of disease. Their self-aggression level rose in stressful and stimulating conditions such as moving from one cage to another. [ 44 ] Stump-tailed macaques were studied to examine the source of their SA. SA increased in an impoverished environment and results support that SA may increase sensory input in poor environments. Captive macaques do not socialize the way wild macaques do which may affect SA. When allowed to socialize by putting another macaque in the cage or not putting them in a cage, SA levels in macaques decrease. Results indicate that SA is a form of redirected social aggression. [ 45 ] SA is related to frustration and social status, especially in macaques that have an intermediate dominance rank. [ 46 ]
http://www.care2.com/causes/can-dogs-lead-us-to-a-cure-for-obsessive-compulsive-disorder.html
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https://en.wikipedia.org/wiki/Animal_psychopathology
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Animal vaccination is the immunisation of a domestic, livestock or wild animal. [ 1 ] The practice is connected to veterinary medicine . [ 1 ] The first animal vaccine invented was for chicken cholera in 1879 by Louis Pasteur . [ 2 ] The production of such vaccines encounter issues in relation to the economic difficulties of individuals, the government and companies. [ 3 ] Regulation of animal vaccinations is less compared to the regulations of human vaccinations. [ 3 ] [ 4 ] Vaccines are categorised into conventional and next generation vaccines. [ 5 ] [ 6 ] Animal vaccines have been found to be the most cost effective and sustainable methods of controlling infectious veterinary diseases. [ 6 ] In 2017, the veterinary vaccine industry was valued at US$7 billion and it is predicted to reach US$9 billion in 2024. [ 7 ]
Animals have been both the receiver and the source of vaccines. Through laboratory testing, the first animal vaccine created was for chicken cholera in 1879 by Louis Pasteur . [ 8 ] Pasteur also invented an anthrax vaccine for sheep and cattle in 1881, and the rabies vaccine in 1884. [ 8 ] Monkeys and rabbits were used to grow and attenuate the rabies virus. [ 9 ] Starting in 1881, dried spinal cord material from infected rabbits was given to dogs to inoculate them against rabies. [ 10 ] The infected nerve tissue was dried to weaken the virus. [ 11 ] Subsequently, in 1885, the vaccine was given to a 9-year-old boy infected with the rabies disease, Joseph Meister , who survived when no one had before. [ 10 ] The French National Academy of Medicine and the world saw this feat as a breakthrough, and thus many scientists started to collaborate and further Pasteur's work. [ 10 ] [ 9 ]
An indirect view of animal vaccinations is seen through smallpox. This is because the vaccine given to humans was animal based. Smallpox was a deadly disease most known for its rash and high death rate of 30% if contracted. [ 12 ]
Edward Jenner tested his theory in 1796, that if a human had already been infected with cowpox that they would be protected from smallpox. It proved to be true and thus started the pathway to the eradication of the disease. [ 13 ]
Through the World Health Organization's (WHO) eradication effort, at least 80% of people were vaccinated in every country. [ 10 ] Subsequently, case finding and then ring vaccination was used, resulting in smallpox becoming the first eradication of a disease through vaccination in 1980. [ 10 ]
The main issues in relation to the vaccination of animals is access and availability. [ 14 ] Vaccines are the most cost-effective measure in preventing disease in livestock populations, although the logistics of distributing vaccines to marginalised populations is still a challenge. [ 15 ] [ 16 ]
Most smallholder farmers' (SHFs) livestock in marginalised populations (MPs) die as a result of a disease, they do not reach their full potential, or they transmit a disease. [ 3 ] The root of this issue could be prevented or controlled by increasing the accessibility to animal vaccines. [ 3 ] Livestock are necessary to an estimated 600 to 900 million poor farmers in the developing world. [ 3 ] [ 17 ] This is because the animals provide food, income, financial reserve and status. [ 17 ]
The diseases have been characterised into diseases that cause economic losses, government-controlled diseases, and neglected diseases, which all link to availability. [ 3 ] The economic losses category entails necessary vaccines in developing countries normally produced by the private sector that make little to no profit, these companies require community support to continue producing. Whereas, government-controlled diseases are controlled by government policy, the main issue here is if the vaccine is expensive it therefore becomes less available to poor farmers. [ 3 ] Furthermore, there are some animal diseases which have been neglected as they mainly only affect poor communities, and thus will not be profitable. This is because producers target the largest markets first to ensure their return on investment (ROI). [ 14 ] For example, the reason why dog transmitted rabies is taking time to eradicate is because it only affects the developing world, thus it is not able to be produced on a large and profitable scale. [ 3 ]
Some other issues include but are not limited to: economic barriers, political barriers, technical and scientific barriers, regulatory barriers, field use barriers, and social and perception barriers. [ 7 ]
There are possible solutions in terms of the issues in the sector of animal vaccinations. These include innovations in both the scientific and the regulatory fields. It has been suggested that regulations are converged between regions and all animal vaccines can be standardised with the same RNA or DNA backbone. It has been found that there needs to be a better mutual understanding between regulators, academia and industry. [ 14 ]
Some other solutions include: free rabies vaccine programs, subsidies as needed, form partnerships across regions (mainly in terms of vaccine banks), a decrease in government taxes, providing positive incentives for disease recording, and building partnerships between global and local manufacturers.
The production of vaccines for animals and humans has always been linked, this relationship has been coined 'One Health', as at least 61% of all human pathogens originate from animals. Two main examples of this link are the rabies and smallpox vaccines. In many cases vaccinating animals is important not only to the animals' health but also to human health and prosperity. The term zoonotic disease defines a disease that can be transferred from animals to humans. [ 18 ]
A current and prominent example of a zoonotic disease is rabies. [ 19 ] It is spread from an animal to humans and other animals through saliva, bites and scratches. [ 19 ] Both domestic and wild animals can catch the rabies disease. Over 59,000 humans die of the disease each year, with 99% of cases occurring because of dog bites. [ 19 ] There has been less than 20 documented cases of rabies survival without treatment to date. [ 19 ] The majority of cases and deaths occur in Africa and Asia, as a result of limited healthcare. [ 20 ] The vaccine for rabies can be administered prior or post to being infected, as a result of the long incubation period of the disease. [ 20 ]
The proactive approach of vaccinating stray dogs, which helps to prevent the disease at its source, has been seen to be the most cost-effective prevention of rabies. In Bangladesh there was a mass dog vaccination campaign between 2010 and 2013, this resulted in a 50% decrease in rabies related deaths. [ 20 ]
WHO has created the campaign of 'Zero by 30', to reduce the number of humans that die from dog related rabies to zero by 2030.
During the last decade 75% of infectious diseases in humans had an animal origin. [ 21 ] Thus, the notion coined 'One Health' was created, where both human and animal health is seen as being equally important. An example of a 'One Health' vaccine, where it can be distributed to both humans and animals, that is currently going through clinical trials is Rift Valley Fever. Associate Professor Warimwe from the University of Oxford states that this approach accelerates the design and development of the vaccine, and it also saves time and money. [ 22 ]
The development of animal vaccines has less regulatory requirements than human vaccines. This has resulted in less time and money involved in the creation and production of animal vaccines. The human vaccine development process generally takes 10 to 15 years, whereas the animal vaccine process only takes an average 5 to 7 years to produce. [ 23 ] Albeit, the ability to prioritise potential vaccine targets and the use of studies to test safety is less in the animal vaccine production compared to human vaccines. [ 24 ]
Pets has grown at a fast rate over time as owners are concerned for their companion animals' health. [ 24 ] In contrast farmed animal vaccines generally only produced when there is a zoonotic disease or it had a significant effect on international trade. Rather than producing for the sole reason of caring for the animal such as with pets, farmed animals are vaccinated for human safety and economic means.
This clearly links to pharmacovigilance (monitoring the effects of licensed drugs). The largest database being the Veterinary Medicines Directorate (VMD) in the UK. Although, the vast majority reported were in terms of companion animals.
There is no standard metric for quantifying the global burden of animal diseases, no standard method for determining the cost effectiveness of a certain animal vaccine, and no cost-effectiveness thresholds in general. Thus, it can be difficult to prioritise animal vaccine development.
As a result of less regulation, some vaccines have been found to contain impurities. An example of this was the rabies vaccine containing a significant amount of Bovine serum albumin (BSA). [ 25 ] BSA can cause severe allergic reactions that can lead to death.
The main conventional vaccines are Live-attenuated and Inactivated . [ 6 ] Live-attenuated vaccines use a weakened form of the virus or bacteria that causes the disease. This form of inoculation is the closest to the actual infection, and thus it has been seen to have a stronger effect than the other types of conventional vaccines. [ 26 ] Albeit, there have been some safety issues related to live-attenuated vaccines. There is a potential for unintended outcomes if another being other than the target species takes the vaccine, and there have been instances where this type of vaccine creates false positives when animals are tested and therefore rids a country of their disease free status (as has been seen through Foot and Mouth Disease , FMD). [ 6 ] Furthermore, inactivated vaccines consist of bacterians of one or more bacterial species, or killed viral strains. The inactivation occurs through chemical or physical treatment which either denatures the protein or damages the nucleic acid. This type of vaccine is more stable and less expensive than live-attenuated vaccines, although it does not provide as effective long-term protection because the pathogen cannot replicate. [ 6 ]
Genomic analysis of pathogens and furthered understanding of the mechanisms of pathogens has resulted in the discovery of antigens and the development of recombinant veterinary vaccines. Currently the pathogens' genome is sequenced, the genes that cause the disease is identified, the genes of interest are cloned, a recombinant is constructed, and then one of three types of vaccines is produced (DNA vaccines, Subunit vaccines, Vectored vaccines). DNA vaccines induce antigen production in the host. It is a plasmid that contains a viral, bacterial or parasite gene. The animal's immune system recognises the expressed protein as foreign, and this can lead to a cellular or humeral response. DNA vaccines overcomes the safety concerns of live-attenuated vaccines. Furthermore, subunit vaccines are short, specific pathogens that cannot replicate. Even though this vaccine is termed as safe, it does not replicate and thus studies have shown issues in relation to yield. Vectored vaccines is another next generation vaccine. This type of vaccine uses a vector to deliver either one or multiple proteins to the immune system of the animal. Currently, there is research being undergone into plant vaccines, which come under the category of vector vaccines.
Domestic chickens have been vaccinated against Pasteurella anatis using bacterial outer membrane vesicles purified by hydrostatic filtration dialysis . Several such vaccines have successfully produced immunity. Antenucci et al. 2020 demonstrates the most consistent product and effective immune provocation among HFD OMV processes, but overall HFD has yet to prove itself against other vaccine production techniques. Nonetheless, it is a very promising line of research as of 2021 [update] . [ 27 ]
The Vaccinations Guidelines Group (VGG) of the World Small Animal Veterinary Association (WSAVA) have defined the core, non-core and not recommended vaccinations for dogs and cats. [ 28 ]
Core vaccines protect animals against severe global diseases. Where rabies is endemic the associated vaccine is treated as being in the core category. [ 28 ]
Canine adenovirus (CAV)
Canine Parvovirus (CPV-2)
Bordetella bronchiseptica (Bb)
Leptospira interrogans
Feline calicivirus (FCV)
Feline herpesvirus (FHV-1)
Chlamydia felis
Feline immunodeficiency virus (FIV)
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Anisocytosis is a medical term meaning that a patient's red blood cells are of unequal size. This is commonly found in anemia and other blood conditions. False diagnostic flagging may be triggered on a complete blood count by an elevated WBC count, agglutinated RBCs, RBC fragments, giant platelets or platelet clumps due to anisocytosis. In addition, it is a characteristic feature of bovine blood.
The red cell distribution width (RDW) is a measurement of anisocytosis [ 1 ] and is calculated as a coefficient of variation of the distribution of RBC volumes divided by the mean corpuscular volume ( MCV ).
Anisocytosis is identified by RDW and is classified according to the size of RBC measured by MCV . According to this, it can be divided into
Increased RDW is seen in iron deficiency anemia and decreased or normal in thalassemia major (Cooley's anemia), thalassemia intermedia
From Ancient Greek : an - without, or negative quality, iso - equal, cyt - cell, - osis condition. [ 3 ]
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https://en.wikipedia.org/wiki/Anisocytosis
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Anisomastia is a medical condition in which there is a severe asymmetry or unequalness in the size of the breasts , generally related to a difference in volume. [ 1 ] In other words, when one of the breasts is much larger than the other. [ 2 ] In contrast to anisomastia, a slight asymmetry of the breasts is common. [ 1 ] Anisomastia may be corrected by surgical breast augmentation or reduction . [ 3 ]
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https://en.wikipedia.org/wiki/Anisomastia
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MD(Manipal India)
Nepal Health Research Council
Medical Education Commission
Anjani Kumar Jha (born 16 April 1964) is a Nepalese physician [ 1 ] [ 2 ] who works as a radiation oncologist . [ 3 ] On September 7, 2023, he was appointed as the Vice- Chairperson of the Medical Education Commission (MEC) by the Council of Ministers of Nepal . [ 4 ] [ 5 ]
He comes from lower middle class family. His father was a school teacher. He earned his MBBS in Bangladesh and MD from Manipal , India. [ 6 ]
Previously he had served as the Chairman of Nepal Health Research Council and Nepal Medical Association . [ 2 ] [ 7 ] [ 8 ]
Some political debates have risen over his appointment in MEC. [ 9 ]
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Anjani Kumar Sharma ( Nepali : अञ्जनी कुमार शर्मा ) was Nepal 's first surgeon. Sharma was born on June 7, 1928, in the remote region of Bhaluwahi in Siraha District in the Terai region of Nepal . Growing up in rural Nepal, there was poor access to healthcare, and because of this, he lost his mother at age 8. [ 1 ] Following her death, he was inspired to become a doctor. With the help of his father and uncle, he achieved his dreams. He completed his MBBS at Calcutta Medical College in 1955. [ 2 ] He was awarded an MS in Surgery from Darbhanga Medical College in India. He also went on to complete his FRCS in the UK. He is credited with establishing the Surgery Department at Bir Hospital , Nepal's oldest hospital. [ 3 ] [ 4 ]
Sharma also established Bhaktapur Cancer Hospital . He has also chaired the Nepal Medical Association (NMA). He was one of the five founding members of the Nepal Medical College in Jorpati . He established the "Anjani Kumar Sharma Gold Medal" in 2009, which is awarded to the student securing the highest marks in Surgery in the final MBBS exams. [ 5 ]
He died on October 7, 2014, in Kathmandu , suffering from transitional cell carcinoma . [ 6 ]
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https://en.wikipedia.org/wiki/Anjani_Kumar_Sharma
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Ankle replacement , or ankle arthroplasty , is a surgical procedure to replace the damaged articular surfaces of the human ankle joint with prosthetic components. This procedure is becoming the treatment of choice for patients requiring arthroplasty, replacing the conventional use of arthrodesis , i.e. fusion of the bones. The restoration of range of motion is the key feature in favor of ankle replacement with respect to arthrodesis. However, clinical evidence of the superiority of the former has only been demonstrated for particular isolated implant designs. [ 1 ]
Since the early 1970s, the disadvantages of ankle arthrodesis and the excellent results attained by arthroplasty at other human joints have encouraged numerous prosthesis designs also for the ankle . In the following decade, the disappointing results of long-term follow-up clinical studies [ 2 ] [ 3 ] of the pioneering designs has left ankle arthrodesis as the surgical treatment of choice for these patients. More modern designs have produced better results, contributing to a renewed interest in total ankle arthroplasty over the past decade. [ citation needed ]
Nearly all designs from pioneers featured two components; these designs have been categorized as incongruent and congruent, according to the shape of the two articular surfaces. After the early unsatisfactory results of the two-component designs, most of the more recent designs feature three components, with a polyethylene meniscal bearing interposed between the two metal bone-anchored components. This meniscal bearing should allow full congruence at the articular surfaces in all joint positions in order to minimize wear and deformation of the components. [ 4 ] Poor understanding of the functions of the structures guiding ankle motion in the natural joint (ligaments and articular surfaces), and poor restoration of these functions in the replaced joint may be responsible for the complications and revisions. [ 5 ]
The main objectives of the prosthetic design for ankle joint replacements are: [ citation needed ]
As with other joint replacements , the traditional dilemma between mobility and congruency must be addressed. [ 6 ] Unconstrained or semiconstrained designs allow the necessary mobility but require incongruent contact, thereby giving rise to large contact stresses and potentially high wear rates. Conversely, congruent designs produce large contact areas with low contact stresses but transmit undesirable constraint forces that can overload the fixation system at the bone-component interface.
The indications for the operation in general are as follow:
The general contraindications are:
Other potential contraindications such as capsuloligamentous instability and hindfoot or forefoot deformities affecting correct posture, are not considered relevant if resolved before or during this surgery. [ 4 ]
The outcome of an ankle replacement includes factors like ankle function, pain, revision and implant survival. Outcome studies on modern designs show a five-year implant survival rate between 67% and 94%. [ 7 ] [ 8 ] [ 9 ] and ten-year survival rates around 75%. [ 7 ] Mobile bearing designs have enabled implant survival rates to continue to improve, reaching as high as 95% for five years and 90% for ten years. [ 10 ] Ankle replacements have a 30-day readmission rate of 2.2%, which is similar to that of knee replacement but lower than that of total hip replacement. 6.6% of patients undergoing primary TAR require a reoperation within 12 months of the index procedure. Early revision rates are significantly higher in low-volume centres. [ 11 ]
Clinical ankle scores, such as the American Orthopaedic Foot and Ankle Society (AOFAS) or the Manchester Oxford Foot & Ankle Questionnaire [ 12 ] are outcome rating system for ankle replacements. Further outcome instruments include radiographic assessment of component stability and migration, and the assessment of its functionality in daily life using gait analysis or video fluoroscopy ; the latter is a tool for three-dimensional measuring of the position and orientation of implanted prosthetic components at the replaced joints. [ 13 ] [ 14 ]
A randomised controlled trial comparing ankle replacement with ankle fusion ( the TARVA study ) found that both led to similar improvements in walking, standing and quality of life. Fixed bearing (but not mobile bearing) ankle replacements outperformed ankle fusion in a separate analysis. A cost-effectiveness analysis revealed that ankle replacement may be better value for money over the course of a person’s lifetime. [ 15 ] [ 16 ]
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https://en.wikipedia.org/wiki/Ankle_replacement
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Ann Arbor staging is the staging system for lymphomas , both in Hodgkin's lymphoma (formerly designated Hodgkin's disease) and non-Hodgkin lymphoma (abbreviated NHL). It was initially developed for Hodgkin's, but has some use in NHL. It has roughly the same function as TNM staging in solid tumors.
The stage depends on both the place where the malignant tissue is located (as located with biopsy , CT scanning , gallium scan and increasingly positron emission tomography ) and on systemic symptoms due to the lymphoma (" B symptoms ": night sweats , weight loss of >10% or fevers ).
The principal stage is determined by location of the tumor: [ citation needed ]
These letters can be appended to some stages: [ citation needed ]
The nature of the staging is (occasionally) expressed with: [ citation needed ]
The staging does not take into account the grade (biological behavior) of the tumor tissue. The prognostic significance of bulky disease, and some other modifiers, were introduced with the "Cotswolds modification". [ 1 ]
The Ann Arbor classification is named after Ann Arbor, Michigan , where the Committee on Hodgkin's Disease Staging Classification met in 1971; [ 2 ] it consisted of experts from the United States, UK , Germany and France, and replaced the older Rye classification from a 1965 meeting. [ 3 ] The Cotswolds modification followed after a 1988 meeting in the UK Cotswolds . [ 4 ]
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https://en.wikipedia.org/wiki/Ann_Arbor_staging
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