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The collagen gel contraction assay is an in vitro model of wound contraction . It is performed using the dermal equivalent model, which consists of dermal fibroblasts seeded into a collagen gel. [ 1 ]
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https://en.wikipedia.org/wiki/Collagen_gel_contraction_assay
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The College of American Pathologists ( CAP ) is a member-based physician organization founded in 1946, comprising approximately 18,000 board-certified pathologists. It serves patients, pathologists, and the public [ 1 ] by fostering and advocating best practices in pathology and laboratory medicine. [ 2 ]
It is the world's largest association composed exclusively of pathologists certified by the American Board of Pathology, [ 3 ] and is widely considered the leader in laboratory quality assurance. The CAP is an advocate for high-quality and cost-effective medical care. [ 4 ] The CAP currently inspects and accredits medical laboratories under authority from the Centers for Medicare & Medicaid Services . Their standards have been called "the toughest and most exacting in the medical business." [ 5 ] The CAP provides resources and guidance to laboratories seeking accreditation in programs for biorepositories, genomics , ISO 15189, and more. [ 6 ] In November 2008, Piedmont Medical Laboratory of Winchester, Virginia became the first laboratory in the United States [ 7 ] to be officially accredited under ISO 15189.
The CAP provides accreditation and proficiency testing to medical laboratories through its laboratory quality solutions programs. Early versions of proficiency testing—known as surveys—which laboratories use to help test and ensure accuracy, were first initiated in 1949. Laboratories first began receiving CAP accreditation in 1964, [ 8 ] and the organization was later given authority to accredit medical laboratories as a result of the Clinical Laboratory Improvement Amendments of 1988. [ 9 ]
The CAP publishes checklists containing requirements pertaining to the performance of laboratory tests. The All Common Checklist (COM) contains a core set of requirements that apply to all areas performing laboratory tests and procedures. [ 10 ] Some requirements exist in both the COM checklist and in a discipline-specific checklist, but with a different checklist note that has a more specific requirement. In these situations, the discipline-specific requirement takes precedence over the COM requirement. [ 10 ] The COM checklist also describes the requirements for analytical validation/verification of the method performance specifications (i.e.
accuracy, precision, reportable range) that laboratories must perform for each test, method, or instrument
system before use in patient testing. [ 10 ] CAP has also created programs that look at the frequency of errors throughout laboratory testing, including Q-Probes and Q-Tracks. [ 11 ] CAP's Q-Probes studies aim to describe errors at different stages of testing; pre-analytic, analytic, and post-analytic. [ 11 ] In order to reduce the frequency of errors occurring at the different stages of testing, performance measures have been put in place in order to improve patient safety . [ 11 ] CAP has created a database to record the error rates seen from more than 130 inter-laboratory studies. [ 12 ]
The CAP opened a Washington, DC, office in 1970 [ 8 ] and advocating for pathology in a legal and policy-oriented capacity remains a core mission of the organization, both through direct action and programs that connect pathologists to legislators. [ 13 ]
The CAP Foundation is the philanthropic arm of the organization and is classified as a 501(c)(3) charitable entity. Its flagship program, See, Test & Treat, partners with hospitals and clinicians to provide free cancer and HPV screening, as well as educational events, to underserved communities. The program served over 900 women in 2017. [ 14 ]
CAP [ 15 ] and Clinical Laboratory Improvement Amendments . [ 16 ] have written policies for the minimum period of that laboratories should keep laboratory records and materials, with some examples as follows:
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The College of Physicians and Surgeons of Ontario (CPSO) is the regulatory college for medical doctors in Ontario , Canada .
The college issues certificates of registration for all doctors to allow them to practise medicine as well as: monitors and maintains standards of practice via assessment and remediation, investigates complaints against doctors, and disciplines those found guilty of professional misconduct and/or incompetence.
The CPSO's power is derived from Regulated Health Professions Act (RHPA), Health Professions Procedural Code under RHPA and the Medicine Act . The college is based in Toronto .
In October 2008, the college was named one of " Canada's Top 100 Employers " by Mediacorp Canada Inc., and was featured in Maclean's newsmagazine. Later that month, the college was also named one of Greater Toronto's Top Employers , which was announced by the Toronto Star newspaper. [ 1 ]
The College of Physicians and Surgeons of Ontario (CPSO) is the self-regulating body for the province's medical profession. The college regulates the practice of medicine to protect and serve the public interest. It issues certificates of registration to doctors to allow them to practise medicine, monitors and maintains standards of practice through peer assessment and remediation, investigates complaints against doctors on behalf of the public, and disciplines doctors who may have committed an act of professional misconduct or incompetence. [ 2 ]
The medical profession has been granted a great degree of authority by provincial law, and that authority is exercised through the college. This system of self-regulation is based on the premise that the college must act first and foremost in the interest of the public. All doctors in Ontario must be members of the college in order to practise medicine in the province. The role of the college, as well as its authority and powers, are set out in the Regulated Health Professions Act 1991 (RHPA) , the Health Professions Procedural Code under the RHPA and the Medicine Act 1991 .
The duties of the college include: issuing certificates of registration to doctors to allow them to practise medicine monitoring and maintaining standards of practice through peer assessment and remediation investigating complaints about doctors on behalf of the public, and conducting discipline hearings when doctors may have committed an act of professional misconduct or incompetence.
In December 2023 the CPSO Council approved a set of governance modernisation initiatives to be effected through by-laws. These included changing the name of the CPSO Council to the Board of Governors (see below). However, this change is cosmetic only as the composition of the CPSO Council / Board of Governors is determined by the Medicine Act 1991. [ 3 ]
The college is governed by a Board of Directors, formerly known as the College Council. The Medicine Act 1991 stipulates that it shall be composed of:
(a) at least 15 and no more than 16 persons who are members elected in accordance with the by-laws;
(b) at least thirteen and no more than fifteen persons appointed by the Lieutenant Governor in Council who are not,
(i) members,
(ii) members of a College as defined in the
Regulated Health Professions Act, 1991, or
(iii) members of a Council as defined in the Regulated Health Professions Act, 1991; and
(c) three persons selected, in accordance with a by-law made under section 12.1, from among members who are members of a faculty of medicine of a university in Ontario.
The College President is elected from and by the Board and serves a one-year term. [ 4 ] [ 5 ]
Board members sit on one or more committees of the college. Each committee has specific functions, most of which are governed by provincial legislation. [ 6 ]
Board meetings are held four times a year, at which time the activities of the college are reviewed and matters of general policy are debated and voted on. Meetings of the Board are no longer open to the public in person but are live streamed on YouTube and may be observed by the public virtually. [ 7 ]
The current composition of the Board of Directors is published on the CPSO website. [ 8 ]
A complaint to the CPSO about a physician may be initiated online or by telephone. Details are published on the CPSO "Complaints and Concerns" page. Before calling the CPSO to file a complaint, the CPSO encourages patients to try to resolve the issue with their physician first, where appropriate.
On March 24, 2020, the CPSO Executive Council met to discuss the potential impact of the COVID-19 pandemic on Council business. The Council declared an emergency under CPSO's Declared Emergency ByLaw and directed to extend the Council Elections for Districts 5 and 10 which were originally scheduled to be held on June 9, 2020. [ 9 ] By May 2020, the CPSO noted they were anticipating a high volume of complaints against senior public health officials, and many related to public health measures and delays in cancer surgeries , mammograms and the like.
On April 30, 2021, the CPSO released a statement on “Public Health Misinformation” accusing Ontario doctors of “using social media to spread blatant misinformation and undermine public health measures.” [ 10 ] In response, a group of Canadian physicians released a declaration titled the “Declaration of Canadian Physicians for Science and Truth”. They described the CPSO's statement as “unethical, anti-science and deeply disturbing.” [ 11 ] As of August 25, 2022, there were 718 signatory physicians and 20,171 on behalf of concerned citizens. [ 12 ]
The CPSO strongly encourages all eligible Ontarians to receive a COVID-19 vaccine or booster shot(s). [ 13 ]
The CPSO followed up its “Public Health Misinformation” statement by starting disciplinary action against a number of physicians. As of 16 January 2024, 21 physicians have been disciplined, with sanctions including suspension or revocation of registration, undertaking with restrictions or “never reapply” undertaking. See chart for further details. 6 cases are still pending final resolution.
Between 2007 and 2013 the college issued more than 1,000 "cautions" against practising doctors. [ 14 ] Cautions are issued to doctors for transgressions that include providing inadequate treatment, poor record-keeping and raising voices in arguments. However, the college has been criticized in the past for not being transparent to patients as to which doctors have been subject to cautions, and for being more interested in protecting doctors than patients.
Between 2004 and 2011 the college prosecuted four physicians for improperly charging block fees to patients. Block fees are annual fees charged by physicians to allow patients to access services. Physicians are permitted to charge block fees to uninsured patients for services not covered by OHIP, but charging block fees to allow insured patients to access OHIP services is considered to be professional misconduct. [ 15 ]
In 2013, in response to some of the above criticisms, the college announced that it would begin its "Transparency Project". The goal of the Transparency Project would be to make it easier for patients to gain more information about doctors who have been accused of wrongdoing. The College Council gave its support to a transparency initiative that had four categories. One, an increase in the transparency of the transfer of patient medical records. Two, a proposal that the Notices of Hearing for the college's Discipline Proceedings be posted to a physician's profile on the public register. Third, a proposal that the status of discipline matters as they are proceeding be added to a physician's profile on the public register. Fourth, that reinstatement decisions in their entirety be posted to a physician's profile on the public register.
In recent years the college has struggled to process an increasing volume of complaints about physicians. In 2007 it successfully lobbied the Ontario Ministry of Health to increase the time limit for disposal of complaints from 120 to 150 days, and to give itself increased powers to extend those time limits. These proposals were contained in amendments to the Regulated Health Professions Act 1991 which were passed by the Ontario Legislative Assembly in 2007 and came into force in 2009. The time taken to dispose of complaints continued to lengthen until the Ontario Ministry of
Health commissioned a report, “Streamlining the Physician Complaints Process in Ontario” which reported in 2016 that “More time and money is spent on a disposition in Ontario than in other jurisdictions, with little apparent benefit to the public in terms of better or safer physician services”, “too many complaints and investigations are in the system too long”, and “the 150 day deadline is not met on many occasions”. [ 16 ] Following this report, the college improved the efficiency of its complaints procedures, including routing suitable complaints via an Alternative Dispute Resolution (ADR) process, and disposal times are once again coming down.
A novel solution adopted by the college to the problem of delays in resolving complaints has been to make increasing use of "never reapply" undertakings. A "never reapply" undertaking is an undertaking made by a physician to surrender his or her licence and never reapply for another licence in Ontario or anywhere else in the world. In return, the college promises not to proceed with the complaint, the investigation is terminated and the file closed. These undertakings are probably legally unenforceable both inside and outside Ontario as they would amount to an unreasonable restraint of trade [ 17 ] and they are rarely used by other medical regulatory authorities. In the past, such undertakings were only used in the most serious cases, for example sexual abuse of a patient, but they are increasingly being used by the college as a way of disposing of less serious or unspecified complaints. A disadvantage of these undertakings are that they remove physicians from practice who may be able and willing to continue practising but just wish to terminate the investigation.
This data was extracted from the CPSO online public register by a combination of electronic and manual searching. 330 physicians were identified who had given undertakings to the CPSO never to reapply for a licence either in Ontario alone, or Ontario plus anywhere else in the world.
In each case an attempt was made to identify why the undertaking was given, and the undertakings were allocated into four categories. "Sexual" indicates that there was an allegation of sexual misconduct, either proven or unproven, and involving either patients or co-workers. "Explicable" indicates that the reason for the undertaking was non-sexual, but there appeared to be some other good reason why it was appropriate, for example, gross incompetence, a serious criminal conviction, dishonesty, psychiatric incapacity or a repeated failure to remediate. "Inexplicable" forms the largest category and indicates either that the reason given was vague ("incompetence", "professional misconduct", "failure to uphold the standards of the profession" or similar) or that it appeared to be an inappropriately harsh penalty (overprescribing of opioids, for example, could be easily remedied by placing restrictions on the physician's licence).
The fourth category, appearing for the first time in 2022, is for COVID-19 related undertakings. Since the start of the COVID-19 pandemic, the CPSO has required physicians not to "disseminate false and misleading information" about COVID-19, which may include the physicians' personal opinions about mask wearing, vaccine safety and the effectiveness of certain COVID treatments. Several physicians have been disciplined for allegedly failing to comply with these guidelines, including five to date who have signed "never reapply" undertakings.
An application is being made to the Ontario Ministry of Health for amendments to the Regulated Health Professions Act 1991 to update the regulations and address some of the above issues. [ 18 ]
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A Collis gastroplasty is a surgical procedure performed when the surgeon desires to create a Nissen fundoplication , but the portion of esophagus inferior to the diaphragm is too short. Thus, there is not enough esophagus to wrap. A vertical incision is made in the stomach parallel to the left border of the esophagus. This effectively lengthens the esophagus. The stomach fundus can then be wrapped around the neo-esophagus, thus reducing reflux of stomach acid into the esophagus.
In fact, gastroplasty can be used when the length of the intra-abdominal esophagus is short and for anti-reflux action such as Nissen fundoplication, it is necessary to increase the intra-abdominal length of the esophagus.
At this time, part of the upper part of the stomach is separated by a stepper, i.e. the stapler fires longitudinally along the esophagus and increases the length of the stomach inside the abdomen.
At this time, a tongue is created from the stomach that can be easily rotated on the new esophagus and all kinds of fundoplication operations such as Nissen fundoplication can be done easily. [ 1 ] It was devised by John Leigh Collis (1911–2003), [ 2 ] a British cardiothoracic surgeon, in 1957. [ 3 ]
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https://en.wikipedia.org/wiki/Collis_gastroplasty
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Coloanal anastomosis (also known as coloanal pull-through ) is a surgical procedure in which the colon is attached to the anus after the rectum has been removed.
This article incorporates public domain material from Dictionary of Cancer Terms . U.S. National Cancer Institute .
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https://en.wikipedia.org/wiki/Coloanal_anastomosis
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Colorimetric capnography is a qualitative measurement method that detects the presence of carbon dioxide (CO2, a relatively acidic gas) in a given gaseous environment. From a medical perspective, the method is usually applied by exposing litmus paper/film to an environment containing a patient's airway gases (i.e. placing it into their breathing circuit/airway circuit ), where it will then change color depending on the amount of exhaled CO2 within the circuit. Although there are multiple uses, the colorimetric capnography method is most frequently used to quickly confirm that an advanced airway device such as an endotracheal tube (ETT) or nasotracheal tube (NTT) has been placed in the desired location. Correct placement is evidenced by sufficient color change of the litmus paper while exposed to the airway gases which, if the device is properly placed, will contain relatively high amounts of exhaled CO2. Conversely, lack of detection of CO2 suggests many possible issues, including improper placement of the advanced airway device, most commonly into the esophagus . [ 1 ] There are no contraindications to capnography . [ 2 ]
Colorimetric capnography devices do not require electricity, change color reversibly (breath-by-breath), and add a small amount of dead space . A variety of devices are available from multiple manufacturers. Specific devices on the market include the Covidien Nellcor EasyCap or PediCap (manufactured by Medtronic), and the StatCO 2 , Mini StatCO 2 , and Neo-StatCO 2 (made by Mercury Medical).
Metacresol purple is an example of a pH -dependent dye commonly used in such devices. The colour change of the EasyCap is from purple to yellow/gold, leading to the phrase ' good as gold ' or 'gold is good', as an aide-mémoire for successful tracheal intubation.
Colorimetric capnography is most frequently used in medical contexts to determine whether exhaled CO2 is present in a patient's airway circuit after placement of an advanced airway device (e.g. ETT or NTT), but the meaningful significance of CO2 detection is in reality much more broad. Detection of sufficient CO2 suggests that a patient is metabolically active and capable of eliminating CO2, while lack of color change or insufficient color change suggests an issue at one or more of many possible levels including issues with cellular metabolism , airway device integrity and placement, circuit integrity, mucous plugging, cardiopulmonary function, device malfunction, and more. [ 1 ]
Inadvertent placement of a nasogastric tube (NGT) into the airway rather than the stomach can lead to complications such as pneumothorax and pneumonia . The use of colorimetric capnography to detect proper placement of a nasogastric tube (NGT) has shown promise, especially in mechanically ventilated patients. With this method, rather than exposing the litmus paper to the patient's airway gases via connection with the airway circuit, the litmus paper is exposed to the gases transmitted via the nasogastric tube. Put simply, just as this method can detect the desired presence of significant CO2 in an airway, it can also detect the desired lack of CO2 in a properly placed nasogastric tube. [ 3 ] [ 4 ] Further research on this particular use of colorimetric capnography and the widespread incorporation of adapters will likely be required if this utilization is to become more commonplace. [ 4 ]
Data inputs from multiple sources (e.g. blood pressure cuff (sphygmomanometer) , pulse oximeter , thermometer , etc.) are used to characterize a patient's vital condition, and the more meaningful data that is available, the more accurate and precise a clinician can be in addressing a patient's health status. Capnography as a whole represents a significantly useful data point in monitoring a patient's respiratory and metabolic status in situations including but not limited to cardiac arrest , metabolic acidemia , mechanical ventilation , and procedural sedation . [ 5 ]
One disadvantage of qualitative capnography methods such as colorimetry is that they do not produce a direct numeric or waveform readout as can a quantitative method such as infrared capnography. The colorimetric method rather presents CO2 simply as a color most commonly on the spectrum of purple (lower CO2) to gold (higher CO2) and leaves the clinician to interpret anything beyond this single returned value. Despite being a more rudimentary method of capnography as compared to quantitative methods such as infrared capnography, colorimetric capnography has proven to remain beneficial in multiple contexts in modern medicine as mentioned in the above section. [ 5 ] Evidence also suggests that colorimetric capnography is just as effective as infrared capnography at determining correct tracheal airway device placement, but may fall short of infrared capnography when detecting inadvertent esophageal airway device placement. [ 6 ]
There has been debate related to the term 'colorimetric capnography,' especially with the growing employment of this method during the COVID-19 pandemic due to an increased volume of patients requiring mechanical ventilation . The use of the term 'capnography' technically implies some type of quantitative result or readout which, as described above, is not produced by the colorimetric method. Descriptors such as "carbon dioxide colorimetry," "colorimetric carbon dioxide detection," and "chemical colorimetric analysis" have been suggested as potentially more accurate replacements. [ 7 ]
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https://en.wikipedia.org/wiki/Colorimetric_capnography
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Combinatorial ablation and immunotherapy is an oncological treatment that combines various tumor-ablation techniques with immunotherapy treatment. [ 1 ] [ 2 ] [ 3 ] [ 4 ] Combining ablation therapy of tumors with immunotherapy enhances the immunostimulating response and has synergistic effects for curative metastatic cancer treatment. [ 2 ] [ 3 ] Various ablative techniques are utilized including cryoablation , radiofrequency ablation, laser ablation, photodynamic ablation , stereotactic radiation therapy , alpha-emitting radiation therapy, hyperthermia therapy , HIFU . [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] Thus, combinatorial ablation of tumors and immunotherapy is a way of achieving an autologous , in-vivo tumor lysate vaccine and treating metastatic disease.
Take magnetic hyperthermia for example. By applying magnetic nanoparticle-mediated hyperthermia with a threshold of 43 °C in order not to damage surrounding normal tissues, a significant quantity of heat-shock proteins (HSP) is expressed within and around the tumor tissues, inducing tumor-specific immune responses. In vivo experiments have indicated that magnetic nanoparticle-mediated hyperthermia can induce the regression of not only a local tumor tissue exposed to heat, but also distant metastatic tumors unexposed to heat. Partially or entirely ablating primary or secondary metastatic tumors induces necrosis of tumor cells, resulting in the release of antigens and presentation of antigens to the immune system. The released tumor antigens help activate anti-tumor T cells, which can destroy remaining malignant cells in local and distant tumors. Combining immunotherapy (ie: checkpoint inhibitors, CAR-T cell therapy ) and vaccine adjuvants (ie: interferon , saponin ) with ablation synergizes the immune reaction, and can treat metastatic disease with curative intent. [ 3 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ]
Various local ablation therapies exist to induce necrosis of tumor cells and release tumor antigens to stimulate an immunological response. These ablation therapies can be combined with a systemic immunotherapy : [ citation needed ]
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https://en.wikipedia.org/wiki/Combinatorial_ablation_and_immunotherapy
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Combined drug intoxication ( CDI ), or multiple drug intake ( MDI ), is a cause of death by drug overdose from poly drug use , often implicated in polysubstance dependence .
People who engage in polypharmacy are at an elevated risk of death from CDI. Other dangers of combining drugs such as "brain damage, heart problems, seizures, stomach bleeding, liver damage/ liver failure, heatstroke, coma, suppressed breathing, and respiratory failure", along with many other complications. Disorders like depression and anxiety can also stem from polydrug use. [ 1 ] Elderly people are at the highest risk of CDI, because of having many age-related and health problems requiring many medications combined with age-impaired judgment, leading to confusion in taking medications. [ 2 ] [ 3 ] Elderly patients are often prescribed more than one drug within the same drug class, and doctors may treat the side effects of prescribed drugs with even more drugs, which can overwhelm the patient. [ 4 ]
In general, the use of multiple drugs should be carefully monitored by a qualified individual such as board certified and licensed medical doctor , either an MD or DO . Close association between prescribing physicians and pharmacies, along with the computerization of prescriptions and patients' medical histories, aim to avoid the occurrence of dangerous drug interactions. Lists of contraindications for a drug are usually provided with it, either in monographs, package inserts (accompanying prescribed medications), or in warning labels (for OTC drugs). CDI/MDI might also be avoided by physicians requiring their patients to return any unused prescriptions. Patients should ask their doctors and pharmacists if there are any interactions between the drugs they are taking.
In 2004, there were 3,800 deaths in the US resulting from a fatal medication error involving alcohol , while in 1983 there were fewer than 100 such deaths. [ 5 ] It is more of a risk for older patients. [ 3 ] [ medical citation needed ]
Alcohol can exacerbate the symptoms and may directly contribute to increased severity of symptoms. The reasons for toxicity vary depending on the mixture of drugs. Usually, most victims die after using two or more drugs in combination that suppress breathing, and the low blood oxygen level causes brain death . [ 6 ]
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https://en.wikipedia.org/wiki/Combined_drug_intoxication
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A combined internal medicine and psychiatry residency program is a post-graduate medical education program in the United States , which leads to board eligibility in both internal medicine and psychiatry . That is, a graduate of the residency is both an internist as well as a psychiatrist . The program takes five years of post-graduate medical training. There are 12 such programs in the country, and around eighteen positions available for new applicants. [ 1 ]
Graduates of such programs can follow a variety of career paths as Dual Internist/Psychiatrists. [ 2 ]
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https://en.wikipedia.org/wiki/Combined_internal_medicine_and_psychiatry_residency
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The COMMANDO Operation or COMMANDO Procedure ( COM bined MA ndibulectomy and N eck D issection O peration) is a complicated operation for 1st degree malignancy of the tongue. [ 1 ] It comprises glossectomy (total removal of the tongue) and hemimandibulectomy together with block dissection of the cervical nodes. The operation is so named because of its extensive nature.
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https://en.wikipedia.org/wiki/Commando_Operation
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The Commission on Dental Competency Assessments (formerly the North East Regional Board of Dental Examiners ) is one of three examination agencies for dentists in the United States . [ 1 ] These were organized to better standardize clinical exams for licensure. Historically each state had its own independent licensing exam.
On January 9, 2015, the NERB became the Commission on Dental Competency Assessments (CDCA). [ 2 ]
August 3, 2021, CDCA, merged with WREB, the Western Regional Examining Board, creating CDCA-WREB. Then, on August 1, 2022, CDCA-WREB merged with The Council on Interstate Testing Agencies.
Now CDCA-WREB-CITA, the organization, administers the ADEX Dental and Dental Hygiene Exams. ADEX exams are administered and portable across the United States and beyond. [ 3 ] The agency also administers the Florida Laws and Rules exam, [ 4 ] and an Expanded Function Dental Assistant (EFDA) exam Sedation, Local Anesthesia, Dental Therapy and Nitrous Oxide examinations.
CDCA-WREB-CITA has grown to include 47* states, Washington, DC, Puerto Rico, US Virgin Islands and Jamaica. The only states that still do not accept the ADEX exams for both Dental and Hygiene exams are: Delaware, Georgia, *Nebraska (accepts Dental but not Hygiene ) , *New York (accepts Hygiene but not Dental ).
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https://en.wikipedia.org/wiki/Commission_on_Dental_Competency_Assessments
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The Common Terminology Criteria for Adverse Events ( CTCAE ), [ 1 ] formerly called the Common Toxicity Criteria ( CTC or NCI-CTC ), are a set of criteria for the standardized classification of adverse events of drugs and treatment used in cancer therapy .
The CTCAE system is a product of the US National Cancer Institute (NCI).
The first Iteration was prior to 1998. In 1999, the FDA released version 2.0. CTCAE version 4.0 in 2009 with an update to y version 4.03 in 2010. [ 2 ] The current version 5.0 was released on November 27, 2017. Many clinical trials , now extending beyond oncology, encode their observations based on the CTCAE system.
It uses a range of grades from 1 to 5. Specific conditions and symptoms may have values or descriptive comment for each level, but the general guideline is:
Grade 1: is defined as mild, asymptomatic symptoms. Clinical or diagnostic observations only; Intervention not indicated.
Grade 2: is moderate; minimal, local or noninvasive intervention was needed.
Grade 3: Severe symptoms or medically significant but not life-threatening but may be disabling or limit self care in ADL
Grade 4: is Life threatening consequences; urgent or emergent intervention needed
Grade 5: Death related to or due to adverse event [ 3 ]
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https://en.wikipedia.org/wiki/Common_Terminology_Criteria_for_Adverse_Events
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The Common Veterinary Entry Document ( CVED ) is the official document used in all member states of the European Union (EU) to pre-notify the arrival of each consignment [ 1 ] of live animals (pets not included), live animal products and products of animal origin intended for import to or transit through the EU from third countries. [ 2 ]
A CVED can be submitted on paper or by electronic means using the application TRACES (TRAde Control and Expert System). [ 6 ]
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https://en.wikipedia.org/wiki/Common_Veterinary_Entry_Document
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Communicans is a Latin word meaning "communicating". It is most commonly used in medical or biological terminology.
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https://en.wikipedia.org/wiki/Communicans
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A communication disorder is any disorder that affects an individual's ability to comprehend , detect, or apply language and speech to engage in dialogue effectively with others. [ 1 ] This also encompasses deficiencies in verbal and non-verbal communication styles. [ 2 ] The delays and disorders can range from simple sound substitution to the inability to understand or use one's native language. [ 3 ] This article covers subjects such as diagnosis, the DSM-IV , the DSM-V , and examples like sensory impairments, aphasia , learning disabilities , and speech disorders .
Disorders and tendencies included and excluded under the category of communication disorders may vary by source. For example, the definitions offered by the American Speech–Language–Hearing Association differ from those of the Diagnostic Statistical Manual 4th edition (DSM-IV). [ 4 ]
Gleason (2001) defines a communication disorder as a speech and language disorder which refers to problems in communication and in related areas such as oral motor function. The delays and disorders can range from simple sound substitution to the inability to understand or use one's native language. [ 3 ] In general, communication disorders commonly refer to problems in speech (comprehension and/or expression) that significantly interfere with an individual's achievement and/or quality of life. Knowing the operational definition of the agency performing an assessment or giving a diagnosis may help. [ 3 ]
Persons who speak more than one language or are considered to have an accent in their location of residence do not have a speech disorder if they are speaking in a manner consistent with their home environment or that is a blending of their home and foreign environment. [ 5 ]
Other conditions, as specified in the Cincinnati Children's Health Library (2019), that may increase the risk of developing a communication disorder include: [ 6 ]
According to the DSM-IV-TR (no longer used), communication disorders were usually first diagnosed in childhood or adolescence, though they are not limited as childhood disorders and may persist into adulthood. [ 7 ] [ full citation needed ] They may also occur with other disorders.
Diagnosis involved testing and evaluation during which it is determined if the scores/performance are "substantially below" developmental expectations and if they "significantly" interfere with academic achievement, social interactions, and daily living. This assessment might have also determined if the characteristic is deviant or delayed. Therefore, it may have been possible for an individual to have communication challenges but not meet the criteria of being "substantially below" criteria of the DSM IV-TR.
The DSM diagnoses did not comprise a complete list of all communication disorders, for example, auditory processing disorder is not classified under the DSM or ICD-10. [ 8 ] The following diagnoses were included as communication disorders:
The DSM-5 diagnoses for communication disorders completely rework the ones stated above. [ 11 ] The diagnoses are made more general in order to capture the various aspects of communications disorders in a way that emphasizes their childhood onset and differentiate these communications disorders from those associated with other disorders (e.g. autism spectrum disorders ). [ 12 ]
Examples of disorders that may include or create challenges in language and communication and/or may co-occur with the above disorders:
Aphasia is loss of the ability to produce or comprehend language . There are acute aphasias which result from stroke or brain injury, and primary progressive aphasias caused by progressive illnesses such as dementia.
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https://en.wikipedia.org/wiki/Communication_disorder
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Community-based clinical trials are clinical trials conducted directly through doctors and clinics rather than academic research facilities. They are designed to be administered through primary care physicians , community health centers and local outpatient facilities. In 1986, the Community Consortium held the first such trials in the United States to determine the efficiency of preventive treatments after the onset of Pneumocystis pneumonia . [ 1 ] The trials give patients access to new medications and keep doctors involved with new developments in research. However, critics state that drug company payments to doctors for patients enrolled in such studies present a conflict of interest and potential for abuse. [ 2 ] [ 3 ] Community-based trials are becoming prevalent in human-testing stage pharmaceutical research.
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https://en.wikipedia.org/wiki/Community-based_clinical_trial
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Comparative endocrinology focuses on the complexities of vertebrate and invertebrate endocrine systems across sub-molecular, molecular, cellular, and organismal levels of analysis. It is an interdisciplinary field that bridges biology and medicine, addressing the morphological and functional aspects of organismal development. [ 1 ] The discovery of new hormones often first occurs in model organisms before their orthologs are identified in mammals. [ 2 ]
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Comparative medicine is a distinct discipline of experimental medicine that uses animal models of human and animal disease in translational and biomedical research . [ 1 ] : 2 [ 2 ] In other words, it relates and leverages biological similarities and differences among species to better understand the mechanism of human and animal disease. It has also been defined as a study of similarities and differences between human and veterinary medicine including the critical role veterinarians , animal resource centers, and Institutional Animal Care and Use Committees play in facilitating and ensuring humane and reproducible lab animal care and use. [ 3 ] The discipline has been instrumental in many of humanity's most important medical advances.
The first documented mention of comparative pathology comes from Hippocrates (460 - 370 BCE) in Airs, Waters, Places where he describes relevant case histories for horse herds and human populations. He insists that diagnosis be based on experience, observation, and logic. [ 4 ] Aristotle (384 - 322 BCE) hypothesized about interspecies transmission of disease. [ 1 ] : 4 The anatomy and physiology schools opened in Alexandria by Erasistratus (404 - 320 BCE) and Herophilus (330 - 255 BCE) were directly inspired by Aristotle's work. Although most of the documents were destroyed when the Library of Alexandria burned. [ 5 ]
In his Disciplinarum Libri IX , Marcus Terentius Varro (c. 100 BCE) made early indications of the germ theory of disease with his conception that tiny invisible animals carried with the air caused disease by entering through the nose and mouth. [ 6 ] He also warned people against establishing homes near swamplands. [ 7 ] Aulus Cornelius Celsus (25 BCE - 50 CE) wrote of experimental physiology in De Medicini Libri Octo detailing numerous dissections and vivisections he performed and pointed out specific interventions as well, such as cupping to remove the poison of a dog's bite. [ 8 ] [ 6 ] : 8
By the time of Claudius Galen (129 - 200 CE), whose name lives on in the term Galenic formulation , human dissection was no longer acceptable and his vivisection studies of comparative anatomy relied mostly on the use of Barbary macaques . [ 9 ] This resulted in several persistent misunderstandings of human anatomy. [ 10 ] Another key early contributor to early comparative medicine through publication of his Digestorum Artis Mulomedicinae libri in 500 CE was Publius Flavius Vegetius Renatus . A work that continued to be published and used in medicine as late as the 16th century. [ 1 ] : 5
The post-antique European world gave rise to a dominant monotheistic culture and with it a de facto ban on human dissection. As such, there was a slow down in comparative medicine's progress through the Middle Ages . This was to be codified in 1637 CE with René Descartes manuscript Discourse on the Method . [ 11 ] : 11 The Persian physician Muhammad ibn Zakariya al-Razi (865 - 925 CE) was the first to describe smallpox and measles and prescribe treatments, making his discoveries largely through animal dissection. [ 12 ]
Due to the far flung nature of their travels the Crusaders imported the Oriental rat flea carrying the bacterium Yersinia pestis and eventually initiating the Black Death . [ 13 ] The massive deleterious effect of the pandemic brought on serious consideration of inoculation and transmission chiefly through the work of Albertus Magnus (1206 - 1280 CE). In the book Liber de Animalibus he discussed human and animal plagues in addition to narrowing down the method of transmission to bites, contact with animals, or respiration of sick air from the diseased. [ 14 ]
Girolamo Fracastoro (1478 - 1553 CE) outlined a concept for rapidly multiplying minute bodies (germs) transmitting infection in De contagione et contagiosis morbis . The theory was widely praised but fell into disuse until Louis Pasteur and Robert Koch developed an empirical version. [ 15 ] The beginnings of microbiology, and thus serious use of comparative medicine, were finally enabled by Antonie Philips van Leeuwenhoek 's refinement of the microscope and subsequent observation of animalcules . [ 16 ]
The first real basis for the structured and regular exchange of knowledge of science and medicine in the western world was established with the 1660 founding of the Royal Society in London . Robert Doyle (1627 - 1691) published key experiments in their classical journal Philosophical Transactions among them interspecies blood transfusion , including from sheep into men. [ 17 ]
The 18th century brought new plagues [ 13 ] and faster communications to Europe creating a fruitful environment for a comparative approach to transfer and contagion. Along with the technology of transference as an experimental in vivo approach to medicine. [ 1 ] : 7 At this stage it was already established in China that it was possible to use pox crusts as an effective treatment for smallpox infections . [ 18 ] Emanuel Timone (1665 - 1741) was the first westerner to publish anything on inoculation, which he called grafting, although it's unclear if he developed it de novo (as new) or inferred it from previous work. [ 19 ]
At this point animal medicine was generally absent from Europe. Bernado Ramazzini (1633 - 1714) and Giovanni Maria Lancisi (1654 - 1720) were the first to draw attention to the danger the general population faced from animal plagues. [ 20 ] This and other work paved the way for Mortimer Cromwell, a secretary of the Royal Society, to raise plagues as a national health issue enabling a general policy of quarantine , isolation, fumigation , and slaughter. [ 21 ] Erasmus Darwin was also impacted by the tragedy of the plagues and it resulted in the publication of his Zoonomia where he discusses infectious disease of both humans and animals.
In 1802 French physiologist François Magendie (1783 - 1855) became the first person to prove interspecies transmission of disease by inoculating a dog from rabies using human spittle. [ 22 ] He also experimented with the injection of putrid fish into animals and was an advocate for experimentation in a time before anesthetics were developed. [ 23 ]
With their usefulness to human health and respectable scientific standing established there were veterinary colleges founded in France , Austria , Sweden , Denmark , Netherlands , and Germany throughout the 18th century. It was Claude Bourgelat , the founder of the first veterinary college in Lyon France in 1761, who, prior to the existence of the veterinary profession, coined the term “comparative pathobiology ”. [ 3 ] When the Royal Veterinary College was established in London in 1790 many students from France moved to England. Among them were John Hunter (1728 - 1793) an anatomist and surgeon that had an interest in comparative anatomy and animal physiology . His teaching on infectious disease was influential on subsequent generations.
A most prominent student of Hunter's was Edward Jenner (1749 - 1823). He introduced animal models for rabies and showed that dogs could be inoculated with the spittle of infected animals. In a 1796 experiment, Jenner demonstrated inoculation from smallpox by exposure to and transmission of the milder cowpox. Jenner's work, a breakthrough in vaccinology and an important precursor to immunology in general, is generally credited as the very beginning of modern medicine . [ 24 ] The experiments of Jenner and others set the stage for certain inoculation programs to be introduced to the general public. The first of such programs was directed by Jean-Baptist Edouard Bousquet (1794 - 1872) laid out guidelines for advisability, inoculation, and re-inoculation. [ 25 ]
The first university chair of comparative medicine was established in 1862 resultant to the vision of Émile Littré a French politician and former student of medicine. [ 26 ]
Robert Koch (1843 - 1910) discovered the pathogens responsible for anthrax , tuberculosis , and cholera . He won a Nobel Prize in Physiology or Medicine in 1905 [ 27 ] He used animal models to complement knowledge of human biology. [ 28 ]
In 1863 John Gamgee (1831 - 1894) organized the first conference of what would evolve into the World Veterinary Association . [ 29 ] Subsequent conferences, such as one on animal vaccination in 1880, led George Fleming to propose in The Lancet that a chair of comparative pathology be established in all medical schools. [ 30 ]
Rudolf Virchow (1821 - 1902) initiated modern pathology with his studies of dogs that lead to distinguishing between pyemia , sepsis , thrombosis , and embolisms . He made observations based on experiments in animals that led to specific medical interventions for humans, a hallmark of comparative medicine. [ 1 ] : 11
Auguste Chauveau (1827 - 1917) experimented on sepsis, and chaired a commission that was responsible for anticipating that smallpox itself could be attenuated by passage through cattle. [ 31 ] [ 32 ]
Louis Pasteur (1822 - 1895) inoculated several animal species against rabies and was able to cure a young boy of the disease. There was much controversy surrounding Pasteur's work after his death when his lab notebooks revealed questionable reporting techniques and the suppression of the work of others in his field such as Pierre Paul Émile Roux . [ 33 ]
Salomon Stricker (1834 - 1898) founded The Institute of Experimental Pathology in 1872, which in 2010 was renamed the Institute of Pathophysiology and Allergy Research to conform to modern nomenclature. From its inception the institute was devoted to laboratory experimentation involving animals. [ 34 ]
William H. Welch (1850 - 1934) was the founding president of the Rockefeller Institute of Medical Research in 1901. It was the first American equivalent to the Pasteur and Koch institutes in Europe. In addition to establishing an institute for animal pathology they began publishing the Journal of Experimental Medicine (JEM) which is still a respected journal today. They are dedicated to the study on intact organisms and prioritize human studies. [ 35 ]
Comparative medicine in the form of experimentation on rhesus monkeys was key to one of the crowning achievements of modern medical science: Jonas Salk 's development of the polio vaccine. In fact the typing portion of the studies - crucial for determining what type of vaccine was needed - required some 17,000 monkeys for the research. [ 36 ] This lead Julius Youngner , one of the researchers on Salk's team to say, "The monkeys were the real heroes of this thing," [ 37 ]
Comparative medicine, particularly through the use of macaque and rhesus monkeys as animal models, has been absolutely essential to the development of treatment for HIV and AIDS . This is particularly so in the ongoing - and as yet unsuccessful - struggle to find a vaccine, [ 38 ] although there are severe limitations due to the uniqueness of Simian immunodeficiency virus (SIV) compared to the human virus and a better animal model is needed. [ 39 ]
The concept of One Medicine is an idea from the 1970s and can be attributed to Calvin Schwabe (1927 – 2006) from his book Veterinary Medicine and Human Health . The idea takes the existing interdisciplinary nature of comparative medicine a step further and considers veterinary and human healthcare to be sufficiently overlapped as to be different aspects of the same thing. [ 40 ] These concepts are carried into the 21st century in works such as Zoobiquity [ 41 ] [ 42 ] and in developments in research for heart transplants, management of psychiatric disorders, prosthetic limbs, cancer treatments and vaccine development. [ 43 ] Despite the potential of this emergent field it has thus far failed to realize its full potential due to the limited interaction of veterinary and medical sciences. [ 44 ]
Despite the usefulness of a comparative approach to medicine and the utility of animal models the literature is fraught with many examples of promising in vivo research failing to translate effectively from animals to humans. [ 45 ] This has raised concerns about reliability, predictive value, and the potential harm that inadequate measures can cause people. [ 46 ] Some researchers have noted that a distinction between exploratory and confirmatory approaches can improve translation. [ 47 ]
A few examples:
There is a current focus in the research community on using the proper context for interpreting animal models and developing better ones. [ 56 ]
Reproducibility has been defined as the ability of a result to be replicated through independent experiments within the same or different laboratories. There are serious concerns about the repeatability of pre-clinical trials with published estimates of irreproducibility ranging from 51% [ 57 ] to 89%. [ 58 ] These concerns are part of the larger reproducibility crisis in science. [ 59 ] [ 60 ]
Some of the reasons for the lack of reproducibility in many studies are:
The theory of utilitarianism and the concept of greater good is most often used as a rationale for animal research in comparative medicine and elsewhere. [ 65 ] The basic idea is that the actions that produce the greatest good for the greatest number are moral actions, [ 66 ] meaning that new drugs and therapies along with the decreased suffering of humans and animals justifies the use of some animals in research. There are concerns that animal experimentation that has no translational benefit or reproducibility is likely unethical. [ 46 ]
There are philosophers that believe that animal testing violates an animal's dignity and is ethically wrong. [ 67 ] Until a better alternative is found though the majority of the scientific community continue to take the utilitarian approach. [ 68 ]
Animal testing regulations are laws and/or guidelines that permit and control the use of animals for experimentation. They are of interest to comparative medicine given the overlap of the discipline and animal experimentation . The regulations vary around the world, but most governments aim to control the number of times animals are used; numbers used; and degree of pain.
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Comparative oncology integrates the study of oncology in non-human animals into more general studies of cancer biology and therapy. The field encompasses naturally seen cancers in veterinary patients [ 1 ] and the extremely low rates of cancers seen in large mammals such as elephants and whales. [ 2 ]
Species that are treated in the veterinary clinic, including dogs , cats , horses and ferrets , present human-relevant cancers. [ 1 ]
Of these, the dog has the greatest number of incidents. [ 1 ] One in four dogs older than 2 dies of cancer, a rate that has increased, which may in part be explained by reductions in other causes of death. Canine cancer shares features with human cancer, including histology , tumor genetics, molecular targets, biological behavior and therapeutic response. Canine histologies include osteosarcoma , melanoma , non-Hodgkin's lymphoma , leukemia , prostate , breast and lung cancer , head and neck cancer, soft tissue sarcomas and bladder cancer . Tumor initiation and progression are influenced by age, nutrition, sex, reproduction and environmental exposure. Canine models support the study of metastasis, disease recurrence and resistance patterns, with relevance to human cancers. [ 1 ]
Since 2009 some ten drugs have been developed in part based on studies with dogs. On July 3, 2019 FDA approved selinexor (Xpovio) for multiple myeloma patients who have failed five or more therapies. Verdinexor is the veterinary form of this drug. [ 3 ] It is under study for canine lymphoma and as a human antiviral therapy. [ 4 ]
Since cancer typically begins as a mutation in a single cell, risks should increase with the number of cells in an organism. Elephants carry 100 times as many cells as humans, while whales have ten times more than elephants. Both should experience higher cancer rates than humans. However, these species instead have few cancers. This situation is known as Peto's paradox . [ 5 ]
Around 50 MYA, mammals began living in the sea, later evolving into whales. They remained small until about 3 MYA when they reached sizes common to modern cetaceans . As whale sizes increased, tumour-suppressor genes increased in number and effect. [ 2 ]
33 tumour-suppressing genes have been identified in humpback whales . These include atr , which detects damage to DNA and halts cell division; amer1 , which slows cell growth; and reck , which limits metastasis . Humpbacks have multiple copies of genes that promote apoptosis . Gigantism in cetacea is associated with selective pressure in favor of tumor-suppressing genes. [ 2 ]
Cancer biologists are familiar with the atr , amer1 and reck genes because they are found in humans. Whales may also harbour tumour-fighting genes unknown in humans. [ 2 ]
Elephants have a cancer-mortality rate of about 5% (humans face 11–25%). Elephant genomes include tp53 , a gene that encodes apoptosis-inducing protein p53 . Humans have two copies of tp53 —one from each parent. If one copy is dysfunctional humans experience Li-Fraumeni syndrome , accompanied by cancer. By contrast, elephant chromosomes have 40 copies of tp53 . [ 2 ]
Elephant p53 appears to be more powerful than its human counterpart. One experiment involves lipid spheres loaded with proteins, including a synthetic form of elephant p53. [ 2 ]
Researchers are investigating cancer rates in 13,000 animal species, including 170,000+ specimens, including sponges that have no reported cancer. [ 2 ]
Tumour-suppressing genes have been identified in 65 species of mammal. Naked mole rats experience low cancer rates even though they are smaller than humans. Crocodiles and birds also experience low cancer rates. Birds may have inherited their resistance from their much larger dinosaur ancestors. [ 2 ]
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https://en.wikipedia.org/wiki/Comparative_oncology
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Compensatory hyperhidrosis is a form of neuropathy. It is encountered in patients with myelopathy , thoracic disease, cerebrovascular disease , nerve trauma or after surgeries. The exact mechanism of the phenomenon is poorly understood. It is attributed to the perception in the hypothalamus (brain) that the body temperature is too high. The sweating is induced to reduce body heat.
Excessive sweating due to nervousness , anger , previous trauma or fear is called hyperhidrosis .
Compensatory hyperhidrosis is the most common side effect of endoscopic thoracic sympathectomy , a surgery to treat severe focal hyperhidrosis , often affecting just one part of the body. It may also be called rebound or reflex hyperhidrosis . In a small number of individuals, compensatory hyperhidrosis following sympathectomy is disruptive, because affected individuals may have to change sweat-soaked clothing two or three times a day. [ 1 ] According to Dr. Hooshmand, sympathectomy permanently damages the temperature regulatory system. The permanent destruction of thermoregulatory function of the sympathetic nervous system causes latent complications, e.g., RSD in contralateral extremity. [ 2 ]
Following surgery for axillary (armpit), palmar (palm) hyperhidrosis (see focal hyperhidrosis ) and blushing , the body may sweat excessively at untreated areas, most commonly the lower back and trunk, but can be spread over the total body surface below the level of the cut. The upper part of the body, above the sympathetic chain transection, the body becomes anhidrotic, where the patient is unable to sweat or cool down, which further compromises the body's thermoregulation and can lead to elevated core temperature , overheating and hyperthermia . Below the level of the sympathetic chain interruption, body temperature is significantly lower, creating a stark contrast that can be observed on thermal images. The difference in temperatures between the sympathetically under- and overactive regions can be as high as 10 Celsius. [ citation needed ]
Gustatory sweating or Frey's syndrome is another presentation of autonomic neuropathy . [ 3 ] Gustatory sweating is brought on while eating, thinking or talking about food that produces a strong salivary stimulus. It is thought that ANS fibres to salivary glands have become connected in error with the sweat glands [ 4 ] after nerve regeneration . Apart from sweating in the anhidrotic area of the body, it can produce flushing , goosebumps , drop of body temperature - vasoconstriction and paresthesia . Aberrant gustatory sweating follows up to 73% of surgical sympathectomies [ 5 ] and is particularly common after bilateral procedures. Facial sweating during salivation has also been described in diabetes mellitus , cluster headache , following chorda tympani injury, and following facial herpes zoster . [ citation needed ]
Phantom sweating is another form of autonomic neuropathy. It can be observed in patients with nerve damage (following accidents), diabetes mellitus and as a result of sympathectomy. Phantom sweating is a sensation that one is sweating, while the skin remains dry. Affected people can not distinguish whether it is real sweating or just a sensation. The phenomenon is experienced in the anhidrotic, denervated area of the body, presenting an abnormal sympathetic nervous system function. [ 6 ]
The term 'compensatory' is largely misleading, as it indicates that there is a compensatory mechanism that takes effect after sympathectomy, in which the body 'redirects' the sweating from the palms or face to other areas of the body. Sweating after sympathetic surgery is a reflex cycle between the sympathetic system and the anterior portion of the hypothalamus. Reflex sweating will not happen if hand sweating can be stopped without interrupting sympathetic tone to the human brain . [ 7 ]
Compensatory hyperhidrosis is aberrant sympathetic nervous system functioning. The only study evaluating the total body sweat prior and shortly after sympathectomy concluded that patients produce more sweat after the surgery, just not so much in the areas treated by the surgery. [ 8 ]
Of people that have a sympathectomy, it is impossible to predict who will end up with a more severe version of this disorder, as there is no link to gender, age or weight. There is no test or screening process that would enable doctors to predict who is more susceptible. [ 9 ]
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https://en.wikipedia.org/wiki/Compensatory_hyperhidrosis
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Occlusion according to The Glossary of Prosthodontic Terms Ninth Edition is defined as "the static relationship between the incising or masticating surfaces of the maxillary or mandibular teeth or tooth analogues". [ 1 ]
When exploring different complete denture occlusal schemes, it is more useful to define occlusion as the relative movement of one object to another viz the dynamic relationship between mandible to the maxillae during function. Bilateral balanced occlusion and non-balanced occlusion are two separate entities that make up complete denture occlusion. Bilateral balanced occlusion is observed when simultaneous contacts achieved in both centric and eccentric positions. Non-balanced occlusion is seen when teeth do not occlude in simultaneous contacts. Both concepts will be explored in greater detail in the following article.
Historically, complete denture occlusion adopted a balanced occlusal scheme (i.e. balanced articulation: "the bilateral simultaneous occlusal contact of the anterior and posterior teeth in excursive movements" synonyms bilateral balanced occlusion. [ 1 ] Indeed, the bilateral balanced occlusion (BBO) scheme was adopted for reconstruction of dentate patients by both the gnathology school [ 2 ] working on the West Coast of America and the Pankey-Mann Schuyler group [ 2 ] [ 3 ] working on the East Coast of the United States [ 2 ] observed that using a balanced occlusion in dentate patients was suboptimal, in that this was associated this with restoration failure and cheek biting. There has been a gradual erosion for this approach for both dentate and edentulous patients.
Generally, complete denture occlusion should be influenced by patient satisfaction following a paternalistic shift in the provision of dental care. Besford et al. suggests that provision that complete denture anterior disclusion should be driven by patient's aesthetic preferences incorporating an overjet . He describes that there should be a shift from a standardized visual aesthetic and instead the appearance of the complete denture should enable patients to "regain their own personal imperfect dental identity", [ 4 ] disregarding any occlusal scheme. Notably, studies have found that canine guidance occlusion (CGO) has superior patient preference compared to Bilateral Balanced Occlusion (BBO). [ 5 ] [ 6 ]
Lemos et al. (2018) compared BBO to other occlusal schemes such as CGO and lingualized occlusion (LO). In this systematic review, they evaluated 18 studies with the aim of establishing which of the different occlusal schemes achieved higher patient satisfaction and masticatory performance. The results showed favourable outcomes from LO (five articles) for both these parameters. There was no significant difference between 'BBO and other schemes in terms of patient satisfaction and quality of life' in the remaining 13 articles. A possible explanation for this might be that LO penetrates the bolus better than BBO. From the patient's point of view, occlusal schemes are inconsequential compared to receiving the prosthesis. [ 7 ]
These can be categorized accordingly:
Gysi's geometrical concept underpinned bilateral occlusion schemes for both edentulous and dentate patients. Bizarrely, the theory was based on scratch-marks created using a simulated sharks' teeth model recorded on an opposing plaster cast .
From the above observation, 33° 'cuspal formed' teeth were introduced such that the cuspal inclination would be parallel with the condylar angle in the sagittal /horizontal plane when set-up mid-way between the condyle and incisors . The aim of this scheme was to achieve cuspal contact in excursive movements such that this would improve the stability of the prostheses in lateral excursions and direct forces towards the alveolar ridges .
Lingualized occlusion is defined as a form of denture occlusion that articulates the maxillary lingual cusps with the mandibular occlusal surfaces in centric, working, and non-working mandibular positions. [ 1 ] The concept of lingualized occlusion was again influenced by Gysi, when he designed a crossbite posterior teeth model concept. [ 8 ] He observed that more than half of edentulous patients at the University of Zurich had a posterior crossbite following normal physiological residual ridge resorption. In addition, a lingualised occlusion overcame the difficulties of setting up teeth in the prosthetic laboratory according to a bilateral balanced occlusion. [ 9 ] It is asserted, based on little evidence that this scheme should be adopted for patients with compromised alveolar bone .
'Linear occlusal concept' was introduced by Frush in 1967. In this, the mesiodistal ridge of the lower posterior teeth contacted the upper posterior teeth with flat occlusal surface in order to achieve balanced occlusion. He relied on the intraoral corrections to obtain balanced occlusion. Again, his main goal was to eliminate deflective occlusal contacts and therefore increase stability of the prostheses.
Dr. Max Pleasure introduced the 'Pleasure curve' where he used a reverse Curve of Monson in the premolar area therefore generating a 'lever' balance effect. This concept arose from observations of tooth wear in both human and primate dentitions. The first molars are flat in the horizontal plane and the second molars follow the Curve of Monson. Similarly, the first premolar teeth are shaped such that they have a reverse curve of Monson. The aim is the same as with all balanced occlusal schemes.
Non-anatomical teeth are set up according to curved occlusal plane both antero-posterior and laterally .
No discussion of bilateral balanced occlusion cannot acknowledge the fundamental contribution of Rudolph L. Hanau in 1925 when he presented a discussion paper entitled, "Articulation: Defined, analysed, and formulated .
Of note, Hanau was not a dentist , but rather an engineer . He believed articulation of artificial teeth was related to nine factors:
He embraced the above nine factors to achieve balanced occlusion using a staggering 44 statements. Subsequently, these were reduced to five factors (refer to the formula below) that make up the Classic Hanau's quint. The only shortcoming of the original diagram of the Hanau's quint is that Hanau suggested that the condylar guidance can be adjusted, and this created confusion for the others working in the field. There is a consensus that Hanau's contribution was central to evolution of the laws of articulation in order to achieve BBO.
Thielemann subsequently simplified Hanau's quint as illustrated to the following formula in order to achieve balanced articulation:
[K × I]/[OP × C × OK]
K = Condyle guidance, I = Incisal guidance, C = Cusp height inclinations, OP = Inclination of the occlusal plane, OK = Curvature of the occlusal surfaces.
Trapozzano then developed the triad of occlusion after carefully analysing Hanau's five factors of occlusion. He eliminated the plane of orientation and compensating curves from the Hanau's five main factors. The reason for this was because of the high variability of this plane within the available ridge space. Trapozzano also stated that there is no need for compensating curves as an alteration in the cuspal angles will result in balanced occlusion.
Then Boucher refined this further by arguing that three fixed factors are required to establish a balanced occlusion and are as following:
Clearly, when considering the sagittal plane only, increasing the condylar angle and the overbite , results in increased separation of the posterior units. Therefore, in order to achieve a balanced occlusion, the compensating curves must be greater.
In this scheme, the Lott concept is refined by recording 1) the condylar angle, the simplest method being positional records, 2) and the incisal angle, by incorporating aesthetic and phonetic requirements. Then, the most important tool to achieve bilateral balanced occlusion is the use of compensating curves. Use of monoplane of low cusp angled teeth are advised.
In this bilateral balanced occlusal scheme, the posterior teeth are set up at different angles in the coronal plane; 5° for the first premolar teeth , 10° for second premolar teeth , and 15° angle for both the first and second molar teeth . In addition, the occlusal surfaces of mandibular posterior teeth are reduced in a buccal lingual dimension with the aim of improving stability of, particularly the lower prosthesis .
Regardless which of the above occlusal schemes are adopted, it is difficult to achieve bilateral balanced occlusion in the prosthetic laboratory. Notwithstanding this, this aspiration of bilateral balanced occlusion is easier to achieve if the 'Buccal Upper Lingual Lower (BU-LL) and Mesial Upper -Distal Lower (MU-DL)' rules are adopted for adjusting cusps. When such are taken to the extreme, the resulting occlusal schemes are essentially the lingulized occlusal scheme, or the Frush linear occlusion.
All the concepts discuss the inclination of the condyle and the teeth in one orientation, predominantly in the sagittal direction. Establishing balanced occlusion bilaterally is difficult because any change in the angulation of the teeth or the curve in buccolingual direction will affect the anteroposterior angulation, hence the difficulty in establishing the balance occlusion inside the patient's mouth. There are many variables that may influence the outcome of balanced occlusion. One major variable that these concepts did not consider is the patient's neuromuscular adaptation for their new denture . Another point worthy of note is that the angle of the condyle in medial direction which also affects the direction of force . It is easy to establish the balanced occlusion on an articulator , but other variables come into play the moment the denture is inside the patient's mouth and this further affects the outcome of treatment.
The assumption that articulator movement is similar to mandibular movement formed the basis of balanced occlusion schemes. Gysi's geometric theories of non-functional movement formed the basis of modern concepts of balanced occlusion. The studies illustrate the geometric variety of rotation centre about its asymmetrical location. To achieve this result, he relays a symmetrical fixed rotation on the articulator assuming that this can be used and ideal for complex anatomical situations. Using this concept, the patient can be trained to open their mandible without movement in the condylar path, demonstrated by McCollum and this movement point located in the condyle, called hinge axis. [ 10 ] On the other hand, Dr Feinstein and Kurth could not find a definite hinge axis point and settled on a 2 mm area of nonmovement in the condylar region. [ 11 ] The right and left condyle have distinct size, shape and angulation. [ 12 ] Therefore, the value of hinge axis to determine or help in establishing balanced occlusion could be questioned. [ 10 ]
To remove occlusal interferences, Schuyler, introduced the BU-LL and MU-DL rule. This included reduction of the buccal cusp in the upper teeth and the lingual cusp of lower teeth in the frontal plane. Additionally, on the sagittal plane reductions are made on the mesial cusp for upper teeth and distal cusp of the lower teeth. Schuler developed this rule on an articulator whose movement is converse to the natural mandibular movement. [ 10 ]
One of the key factors in establishing the balanced occlusion is the assumption that condylar guidance of the patient is constant or fixed. [ 13 ] The path of the condyle is determined by the temporal bone and that cannot be changed. However, records can be altered on the articulator or when transferring occlusal records from the patient's mouth to the articulator. Subsequently, it is difficult to state that condylar guidance is constant, and this may affect the statement that it is the only fixed factor in establishing balanced occlusion. [ 10 ]
In conclusion, an ideal occlusion is set by various groups based on a hypothetical assumption. While, questioning this concept may be ignorant, criticizing this technique does not mean it does not work on a clinical level. Other studies show that there is another occlusion scheme that can be considered in place of the balanced occlusion. [ 7 ] [ 10 ]
Mammals have undergone extensive changes in terms of their occlusion over time. A factor which influenced this change was diet . Dietary adjustment from an abrasive to soft diet has made a major difference in function, enabling the human dentition to not work as hard as it was before. As people grow older, they lose their natural dentition due to physiological changes.
As a result of this, a full denture is required to restore their masticatory function. Patients and dentists both have a mutualistic, indispensable role in the construction of a fully functional denture, which include elements such as adequate retention, stability, extensions and aesthetic appearance. [ 14 ]
Apart from the balanced occlusion schemes as described above, other approaches for obtaining functional occlusion in complete dentures have been proposed. The concept of "Non-Balanced Occlusion" was based on the difficulty of achieving this, not only in the prosthetics laboratory, but for patients with displaceable mucosae . Then there is the much-quoted truism first cited by Boucher "Enter Bolus, Exit Balance"; whenever the patient masticates food on their working side, it negates the balance on the opposing side. [ 15 ] As a result, the Non-Balanced occlusion concept was conceived as an alternative to the balanced occlusion scheme.
Canine guidance occlusion/mutually protected/ cuspid protection is a concept that was introduced by Nagao in 1919. [ 16 ] It is defined as the contact of maxillary cuspids with the lower cuspids or premolars on all eccentric movements. [ 1 ] Support of the Cuspid Protected Occlusion (CPO) was made by early studies that showed predominance of innate CPO in mammals. [ 17 ] They also argued that the canine tooth possessed enhanced proprioception , thereby 'protecting' unfavourable forces on other teeth in the dentition . [ 18 ] There are parallels between Bilateral Balanced Occlusion (BBO) and canine guided occlusion in complete dentures in that there are simultaneous contacts in centric occlusion. The two concepts of occlusion in complete dentures differ during eccentric movements. Arguments for canine guided occlusion in complete dentures have been gaining momentum because of its ease of fabrication and better patient preference. [ 19 ]
There has been a presumption that canine guided occlusion in complete dentures promotes denture instability by introducing interferences during function. However, it has been shown that CPO has better patient preference for dental aesthetics compared with bilateral balanced occlusion. [ 20 ] Also, it has been argued that CPO reduces destructive lateral forces on the alveolar bone by promoting vertical chewing . [ 21 ] [ 20 ] As stated above, it has been reported that fabrication of dentures using cuspid protection occlusal scheme both realizable and less time-consuming compared to constructing dentures with bilateral balanced occlusion. [ 7 ] [ 19 ]
This occlusal scheme was first described by Dr. M. M. DeVan in 1951. [ 22 ] [ 23 ] Monoplane occlusion involves having non-anatomic denture teeth with a 0˚ incisal guidance angle, arranged on a flat occlusal plane. [ 1 ] As a consequence, when patients with monoplane occlusion occlude anteriorly, an interocclusal gap appears posteriorly. [ 24 ] [ 25 ] This is termed the 'Christensen phenomenon' [ 24 ] and forms the basis for categorising monoplane occlusion as non-balanced. Monoplane occlusion correspondingly requires having anterior teeth with no vertical overlap thus resulting in suboptimal dental aesthetics. [ 20 ] However, some studies have suggested that a monoplane occlusion can result in reduced masticatory ability. [ 20 ] [ 26 ]
DeVan rejected the concept of BBO because in function, the stability of the denture is lost. He therefore suggested that function can most satisfactorily be achieved by a neurocentric scheme adopting the following five factors:
Monoplane occlusion correspondingly requires having anterior teeth with no vertical overlap thus resulting in suboptimal dental aesthetics. [ 20 ] However, some studies have suggested that a monoplane occlusion can result in reduced masticatory ability. [ 20 ] [ 26 ] DeVan [ 22 ] argued that this occlusal scheme resulted in preservation of the alveolar bone .
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A complication in medicine , or medical complication, is an unfavorable result of a disease , health condition, or treatment . Complications may adversely affect the prognosis , or outcome, of a disease. Complications generally involve a worsening in the severity of the disease or the development of new signs, symptoms , or pathological changes that may become widespread throughout the body and affect other organ systems. Thus, complications may lead to the development of new diseases resulting from previously existing diseases. Complications may also arise as a result of various treatments.
The development of complications depends on a number of factors, including the degree of vulnerability, susceptibility, age , health status, and immune system condition. Knowledge of the most common and severe complications of a disease, procedure, or treatment allows for prevention and preparation for treatment if they should occur.
Complications are not to be confused with sequelae , which are residual effects that occur after the acute (initial, most severe) [ 1 ] phase of an illness or injury. Sequelae can appear early in the development of disease or weeks to months later and are a result of the initial injury or illness. For example, a scar resulting from a burn or dysphagia resulting from a stroke would be considered sequelae. [ 2 ] In addition, complications should not be confused with comorbidities , which are diseases that occur concurrently but have no causative association. Complications are similar to adverse effects , but the latter term is typically used in pharmacological contexts or when the negative consequence is expected or common.
Medical errors can fall into various categories listed below: [ 3 ]
Atrial fibrillation is a type of arrhythmia characterized by rapid and irregular heart rhythms due to irregular atrial activation by the atrioventricular (AV) node. [ 7 ] In the pathogenesis of atrial fibrillation, there is no effective pumping of blood into either the pulmonary or systemic circulation from the left ventricle of the heart. The left and right ventricles (lower chambers of the heart) do not fill properly due to the irregular contraction of the left and right atria (upper chambers of the heart). [ 7 ]
A patient with atrial fibrillation may experience symptoms of fatigue , dizziness or lightheadedness , heart palpitations , chest pain , and shortness of breath . [ 7 ] [ 8 ] The heart does not effectively pump blood into the pulmonary or systemic vasculature, and causes the blood to remain within the chambers of the heart. [ 8 ] [ 9 ] The collection of blood within the heart due to atrial fibrillation can cause and increase the risk of development of a thrombus (blood clot). [ 9 ] The thrombus can also develop into an embolus (mobile blood clot) and travel into the systemic circulation. [ 9 ] Atrial fibrillation is associated with an increase in risk of having a stroke especially if the embolus travels to the brain. [ 9 ]
Other examples
Diabetes mellitus , also known simply as diabetes, is a disorder of the regulation of blood glucose (a common type of sugar) levels. There are two types of chronic diabetes mellitus: type I and type II. Both lead to abnormally high levels of blood glucose as the body is not able to properly absorb the sugar into tissues. Diabetes requires a life-long consistent monitoring of food intake, blood sugar levels, and physical activity. Diabetes mellitus may present a series of complications in an advanced or more severe stage, such as:
Pregnancy is the development of an embryo or fetus inside the womb of a female for the rough duration of 9 months or 40 weeks from the last menstrual period until birth. [ 31 ] It is divided into three trimesters, each lasting for about 3 months. The first trimester is when the developing embryo becomes a fetus, organs start to develop, limbs grow, and facial features appear. [ 32 ] The 2nd and 3rd trimesters are marked by a significant amount of growth and functional development of the body. [ 31 ] During this time, the woman's body undergoes a series of changes and many complications may arise involving either the fetus, the mother, or both. [ 33 ]
Streptococcal pharyngitis , also known as strep throat, is an infection of the respiratory tract caused by group A Strep , Streptococcus pyogenes , a gram-positive, cocci, beta-hemolytic (lyses blood cells) bacteria. [ 42 ] It is primarily spread by direct contact and the transfer of fluids via oral or other secretions and manifests largely in children. [ 42 ] Common symptoms associated with streptococcal pharyngitis include sore throat, fever, white excretions at the back of the mouth, and cervical adenopathy (swollen lymph nodes underneath the chin and around the neck area). [ 43 ] Streptococcal pharyngitis can lead to various complications [ 44 ] and recurrent infection can increase the likelihood. In many of these, lack of treatment [ 45 ] and the body's immune response is responsible for the additional adverse reactions. [ 46 ] These include: [ 44 ]
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A component cause is an event or condition that contributes to the development of a disease , but is not sufficient on its own to cause the disease. Instead, it is part of a larger set of conditions, known as a "sufficient cause," that together result in the disease.
A component cause is a factor that, along with other component causes, forms a sufficient cause for a disease. A sufficient cause is a complete combination of component causes necessary for the disease to manifest. Diseases result from a chain of causally related events, starting from an initial event to the clinical appearance of the disease . No single antecedent event is sufficient on its own to cause the disease; each event is a part of the sufficient cause , making it a component cause.
The concept of component causes is part of the broader causal pie model proposed by epidemiologist Kenneth Rothman . [ 1 ] In this model, each disease is the result of multiple causal pies, each representing a combination of component causes. A single factor can be a component cause in multiple sufficient causes [ 2 ] for different diseases.
Understanding component causes is crucial for identifying intervention points to prevent disease. By recognizing and mitigating key component causes, public health initiatives can reduce the incidence of disease.
Consider lung cancer as an example. Smoking is a major component cause of lung cancer, but not everyone who smokes develops lung cancer. Other component causes might include genetic predisposition, other environmental factors, etc. Only when all necessary component causes are present does the sufficient cause of lung cancer come into play.
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Composite odontoma is a rare defect in humans in which a benign tumor forms in the mouth, generally as a result of the abnormal growth of a single tooth , causing additional teeth to form within the tumor. Most cases have been found in the upper jaw of patients. Unchecked growth of the tumor can make swallowing and eating difficult, and can also lead to grotesque facial swelling.
In most cases, surgery is required to remove the extra teeth and tumorous tissue. Prior to 2014, the maximum recorded number of teeth removed in such an operation was 37. However, in July 2014 Ashiq Gavai, a 17-year-old boy in India, suffered from an extreme case of composite odontoma in his lower jaw, which required the removal of more than 232 teeth altogether. The surgery was performed by Dr. Sunanda Dhiware at Sir J. J. Hospital in Mumbai, India . [ 1 ] [ 2 ] In July 2019, a 7-year-old boy in India had surgery to remove the 526 teeth that were in a "bag" in his lower jaw. The surgery was performed at the hospital of Chennai. [ 3 ]
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Comprehensive Psychiatry is a bimonthly peer-reviewed medical journal covering psychopathology . It was established in 1960 and is published by Elsevier . The editor-in-chief is Naomi Fineberg ( University of Hertfordshire ). According to the Journal Citation Reports , the journal has a 2017 impact factor of 2.128. [ 1 ]
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Comprehensive medication management (CMM) is the process of delivering clinical services aimed at ensuring a patient's medications (including prescribed, over-the-counter, vitamins, supplements and alternative) are individually assessed to determine that they have an appropriate reason for use, are efficacious for treating their respective medical condition or helping meet defined patient or clinical goals, are safe considering comorbidities and other medications being taken, and are able to be taken by the patient as intended without difficulty. [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]
CMM is generally delivered directly by a pharmacist in a clinic setting, in collaboration with other health care providers including primary care providers, nurse care coordinators, social workers, dietitians, diabetes educators, behavioral health, and more. Pharmacists who conduct CMM generally have a collaborative practice agreement with a physician at their site of practice, allowing them to prescribe and adjust medications for several chronic conditions including high blood pressure, diabetes, high cholesterol, asthma, chronic-obstructive pulmonary disease, anticoagulation management and smoking cessation among others. [ 6 ] [ 7 ]
Beyond assessing a patient's medications in their present state, the pharmacist delivering CMM will work with the patient to develop goals for the utilization of drug therapy, and schedule continual follow-up to ensure these goals are met. [ 4 ] [ 6 ] A key component of CMM is patient-centeredness, referring to the process by which the patient understands and agrees to the goals of therapy and actively participates in the plan for care. [ 5 ] [ 6 ]
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Compulsive talking (or talkaholism ) is talking that goes beyond the bounds of what is considered to be socially acceptable. [ 1 ] The main criteria for determining if someone is a compulsive talker are talking in a continuous manner or stopping only when the other person starts talking, and others perceiving their talking as a problem. Personality traits that have been positively linked to this compulsion include assertiveness , willingness to communicate, self-perceived communication competence, and neuroticism . [ 2 ] Studies have shown that most people who are talkaholics are aware of the amount of talking they do, but are unable to stop or do not see it as a problem. [ 3 ]
It has been suggested, through research done by James C. McCroskey and Virginia P. Richmond, that United States society finds talkativeness attractive. [ 4 ] It is something which is rewarded and positively correlated with leadership and influence. [ 1 ] However, those who compulsively talk are not to be confused with those who are simply highly verbal and vary their quantity of talk. Compulsive talkers are those who are highly verbal in a manner that differs greatly from the norm and is not in the person's best interest. [ 2 ] Those who have been characterized as compulsive talkers talk with a greater frequency, dominate conversations, and are less inhibited than others. [ 1 ] They have also been found to be more argumentative and have a positive attitude regarding communication. [ 1 ] Tendencies towards compulsive talking also are more frequently seen in the personality structure of neurotic psychotic extraverts. [ 5 ] It has also been found that talkaholics are never behaviorally shy. [ 4 ]
In 1993 James C. McCroskey and Virginia P. Richmond constructed the Talkaholic Scale, a Likert-type model, to help identify those who are compulsive talkers. A score of 40 or above, which indicates two standard deviations above the norm, would signal someone to be a true talkaholic. [ 2 ]
A study of 811 university students in the United States found 5.2% had results indicating they were talkaholics. A similar study of students from New Zealand found similar results, with 4.7% scoring above 40. [ 6 ]
Compulsive talking can drive people away, which in turn can leave that person with no social support. [ 7 ] Interrupting, another act that is associated with talkaholics, can signal to other people a lack of respect. [ 7 ]
According to Elizabeth Wagele , an author of best-selling books on personality types, there are different ways to handle compulsive talkers. Such coping techniques include changing the focus of the conversation, taking attention away from the talkaholic, leaving the conversation, and creating a distraction. [ 8 ]
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Compulsory sterilization , also known as forced or coerced sterilization , refers to any government-mandated program to involuntarily sterilize a specific group of people. Sterilization removes a person's capacity to reproduce, and is usually done by surgical or chemical means.
Purported justifications for compulsory sterilization have included population control , eugenics , limiting the spread of HIV , and ethnic genocide .
Forced sterilization can also occur as a form of racial discrimination. While not always mandated by law ( de jure ), there are cases where forced sterilization has occurred in practice ( de facto ). This distinction highlights the difference between official policies and actual implementation, where coerced sterilization take place even without explicit legal authorization.
Several countries implemented sterilization programs in the early 20th century. [ 1 ] Although such programs have been made illegal in much of the world, instances of forced or coerced sterilizations still persist.
Governmental family-planning programs emerged in the late 1800s, and have continued to progress through the 21st century. During this time, feminists began advocating for reproductive choice, but eugenicists and hygienists were advocating for low-income and disabled peoples to be sterilized or have their fertility tightly regulated, in order to "clean" or "perfect" nations. [ 2 ] [ 3 ] The second half of the 20th century saw national governments' uptake of neo-Malthusian ideology that directly linked population growth to increased (and uncontrollable) poverty, which, during the embrace of capitalism, meant that countries were unable to economically develop due to this poverty. [ citation needed ]
Much of these governmental population control programs were focused on using sterilization as the main avenue to reduce high birth rates, even though public acknowledgement that sterilization made an impact on the population levels of the developing world is still widely lacking. [ 4 ] Early population programs of the 20th century were marked as part of the eugenics movement, with Nazi Germany's programs providing the most well-known examples of sterilization of disabled people. [ 5 ] In the 1970s, population control programs focused on the "third world" to help curtail over population of poverty areas that were beginning to "develop" (Duden 1992).
As of 2013, 24 countries in Europe required sterilization for legal gender recognition and 16 countries did not provide for any possibility to change legal gender at all, which meant that transgender people could have challenges applying for jobs, opening bank accounts, boarding planes, or may not be able to do these things at all. [ 6 ] Disabled women in Europe are also common targets of forced sterilization. "'So many times, you hear it’s in the best interest of the woman,' said Catalina Devandas Aguilar , a former United Nations special rapporteur for disability rights. 'But often, it’s because it’s more convenient for the family or the institution that takes care of them.'" [ 7 ]
On 1 February 2013, the United Nations Special Rapporteur on Torture (SRT) issued a report on abusive practices in health care settings that has important implications for LGBT people and people with intersex conditions. In section 88, the SRT says States should:
repeal any law allowing intrusive and irreversible treatments, including forced genital-normalizing surgery, involuntary sterilization, unethical experimentation, medical display, "reparative therapies" or "conversion therapies", when enforced or administered without the free and informed consent of the person concerned. He also calls upon them to outlaw forced or coerced sterilization in all circumstances and provide special protection to individuals belonging to marginalized groups. [ 8 ]
In May 2014, the World Health Organization , OHCHR , UN Women , UNAIDS , UNDP , UNFPA , and UNICEF issued a joint statement on "Eliminating forced, coercive, and otherwise involuntary sterilization". The report references the involuntary sterilization of a number of specific population groups. [ citation needed ] They include:
The report recommends a range of guiding principles for medical treatment, including ensuring patient autonomy in decision-making, and ensuring non-discrimination, accountability, and access to remedies. [ 12 ] Scholars have also emphasized the importance of including the voices and stories of those that have been affected. [ 13 ]
Human population planning is the practice of artificially altering the rate of growth of a human population. Historically, human population planning has been implemented by limiting the population's birth rate , usually by government mandate, and has been undertaken as a response to factors including high or increasing levels of poverty , environmental concerns , religious reasons, and overpopulation . While population planning can involve measures that improve people's lives by giving them greater control of their reproduction, some programs have exposed them to exploitation. [ 14 ]
In the 1977 textbook Ecoscience: Population, Resources, Environment , authors Paul and Anne Ehrlich, and John Holdren discuss a variety of means to address human overpopulation, including the possibility of compulsory sterilization. [ 15 ] This book received renewed media attention with the appointment of Holdren as Assistant to the President for Science and Technology, Director of the White House Office of Science and Technology Policy , largely from conservative pundits who have published scans of the textbook online. [ 16 ] Several forms of compulsory sterilization are mentioned, including the proposal for vasectomies for men with three or more children in India in the 1960s, [ 17 ] sterilizing women after the birth of their second or third child, birth control implants as a form of removable, long-term sterilization, a licensing system allotting a certain number of children per woman, [ 18 ] economic and quota systems of having a certain number of children, [ 19 ] and adding a sterilant to drinking water or food sources, although the authors are clear that no such sterilant exists nor is one in development. [ 20 ] The authors state that most of these policies are not in practice, have not been tried, and most will likely "remain unacceptable to most societies." [ 20 ]
Holdren stated in his confirmation hearing that he no longer supports the creation of an optimum population by the U.S. government. [ 21 ] However, the population control policies suggested in the book are indicative of the concerns about overpopulation , also discussed in The Population Bomb a book written by Paul R. Ehrlich and Anne Ehrlich predicting major societal upheavals due to overpopulation . As this concern about overpopulation gained political, economic, and social currency, attempts to reduce fertility rates, often through compulsory sterilization, were results of this drive to reduce overpopulation. [ 22 ] These coercive and abusive population control policies impacted people around the world in different ways, and continue to have social, health, and political consequences, one of which is lasting mistrust in current family planning initiatives by populations who were subjected to coercive policies like forced sterilization. [ 23 ] Population control policies were widely critiqued by women's health movement in the 1980s and 1990s, with the International Conference on Population and Development in 1994 in Cairo initiating a shift from population control to reproductive rights and the contemporary reproductive justice movement. [ 24 ] [ 25 ] However, new forms of population control policies, including coercive sterilization practices are a global issue and a reproductive rights and justice issue. [ 26 ]
The Istanbul Convention prohibits forced sterilization in most European countries (Article 39). [ 27 ] Widespread or systematic forced sterilization has been recognized as a Crime against Humanity by the Rome Statute of the International Criminal Court in the explanatory memorandum. This memorandum defines the jurisdiction of the International Criminal Court . [ 28 ] [ 29 ] It does not have universal jurisdiction, with the United States, Russia and China among the countries to exclude themselves. [ 30 ] Rebecca Lee wrote in the Berkeley Journal of International Law that, as of 2015 [update] , twenty-one Council of Europe member states require proof of sterilization in order to change one's legal sex categorization. Lee wrote that requiring sterilization is a human rights violation and that LGBTQ-specific international treaties may need to be developed in order to protect LGBTQ human rights. [ 31 ]
Bangladesh has a long-running government-operated civilian sterilization program as a part of its population control policy, which targets mainly poor women and men. The government offers 2,000 Bangladeshi Taka (US$18) for women who are persuaded to undergo tubal ligation and for men who are persuaded to undergo vasectomy . Women are also offered a sari and men are offered a kurta to wear for undergoing sterilization. The referrer, who persuades the woman or man to undergo sterilization gets 300 Bangladeshi Taka (US$2.70). [ 32 ]
In 1965, the targeted number of sterilizations per month was 600–1,000 in contrast to the insertion of 25,000 IUDs , which was increased in 1978 to about 50,000 sterilizations per month on average. [ 33 ] A 50% rise in the amount paid to men coincided with a doubling of the number of vasectomies between 1980 and 1981. [ 34 ]
One study conducted in 1977, when incentives were only equivalent to US$1.10 (at that time), indicated that between 40% and 60% of the men chose vasectomy because of the payment, who otherwise did not have any serious urge to get sterilized. [ 35 ]
The "Bangladesh Association for Voluntary Sterilization", alone performed 67,000 tubal ligations and vasectomies in its 25 clinics in 1982. The rate of sterilization increased 25 percent each year. [ 36 ]
On 16 December 1982, Bangladesh's military ruler Lieutenant General Hussain Muhammad Ershad launched a two-year mass sterilization program for Bangladeshi women and men. About 3,000 women and men were planned to be sterilized on 16 December 1982 (the opening day). Ershad's government trained 1,200 doctors and 25,000 field workers who must conduct two tubal ligations and two vasectomies each month to earn their salaries. The government wanted to persuade 1.4 million people, both women and men to undergo sterilization within two years. [ 37 ] One population control expert called it 'the largest sterilization program in the world'. [ 38 ] By January 1983, 40,000 government field workers were employed in Bangladesh's 65,000 villages to persuade women and men to undergo sterilization and to promote usage of birth-control across the country. [ 36 ]
Food subsidies under the group feeding program (VGF) were given to only those women with certificates showing that they had undergone tubal ligation. [ 39 ]
There are reports that often when a woman had to undergo a gastrointestinal surgery , doctors took this opportunity to sterilize her without her knowledge. [ 40 ] According to Bangladesh governmental website "National Emergency Service", the 2000 Bangladeshi Taka (US$24) and the sari/lungi given to the persons undergoing sterilizations are their " compensations ". Where Bangladesh government also assures the poor people that it will cover all medical expenses if complications arise after the sterilization. [ 41 ]
For the women who are persuaded to have an IUD inserted into their uterus , the government also offers 150 Bangladeshi Taka (US$1.80) after the procedure and 80+80+80=240 Bangladeshi Taka (0.96+0.96+0.96=2.88 USD) in three followups, where the referrer gets 50 Bangladeshi Taka (US$0.60). For the women who are persuaded to have an etonogestrel birth control implant placed under the skin in their upper arm, the government offers 150 Bangladeshi Taka (US$1.80) after the procedure and 70+70+70=210 Bangladeshi Taka (0.84+0.84+0.84=2.52 USD) in three followups, where the referrer gets 60 Bangladeshi Taka (US$0.72). [ 32 ]
In the 1977 study, a one-year follow-up of 585 men sterilized at vasectomy camps in Shibpur and Shalna in rural Bangladesh showed that almost half of the men were dissatisfied with their vasectomies. [ citation needed ]
58% of the men said their ability to work had decreased in the last year. 2–7% of the men said their sexual performance decreases. 30.6% of the Shibpur and 18.9% of the Shalna men experienced severe pain during the vasectomy. The men also said they had not received all of the incentives they had been promised. [ 35 ]
According to another study on 5042 women and 264 men who underwent sterilization, complications such as painful urination, shaking chills, fever for at least two days, frequent urination, bleeding from the incision, sore with pus, stitches or skin breaking open, weakness and dizziness arose after the sterilization. [ citation needed ]
The person's sex, the sponsor and workload in the sterilization center, and the dose of sedatives administered to women were significantly associated with specific postoperative complaints. Five women died during the study, resulting in a death-to-case rate of 9.9/10,000 tubectomies (tubal ligations); four deaths were due to respiratory arrest caused by overuse of sedatives. The death-to-case rate of 9.9/10,000 tubectomies (tubal ligation) in this study is similar to the 10.0 deaths/10,000 cases estimated on the basis of a 1979 follow-up study in an Indian female sterilization camp. The presence of a complaint before the operation was generally a good predictor of postoperative complaints. Centers performing fewer than 200 procedures were associated with more complaints. [ 42 ]
According to another study based on 20 sterilization-attributable deaths in Dacca (now Dhaka) and Rajshahi Divisions in Bangladesh, from 1 January 1979, to 31 March 1980, overall, the sterilization-attributable death-to-case rate was 21.3 deaths/100,000 sterilizations. The death rate for vasectomy was 1.6 times higher than that for tubal ligation. Anesthesia overdosage was the leading cause of death following tubal ligation along with tetanus (24%), where intraperitoneal hemorrhage (14%), and infection other than tetanus (5%) was other leading causes of death. [ citation needed ]
Two women (10%) died from pulmonary embolism after tubal ligation; one (5%) died from each of the following: anaphylaxis from anti-tetanus serum, heat stroke , small bowel obstruction , and aspiration of vomitus. All seven men died from scrotal infections after vasectomy. [ 43 ]
According to a second epidemiologic investigation of deaths attributable to sterilization in Bangladesh, where all deaths resulting from sterilizations performed nationwide between 16 September 1980 and 15 April 1981, were investigated and analyzed, nineteen deaths from tubal ligation were attributed to 153,032 sterilizations (both tubal ligation and vasectomy), for an overall death-to-case rate of 12.4 deaths per 100,000 sterilizations. This rate was lower than that (21.3) for sterilizations performed in Dacca (now Dhaka) and Rajshahi Divisions from 1 January 1979 to 31 March 1980, although this difference was not statistically significant. Anesthesia overdosage, tetanus, and hemorrhage (bleeding) were the leading causes of death. [ 44 ]
These civilian sterilization programs are funded by the countries from northern Europe and the United States . [ 40 ] World bank is also known to have sponsored these civilian exploitative sterilization programs in Bangladesh. Historically, World Bank is known to have pressured 3rd World governments to implement population control programs. [ 45 ]
Bangladesh has the highest population density in the world among the countries having at least 10 million people. The capital Dhaka is the 4th most densely populated city in the world, which ranked as the world's 2nd most unlivable city, just behind Damascus , Syria , according to the annual " Liveability Ranking " 2015 by the Economist Intelligence Unit (EIU). [ 46 ] [ 47 ]
Bangladesh is planning to introduce a sterilization program in its overcrowded Rohingya refugee camps, where nearly a million refugees are fighting for space, after efforts to encourage birth control failed. Since 25 August 2017, more than 600,000 Rohingya Muslims have fled from Rakhine state , Myanmar to neighboring Bangladesh, which is a Muslim majority country, following a military crackdown against Rohingya Muslims in Rakhine. Sabura, a Rohingya mother of seven, said her husband believed the couple could support a large family. [ 48 ]
I spoke to my husband about birth control measures. But he is not convinced. He was given two condoms but he did not use them. My husband said we need more children as we have land and property (in Rakhine). We don't have to worry to feed them.
District family planning authorities have managed to distribute just 549 packets of condoms among the refugees, amid reports they are reluctant to use them. They have asked the government to approve a plan to provide vasectomies for men and tubectomies (tubal ligation) for women in the camps. [ 48 ]
One volunteer, Farhana Sultana, said the women she spoke to believed birth control was a sin and others saw it as against the tenets of Islam. [ 48 ]
Bangladeshi officials say about 20,000 Rohingya refugee women are pregnant and 600 have given birth since arriving in the country, but this may not be accurate as many births take place without formal medical help. [ 48 ]
Every month 250 Bangladeshis undergo sterilization routinely under the government's sterilization program in the border district of Cox's Bazar , where the Rohingya refugee Muslims have taken shelter. [ 48 ] [ 49 ]
During the 1970s–80s, the U.S. government sponsored family planning campaigns in Brazil, although sterilization was illegal at the time there. [ 50 ] Dalsgaard examined sterilization practices in Brazil; analyzing the choices of women who opt for this type of reproductive healthcare in order to prevent future pregnancies and so they can accurately plan their families. [ 51 ] While many women choose this form of contraception, there are many societal factors that impact this decision, such as poor economic circumstances, low rates of employment, and Catholic religious mandates that stipulate sterilization as less harmful than abortion. [ 52 ]
An important case in the legal history of compulsory sterilization in Brazil is the 2018 São Paulo case. [ 53 ] Prosecutors filed to have a mother of eight forcibly sterilized after she was arrested on charges of drug trafficking. [ 54 ] This motion was justified by the mother's poverty, substance abuse disorder, and inability to care for her children, and the judge ruled in favor of sterilization. [ 55 ] The surgery was carried out, reportedly against the woman's will. [ 54 ] Legal experts discussing the case have stated the sterilization of a woman in Brazil is legal when determined absolutely necessary, but it is not clear what qualifies as necessary. [ 54 ]
Compulsory sterilization in Canada of individuals deemed mentally unfit or "socially inadequate" was widespread in the early to mid-20th century. [ 56 ] The belief was that by preventing these individuals from reproducing, society would be protected from the perceived negative impact of their genes. This led to compulsory sterilization of thousands of people, many of whom were Indigenous women, individuals with disabilities, and those deemed to have "undesirable" traits. [ 57 ]
The legal basis for compulsory sterilization in Canada can be traced back to the passage of the Sexual Sterilization Act in Alberta in 1928. [ 58 ] This legislation allowed for the sterilization of individuals deemed mentally deficient or mentally ill without their consent. [ 58 ] Similar legislation existed in British Columbia, although records on sterilizations there are incomplete. [ 59 ] Additionally, sterilizations occurred in Saskatchewan, Quebec, Manitoba, Ontario and other regions without specific legal frameworks. [ 60 ] [ 61 ] [ 62 ] These laws remained in place until the 1970s, when public opinion began to shift and the practice was eventually deemed unethical and inhumane. [ 63 ]
In 1978, Chinese authorities became concerned with the possibility of a baby boom that the country could not handle, and they initialized the one-child policy . In order to effectively deal with the complex issues surrounding childbirth, the Chinese government placed great emphasis on family planning. Because this was such an important matter, the government thought it needed to be standardized, and so to this end laws were introduced in 2002. [ 67 ] These laws uphold the basic tenets of what was previously put into practice, outlining the rights of the individuals and outlining what the Chinese government can and cannot do to enforce policy.
However, accusations have been raised from groups such as Amnesty International , who have claimed that practices of compulsory sterilization have been occurring for people who have already reached their one child quota. [ 67 ] These practices run contrary to the stated principles of the law, and seem to differ on a local level.
The Chinese government appears to be aware of these discrepancies in policy implementation on a local level. For example, The National Population and Family Planning Commission put forth in a statement that, "Some persons concerned in a few counties and townships of Linyi did commit practices that violated law and infringed upon legitimate rights and interests of citizens while conducting family planning work." This statement comes in reference to some charges of forced sterilization and abortions in Linyi city of Shandong Province. [ 68 ]
The policy requires a "social compensation fee" for those who have more than the legal number of children. According to Forbes editor Heng Shao, critics claims this fee is a toll on the poor but not the rich. [ 69 ] But after 2016, the country has allowed parents to give birth to two children . In 2017, the government offered to surgically remove the IUDs that had been implanted in women to force them to adhere to the one child policy, if they qualified to have a second child. The removal of these long used IUDs is a major surgery and many women are not informed of the risks that are associated with the surgery, such as bleeding, infection, and removal of the uterus. [ 70 ]
Beginning in 2019, reports of forced sterilization in Xinjiang began to surface. [ 71 ] [ 72 ] [ 73 ] In 2020, public reporting continued to indicate that large-scale compulsory sterilization was being carried out. [ 74 ] [ 75 ] While national sterilization rates have fallen since the passing of the two child policy in 2016, there has been a sharp increase in the amount of sterilizations in Xinjiang. [ 76 ] Many of these surgeries have been forced according to reports, but this is difficult to confirm due to the closed off nature of the area. [ 76 ] These measures have sometimes been characterised as part of an ongoing Uyghur genocide in the province.
Czechoslovakia carried out a policy to sterilize Romani women, starting in 1973 continuing through the Velvet Revolution of 1989. In some cases, the sterilization was in exchange for social welfare benefits, and the people who were affected were given written agreements which described what was to be done to them, but which they were unable to read due to their illiteracy. [ 77 ] The dissidents of the Charter 77 movement denounced these practices in 1977–78 as a genocide . [ 78 ] A 2005 report by the Czech government's independent ombudsman, Otakar Motejl , identified dozens of cases of coercive sterilization between 1979 and 2001, and called for criminal investigations and possible prosecution against several healthcare workers and administrators. [ 79 ]
Beginning 2012 undergoing sterilization is a requirement for change of name and/or gender markers on official documents for all transgender people in Czechia. [ 80 ] In May 2024 the constitutional court found the laws requiring sterilization to be in violation of EU human rights laws. The court established a deadline of June 2025 where the current government is to draft replacement laws. [ 81 ]
The time period of 1964–1970 started Colombia's population policy development, including the foundation of PROFAMILIA and through the Ministry of Health the family planning program promoted the use of IUDs, the Pill, and sterilization as the main avenues for contraception. By 2005, Colombia had one of the world's highest contraceptive usage rates at 76.9%, with female sterilization being the highest percentage of use at just over 30% (second highest is the IUD at around 12% and the pill around 10%) [ 82 ] (Measham and Lopez-Escobar 2007). In Colombia during the 1980s, sterilization was the second most popular choice of pregnancy prevention (after the Pill), and public healthcare organizations and funders (USAID, AVSC, IPPF) supported sterilization as a way to decrease abortions rates. While not directly forced into sterilization, women of lower socio-economic standing had significantly less options to afford family planning care as sterilizations were subsidized. [ 50 ]
11,000 people were sterilized in Denmark from 1929–67, about half were sterilized against their will. [ 83 ] The forced sterilization program was "mainly was directed at people who were mentally handicapped" because of the popularity of eugenics at the time in Denmark. [ 83 ] During the 1960s and 1970s, thousands of Greenlandic Inuit women and girls had IUDs placed without their consent. The birth rate in Greenland was reduced by around 50%. In 2022, Denmark and Greenland agreed to hold a two-year investigation into the program, known as the spiral case . [ 84 ]
Until 11 June 2014, sterilization was requisite for legal sex change in Denmark. [ 85 ] [ 86 ] [ 87 ]
Finland required forced sterilization for adults to legally change their sex, until 3 April 2023 [ 88 ]
One of the first acts by Adolf Hitler after the Reichstag Fire Decree and the Enabling Act of 1933 gave him de facto legal dictatorship over the German state was to pass the Law for the Prevention of Hereditarily Diseased Offspring ( Gesetz zur Verhütung erbkranken Nachwuchses ) in July 1933. [ 89 ] [ 90 ] The law was signed by Hitler himself, and over 200 eugenic courts were created specifically as a result of this law. Under it, all doctors in the Third Reich were required to report any patients of theirs who were deemed intellectually disabled , characterized mentally ill (including schizophrenia and manic depression ), epileptic , blind, deaf, or physically deformed, and a steep monetary penalty was imposed for any patients who were not properly reported. Individuals with alcoholism or Huntington's disease could also be sterilized. The individual's case was then presented in front of a court of Nazi officials and public health officers who would review their medical records, take testimony from friends and colleagues, and eventually decide whether or not to order a sterilization operation performed upon the individual, using force if necessary. Though not explicitly covered by the law, 400 mixed-race " Rhineland Bastards " were also sterilized beginning in 1937. [ 91 ] [ 92 ] [ 93 ] The sterilization program went on until the war started, with about 600,000 people sterilized. [ 94 ]
By the end of World War II , over 400,000 individuals were sterilized under the German law and its revisions, most within its first four years of being enacted. When the issue of compulsory sterilization was brought-up at the Nuremberg trials after the war, many Nazis defended their actions on the matter by indicating that it was the United States itself from which they had taken inspiration. The Nazis had many other eugenics-inspired racial policies , including their T-4 euthanasia program , in which around 70,000 people who were institutionalized or had birth defects were killed. [ 95 ]
Guatemala is one country that resisted family planning programs, largely due to lack of governmental support, including civil war strife, and strong opposition from both the Catholic Church and Evangelical Christians until 2000, and as such, has the lowest prevalence of contraceptive usage in Latin America. In the 1980s, the archbishop of the country accused USAID of mass sterilizations of women without consent, but a President Reagan backed commission found the allegations to be false. [ 96 ]
Since 2019, nonconsensual sterilization is forbidden in Iceland unless deemed medically necessary. However, this law only addresses the procedures of tubal ligation and surgical blocking of the fallopian tubes, excluding hysterectomies from the ban. Iceland's laws surrounding legalization of sterilization practices also do not address consent of the disabled individuals undergoing these procedures. In March 2023, mother Hermina Hreidarsdottir authorized a hysterectomy for her severely cognitively impaired 20-year-old daughter due to her abnormal menstrual cycle. Ms. Hreidarsdottir took liberty of this decision for her daughter without consulting her because she believed that this sterilization procedure would improve her daughter's quality of life. [ 7 ]
The Emergency in India from 1975 and 1977 resulted from internal and external conflict for the country, and resulted in misuse of power and human rights violations from the government. [ 97 ] On 6 August 1976, the state of Maharashtra became the first governmental unit to enact legislation mandating compulsory sterilization of men and women after the birth of a third child, passing the Family (Restrictions on Size) Bill on its third reading and sending it to the President of India for the required assent. The President reacted favorably and sent the bill back to the Maharashtra government with suggested amendments that would be necessary for an enactment, but before the measure could be passed, new elections were called and the legislation was not passed. [ 98 ]
Stopping short of forced sterilization, the national government enacted an incentive program for a family planning initiative that began in 1976 in an attempt to lower the exponentially increasing population. This program focused on male citizens and used propaganda and monetary incentives to impoverished citizens to get sterilized. [ 99 ] People who agreed to get sterilized would receive land, housing, and money or loans. [ 100 ] This program led millions of men to receive vasectomies, and an undetermined amount of these were coerced. There were reports of officials blocking off villages and dragging men to surgical centers for vasectomies. [ 101 ] However, after much protest and opposition, the country switched to targeting women through coercion, withholding welfare or ration card benefits, and bribing women with food and money. [ 102 ] This switch was theorized to be based on the principle women are less likely to protest for their own rights. [ 101 ] Many deaths occurred as a result of both the male and the female sterilization programs. [ 101 ] These deaths were likely attributed to poor sanitation standards and quality standards in the Indian sterilization camps.
Sanjay Gandhi , son of the then-Prime Minister Indira Gandhi , was largely responsible for what turned out to be a failed program. [ 97 ] A strong mistrust against family planning initiatives followed the highly controversial program, the effect of which continues into the 21st century. [ 103 ] Sterilization policies are still enforced in India, targeting mostly indigenous and lower-class women who are herded into the sterilization camps. [ 102 ] The most recent abuse of family planning systems was highlighted by the death of 15 lower-class women in a sterilization center in Chhattisgarh in 2014. [ 102 ] Despite these deaths, sterilization is still the highest used method of birth control with 39% of women in India turning to sterilization in 2015. [ 104 ]
According to Human Rights Law Network :
In September 2016, the Supreme Court of India directed the Union Government to ensure the discontinuation of 'sterilization camps' within the following three years and to induce the state governments to follow suit. It also charged the government to ensure proper monitoring of the programme, investigate sterilization failures, complications or deaths, and increase the compensation amount in these cases. It further ordered the implementation of established legal, medical and technical standards for sterilization [...] Women were made to lay on bare mattresses for the surgeries, with no post-surgery recuperation facilities. Often the women were made to wait up to five hours after registering, and by the time they reached the operating table their an aesthetic would have worn off. In places like Bhubaneshwar, Odisha and Ferozpur, Uttar Pradesh, the doctors conducting surgeries would use bicycle pumps instead of an insufflator, to introduce air into the women's abdomens (as reported by Shreelatha Menon). The doctor in Bhubaneshwar stated that he had done over 60,000 tubectomies and many of them with bicycle pumps. In Kaparfora, Bihar, a woman was operated upon, even though she was pregnant, and suffered a miscarriage as a result. [...] Today, while laws may not announce eugenic aims, hidden agenda to dispose of "undesirables" in society can still be discovered by looking beyond the face of the law. While many population control policies may appear benign on their face, upon further investigation the stated medical reasons for sterilization and the identification of groups to which the law applies are revealed to be morally and legally suspect. For example, compulsory sterilization law laws often target LGBT+ people, especially transgender people. [ 105 ] [ excessive quote ]
Forced sterilization has been an issue that has also affected the disabled population of women in India . In 2016, the Right to Persons with Disabilities Act (RPWD) was introduced to legally address the problems faced by the disabled community and ensure equitable access to justice for all members of society: [ 106 ]
"While the RPWD Act took a step towards recognizing the issue of forced abortions under Section 92(f)[1] which states that any medical procedure performed on a disabled woman without her express consent that leads to the termination of pregnancy is punishable with an imprisonment term, there is still no specific mention of forced sterilization as a problem." [ 107 ]
There is no clause in the RPWD that addresses the notion of "expressed consent." [ 106 ] Consent in relation to family planning and sterilization practices has been a point of contention in India's history of reproductive justice of disabled individuals.
In the late 2000s, reports in the Israeli media claimed that injections of long-acting contraceptive Depo-Provera (the effects of which are temporary, lasting only 3 months) [ 108 ] had been forced on hundreds of Ethiopian-Jewish immigrants both in transit camps in Ethiopia and after their arrival in Israel. [ 109 ] In 2009, feminist NGO Haifa Women's Coalition published a first survey on the story, which was followed up by Israeli Educational Television a few years later. [ 110 ] Ethiopian-Jewish women said they were intimidated or tricked into taking the shot every three months. [ citation needed ] In 2013, the Israeli Health Ministry instructed HMOs to stop automatically renewing Depo-Provera prescriptions for Ethiopian-Israelis if there was any chance that the patients did not fully understand the implications of the treatment. [ 111 ]
In the first part of the reign of Emperor Hirohito, Japanese governments promoted increasing the number of healthy Japanese, while simultaneously decreasing the number of people who were afflicted with mental retardation, disability, genetic disease, and other conditions that led to inferiority in the Japanese genepool. [ 112 ] [ 113 ]
The Leprosy Prevention laws of 1907, 1931, and 1953 permitted the segregation of patients in sanitariums where forced abortions and sterilization were common, and authorized punishment of patients "disturbing peace". [ 114 ] Under the colonial Korean Leprosy prevention ordinance , Korean patients were also subjected to hard labor. [ 115 ]
The "National Eugenic Law" was promulgated in 1940 by the Konoe government, after rejection of the original "Race Eugenic Protection Law" in 1938. [ 112 ] From 1940 to 1945, sterilization was done to 454 Japanese persons under this law. Appx. 25,000 people, including 8,500 under (forced or spontaneous) consent, were surgically processed until 1995. [ 116 ]
According to the Eugenic Protection Law (1948), sterilization could be enforced upon criminals "with genetic predisposition to commit crime", patients with genetic diseases including mild ones such as total color-blindness, hemophilia , albinism , ichthyosis , and mental affections such as schizophrenia, manic-depression possibly deemed occurrent in their opposition and epilepsy. [ 117 ] The mental sicknesses were added in 1952.
In early 2019, Japan's supreme court upheld a requirement that transgender people must have their reproductive organs removed. [ 118 ] [ 119 ] [ 120 ]
In March 2019, Japan's legal policy about transgender people was:
In Japan, transgender people who want to legally change their gender must appeal to a family court under the GID Act, which was introduced in 2004. The procedure is discriminatory, requiring applicants to be single and without children under age 20, to undergo a psychiatric evaluation to receive a diagnosis of "gender identity disorder," and to be sterilized. The requirements rest on an outdated and pejorative notion that a transgender identity is a mental health condition, and compel transgender people to undergo lengthy, expensive, invasive, and irreversible medical procedures. [ 121 ] [ 120 ] [ 122 ]
The last stipulation of the GID Act concerning forced sterilization was recently overturned in October 2023. Japan’s supreme court ruled that requiring transgender people to undergo sterilization so that they can legally change their gender identity is unconstitutional. The court stated that forcing the sterilization of the plaintiff, a transgender woman, as a requirement to change her gender on her Japanese family registry certificate was a restriction on "her freedom not to harm herself against her will". [ 123 ] The court did not address the other requirement under the GID Act, which outlines that transgender people must undergo transition surgery in order to legally register as the gender with which they identify. [ 123 ]
In July 2024, the Supreme Court of Japan ruled that the Eugenic Protection Law passed in 1948 was unconstitutional, and eliminated the 20-year statute of limitations for those affected by the law. [ 124 ] [ 125 ]
In Kenya, HIV was considered an ongoing issue, and the governor believed that compulsory sterilization of women infected with HIV could stop the spread of the virus. In 2012, a report titled "Robbed of Choice" sparked outrage. The report outlined the experiences of 40 women infected with HIV that had been sterilized against their will. 5 of the 40 women filed a lawsuit against the government of Kenya, claiming violations of their Health and Human Rights. [ 126 ] [ 127 ] The majority of the women who were sterilized knew nothing about the procedure or its consequences, which was one reason they did not push the issue. The President thought it would be good to keep a list of women who had been infected with HIV, but by naming these women, many of them did not to want to receive medical treatment due to the shame associated with the virus. "The authors concluded that punitive and restrictive laws related to pregnancy have numerous adverse consequences—both health-related and socioeconomic—for women, and urged human rights groups to work with government institutions to protect and fulfill women's fundamental reproductive rights." [ 126 ] [ 127 ]
Laws in Ghana, Nigeria, and Tanzania involve references to medical operations where the intended benefit for the patient is not tied to any legal consequences for medical professionals involved. Specifically, the criminal Code of Nigeria States that: “Performing with good faith and with reasonable care and skill a surgical operation upon any person for his benefit, if the performance of the operation is reasonable, having regard to the patient’s state and to all the circumstances of the case.” [ 128 ]
In Nigeria, young girls with intellectual disabilities are susceptible to non consensual sterilization. No current laws explicitly prevent involuntary sterilization. And the laws that currently surround and may apply to the issue are not helpful in preventing it. The African Commission on Human and People’s Rights declared that involuntary sterilization violates the right to “equality and non-discrimination, dignity, liberty and security of the person.” [ 129 ]
Involuntary sterilization in Nigeria is more common for girls with intellectual disabilities than for boys with intellectual disabilities and more common for those with intellectual disabilities specifically in comparison to other disabilities. Involuntary sterilization commonly occurs when relatives initiate it. In several studies involving parents of girls with disabilities who had initiated involuntary sterilization, respondents said that the primary reason for sterilization was to prevent pregnancy either for financial reasons or due to risk of offspring with intellectual disabilities. However, similar motivations for sterilization were not common for girls without intellectual disabilities. There is also a gendered element sterilization as the Nigeria law code penalizes emasculation, which makes it so that men cannot reproduce. There is no such penalization for sterilization of women. [ 129 ]
Civil Society Organizations such as Balance, Promocion para el Desarrollo y Juventud, A.C., have received in the last years numerous testimonies of women living with HIV in which they inform that misinformation about the virus transmission has frequently lead to compulsory sterilization. Although there is enough evidence regarding the effectiveness of interventions aimed to reduce mother-to-child transmission risks, there are records of HIV-positive women forced to undergo sterilization or have agreed to be sterilized without adequate and sufficient information about their options." [ 130 ]
A report made in El Salvador, Honduras, Mexico, and Nicaragua concluded that women living with HIV, and whose health providers knew about it at the time of pregnancy, were six times more likely to experience forced or coerced sterilization in those countries. In addition, most of these women reported that health providers told them that living with HIV cancelled their right to choose the number and spacing of the children they want to have as well as the right to choose the contraceptive method of their choice; provided misleading information about the consequences for their health and that of their children and denied them access to treatments that reduce mother-to-child HIV transmission in order to coerce them into sterilization. [ 131 ]
This happens even when the health norm NOM 005-SSA2-1993 Archived 31 August 2009 at the Wayback Machine states that family planning is "the right of everyone to decide freely, responsibly and in an informed way the number and spacing of their children and to obtain specialized information and proper services" and that "the exercise of this right is independent of gender, age, and social or legal status of persons". [ 130 ]
In Peru , President Alberto Fujimori (in office from 1990 to 2000) has been accused of genocide and crimes against humanity as a result of the Programa Nacional de Población , a sterilization program put in place by his administration. [ 132 ] [ 133 ] During his presidency, Fujimori put in place a program of forced sterilizations against indigenous people (mainly the Quechuas and the Aymaras ), in the name of a " public health plan", presented on 28 July 1995. The plan was principally financed using funds from USAID (36 million dollars), the Nippon Foundation , and later, the United Nations Population Fund (UNFPA). [ 134 ] On 9 September 1995, Fujimori presented a Bill that would revise the "General Law of Population", in order to allow sterilization. Several contraceptive methods were also legalized, all measures that were strongly opposed by the Roman Catholic Church , as well as the Catholic organization Opus Dei . In February 1996, the World Health Organization (WHO) itself congratulated Fujimori on his success in controlling demographic growth. [ 134 ]
On 25 February 1998, a representative for USAID testified before the U.S. government's House Committee on International Relations , to address controversy surrounding Peru's program. He indicated that the government of Peru was making important changes to the program, in order to:
In September 2001, Minister of Health Luis Solari launched a special commission into the activities of the voluntary surgical contraception, initiating a parliamentary commission tasked with inquiring into the "irregularities" of the program, and to put it on an acceptable footing. In July 2002, its final report ordered by the Minister of Health revealed that between 1995 and 2000, 331,600 women were sterilized, while 25,590 men submitted to vasectomies. [ 134 ] The plan, which had the objective of diminishing the number of births in areas of poverty within Peru, was essentially directed at the indigenous people living in deprived areas (areas often involved in internal conflicts with the Peruvian government, as with the Shining Path guerilla group). Deputy Dora Núñez Dávila made the accusation in September 2003 that 400,000 indigenous people were sterilized during the 1990s. Documents proved that President Fujimori was informed, each month, of the number of sterilizations done, by his former Ministers of Health, Eduardo Yong Motta (1994–96), Marino Costa Bauer (1996–1999) and Alejandro Aguinaga (1999–2000). [ 134 ] A study by sociologist Giulia Tamayo León [ es ] , Nada Personal (in English: Nothing Personal), showed that doctors were required to meet quotas. According to Le Monde diplomatique , "tubal ligation festivals" were organized through program publicity campaigns, held in the pueblos jóvenes (in English: shantytowns). In 1996 there were, according to official statistics, 81,762 tubal ligations performed on women, with a peak being reached the following year, with 109,689 ligatures, then only 25,995 in 1998. [ 132 ]
On 21 October 2011, Peru's Attorney General José Bardales decided to reopen an investigation into the cases, which had been halted in 2009 under the statute of limitations, after the Inter-American Commission on Human Rights ruled that President Fujimori's sterilization program involved crimes against humanity, which are not time-limited. [ 136 ] [ 137 ] It is unclear as to any progress in matter of the execution (debido ejecución sumaria) of the suspect in the course of any proof of their relevant accusations in the legal sphere of the constituted people in vindication of the rights of the people of South America. It may carry a parallel to any suspect cases for international investigation in any other continent, and be in the sphere of medical genocide. As of 12 December 2021:
A Peruvian judge ruled last week that the 83-year-old could not be brought to court because of the forced sterilization, as the allegation was not included in an old extradition request for Fujimori. The ex-president was extradited from Chile to Peru in 2007. According to the judge, Chile's Supreme Court, which gave the go-ahead for extradition at the time, must agree to Fujimori's charge of forced sterilization. [ 138 ]
Since children cannot legally live in psychoneurologic internats in Russia, and there are no institutions where internats' patients can live with their children, almost all pregnant women are aborted in PNIs. During abortions, PNI patients are also often subjected to forced sterilization - their fallopian tubes are tied , motivated by allegedly detected "serious complications". [ 139 ]
In South Africa , there have been multiple reports of HIV-positive women sterilized without their informed consent and sometimes without their knowledge. [ 140 ] The Commission for Gender Equality investigated 48 sterilizations that were performed in fifteen state hospitals without patient consent from 2002 to 2005. [ 141 ] This investigation into these hospitals revealed that medical providers threatened to not assist women during birth if they did not sign consent forms to being sterilized. [ 141 ] In most cases these forms were not explained to patients by medical personnel. However, the inquiry was hampered by hostile hospital staff and the sudden "disappearance" of patient files. An interview with one of these patients revealed that she did not learn that she had been sterilized during her C-section until a physician told her eleven years after that she had no uterus. [ 142 ] She went to the hospital were the surgery was performed and was told by a physician that it was done to save her life and consent was received from her mother. [ 142 ] The patient did not have HIV or any other life-threatening condition, and her mother had not consented to the removal of her uterus. [ 142 ] The report from the Commission for Gender Equality noted that some of the patients interviewed were given consent forms that they did not understand and were coerced to sign. [ 143 ] The bulk of these operations were performed to prevent women who are HIV-positive from having more children. [ 143 ] The HIV epidemic in South Africa has a prevalence of 13% and has largely affected the family structures in the country. [ 143 ] Medical staff of these hospitals have justified their actions as an effort to stop the growing HIV numbers in the country that exhaust the healthcare systems. [ 141 ] The Commission urged Health Minister Zweli Mkhize to take action against these state hospitals and to provide some form of redress to the many affected women. [ 143 ]
The eugenics program in Sweden was enacted in 1934 and was formally abolished in 1976. According to the 2000 governmental report, 21,000 were estimated to have been forcibly sterilized, 6,000 were coerced into a 'voluntary' sterilization while the nature of a further 4,000 cases could not be determined. [ 144 ] Of those sterilized 93% were women. [ 145 ] The reasons given for these sterilizations included mental slowness, racial differences, antisocial behavior, promiscuous behavior, and other behaviors deemed inappropriate. [ 146 ] At the time, the government saw itself as a forward-thinking and enlightened welfare state. [ 146 ] The Swedish state subsequently formed a commission of inquiry to determine victims that could claim compensation for trauma at the hands of the state. The sterilization program ended in the government paying over $22,000 in compensation to victims. [ 147 ]
Until December 2012, Swedish law forced transgender individuals to be sterilized before having their legal documents updated. [ 148 ] After the law was repealed, those who were forcibly sterilized under the law began to demand compensation. [ 148 ] In 2017, the government announced that it will pay these compensations. [ 149 ]
In 1911, while he was serving as Home Secretary , Winston Churchill favored the sterilization of feeble-minded persons. Reginald McKenna , who succeeded Churchill as Home Secretary, introduced the Feeble-Minded Control Bill , a bill that would enact forcible sterilization of such individuals; the bill gained the support of the Anglican archbishops of Canterbury and York , that included forced sterilization. Despite support for the bill by the Anglican primates , English writer G. K. Chesterton and the Catholic Church in the United Kingdom led a successful effort to defeat that clause's inclusion in what would eventually become the 1913 Mental Deficiency Act , though the final act did create a scheme for state-enforced confinement of mentally disabled persons in specialized institutions. [ 150 ] In 1934, the Brock Report recommended sterilisation of people who were mentally and physically disabled, but its proposals did not gain enough support to be made law. [ 151 ]
In one specific case in 2015, the Court of Protection of the United Kingdom ruled that a woman with six children and an IQ of 70 should be sterilized for her own safety because another pregnancy would have been a "significantly life-threatening event" for her and the fetus and was not related to eugenics. [ 152 ]
During the Progressive Era ( c. 1890 to 1920), the United States was the first country to concertedly undertake compulsory sterilization programs for the purpose of eugenics. [ 153 ] Thomas C. Leonard , professor at Princeton University, describes American eugenics and sterilization as ultimately rooted in economic arguments and further as a central element of Progressivism alongside minimum wage laws, restricted immigration, and the introduction of pension programs. [ 154 ] The heads of the programs were avid proponents of eugenics and frequently argued for their programs which achieved some success nationwide mainly in the first half of the 20th century.
Eugenics had two essential components. First, its advocates accepted as axiomatic that a range of mental and physical handicaps—blindness, deafness, and many forms of mental illness —were largely, if not entirely, hereditary in cause. Second, they assumed that these scientific hypotheses could be used as the basis of social engineering across several policy areas, including family planning, education, and immigration. The most direct policy implications of eugenic thought were that "mental defectives" should not produce children, since they would only replicate these deficiencies, and that such individuals from other countries should be kept out of the polity. [ 155 ] The principal targets of the American sterilization programs were intellectually disabled people and the mentally ill, but also targeted under many state laws were the deaf, the blind, people with epilepsy, and the physically deformed. While the claim was that the focus was mainly the mentally ill and disabled, the definition of this during that time was much different from today's. At this time, there were many women that were sent to institutions under the guise of being " feeble-minded " because they were promiscuous or became pregnant while unmarried.
A relative minority of sterilizations targeting crime took place in prisons and other penal institutions . [ 156 ] In the end, over 65,000 individuals were sterilized in 33 states under state compulsory sterilization programs in the United States. [ 157 ]
The first state to introduce a compulsory sterilization bill was Michigan , in 1897, but the proposed law failed to pass. Eight years later Pennsylvania 's state legislators passed a sterilization bill that was vetoed by the governor. Indiana became the first state to enact sterilization legislation in 1907, [ 158 ] followed closely by California and Washington in 1909. Several other states followed, but such legislation remained controversial enough to be defeated in some cases, as in Wyoming in 1934. [ 159 ] In the 1920s, Eugenicists were particularly interested in black women in the South and Latina women in the Southwest in order to break the chain of welfare dependency and curb the population rise of non-white citizens. [ 160 ] [ 3 ]
After World War II, public opinion towards eugenics and sterilization programs became more negative in the light of the connection with the genocidal policies of Nazi Germany , though a significant number of sterilizations continued in a few states through the 1970s. Between 1970 and 1976, Indian Health Services sterilized between 25 and 42 percent of women of reproductive age who came in seeking healthcare services. [ 161 ] In California , ten women who delivered their children at LAC-USC hospital between 1971-1974 and were sterilized without proper consent sued the hospital in the landmark Madrigal v. Quilligan case in 1975. [ citation needed ] [ 162 ] The plaintiffs lost the case, but numerous changes to the consent process were made following the ruling, such as offering consent forms in the patient's native language, and a 72-hour waiting period between giving consent and undergoing the procedure. [ citation needed ]
The Oregon Board of Eugenics, later renamed the Board of Social Protection, existed until 1983, [ 163 ] with the last forcible sterilization occurring in 1981. [ 164 ] The U.S. commonwealth of Puerto Rico had a sterilization program as well. Some states continued to have sterilization laws on the books for much longer after that, though they were rarely if ever used. California sterilized more than any other state by a wide margin, and was responsible for over a third of all sterilization operations. Information about the California sterilization program was produced into book form and widely disseminated by eugenicists E. S. Gosney and Paul Popenoe , which was said by the government of Adolf Hitler to be of key importance in proving that large-scale compulsory sterilization programs were feasible. [ 165 ]
In recent years, the governors of many states have made public apologies for their past programs beginning with Virginia and followed by Oregon [ 163 ] and California. Few have offered to compensate those sterilized, however, citing that few are likely still living (and would of course have no affected offspring) and that inadequate records remain by which to verify them. At least one compensation case, Poe v. Lynchburg Training School & Hospital (1981), was filed in the courts on the grounds that the sterilization law was unconstitutional. It was rejected because the law was no longer in effect at the time of the filing. However, the petitioners were granted some compensation because the stipulations of the law itself, which required informing the patients about their operations, had not been carried out in many cases. [ 166 ] The 27 states where sterilization laws remained on the books (though not all were still in use) in 1956 were: Arizona , California , Connecticut , Delaware , Georgia , Idaho , Indiana , Iowa , Kansas , Maine , Michigan , Minnesota , Mississippi , Montana , Nebraska , New Hampshire , North Carolina , North Dakota , Oklahoma , Oregon , South Carolina , South Dakota , Utah , Vermont , Virginia , Washington , [ 167 ] West Virginia and Wisconsin . [ 168 ] [ better source needed ] Some states still have forced sterilization laws in effect, such as Washington state. [ needs update ] [ 167 ]
As of January 2011, discussions were under way regarding compensation for the victims of forced sterilization under the authorization of the Eugenics Board of North Carolina . Governor Bev Perdue formed the NC Justice for Sterilization Victims Foundation in 2010 in order "to provide justice and compensate victims who were forcibly sterilized by the State of North Carolina". [ 169 ] In 2013 North Carolina announced that it would spend $10 million beginning in June 2015 to compensate men and women who were sterilized in the state's eugenics program; North Carolina sterilized 7,600 people from 1929 to 1974 who were deemed socially or mentally unfit. [ 170 ]
The inability to pay for the cost of raising children has been a reason courts have ordered coercive or compulsory sterilization. In June 2014, a Virginia judge ruled that a man on probation for child endangerment must be able to pay for his seven children before having more children; the man agreed to get a vasectomy as part of his plea deal. [ 171 ] In 2013, an Ohio judge ordered a man owing nearly $100,000 in unpaid child support to "make all reasonable efforts to avoid impregnating a woman" as a condition of his probation. [ 172 ] Kevin Maillard wrote that conditioning the right to reproduction on meeting child support obligations amounts to "constructive sterilization" for men unlikely to make the payments. [ 173 ]
As of 19 July 2021 it was reported that:
"under new provisions signed into California's budget this week, the state will offer reparations for the thousands of people who were sterilized in California institutions, without adequate consent, often because they were deemed "criminal", "feeble-minded" or "deviant"." [ 174 ]
and that
"The program will be the first in the nation to provide compensation to modern-day survivors of prison system sterilizations, like Dillon, whose attorney obtained medical records to show that, while she was an inmate in the Central California women's facility in Chowchilla, surgeons had removed her ovaries during what was supposed to be an operation to take a biopsy and remove a cyst.
The investigations sparked by her case, which is featured in the documentary Belly of the Beast, showed hundreds of inmates had been sterilized in prisons without proper consent as late as 2010, even though the practice was by then illegal.
The new California reparations program will also seek to compensate hundreds of living survivors of the state's earlier eugenics campaign, which was first codified into state law in 1909 and wasn't repealed until 1979." [ 175 ] [ 174 ]
In 2020, four non-profit organizations (which are listed below) joined Dawn Wooten to accuse a privately-owned U.S. immigration detention center in the U.S. state of Georgia of forcibly sterilizing women. The reports claimed that a doctor conducted unauthorized medical procedures upon women who were detained by Immigration and Customs Enforcement . [ 176 ] Dawn Wooten was a nurse and former employee. She claims that a high rate of sterilizations were performed upon Spanish-speaking women and women who spoke various indigenous languages that are common in Latin America. Wooten said that the center did not obtain proper consent for these surgeries, or lied to women about the medical procedures. More than 40 women submitted testimony in writing to document these abuses. [ 177 ]
In September 2020, Mexico demanded more information from U.S. authorities about medical procedures that were performed upon illegal immigrants in detention centers, after allegations that six Mexican women were sterilized without their consent. The ministry said that consulate personnel had interviewed 18 Mexican women who were detained at the center, none of which "claimed to have undergone a hysterectomy". Another woman said that she had undergone a gynecological operation, although there was nothing in her detention file to support that she agreed to the procedure. [ 178 ]
The nurse said that detained women told her they did not fully understand why they had to get a hysterectomy.
Project South , the Georgia Detention Watch, the Georgia Latino Alliance for Human Rights, and South Georgia Immigrant Support Network filed a complaint to the government on behalf of detained immigrants and the nurse.
The U.S. congresswoman Pramila Jayapal has called for an urgent investigation into allegations that at least 17 women were subjected to unnecessary gynecological procedures that she called "the most abhorrent of human rights violations". [ 179 ]
As stated previously, eugenics in the United States spread to target mentally disabled persons. Sterilization rates across the country were relatively low, with the sole exception of California, until the 1927 U.S. Supreme Court decision in Buck v. Bell , which upheld under the U.S. Constitution the forced sterilization of patients at a Virginia home for intellectually disabled people. [ 180 ] In the wake of that decision, over 62,000 people in the United States, most of them women, were sterilized. [ 181 ] The number of sterilizations performed per year increased until another Supreme Court case, Skinner v. Oklahoma , 1942, complicated the legal situation by ruling against sterilization of criminals if the equal protection clause of the constitution was violated. That is, if sterilization was to be performed, then it could not exempt white-collar criminals . [ 182 ] This case, however, does not directly overturn the decision made in Buck v. Bell . [ 183 ] Instead, it invalidates the central argument of the decision, and has been used in several cases to deny guardians the right to sterilize the disabled person under their care. [ 183 ]
The Congress of Obstetricians and Gynecologists (ACOG) believes that mental disability is not a reason to deny sterilization. The opinion of ACOG is that "the physician must consult with the patient's family, agents, and other caregivers" if sterilization is desired for a mentally limited patient. [ 184 ] In 2003, Douglas Diekema wrote in Volume 9 of the journal Mental Retardation and Developmental Disabilities Research Reviews that "involuntary sterilization ought not be performed on mentally retarded persons who retain the capacity for reproductive decision-making, the ability to raise a child, or the capacity to provide valid consent to marriage." [ 185 ] The Journal of Medical Ethics claimed, in a 1999 article, that doctors are regularly confronted with requests to sterilize mentally limited people who cannot give consent for themselves. The article recommend that sterilization should only occur when there is a "situation of necessity" and the "benefits of sterilization outweigh the drawbacks." [ 186 ]
The American Journal of Bioethics published an article, in 2010, that concluded the interventions used in the Ashley treatment may benefit future patients. [ 187 ] These interventions, at the request of the parents and guidance from the physicians, included a hysterectomy and surgical removal of the breast buds of the mentally and physically disabled child. [ 188 ] Proponents of the treatments argue that it protects disabled persons from sexual assault, unwanted pregnancy, and difficulties of menstruation. [ 189 ] The interventions are still legal in many states, despite the argument that it violates a person's constitutional right to avoid unwanted intrusions. [ 189 ] Discussion on the involuntary sterilization of disabled persons is now largely focused on the right of a guardian to request sterilization.
In addition to eugenics purposes, sterilization was used as a punitive measure against sex offenders, people identified as homosexual, or people deemed to masturbate too much. [ 190 ] California, the first state in the U.S. to enact compulsory sterilization based on eugenics, sterilized all prison inmates under the 1909 sterilization law. [ 190 ] In the last 40 years, judges have offered lighter punishment (i.e. probation instead of jail sentences) to people willing to use contraception or be sterilized, particularly in child abuse/endangerment cases. [ 191 ] One of the most famous cases of this was People v. Darlene Johnson , during which Johnson, a woman charged with child abuse sentenced to seven years in prison, was offered probation and a reduced prison sentence if she agreed to use Norplant . [ 192 ]
In addition to child abuse cases, some politicians proposed bills mandating Norplant use among women on public assistance as a requirement to maintain welfare benefits. [ 192 ] As noted above, some judges offered probation in lieu of prison time to women who agreed to use Norplant, while other court cases have ordered parents to cease childbearing until regaining custody of their children after abuse cases. Some legal scholars and ethicists argue such practices are inherently coercive. [ 192 ] Furthermore, such scholars link these practices to eugenic policies of the 19th and early 20th century, highlighting how such practices not only targeted poor people, but disproportionately impacted minority women and families in the U.S., particularly black women.
In the late 1970s, to acknowledge the history of forced and coercive sterilizations and prevent ongoing eugenics/population control efforts, the federal government implemented a standardized informed consent process and specific eligibility criteria for government funded sterilization procedures. [ 193 ] Some scholars argue the extensive consent process and 30-day waiting period go beyond preventing instances of coercion and serve as a barrier to desired sterilization for women relying on public insurance. [ 193 ]
Though formal eugenics laws are no longer routinely implemented and have been removed from government documents, instances of reproductive coercion still take place in U.S. institutions today. In 2011, investigative news released a report revealing that between 2006 and 2011, 148 female prisoners in two California state prisons were sterilized without adequate informed consent. [ 194 ] In September 2014, California enacted Bill SB 1135 that bans sterilization in correctional facilities, unless the procedure shall be required in a medical emergency to preserve an inmate's life. [ 195 ]
Puerto Rican physician Lanauze Rolón founded the League for Birth Control in Ponce, Puerto Rico , in 1925, but the League was quickly squashed by opposition from the Catholic church . [ 196 ] [ 197 ] A similar League was founded seven years later, in 1932, in San Juan and continued in operation for two years before opposition and lack of support forced its closure. [ 196 ] [ 197 ] Yet another effort at establishing birth control clinics was made in 1934 by the Federal Emergency Relief Administration in a relief response to the conditions of the Great Depression . [ 197 ] As a part of this effort, 68 birth control clinics were opened on the island. [ 197 ] The next mass opening of clinics occurred in January 1937 when American Clarence Gamble , in association with a group of wealthy and influential Puerto Ricans, organized the Maternal and Infant Health Association and opened 22 birth control clinics. [ 197 ]
The Governor of Puerto Rico, Blanton Winship , enacted Law 116, [ 198 ] which went into effect on 13 May 1937. [ 199 ] It was a birth control and eugenic sterilization law that allowed the dissemination of information regarding birth control methods and legalized the practice of birth control. [ 196 ] [ 197 ] The government cited a growing population of the poor and unemployed as motivators for the law. Changers were made to the Penal Code in 1937 which made abortion effectively legal. It was allowed for health reasons, without specifying details in the law. This gave doctors discretion to interpret what constituted a health reason, effectively legalizing abortion. [ 200 ] By 1965, approximately 34 percent of women of childbearing age had been sterilized, two thirds of whom were still in their early twenties. The law was repealed on 8 June 1960. [ 196 ]
Unemployment and widespread poverty would continue to grow in Puerto Rico in the 40s, both threatening U.S. private investment in Puerto Rico and acting as a deterrent for future investment. [ 196 ] In an attempt to attract additional U.S. private investment in Puerto Rico, another round of liberalizing trade policies were implemented and referred to as " Operation Bootstrap ." [ 196 ] Despite these policies and their relative success, unemployment and poverty in Puerto Rico remained high, high enough to prompt an increase in emigration from Puerto Rico to the United States between 1950 and 1955. [ 196 ] The issues of immigration , Puerto Rican poverty, and threats to U.S. private investment made population control concerns a prime political and social issue for the United States. [ 196 ]
The 50s also saw the production of social science research supporting sterilization procedures in Puerto Rico. [ 196 ] Princeton's Office of Population Research , in collaboration with the Social Research Department at the University of Puerto Rico, conducted interviews with couples regarding sterilization and other birth control. [ 196 ] Their studies concluded that there was a significant need and desire for permanent birth control among Puerto Ricans. [ 196 ] In response, Puerto Rico's governor and Commissioner of health opened 160 private, temporary birth control clinics with the specific purpose of sterilization. [ 196 ]
Also during this era, private birth control clinics were established in Puerto Rico with funds provided by wealthy Americans. [ 196 ] [ 197 ] Joseph Sunnen , a wealthy American Republican and industrialist, established the Sunnen Foundation in 1957. [ 196 ] [ 197 ] The foundation funded new birth control clinics under the title "La Asociación Puertorriqueña el Biensestar de la Familia" and spent hundreds of thousands of dollars in an experimental project to determine if a formulaic program could be used to control population growth in Puerto Rico and beyond. [ 196 ]
From beginning of the 1900s, U.S. and Puerto Rican governments espoused rhetoric connecting the poverty of Puerto Rico with overpopulation and the "hyper-fertility" of Puerto Ricans. [ 201 ] Such rhetoric combined with eugenics ideology of reducing "population growth among a particular class or ethnic group because they are considered...a social burden," was the philosophical basis for the 1937 birth control legislation enacted in Puerto Rico. [ 201 ] [ 202 ] A Puerto Rican Eugenics Board, modeled after a similar board in the United States, was created as part of the bill, and officially ordered ninety-seven involuntary sterilizations. [ 202 ]
The legalization of sterilization was followed by a steady increase in the popularity of the procedure, both among the Puerto Rican population and among physicians working in Puerto Rico. [ 202 ] [ 203 ] Though sterilization could be performed on men and women, women were most likely to undergo the procedure. [ 196 ] [ 197 ] [ 202 ] [ 203 ] Sterilization was most frequently recommended by physicians because of a pervasive belief that Puerto Ricans and the poor were not intelligent enough to use other forms of contraception. [ 202 ] [ 203 ] Physicians and hospitals alike also implemented hospital policy to encourage sterilization, with some hospitals refusing to admit healthy pregnant women for delivery unless they consented to be sterilized. [ 202 ] [ 203 ] This has been best documented at Presbyterian Hospital, where the unofficial policy for a time was to refuse admittance for delivery to women who already had three living children unless she consented to sterilization. [ 202 ] [ 203 ] There is additional evidence that true informed consent was not obtained from patients before they underwent sterilization, if consent was solicited at all. [ 203 ]
By 1949 a survey of Puerto Rican women found that 21% of women interviewed had been sterilized, with sterilizations being performed in 18% of all hospital births statewide as a routine post-partum procedure, with the sterilization operation performed before women left the hospitals after giving birth. [ 196 ] As for the birth control clinics founded by Sunnen, the Puerto Rican Family Planning Association reported that around 8,000 women and 3,000 men had been sterilized in Sunnen's privately funded clinics. [ 196 ] At one point, the levels of sterilization in Puerto Rico were so high that they alarmed the Joint Committee for Hospital Accreditation, who then demanded that Puerto Rican hospitals limit sterilizations to ten percent of all hospital deliveries in order to receive accreditation. [ 196 ] The high popularity of sterilization continued into the 60s and 70s, during which the Puerto Rican government made the procedures available for free and reduced fees. [ 202 ] The effects of the sterilization and contraception campaigns of the 1900s in Puerto Rico are still felt in Puerto Rican cultural history today. [ 201 ]
There has been much debate and scholarly analysis concerning the legitimacy of choice given to Puerto Rican women in regard to sterilization, reproduction, and birth control, as well as with the ethics of economically motivated mass-sterilization programs.
Some scholars, such as Bonnie Mass [ 196 ] and Iris Lopez, [ 201 ] have argued that the history and popularity of mass-sterilization in Puerto Rico represents a government-led eugenics initiative for population control . [ 196 ] [ 201 ] [ 203 ] [ 204 ] They cite the private and government funding of sterilization, coercive practices, and the eugenics ideology of Puerto Rican and American governments and physicians as evidence of a mass-sterilization campaign. [ 201 ] [ 203 ] [ 204 ]
On the other side of the debate, scholars like Laura Briggs [ 202 ] have argued that evidence does not substantiate claims of a mass-sterilization program. [ 202 ] She further argues that reducing the popularity of sterilization in Puerto Rico to a state initiative ignores the legacy of Puerto Rican feminist activism in favor of birth control legalization, and the individual agency of Puerto Rican women in making decisions about family planning. [ 202 ]
A system was proposed by the California state senator Nancy Skinner to compensate victims of the well-documented examples of prison sterilizations that resulted from California's eugenics programs , but this did not pass by the bill's 2018 deadline in the legislature. [ 205 ]
When the United States took census of Puerto Rico in 1899, the birth rate was 40 births per one thousand people. [ 197 ] By 1961, the birth rate had dropped to 30.8 per thousand. [ 196 ] In 1955, 16.5% of Puerto Rican women of childbearing age had been sterilized, this jumped to 34% in 1965. [ 196 ]
In 1969, sociologist Harriet Presser analyzed the 1965 Master Sample Survey of Health and Welfare in Puerto Rico. [ 206 ] She specifically analyzed data from the survey for women ages 20 to 49 who had at least one birth, resulting in an overall sample size of 1,071 women. [ 206 ] She found that over 34% of women aged 20–49 had been sterilized in Puerto Rico in 1965. [ 206 ]
Presser's analysis also found that 46.7% of women who reported they were sterilized were between the ages of 34 and 39. [ 206 ] Of the sample of women sterilized, 46.6% had been married 15 to 19 years, 43.9% had been married for 10-to-14 years, and 42.7% had been married for 20-to-24 years. [ 206 ] Nearly 50% of women sterilized had three or four births. [ 206 ] Over 1/3 of women who reported being sterilized were sterilized in their twenties, with the average age of sterilization being 26. [ 206 ]
A survey by a team of Americans in 1975 confirmed Presser's assessment that nearly 1/3 of Puerto Rican women of childbearing age had been sterilized. [ 196 ] As of 1977, Puerto Rico had the highest proportion of childbearing-aged persons sterilized in the world. [ 196 ] In 1993, ethnographic work done in New York by anthropologist Iris Lopez [ 201 ] showed that the history of sterilization continued to effect the lives of Puerto Rican women even after they immigrated to the United States and lived there for generations. [ 201 ] The history of the popularity of sterilization in Puerto Rico meant that Puerto Rican women living in America had high rates of female family members who had undergone sterilization, and it remained a highly popular form of birth control among Puerto Rican women living in New York. [ 201 ]
According to reports, as of 2012 [update] , forced and coerced sterilization is the current governmental policy in Uzbekistan for women with two or three children, as a means of forcing population control and to improve maternal mortality rates. [ 207 ] [ 208 ] [ 209 ] [ 210 ] [ 211 ] In November 2007, a report by the United Nations Committee Against Torture reported that "the large number of cases of forced sterilization and removal of reproductive organs of women at reproductive age after their first or second pregnancy indicate that the Uzbek government is trying to control the birth rate in the country" and noted that such actions were not against the national Criminal Code. [ 212 ] In response to that, the Uzbek delegation to the associated conference was "puzzled by the suggestion of forced sterilization, and could not see how this could be enforced". [ 213 ]
Reports of forced sterilizations, hysterectomies , and IUD -insertions first emerged in 2005, [ 207 ] [ 208 ] [ 209 ] [ 214 ] although it is reported that the practice originated in the late 1990s, [ 215 ] with reports of a secret decree dating from 2000. [ 214 ] The current policy was allegedly instituted by Islam Karimov under Presidential Decree PP-1096, which is titled: "on additional measures to protect the health of the mother and child, the formation of a healthy generation", [ 216 ] and which came into force in 2009. [ 217 ] In 2005, Deputy Health Minister Assomidin Ismoilov confirmed that doctors in Uzbekistan were being held responsible for increased birth rates. [ 214 ]
Based upon a report by the journalist Natalia Antelava, doctors reported that the Ministry of Health told doctors that they must perform surgical sterilizations upon women. One doctor reported: "It's ruling number 1098, and it says that after two children, in some areas after three, a woman should be sterilized.", in a loss of the former surface decency of Central Asian mores in regard of female chastity. [ 218 ] In 2010, the Ministry of Health passed a decree stating all clinics in Uzbekistan should have sterilization equipment ready for use. The same report also states that sterilization is to be done on a voluntary basis with the informed consent of the patient. [ 218 ] In the 2010 Human Rights Report of Uzbekistan, there were many reports of forced sterilization of women along with allegations of the government pressuring doctors to sterilize women in order to control the population. [ 219 ] Doctors also reported to Antelava that there are quotas they must reach every month on how many women they need to sterilize. These orders are passed on to them through their bosses and, allegedly, from the government. [ 218 ]
On 15 May 2012, during a meeting with the Russian president Vladimir Putin in Moscow , the Uzbek president Islam Karimov said: "we are doing everything in our hands to make sure that the population growth rate [in Uzbekistan] does not exceed 1.2–1.3" [ 220 ] The Uzbek version of RFE/RL reported that, with this statement, Karimov indirectly admitted that forced sterilization of women is indeed taking place in Uzbekistan. [ 220 ] The main Uzbek television channel, called O'zbekiston, cut-out Karimov's statement about the population growth rate while broadcasting his conversation with Putin. [ 220 ]
Despite international agreement concerning the inhumanity and illegality of forced sterilization, it has been suggested that the government of Uzbekistan continues to pursue such programs. [ 207 ]
Eugenics programs including forced sterilization existed in most of the Northern European countries, as well as in other more-or-less Protestant countries . Other countries that had notably active sterilization programs include Denmark ("that country's forced sterilization of 60,000 people in 1935-76"), [ 83 ] [ 221 ] Norway , [ 222 ] [ 223 ] [ 221 ] Finland [ 224 ] [ 225 ] [ 226 ] [ 227 ] ("In Finland, to change one's gender markers in the juridical system (also known as gender recognition), trans people are, still, forcibly sterilised. In the laws regarding gender recognition, this requirement is called the 'inability to reproduce', a choice of words that makes it sound a lot less threatening than 'forced sterilisation'"), [ 227 ] Estonia , [ 228 ] Switzerland , [ 229 ] [ 230 ] Iceland , [ 231 ] and some countries in Latin America (including Panama ). [ citation needed ]
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Computational epidemiology is a multidisciplinary field that uses techniques from computer science , mathematics , geographic information science and public health to better understand issues central to epidemiology such as the spread of diseases or the effectiveness of a public health intervention. Computational epidemiology traces its origins to mathematical epidemiology , but began to experience significant growth with the rise of big data and the democratization of high-performance computing through cloud computing . [ 1 ]
In contrast with traditional epidemiology , computational epidemiology looks for patterns in unstructured sources of data, such as social media. It can be thought of as the hypothesis-generating antecedent to hypothesis-testing methods such as national surveys and randomized controlled trials.
A mathematical model is developed which describes the observed behavior of the viruses, based on the available data. Then simulations of the model are performed to understand the possible outcomes given the model used. These simulations produce as results projections which can then be used to make predictions or verify the facts and then be used to plan interventions and meters towards the control of the disease's spread.
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Computer-aided auscultation ( CAA ), or computerized assisted auscultation , is a digital form of auscultation . It includes the recording, visualization, storage, analysis and sharing of digital recordings of heart or lung sounds. The recordings are obtained using an electronic stethoscope or similarly suitable recording device.
Computer-aided auscultation is designed to assist health care professionals who perform auscultation as part of their diagnostic process. Commercial CAA products are usually classified as clinical decision support systems that support medical professionals in making a diagnosis. As such they are medical devices and require certification or approval from a competent authority (e.g. FDA approval, CE conformity issued by notified body).
Compared to traditional auscultation, computer-aided auscultation (CAA) offers a range of improvements beneficial to multiple stakeholders:
In a CAA system, sounds are recorded through an electronic stethoscope. The audio data is transferred to an electronic device via Bluetooth or an audio cable connection. Special software on that device visualizes, stores and analyzes the data. With some of the more sophisticated CAA systems, the CAA analysis yields results that can be used to objectify diagnoses ( decision support system ). [ citation needed ]
The components of a CAA system depend on its complexity. Whereas some of the simpler systems provide only visualization or storage options, other systems combine visualization, storage, analysis and the ability to electronically manage said data.
Electronic stethoscopes (also digital stethoscopes) convert acoustic sound waves into digital electrical signals. These signals are then amplified by means of transducers and currently reach levels up to 100 times higher than traditional acoustic stethoscopes. Additionally, electronic stethoscopes can be used to filter out background noise, a feature that can be safety-relevant and facilitate more accurate diagnoses. Whereas sound amplification and filtering are the main functions of an electronic stethoscope, the ability to access the sounds through external means via Bluetooth or audio cables makes them an ideal sound-capturing device for CAA systems. [ citation needed ]
Devices that can be used to connect to an electronic stethoscope and record the audio signal (e.g. heart or lung sounds) include PC, laptop and mobile devices like smartphones or tablets. Generally, CAA systems include software that can visualize the incoming audio signal. More sophisticated CAA systems include live noise detection algorithms, designed to help the user achieve the best possible recording quality.
A key feature of CAA systems is the automated analysis of the recorded audio signals by signal processing algorithms. Such algorithms can run directly on the device used for making the recording, or be hosted in a cloud connected to the device. The degree of autonomy of currently available analysis algorithms varies greatly. While some systems operate fully autonomously, [ 7 ] early PC-based systems required significant user interaction and interpretation of results, [ 8 ] and other analysis systems require some degree of assistance by the user like manual confirmation/correction of estimated heart rates. [ 9 ]
Recorded sounds and associated analytical and patient data can be electronically stored, managed or archived. Patient identifying information might be handled or stored in the process. If the stored data classifies as PHI (protected health information), a system hosting such data must be compliant with country-specific data protection laws like HIPAA for the US or the Data Protection Directive for the EU. Storage options for current CAA systems range from the basic ability to retrieve a downloadable PDF report to a comprehensive cloud-based interface for electronic management of all auscultation-based data. [ citation needed ]
The user can review all their patient records (including replaying the audio files) via a user interface, e.g. via a web-portal in the browser or stand-alone software on the electronic device. Other functionalities include sharing records with other users, exporting patient records and integration into EHR systems .
Computer-aided auscultation aimed at detecting and characterizing heart murmurs is called computer-aided heart auscultation (also known as automatic heart sound analysis).
Auscultation of the heart using a stethoscope is the standard examination method worldwide to screen for heart defects by identifying murmurs. It requires that an examining physician have acute hearing and extensive experience. An accurate diagnosis remains challenging for various reasons including noise, high heart rates, and the ability to distinguish innocent from pathological murmurs.
Properly performed, the auscultatory examination of the heart is commonly regarded as an inexpensive, widely available tool in the detection and management of heart disease. [ 10 ] The auscultation skills of physicians, however, have been reported to be declining. [ 11 ] [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] This leads to missed disease diagnoses and/or excessive costs for unnecessary and expensive diagnostic testing. A study suggests that more than one third of previously undiagnosed congenital heart defects in newborns are missed by their 6-week examination. [ 18 ] More than 60% of referrals to medical specialists for costly echocardiography are due to a misdiagnosis of an innocent murmur. [ 14 ] CAA of the heart thus has the potential to become a cost-effective screening and diagnostic tool, provided that its underlying algorithms have been clinical tested in stringent, blinded fashions for their ability to detect the difference between normal and abnormal heart sounds.
Heart murmurs (or cardiac murmurs) are audible noises through a stethoscope, generated by a turbulent flow of blood. Heart murmurs need to be distinguished from heart sounds which are primarily generated by the beating heart and the heart valves snapping open and shut.
Generally, heart murmurs are classified as innocent (also called physiological or functional) or pathological (abnormal). Innocent murmurs are usually harmless, often caused by physiological conditions outside the heart, and the result of certain benign structural defects. Pathological murmurs are most often associated with heart valve problems but may also be caused by a wide array of structural heart defects.
Various characteristics constitute a qualitative description of heart murmurs, including timing ( systolic murmur and diastolic murmur ), shape, location, radiation, intensity , pitch and quality.
CAA systems typically categorize heart sounds and murmurs as Class I and Class III according to the American Heart Association: [ 19 ]
More sophisticated CAA systems provide additional descriptive murmur information like murmur timing, grading, or the ability to identify the positions of the S1/S2 heart sounds.
The detection of heart murmurs in CAA systems is based on the analysis of digitally recorded heart sounds.
Most approaches use the following four stages:
The most common types of performance measures for CAA systems are based on two approaches: retrospective (non-blinded) studies using existing data and prospective blinded clinical studies on new patients.
In retrospective CAA studies, a classifier is trained with machine learning algorithms using existing data. The performance of the classifier is then assessed using the same data. Different approaches are used to do this (e.g., k-Fold cross-validation , leave-one-out cross-validation ).
The main shortcoming of judging the quality (sensitivity, specificity) of a CAA system based on retrospective performance data alone comes from the risk that the approaches used can overestimate the true performance of a given system. Using the same data for training and validation can itself lead to significant overfitting of the validation set, because most classifiers can be designed to analyse known data very well, but might not be general enough to correctly classify unknown data; i.e. the results look much better than they would if tested on new, unseen patients. “The true performance of a selected network (CAA system) should be confirmed by measuring its performance on a third independent set of data called a test set”. [ 20 ] In summary, the reliability of retrospective, non-blinded studies are usually considered to be much lower than that of prospective clinical studies because they are prone to selection bias and retrospective bias. Published examples include Pretorius et al. [ 21 ] Prospective clinical studies, on the other hand, are better suited to assess the true performance of a CAA system (provided that the study is blinded and well controlled). In a prospective clinical study to evaluate the performance of a CAA system, the output of the CAA system is compared to the gold standard diagnoses. In the case of heart murmurs, a suitable gold standard diagnosis would be auscultation-based expert physician diagnosis, stratified by an echocardiogram-based diagnosis. Published examples include Lai et al. [ 1 ]
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The Computer Aided Surgery is a scientific journal covering all aspects of Computer-assisted surgery (CAS), a surgical concept and set of methods, that use computer technology for presurgical planning , and for guiding or performing surgical interventions .
The International Society for Computer Aided Surgery (ISCAS) is involved in the publication of the Journal.
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See tips for writing articles about academic journals . Further suggestions might be found on the article's talk page .
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Computerized physician order entry ( CPOE ), sometimes referred to as computerized provider order entry or computerized provider order management ( CPOM ), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care.
The entered orders are communicated over a computer network to the medical staff or to the departments ( pharmacy , laboratory, or radiology ) responsible for fulfilling the order. CPOE reduces the time it takes to distribute and complete orders, while increasing efficiency by reducing transcription errors including preventing duplicate order entry, while simplifying inventory management and billing.
CPOE is a form of patient management software . [ 1 ]
In a graphical representation of an order sequence, specific data should be presented to CPOE system staff in cleartext, including:
Some textual data can be reduced to simple graphics.
CPOE systems use terminology familiar to medical and nursing staff, but there are different terms used to classify and concatenate orders. The following items are examples of additional terminology that a CPOE system programmer might need to know:
The application responding to, i.e. , performing, a request for services (orders) or producing an observation. The filler can also originate requests for services (new orders), add additional services to existing orders, replace existing orders, put an order on hold, discontinue an order, release a held order, or cancel existing orders.
A request for a service from one application to a second application. In some cases an application is allowed to place orders with itself.
One of several segments that can carry order information. Future ancillary specific segments may be defined in subsequent releases of the Standard if they become necessary.
The application or individual originating a request for services (order).
A list of associated orders coming from a single location regarding a single patient.
A grouping of orders used to standardize and expedite the ordering process for a common clinical scenario. (Typically, these orders are started, modified, and stopped by a licensed physician.)
A grouping of orders used to standardize and automate a clinical process on behalf of a physician. (Typically, these orders are started, modified, and stopped by a nurse, pharmacist, or other licensed health professional.)
Features of the ideal computerized physician order entry system (CPOE) include:
In the past, physicians have traditionally hand-written or verbally communicated orders for patient care, which are then transcribed by various individuals (such as unit clerks, nurses , and ancillary staff) before being carried out. Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to errors and injuries to patients, . [ 2 ] A follow-up IOM report in 2001 advised use of electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. [ 3 ] Prescribing errors are the largest identified source of preventable hospital medical error. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay. [ 4 ] While further studies have estimated that CPOE implementation at all nonrural hospitals in the United States could prevent over 500,000 serious medication errors each year. [ 5 ] Studies of computerized physician order entry (CPOE) has yielded evidence that suggests the medication error rate can be reduced by 80%, and errors that have potential for serious harm or death for patients can be reduced by 55%, [ 6 ] and other studies have also suggested benefits. [ 7 ] Further, in 2005, CMS and CDC released a report that showed only 41 percent of prophylactic antibacterials were correctly stopped within 24 hours of completed surgery. The researchers conducted an analysis over an eight-month period, implementing a CPOE system designed to stop the administration of prophylactic antibacterials. Results showed CPOE significantly improved timely discontinuation of antibacterials from 38.8 percent of surgeries to 55.7 percent in the intervention hospital. [ 8 ] CPOE/e-Prescribing systems can provide automatic dosing alerts (for example, letting the user know that the dose is too high and thus dangerous) and interaction checking (for example, telling the user that 2 medicines ordered taken together can cause health problems). In this way, specialists in pharmacy informatics work with the medical and nursing staffs at hospitals to improve the safety and effectiveness of medication use by utilizing CPOE systems.
Generally, CPOE is advantageous, as it leaves the trails of just better formatting retrospective information, similarly to traditional hospital information systems designs. The key advantage of providing information from the physician in charge of treatment for a single patient to the different roles involved in processing he treatise itself is widely innovative. This makes CPOE the primary tool for information transfer to the performing staff and lesser the tool for collecting action items for the accounting staff. However, the needs of proper accounting get served automatically upon feedback on completion of orders.
CPOE is generally not suitable without reasonable training and tutoring respectively. As with other technical means, the system based communicating of information may be inaccessible or inoperable due to failures. That is not different from making use of an ordinary telephone or with conventional hospital information systems. Beyond, the information conveyed may be faulty or erratic. A concatenated validating of orders must be well organized. Errors lead to liability cases as with all professional treatment of patients.
Prescriber and staff inexperience may cause slower entry of orders at first, use more staff time, and is slower than person-to-person communication in an emergency situation. Physician to nurse communication can worsen if each group works alone at their workstations.
But, in general, the options to reuse order sets anew with new patients lays the basic for substantial enhancement of the processing of services to the patients in the complex distribution of work amongst the roles involved. The basic concepts are defined with the clinical pathway approach. However, success does not occur by itself. The preparatory work has to be budgeted from the very beginning and has to be maintained all the time. Patterns of proper management from other service industry and from production industry may apply. However, the medical methodologies and nursing procedures do not get affected by the management approaches.
CPOE presents several possible dangers by introducing new types of errors. [ 9 ] [ 10 ] Automation causes a false sense of security, a misconception that when technology suggests a course of action, errors are avoided. These factors contributed to an increased mortality rate in the Children's Hospital of Pittsburgh 's Pediatric ICU when a CPOE system was introduced. [ 11 ] In other settings, shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses. [ citation needed ] Frequent alerts and warnings can interrupt work flow, causing these messages to be ignored or overridden due to alert fatigue. CPOE and automated drug dispensing was identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia . [ 12 ] Introducing CPOE to a complex medical environment requires ongoing changes in design to cope with unique patients and care settings, close supervision of overrides caused by automatic systems, and training, testing and re-training all users.
CPOE systems can take years to install and configure. Despite ample evidence of the potential to reduce medication errors, adoption of this technology by doctors and hospitals in the United States has been slowed by resistance to changes in physician's practice patterns, costs and training time involved, and concern with interoperability and compliance with future national standards. [ 13 ] According to a study by RAND Health, the US healthcare system could save more than 81 billion dollars annually, reduce adverse medical events and improve the quality of care if it were to widely adopt CPOE and other health information technology . [ 14 ] As more hospitals become aware of the financial benefits of CPOE, and more physicians with a familiarity with computers enter practice, increased use of CPOE is predicted. Several high-profile failures of CPOE implementation have occurred, [ 15 ] so a major effort must be focused on change management , including restructuring workflows, dealing with physicians' resistance to change, and creating a collaborative environment.
An early success with CPOE by the United States Department of Veterans Affairs (VA) is the Veterans Health Information Systems and Technology Architecture or VistA . A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient's record at any computer in the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders by CPOE, including medications, special procedures, x-rays, patient care nursing orders, diets and laboratory tests.
The world's first successful implementation of a CPOE system was at El Camino Hospital in Mountain View, California in the early 1970s. The Medical Information System (MIS) was originally developed by a software and hardware team at Lockheed in Sunnyvale, California, which became the TMIS group at Technicon Instruments Corporation. The MIS system used a light pen to allow physicians and nurses to quickly point and click items to be ordered.
As of 2005 [update] , one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom . The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT). The NHS component, known as the "Connecting for Health Programme", [ 16 ] includes office-based CPOE for medication prescribing and test ordering and retrieval, although some concerns have been raised about patient safety features. [ 17 ]
In 2008, the Massachusetts Technology Collaborative and the New England Healthcare Institute (NEHI) published research showing that 1 in 10 patients admitted to a Massachusetts community hospital suffered a preventable medication error. The study argued that Massachusetts hospitals could prevent 55,000 adverse drug events per year and save $170 million annually if they fully implemented CPOE. The findings prompted the Commonwealth of Massachusetts to enact legislation requiring all hospitals to implement CPOE by 2012 as a condition of licensure. [ 18 ] [ 19 ]
In addition, the study [ 20 ] also concludes that it would cost approximately $2.1 million to implement a CPOE system, and a cost of $435,000 to maintain it in the state of Massachusetts while it saves annually about $2.7 million per hospital. The hospitals will still see payback within 26 months through reducing hospitalizations generated by error. Despite the advantages and cost savings, the CPOE is still not well adapted by many hospitals in the US.
The Leapfrog 's 2008 survey [ 21 ] showed that most hospitals are still not complying with having a fully implemented, effective CPOE system. The CPOE requirement became more challenging to meet in 2008 because the Leapfrog introduced a new requirement: Hospitals must test their CPOE systems with Leapfrog's CPOE Evaluation Tool. So the number of hospitals in the survey considered to be fully meeting the standard dropped to 7% in 2008 from 11% the previous year. Though the adoption rate seems very low in 2008, it is still an improvement from 2002 when only 2% of hospitals met this Leapfrog standard.
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Computing in Cardiology (formerly known as Computers in Cardiology ) is a scientific conference held annually since 1974. It brings together scientists from medicine, bioengineering, and other related fields, focused on the application of computational methods in cardiology . Papers presented at the conference are published by the Institute of Electrical and Electronics Engineers . Since 2006, papers at the conference have been published under a Creative Commons license. The current president of the board of directors is Rob S. Macleod. [ 1 ]
Since 2000, the conference has hosted the annual Physionet/CinC data challenge. [ 2 ] [ 3 ]
Computing in Cardiology is abstracted and indexed in:
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Concealed conduction is tissue stimulation without direct effect, but leading to a change in conduction characteristics. [ 1 ] The term "concealed" is in reference to that the conduction is not observable by electrocardiogram.
A common example would be an interpolated PVC (a type of premature ventricular contraction ) during normal sinus rhythm ; the PVC does not cause an atrial contraction, because the retrograde impulse from the PVC does not completely penetrate the AV node. However, this AV node stimulation can cause a delay in subsequent AV conduction by modifying the AV node's subsequent conduction characteristics. Hence, the P-R interval after the PVC is longer than the baseline P-R interval. [ citation needed ]
Concealed conduction can be seen in cardiac aberrancy when a bundle branch temporarily blocks due to being refractory, and conduction from the other bundle branch conceals into the blocked branch retrograde thus perpetuation the bundle branch block morphology in subsequent beats. For example, if a Premature atrial contraction reaches the right bundle branch while refractory the PAC will conduct with RBBB morphology. As this PAC conducts down the left bundle, it will depolarize the septum then proceed retrograde up the right bundle. Eventually, this will reach refractory conduction tissue and stop. The subsequent beat — if early enough — will find the right bundle still refractory and the process will repeat yielding a continued RBBB morphology.
Another variation on this concept is seen in atrial flutter . As a result of the rapid atrial rate, some of the atrial activity fails to get through the AV node in an antegrade direction but can alter the rate at which a subsequent atrial impulse is conducted. In this circumstance, an alteration in the F-wave to QRS relationship is seen. [ citation needed ]
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In the study of inhaled anesthetics , the concentration effect is the increase in the rate that the Fa (alveolar concentration)/Fi (inspired concentration) ratio rises as the alveolar concentration of that gas is increased. In simple terms, the higher the concentration of gas administered, the faster the alveolar concentration of that gas approaches the inspired concentration. In modern practice it is only relevant for nitrous oxide since other inhaled anesthetics are delivered at much lower concentrations due to their higher potency.
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Concentric hypertrophy is a hypertrophic growth of a hollow organ without overall enlargement, [ 1 ] in which the walls of the organ are thickened and its capacity or volume is diminished.
Sarcomeres are added in parallel, as for example occurs in hypertrophic cardiomyopathy . [ citation needed ]
In the heart , concentric hypertrophy is related to increased pressure overload of the heart, often due to hypertension and/or aortic stenosis . The consequence is a decrease in ventricular compliance and diastolic dysfunction , followed eventually by ventricular failure and systolic dysfunction . [ citation needed ]
Laplace's law for a sphere states wall stress (T) is proportionate to the product of the transmural pressure (P) and cavitary radius (r) and inversely proportionate to wall thickness (W): In response to the pressure overload left ventricular wall thickness markedly increases—while the cavitary radius remains relatively unchanged. These compensatory changes, termed "concentric hypertrophy," reduce the increase in wall tension observed in aortic stenosis. [ citation needed ]
This article related to pathology is a stub . You can help Wikipedia by expanding it .
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Conditioned play audiometry ( CPA ) is a type of audiometry done in children from ages 2 to 5 years old, in developmental age. It is the test that directly follows visual reinforcement audiometry when the child becomes able to focus on a task. It is a type of behavioral hearing test, of which there are many.
Conditioned play audiometry uses toys to direct the child's attention on the listening task and turns it into a game. Instead of raising one's hand in response to the sound, as an adult would, the child might drop a toy into a bucket every time he or she hears a sound. This keeps the child interested in the listening task for longer. [ 1 ] [ 2 ] Common games include dropping balls in buckets, placing rings on a stick, feeding coins in a play pig, among many others.
The first part of CPA involves conditioning the child. The audiologist presents a loud sound that the child can comfortably hear, while encouraging the child to "drop the ball in the bucket every time you hear the sound," or whichever game is being used. After a few trials to get the child comfortable with the task, the audiologist then attempts to drop to low levels in order to find the softest sound the child can hear. [ 3 ] It's incredibly important to go quickly to ensure the child does not lose attention to the task.
There are precautions to take to ensure good reliability when performing solo play audiometry. It is important that the child not react to the clinician's hand movements, instead of sounds themselves. To address this, false taps on the tablet are essential to ensure the child is abiding by the listening task and not visual cues. Should the child react to non-sound producing (false) taps, re-conditioning may be warranted. [ 4 ]
Just like typical audiometry , CPA is performed at multiple frequencies, from 250 to 8000 Hz, to get a full range of the child's hearing. This can be performed using typical headphones and with a bone oscillator , and all thresholds are plotted on an audiogram . Once the child has reached approximately five years old, conventional audiometry using a button or hand-raising can typically be performed.
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Condom-associated erection problem (CAEP) is erectile dysfunction experienced due to condoms . [ 1 ] CAEP can occur in young and healthy men who otherwise have no erectile dysfunctions, although men who experience CAEP have greater odds of having mild-to-moderate erectile dysfunction. CAEP has the effect of discouraging condom use by both males and females. [ 1 ] One possible way to reduce CAEP is to encourage men with CAEP to try a variety of sizes, shapes, and textures of condoms to find the most comfortable ones. [ 2 ]
This medical article is a stub . You can help Wikipedia by expanding it .
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https://en.wikipedia.org/wiki/Condom-associated_erection_problem
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Conductive hearing loss (CHL) is a type of hearing impairment that occurs when sound waves are unable to efficiently travel through the outer ear, tympanic membrane (eardrum), or middle ear structures such as the ossicles. This blockage or dysfunction prevents sound from being effectively conducted to the inner ear, resulting in reduced hearing ability. Common causes include ear infections, fluid in the middle ear, earwax buildup, damage to the eardrum, or abnormalities in the ossicles.
CHL can occur alone or alongside sensorineural hearing loss, in which case it is classified as mixed hearing loss . Depending on the underlying cause, conductive hearing loss is often treatable and sometimes reversible through medical interventions, such as medication, surgery, or assistive devices like hearing aids. However, chronic or permanent cases may require long-term management to improve hearing and communication abilities. [ 1 ]
Common causes of conductive hearing loss include: [ 2 ]
Fluid accumulation is the most common cause of conductive hearing loss in the middle ear, especially in children. [ 3 ] Major causes are ear infections or conditions that block the eustachian tube , such as allergies or tumors. [ 3 ] Blocking of the eustachian tube leads to decreased pressure in the middle ear relative to the external ear, and this causes decreased motion of both the ossicles and the tympanic membrane. [ 4 ]
Third window effect caused by:
Conductive hearing loss makes all sounds seem faint or muffled. The hearing loss is usually worse in lower frequencies. Congenital conductive hearing loss is identified through newborn hearing screening or may be identified because the baby has microtia or other facial abnormalities. Conductive hearing loss developing during childhood is usually due to otitis media with effusion and may present with speech and language delay or difficulty hearing. Later onset of conductive hearing loss may have an obvious cause such as an ear infection, trauma or upper respiratory tract infection or may have an insidious onset related to chronic middle ear disease, otosclerosis or a tumour of the naso-pharynx. Earwax is a very common cause of a conductive hearing loss which may present suddenly when the wax blocks sound from getting through the external ear canal to the middle and inner ear.
Diagnosis requires a detailed history, local examination of the ear, nose, throat and neck, and detailed hearing tests. In children a more detailed examination may be required if the hearing loss is congenital.
Examination of the external ear canal and ear drum is important and may help identify problems located in the outer ear up to the tympanic membrane.
For basic screening, a conductive hearing loss can be identified using the Rinne test with a 256 Hz tuning fork. The Rinne test , in which a patient is asked to say whether a vibrating tuning fork is heard more loudly adjacent to the ear canal (air conduction) or touching the bone behind the ear (bone conduction), is negative indicating that bone conduction is more effective that air conduction. A normal, or positive, result, is when air conduction is more effective than bone conduction.
With a one-sided conductive component the combined use of both the Weber and Rinne tests is useful. If the Weber test is used, in which a vibrating tuning fork is touched to the midline of the forehead, the person will hear the sound more loudly in the affected ear because background noise does not mask the hearing on this side.
The following table compares sensorineural hearing loss to conductive:
Tympanometry , or acoustic immitance testing, is a simple objective test of the ability of the middle ear to transmit sound waves from the outer ear to the middle ear and to the inner ear. This test is usually abnormal with conductive hearing loss. A type B tympanogram reveals a flat response, due to fluid in the middle ear (otitis media), or an eardrum perforation. [ 5 ] A type C tympanogram indicates negative middle ear pressure, which is commonly seen in eustachian tube dysfunction. [ 5 ] A type As tympanogram indicates a shallow compliance of the middle ear, which is commonly seen in otosclerosis. [ 5 ]
Pure tone audiometry , a standardized hearing test over a set of frequencies from 250 Hz to 8000 Hz, may be conducted by a medical doctor, audiologist or audiometrist, with the result plotted separately for each ear on an audiogram . The shape of the plot reveals the degree and nature of hearing loss, distinguishing conductive hearing loss from other kinds of hearing loss. A conductive hearing loss is characterized by a difference of at least 15 decibels between the air conduction threshold and bone conduction threshold at the same frequency. On an audiogram, the "x" represents responses in the left ear at each frequency, while the "o" represents responses in right ear at each frequency.
Most causes of conductive hearing loss can be identified by examination but if it is important to image the bones of the middle ear or inner ear then a CT scan is required. CT scan is useful in cases of congenital conductive hearing loss, chronic suppurative otitis media or cholesteatoma, ossicular damage or discontinuity, otosclerosis and third window dehiscence. Specific MRI scans can be used to identify cholesteatoma.
Management falls into three modalities: surgical treatment, pharmaceutical treatment, and supportive, depending on the nature and location of the specific cause. [ 1 ]
In cases of infection, antibiotics or antifungal medications are an option. Some conditions are amenable to surgical intervention such as middle ear fluid, cholesteatoma, and otosclerosis. If conductive hearing loss is due to head trauma , surgical repair is an option. [ 6 ] If absence or deformation of ear structures cannot be corrected, or if the patient declines surgery, hearing aids which amplify sounds are a possible treatment option. [ 3 ] Bone conduction hearing aids are useful as these deliver sound directly, through bone, to the cochlea or organ of hearing bypassing the pathology. These can be on a soft or hard headband or can be inserted surgically, a bone anchored hearing aid, of which there are several types. Conventional air conduction hearing aids can also be used.
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Conductive keratoplasty ( CK ) is a type of refractive surgery that uses radio waves to adjust the contour of the cornea by shrinking the corneal collagen around it. [ 1 ] It is used to treat mild to moderate hyperopia . It is a non-invasive alternative to other types of eye surgery . It uses the same principles of laser thermokeratoplasty (LTK) and radial keratocoagulation, although the former uses holmium laser and the latter a 700°C needle to correct hyperopia. [ 2 ]
This surgery article is a stub . You can help Wikipedia by expanding it .
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Cone beam computed tomography (or CBCT , also referred to as C-arm CT , cone beam volume CT , flat panel CT or Digital Volume Tomography (DVT)) is a medical imaging technique consisting of X-ray computed tomography where the X-rays are divergent, forming a cone. [ 1 ]
CBCT has become increasingly important in treatment planning and diagnosis in implant dentistry , ENT, orthopedics, and interventional radiology (IR), among other things. Perhaps because of the increased access to such technology, CBCT scanners are now finding many uses in dentistry, such as in the fields of oral surgery , endodontics and orthodontics . Integrated CBCT is also an important tool for patient positioning and verification in image-guided radiation therapy (IGRT).
During dental/orthodontic imaging, the CBCT scanner rotates around the patient's head, obtaining up to nearly 600 distinct images. For interventional radiology, the patient is positioned offset to the table so that the region of interest is centered in the field of view for the cone beam. A single 200 degree rotation over the region of interest acquires a volumetric data set. The scanning software collects the data and reconstructs it, producing what is termed a digital volume composed of three-dimensional voxels of anatomical data that can then be manipulated and visualized with specialized software. [ 2 ] [ 3 ] CBCT shares many similarities with traditional (fan beam) CT however there are important differences, particularly for reconstruction . CBCT has been described as the gold standard for imaging the oral and maxillofacial area.
In the late 1990s, Dr Yoshinori Arai in Japan and Dr Piero Mozzo in Italy independently developed Cone Beam Computed Technology for oral and maxillofacial radiology . [ 4 ] The first commercial system (the NewTom 9000) was introduced in the European market in 1996 and into the US market in 2001, by Italian company Quantitative Radiology. [ 2 ] [ 5 ]
Cone beam CT using kilovoltage X-rays (as used for diagnostic , rather than therapeutic purposes) attached to a linear accelerator treatment machine was first developed in the late 1990s and early 2000s. [ 7 ] Such systems have since become common on latest generation linacs. [ 8 ] In the late 2010s CBCT also started to become available on-board particle therapy delivery systems. [ 9 ]
While CBCT with X-ray image intensifiers was experimented with in the late 1990s, it was not until the adoption of flat-panel X-ray detectors , with improved contrast and spatial resolution, that CBCT became practical for clinical use in interventional radiology procedures. [ 10 ] [ 11 ] Many fixed, and even mobile, C-arm fluoroscopy systems are now capable of CBCT acquisitions, in addition to traditional planar fluoroscopy. [ 12 ] [ 13 ] CBCT aids image guidance during interventional radiology procedures treating various medical conditions including knee osteoarthritis, benign prostatic hyperplasia, and hepatocellular carcinoma. [ 14 ] [ 15 ] [ 16 ] [ 17 ]
The most significant advantage of the CBCT in Endodontics is that it can show critical root canal anatomical features that conventional intraoral or panoramic images cannot. [ 18 ]
According to the American Association of Endodontics, there are numerous specific situations in which 3D images produced by CBCT enhance diagnosis and influence treatment, and its use cannot be disputed over conventional intraoral radiology based on ALARA principles. [ 19 ]
A dental cone beam scan offers useful information when it comes to the assessment and planning of surgical implants. The American Academy of Oral and Maxillofacial Radiology (AAOMR) suggests cone-beam CT as the preferred method for presurgical assessment of dental implant sites. [ 20 ]
As a 3D rendition, CBCT offers an undistorted view of the dentition that can be used to accurately visualize both erupted and non-erupted teeth, tooth root orientation and anomalous structures, that conventional 2D radiography cannot. [ 21 ]
Processing example using x-ray data from a tooth model:
The CBCT scanner offers undistorted views of the extremities. One advantage of orthopedic CBCT is the ability to take weight bearing images of the lower extremities . In the realm of the foot and ankle particularly, weight bearing CBCT is gaining momentum due to its ability to combine 3 dimensional and weight bearing information which are of the utmost importance in diagnosis and surgical planning. [ 22 ] The preferred term used for CBCT in the lower limb is thus WBCT for Weight Bearing CT following the first scientific publications on the subject. [ 23 ] [ 24 ] [ 25 ] [ 26 ]
Image-guided radiation therapy is a form of external beam radiotherapy where the patient is positioned with the organs to be treated accurately matched in position to the treatment field, to reduce the dose to nearby organs which are not being treated. Many organs inside the body move by millimeters relative to the external skin surfaces, and a CBCT scanner mounted on the head of the radiotherapy unit is used immediately before treatment (and sometimes again during treatment) to ensure the patient's organs are in exactly the right position to match the treatment field, and to adjust the position of the treatment table if necessary. The images may also be used to check for other requirements of some types of treatment, such as full or empty bladder, empty rectum, etc. [ 8 ] [ 27 ] The same cone beam beam source and detector can alternatively be used to take simple X-ray positioning images if the organ shows particularly well on X-ray or if Fiducial markers have been inserted into the organ. [ 28 ]
The CBCT scanner is mounted on a C-arm fluoroscopy unit in the interventional radiology (IR) suite, which offers real time imaging with a stationary patient. This eliminates the time needed to transfer a patient from the angiography suite to a conventional computed tomography scanner and facilitates a broad spectrum of applications of CBCT during IR procedures. The clinical applications of CBCT in IR include treatment planning, device or implant positioning and assessment, intra-procedural localization, and assessment of procedure endpoints. CBCT is useful as a primary and supplemental form of imaging. It is an excellent adjunct to DSA and fluoroscopy for soft tissue and vascular visibility during complex procedures. The use of CBCT before fluoroscopy potentially reduces patient radiation exposure. [ 3 ]
Cone beam CT is used for material analysis, metrology , and nondestructive testing in the manufacturing sector. Cone beam CT is also inspect and detect defects of tiny sizes, such as internal pitting corrosion or cracks of an object in quality control . [ 34 ]
Cone beam reconstruction algorithms are similar to typical tomographic reconstruction algorithms, and methods such as filtered backprojection or iterative reconstruction may be used. However, since the reconstruction is three-dimensional, modifications such as the FDK algorithm [ 35 ] may be needed.
Total radiation doses from 3D dental CBCT exams are 96% lower than conventional CT exams, but deliver 5-16x more radiation than standard dental 2D x-ray (OPG). The time of exposure in CBCT is also comparatively less when compared to conventional CT. [ 36 ] [ 37 ] [ 38 ] [ 39 ] [ 40 ]
CBCT use is only lightly regulated in the US. The recommended standard of care is to use the smallest possible field of view (FOV), the smallest voxel size, the lowest mA setting and the shortest exposure time in conjunction with a pulsed exposure mode of acquisition. [ 41 ] International organisations such as the World Health Organization and ICRP , as well as many local bodies and legislation, encourage the idea of justification for all medical exposures, where risks and benefits must be weighed up before a procedure goes ahead. [ 42 ]
There are a number of drawbacks of CBCT technology over that of CT scans, such as increased susceptibility to movement artifacts (in first generation machines) and to the lack of appropriate bone density determination. [ 43 ]
The Hounsfield scale is used to measure radiodensity and, in reference to CT scans , can provide an accurate absolute density for the type of tissue depicted. The radiodensity, measured in Hounsfield Units (HU, also known as CT number) is inaccurate in CBCT scans because different areas in the scan appear with different greyscale values depending on their relative positions in the organ being scanned, despite possessing identical densities, because the image value of a voxel of an organ depends on the position [ clarification needed ] in the image volume. [ 44 ] HU measured from the same anatomical area with both CBCT and medical-grade CT scanners are not identical [ 45 ] and are thus unreliable for determination of site-specific, radiographically-identified bone density for purposes such as the placement of dental implants, as there is "no good data to relate the CBCT HU values to bone quality." [ 46 ]
Although some authors have supported the use of CBCT technology to evaluate bone density by measuring HU, [ 47 ] [ 48 ] such support is provided erroneously because scanned regions of the same density in the skull can have a different grayscale value in the reconstructed CBCT dataset. [ 49 ]
X-ray attenuation of CBCT acquisition systems currently produces different HU values for similar bony and soft tissue structures in different areas of the scanned volume (e.g. dense bone has a specific image value at the level of the menton, but the same bone has a significantly different image value at the level of the cranial base). [ 43 ]
Dental CBCT systems do not employ a standardized system for scaling the grey levels that represent the reconstructed density values and, as such, they are arbitrary and do not allow for assessment of bone quality. [ 50 ] In the absence of such a standardization, it is difficult to interpret the grey levels or impossible to compare the values resulting from different machines. While there is a general acknowledgment that this deficiency exists with CBCT systems (in that they do not correctly display HU), there has been little research conducted to attempt to correct this deficiency. [ 51 ]
With time, further advancements in CBCT reconstruction algorithms will allow for improved area detectors, [ 52 ] and this, together with enhanced postprocessing, will likely solve or reduce this problem. [ 44 ] A method for establishing attenuation coefficients with which actual HU values can be derived from CBCT "HU" values was published in 2010 and further research is currently underway to perfect this method in vivo . [ 51 ]
While the practicality of CBCT fosters its increasing application in IR, technical limitations hinder its integration into the field. The two most significant factors that affect successful integration are image quality and time (for set up, image acquisition, and image reconstruction). Compared to multidetector computed tomography (MDCT), the wider collimation in CBCT leads to increased scatter radiation and degradation of image quality as demonstrated by artifacts and decreased contrast-to-noise ratio . The temporal resolution of cesium iodide detectors in CBCT slows data acquisition time to approximately 5 to 20 seconds, which increases motion artifacts . The time required for image reconstruction takes longer for CBCT (1 minute) compared to MDCT (real time) due to the computationally demanding cone beam reconstruction algorithms. [ 3 ] [ 29 ]
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In dentistry , the configuration factor (or c-factor ) refers to the number of bonded surfaces in an adhesive dental restoration . Because adhesive dental restorative material will adhere to the walls of a cavity preparation made available to it during polymerization, competing forces can arise during restoration of the tooth that can have both short and long term effects that correlate to the configuration of the cavity preparation.
Adhesive dental materials are generally used in a semi-liquid or semi-solid state that is then changed into a solid state during or after placement of the material into the cavity preparation -- this process is known as polymerization . This modification of state can occur automatically after a given time period after the material is discharged from the cartridge (referred to as self-polymerization ) or this change can be activated by certain wavelengths of light (referred to as light-cured or light-sensitive material) or the material can be activated in both ways (referred to as dual curing ).
Because these materials are adhesive in nature, they bond to the walls of the cavity preparation during curing. Another feature of polymerization is called polymerization shrinkage -- the material shrinks a tiny bit during this change from semi-liquid / semi-solid to solid. Because the material both shrinks and adheres to the walls and floor of the cavity preparation, competing forces arise that can lead to strain in the material (weaknesses in the final restoration) and subsequent early failure of the restoration, and lack of marginal integrity (small gaps between the restoration and the tooth) resulting in post-operative pain and or sensitivity.
The number of walls in a cavity preparation have been found to correlate with the number and magnitude of competing forces.
For example, a class I cavity preparation exhibits 5 surfaces that will be bonded to by the future adhesive restorative dental material: mesial, distal, facial, lingual and the floor of the preparation; the c-factor would thus be 5. If the restorative material is added to the cavity preparation in one application, this high c-factor will put sufficient stress on the restorative material and increase the likelihood of post-operative pain and sensitivity and early failure. [ 1 ] From a very technical perspective, it can be said that "the developing curing contraction in a bonded restoration generates stress on the bonded interfaces that are in competition with the developing bond strength of the setting restorative to the cavity surfaces, which may result in (partial) debonding, marginal leakage and post-operative pain." [ 2 ]
Internal stress can be reduced in an adhesive restoration by employing the following techniques:
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In psychology , confusion is the quality or emotional state of being bewildered or unclear. The term "acute mental confusion" [ 1 ] is often used interchangeably with delirium [ 2 ] in the International Statistical Classification of Diseases and Related Health Problems and the Medical Subject Headings publications to describe the pathology . These refer to the loss of orientation , or the ability to place oneself correctly in the world by time, location and personal identity. Mental confusion is sometimes accompanied by disordered consciousness (the loss of linear thinking) and memory loss (the inability to correctly recall previous events or learn new material). [ 3 ]
The word confusion derives from the Latin word, confundo , which means "confuse, mix, blend, pour together, disorder, embroil."
Confusion may result from drug side effects or from a relatively sudden brain dysfunction. Acute confusion is often called delirium (or "acute confusional state"), [ 4 ] although delirium often includes a much broader array of disorders than simple confusion. These disorders include the inability to focus attention; various impairments in awareness, and temporal or spatial dis-orientation. Mental confusion can result from chronic organic brain pathologies, such as dementia , [ 5 ] as well.
The most common causes of drug induced acute confusion are dopaminergic drugs (used for the treatment of Parkinson's disease ), diuretics , tricyclic , tetracyclic antidepressants and benzodiazepines or alcohol . The elderly, and especially those with pre-existing dementia, are most at risk for drug induced acute confusional states. [ 8 ] New research is finding a link between vitamin D deficiency and cognitive impairment (which includes "foggy brain"). [ 9 ]
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Congenital Heart Surgeons' Society (CHSS) is a professional membership organization of heart surgeons who specialize in treating congenital heart defects . The society is a non-profit organization registered in the United States.
The history of the group goes back to the early days of cardiac surgery in the mid 1950s, when 16 surgeons met annually to relate their early pioneering experience in operating on children with congenital heart defects. The CHSS' purpose is to associate persons interested in, and carry on activities related to, the science and practice of congenital heart surgery. It also strives to encourage and stimulate investigation and study with an aim to increase the knowledge of congenital cardiac physiology, pathology and therapy, and to correlate and disseminate such knowledge. [ citation needed ]
Congenital Heart Surgeons who have a significant interest in congenital heart surgery may apply for membership in the Congenital Heart Surgeons' Society (CHSS). There are three types of membership in the CHSS: Active, Emeritus and Honorary. Currently the CHSS has over 140 member surgeons from more than 70 hospitals. [ citation needed ]
In 1985 Dr. John Kirklin and Dr. Eugene Blackstone proposed that the centers pool their experience and data in managing infants with rare congenital anomalies of the heart. Data collection required the establishment of a Data Center, initially in Birmingham, Alabama . [ 1 ] In 1997, the Data Center moved to The Hospital for Sick Children in Toronto , Canada . The CHSS sponsors and oversees multi-institutional clinical studies evaluating the application of surgical interventions in congenital heart disease. [ 2 ]
The mission of the Data Center is to improve care for patients with congenital heart disease through collaborative research. Some of the CHSS studies involve treatment of heart defects like the transposition of the great arteries , congenital valvular heart disease , coarctation of aorta , hypoplastic left heart syndrome , anomalous aortic origin of a coronary artery among others. Approximately 6000 patients have participated in CHSS research studies, of which about 4000 patients are being actively followed by the Data Center. [ 3 ] The CHSS also collaborates with other professional organizations to advance care of the children with heart diseases. They include Society of Thoracic Surgeons, European Association of Congenital Heart Surgeons, etc. [ citation needed ]
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Congenital anosmia is a rare condition characterized by the complete inability to perceive smell from birth. It affects approximately 1 in 10,000 individuals and is often diagnosed later in life due to its subtle presentation and lack of associated symptoms. [ 7 ] [ 8 ]
The cause of congenital anosmia is not fully understood, but it is often linked to the underdevelopment or absence of the olfactory bulbs and tracts. [ 9 ] Diagnosis typically involves clinical evaluation, smell tests, and imaging studies to identify any structural abnormalities in the olfactory system. [ 10 ] This condition can occur in isolation or as part of a syndrome, such as Kallmann syndrome or CHARGE syndrome . [ 11 ]
There is no known cure for congenital anosmia. Management focuses on safety precautions to mitigate risks associated with the inability to smell, such as not detecting smoke or gas leaks. [ 10 ] Despite the challenges, individuals with congenital anosmia can lead normal lives with appropriate support and counseling. [ 8 ]
There is no single test to definitively diagnose congenital anosmia. Instead, the diagnosis is made through a combination of clinical evaluations, smell tests, imaging studies, and the exclusion of other potential causes of smell loss. [ 1 ] [ 12 ] This comprehensive approach ensures that other conditions that might interfere with the sense of smell are ruled out before confirming a diagnosis of congenital anosmia. [ 13 ]
The diagnostic process typically includes the following steps:
Many individuals with congenital anosmia are unaware of their condition until later in childhood or adolescence when they begin to realize they cannot smell things that others can. Therefore, diagnosis may not occur until well after birth, despite the condition being present from birth. [ 17 ]
A multidisciplinary approach involving ENT specialists, neurologists, and geneticists may be necessary for a comprehensive diagnosis, especially in complex cases or when congenital anosmia is suspected to be part of a broader syndrome. [ 19 ] [ 13 ]
The inability to detect odors poses safety risks such as the inability to smell smoke or gas leaks, [ 8 ] difficulty identifying spoiled food (leading to food poisoning), [ 5 ] [ 4 ] and challenges in detecting harmful chemicals or fumes. [ 20 ]
The sense of smell is closely linked to memory and emotions because the olfactory system is connected to the brain's limbic system, which is involved in emotional processing and memory formation. This connection means that specific scents can trigger vivid memories and strong emotional responses. For example, the smell of a particular perfume might remind someone of a loved one, or the scent of freshly baked cookies could evoke childhood memories. Without the sense of smell, individuals with congenital anosmia may miss out on these powerful sensory experiences that enhance and enrich one's emotional lives and memories. [ 24 ] [ 25 ] [ 26 ] [ 27 ]
Currently, there is no definitive treatment for congenital anosmia, as the condition involves the absence or underdevelopment of the olfactory bulbs and tracts, which are critical for the sense of smell. Management primarily focuses on safety precautions and coping strategies to mitigate the risks associated with the inability to smell. [ 2 ] [ 4 ] [ 5 ]
According to medical professionals and patient support organizations such as Fifth Sense, individuals with congenital anosmia are advised to take several safety measures to protect themselves from potential hazards. [ 28 ] [ 29 ] These measures include:
While there is no cure for congenital anosmia, individuals can use psychological counseling and support groups to help individuals cope with the emotional and practical challenges of living without a sense of smell. [ 4 ]
Research into potential treatments for congenital anosmia is ongoing. Gene therapy has shown promise in animal models, where scientists have successfully restored the sense of smell in mice with congenital anosmia. [ 6 ] Additionally, identifying the genetic causes of congenital anosmia could lead to the development of targeted gene therapies for humans in the future. [ 31 ]
Clinical trials and research studies are being conducted to explore new treatments and improve the understanding of congenital anosmia. Individuals with congenital anosmia may consider participating in these studies to contribute to scientific advancements and potentially benefit from emerging therapies. [ 32 ]
Congenital anosmia is a rare condition, with limited large-scale epidemiological studies available. The exact prevalence is difficult to determine due to underreporting and challenges in early diagnosis. [ 19 ] However, it is estimated to affect approximately 1 in 10,000 individuals. [ 4 ] [ 7 ]
Located in Philadelphia, USA, the Monell Chemical Senses Center is a research institute focused on the senses of smell and taste. The lab of Joel Mainland has been studying genetic inheritance patterns to identify genes that cause congenital anosmia. This research is part of a broader effort to understand the mechanisms of smell and develop effective treatments for smell disorders. [ 12 ]
The NYU Langone Health Anosmia Center specializes in diagnosing and treating anosmia, including congenital anosmia. The center's team of otolaryngologists conducts evaluations and research to improve understanding and management of smell disorders. [ 33 ]
Located in Gainesville, FL, the University of Florida Center for Smell and Taste coordinates and promotes research on taste and smell. Researchers are exploring gene therapy approaches to restore the sense of smell in individuals with congenital anosmia. [ 34 ]
Fifth Sense is a UK-based charity dedicated to supporting people with smell and taste disorders. They collaborate with researchers and institutions to advance the understanding of congenital anosmia. They provide resources, support, and advocacy for individuals affected by the condition. [ 1 ]
Under the direction of Professor Thomas Hummel, the University of Dresden Smell and Taste Center in Germany conducts fundamental and clinical research on the diagnosis, consequences, and treatments of anosmia, including congenital anosmia. [ 35 ]
Smell and Taste Association of North America is a non-profit organization dedicated to advancing research, education, and advocacy for individuals affected by smell and taste disorders, including congenital anosmia. STANA connects researchers, clinicians, and patients. The organization promotes research initiatives and raises awareness about chemosensory disorders. [ 36 ] STANA collaborates with various research institutions and is involved in organizing conferences that bring together scientists, clinicians, and individuals with smell and taste disorders to further research and understanding of conditions like congenital anosmia. [ 37 ]
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Conjugate gaze palsies are neurological disorders affecting the ability to move both eyes in the same direction. These palsies can affect gaze in a horizontal, upward, or downward direction. [ 1 ] These entities overlap with ophthalmoparesis and ophthalmoplegia .
Symptoms of conjugate gaze palsies include the impairment of gaze in various directions and different types of movement, depending on the type of gaze palsy. Signs of a person with a gaze palsy may be frequent movement of the head instead of the eyes. [ 2 ] For example, a person with a horizontal saccadic ( saccade ) palsy may jerk their head around while watching a movie or high action event instead of keeping their head steady and moving their eyes, which usually goes unnoticed. Someone with a nonselective horizontal gaze palsy may slowly rotate their head back and forth while reading a book instead of slowly scanning their eyes across the page. [ citation needed ]
A lesion, which is an abnormality in tissue due to injury or disease, can disrupt the transmission of signals from the brain to the eye. Almost all conjugate gaze palsies originate from a lesion somewhere in the brain stem , usually the midbrain , or pons . These lesions can be caused by stroke , or conditions such as Koerber-Salus-Elschnig syndrome, Progressive supranuclear palsy , Olivopontocerebellar syndrome , Niemann-Pick Disease, Type C , or envenomation such as from a scorpion sting. [ 3 ]
The location of the lesion determines the type of palsy.
Nonselective horizontal gaze palsies are caused by lesions in the Abducens nucleus . This is where the cranial nerve VI leaves on its way to the Lateral rectus muscle , which controls eye movement horizontally away from the midline of the body. The cranial nerve VI also has interneurons connecting to the medial rectus , which controls horizontal eye movement towards from the midline of the body. [ 4 ] Since the lateral rectus controls movement away from the center of the body, a lesion in the abducens nucleus disrupts the pathways controlling outward movements, not allowing the right eye to move right and the left eye to move left. Nerve VI has the longest subarachnoid distance to its target tissue, making it susceptible to lesions. [ 5 ] Lesions anywhere in the abducens nucleus, cranial nerve VI neurons, or interneurons can affect eye movement towards the side of the lesion. Lesions on both sides of the abducens nucleus can cause a total loss of horizontal eye movement. [ 6 ]
One other type of gaze palsy is a horizontal saccadic palsy. Saccades are very quick intermittent eye movements. [ 7 ] The paramedian pontine reticular formation (PPRF), also in the pons is responsible for saccadic movement, relaying signals to the abducens nucleus. [ 8 ] Lesions in the PPRF cause what would be saccadic horizontal eye movements to be much slower or in the case of very severe lesions, nonexistent. [ 6 ] Horizontal gaze palsies are known to be linked to Progressive Scoliosis . [ 9 ] This occurs because pathways controlling saccadic movements are disrupted by the lesion and only slow movements controlled by a different motor pathway are unaffected.
Lesions in the midbrain can interfere with efferent motor signals before they arrive at the pons. This can also cause slowed horizontal saccadic movements and failure for the eye to reach its target location during saccades. This damage normally happens in the oculomotor nucleus of the midbrain [ 10 ] As in horizontal saccadic palsy, the saccades are stopped or slowed from the disrupted pathway, only in this case the signal is disrupted before it reaches the PPRF.
One-and-a-half syndrome is associated with damage to the paramedian pontine reticular formation and the medial longitudinal fasciculus . [ 11 ] These combined damages cause both a complete gaze impairment on the ipsilateral side and a "half" gaze impairment on the contralateral side. [ 6 ] As seen in horizontal saccadic palsy, the impairment of the contralateral side gaze is caused by the disrupted pathways coming from the PPRF, while the "half" impairment is from the signal passing through the medial longitudinal fascicles not being able to reach its target. One-and-a-Half syndrome is normally associated with horizontal gaze.
Although more rare than horizontal, one-and-a-half syndrome from damage to the paramedian pontine reticular formation and the medial longitudinal fasciculus can be shown to affect vertical gaze. This can cause impairment of vertical gaze, allowing only one eye to move vertically. [ 6 ]
A patient may be diagnosed with a conjugate gaze palsy by a physician performing a number of tests to examine the patient's eye movement abilities. In most cases, the gaze palsy can simply be seen by inability to move both eyes in one direction. However, sometimes a patient exhibits an abduction nystagmus in both eyes, indicating evidence of a conjugate gaze palsy. [ 12 ] A nystagmus is a back and forth "jerk" of the eye when attempting to hold a gaze in one direction. [ 13 ]
Conjugate gaze palsies can be classified into palsies affecting horizontal gaze and vertical gaze. [ citation needed ]
Horizontal gaze palsies affect gaze of both eyes either toward or away from the midline of the body. Horizontal gaze palsies are generally caused by a lesion in the brain stem and connecting nerves, normally in the pons . [ 6 ]
Horizontal gaze palsy with progressive scoliosis (HGPPS) is a very rare form of conjugate gaze palsy, appearing only in a few dozen families worldwide. HGPPS prevents horizontal movement of both eyes, causing people with this condition to have to move their head to see moving objects. In addition to the eye movement impairment, HGPPS is coupled with progressive scoliosis , although eye symptoms usually appear before scoliosis. HGPPS is caused by a mutation in the ROBO3 gene, which is important in cross-over of motor and sensory signals, preventing horizontal eye movement. In addition to the mutation, lesions in the midbrain and pons are common. This can also include a complete absence of a formation in the pons, the facial colliculus , which is responsible for some facial movements. [ 14 ] The cause of progressive scoliosis in HGPPS and why HGPPS does not affect vertical gaze is unclear. Progressive scoliosis is normally treated with surgery. [ 2 ]
Vertical gaze palsies affect movement of one or both eyes either in upward direction, up and down direction, or more rarely only downward direction. Very rarely only movement of one eye in one direction is affected. Vertical gaze palsies are often caused by lesions to the midbrain due to a stroke or a tumor. In the case that only downward gaze is affected, the cause is normally progressive supranuclear palsy. [ 15 ]
There is no treatment of conjugate gaze palsy itself, so the disease or condition causing the gaze palsy must be treated, likely by surgery. [ 1 ] As stated in the causes section, the gaze palsy may be due to a lesion caused by stroke or a condition. Some of the conditions such as Progressive supra nuclear palsy are not curable, [ 16 ] and treatment only includes therapy to regain some tasks, not including gaze control. Other conditions such as Niemann-Pick disease type C have limited drug therapeutic options. [ 17 ] Stroke victims with conjugate gaze palsies may be treated with intravenous therapy if the patent presents early enough, or with a surgical procedure for other cases. [ 18 ]
The prognosis of a lesion in the visual neural pathways that causes a conjugate gaze palsy varies greatly. Depending on the nature of the lesion, recovery may happen rapidly or recovery may never progress. For example, optic neuritis , which is caused by inflammation, may heal in just weeks, while patients with an ischemic optic neuropathy may never recover. [ 19 ] [ 20 ]
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Conjunctival squamous cell carcinoma ( conjunctival SCC ) and corneal intraepithelial neoplasia comprise ocular surface squamous neoplasia (OSSN). SCC is the most common malignancy of the conjunctiva in the US, with a yearly incidence of 1–2.8 per 100,000. Risk factors for the disease are exposure to sun (specifically occupational), exposure to UVB , and light-colored skin. Other risk factors include radiation, smoking, HPV , arsenic , and exposure to polycyclic hydrocarbons . [ 1 ]
Conjunctival SCC is often asymptomatic at first, but it can present with the presence of a growth, red eye, pain, itching, burning, tearing, sensitivity to light, double vision, and decreased vision. [ 1 ] Spread of conjunctival SCC can occur in 1–21% of cases, with the first site of spread being the regional lymph nodes. [ 1 ] Mortality for conjunctival SCC ranges from 0–8%. [ 1 ] Diagnosis is often made by biopsy, as well as CT (in the case of invasive SCC).
Treatment of conjunctival SCC is usually surgical excision followed by cryotherapy . [ 1 ] After this procedure, Conjunctival SCC can recur 8–40% of the time. [ 1 ] Radiation treatment, topical Mitomycin C , and removal of the contents of the orbit, or exenteration, are other methods of treatment. [ 1 ] Close follow-up is recommended, because the average time to recurrence is 8–22 months. [ 1 ]
Cancer can be considered a very large and exceptionally heterogeneous family of malignant diseases, with squamous cell carcinomas comprising one of the largest subsets. [ 2 ] [ 3 ] [ 4 ]
All squamous cell carcinoma lesions are thought to begin via the repeated, uncontrolled division of cancer stem cells of epithelial lineage or characteristics. Accumulation of these cancer cells causes a microscopic focus of abnormal cells that are, at least initially, locally confined within the specific tissue in which the progenitor cell resided. This condition is called squamous cell carcinoma in situ , and it is diagnosed when the tumor has not yet penetrated the basement membrane or other delimiting structure to invade adjacent tissues. Once the lesion has grown and progressed to the point where it has breached, penetrated, and infiltrated adjacent structures, it is referred to as " invasive " squamous cell carcinoma. Once a carcinoma becomes invasive, it is able to spread to other organs and cause a metastasis , or "secondary tumor", to form. [ citation needed ]
Human papilloma virus
The differential for OSSN includes pterygium , pingueculum , papilloma , solar keratosis , lipoma , lymphoma , chronic blepharoconjunctivitis , inflammation , melanoma , ocular pannus , pyogenic granuloma , kaposi sarcoma , keratocanthoma , mucoepidermoid carcinoma, pseudoepitheliomatous hyperplasia, and adenocarcinoma. [ 5 ] While confocal microscopy can be used for diagnosis, biopsy is considered the standard, especially before treatment with a cytotoxic medication. [ 5 ]
Most conjunctival squamous cell carcinomas are removed with surgery. A few selected cases are treated with topical medication. Surgical excision with a free margin of healthy tissue is a frequent treatment modality. Radiotherapy, given as external beam radiotherapy or as brachytherapy (internal radiotherapy), can also be used to treat squamous cell carcinomas. [ 6 ]
Squamous cell carcinoma of eye tissues is one of the most frequent neoplasms of cattle . [ 7 ]
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A connective tissue neoplasm or connective tissue tumor is a neoplasm arising from the tissues of the connective tissue . [ 1 ] (Not all tumors in the connective tissue are of the connective tissue.)
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Conolly Norman (12 March 1853 – 23 February 1908 [ 1 ] ) was an Irish alienist, or psychiatrist , of the late nineteenth and early twentieth centuries. He was the Resident Medical Superintendent of a number of district asylums, most notably Ireland's largest asylum, the Richmond District Lunatic Asylum, now known as St. Brendan's Hospital .
That fellow I was in the Ship with last night, said Buck Mulligan, says you have g.p.i. He's up in Dottyville with Conolly Norman. General Paralysis of the Insane.
Norman was born on 12 March 1853 at All Saints' Glebe, Newtown Cunningham , County Donegal , Ireland. The fifth child of six boys, his father, Hugh Norman, was the rector of All Saints' and later of Barnhill . [ 3 ] His family were prominent [ 4 ] and politically active in Derry with several members serving as mayor of Derry. Two members of his family were also elected to parliament. [ 1 ]
Educated at home due to his fragile health as a child, at the age of seventeen Norman began his medical studies at Trinity College, Dublin , the Carmichael Medical School, and the Richmond Surgical Hospital, gaining a M.D. [ 1 ] [ 5 ] In 1874 he became a licentiate of the Royal College of Physicians and Surgeons, a fellow of the Royal College of Surgeons in 1878 and a fellow of the Royal College of Physicians in 1890. [ 3 ] [ 5 ]
After he graduated in 1874, Norman immediately took up a post as an assistant medical officer in the Monaghan District Lunatic Asylum . He remained in that post until 1880 when he joined the staff of the Bethlem Royal Hospital in London where he worked under the prominent English alienist Sir George Savage . [ 1 ] [ 4 ] Returning to Ireland in 1882 he was appointed the Resident Medical Superintendent of Castlebar District Lunatic Asylum in Co. Mayo . [ 1 ] [ 4 ] [ 5 ] He remained there until 1885 when he was appointed Resident Medical Superintendent of the Monaghan Asylum. [ 1 ] In 1886, he was appointed by the Lord Lieutenant as Resident Medical Superintendent to Ireland's largest asylum, the Richmond District Lunatic Asylum. [ 4 ] He would remain in this last post until his death in 1908 at the age of fifty-five.
While the Richmond asylum prior to Norman's arrival has been described as primitive and prisonlike [ 1 ] this is perhaps to overlook the international praise that his predecessor, John Lalor had received, particularly in regard to his educational initiatives in establishing a national school for the patients in the grounds of the hospital. [ 6 ] In any case, by 1904, Connolly could assert like a growing number of reforming alienists, that Emil Kraepelin's dementia praecox (a concept intimately linked with schizophrenia) was not incurable. [ 7 ]
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Conscious breathing encompasses techniques directing awareness toward the breathing process, serving purposes from improving respiration to building mindfulness . In martial arts like tai chi and qigong , breathing exercises are said to strengthen diaphragm muscles and protect organs, with reverse breathing being a common method. Meditation traditions, including yoga and Buddhist meditation , emphasize breath control. Yoga's pranayama is believed by practitioners to elevate life energies , while Buddhist vipassanā uses anapanasati for mindfulness of breathing.
In music, circular breathing enables wind instrument players to produce a continuous tone. Singers, too, rely on breath control through consciously managed breathing stages. The Buteyko method in physical therapy focuses on breathing exercises for conditions like asthma, emphasizing nasal breathing and relaxation. In psychology, Integrative Breathing combines various techniques to address specific needs, particularly in cases of drug abuse disorders and post-traumatic stress disorder.
New Age breathwork practices, like Holotropic Breathwork and Rebirthing-breathwork, developed in the late 1960s and 1970s, use deepened breathing for accessing altered states of consciousness and purging repressed memories. However, the medical community questions the efficacy of some methods, such as the Buteyko method, due to limited evidence supporting their claims.
In tai chi , anaerobic exercise is combined with breathing exercises to strengthen the diaphragm muscles , improve posture and make better use of the body's qi . [ 1 ]
In qigong , reverse breathing is a breathing technique which consists of contracting the abdomen and expanding the thoracic cage while breathing in through the nose and then gently compressing it while exhaling through the mouth, which is the opposite of what an abdomen would do during natural, diaphragmic instinctive breathing. [ 2 ] The technique is also widely practiced in a number of martial arts. Some notable ones include Chinese systems such as baguazhang , tai chi and other styles of kung fu . Reverse breathing is believed to activate healing and protective qi as the practitioner is consciously controlling the breath in a way opposite to normal breathing. By expanding the abdomen while delivering some technique (e.g. punch), the martial artists also protect the inner organs from any received counterattack. [ 3 ]
Different forms of meditation and yoga advocate various breathing methods. In yoga these methods are called pranayama . [ 1 ] In yoga, breath is associated with prana , thus, pranayama is a means to elevate the prana - shakti , or life energies. Pranayama is described in Hindu texts such as the Bhagavad Gita and the Yoga Sutras of Patanjali . Methods include prolonging the in- and outbreaths, holding pauses on the in- or outbreath or both, alternate nostril breathing, and breathing with the glottis slightly engaged. Later in Hatha yoga texts, it meant the complete suspension of breathing. The pranayama practices in modern yoga as exercise are unlike those of the Hatha yoga tradition.
In Buddhism , vipassanā focuses on breathing in and around the nose to calm the mind using anapanasati , [ 4 ] a form of Buddhist meditation meaning "mindfulness of breath", which was first introduced by Buddha . [ 1 ]
In music, some wind instrument players use a technique called circular breathing , a technique used by players of some wind instruments to produce a continuous tone without interruption. It is accomplished by inhaling through the nose while simultaneously pushing air out through the mouth using air stored in the cheeks . The technique was developed independently by several cultures and is used for many traditional wind instruments . [ 5 ]
Singers also rely on breath control . Natural breathing has three stages: a breathing-in period, breathing out period, and a resting or recovery period; these stages are not usually consciously controlled. Within singing, there are four stages of breathing: a breathing-in period (inhalation); a setting up controls period (suspension); a controlled exhalation period (phonation); and a recovery period.
These stages must be under conscious control by the singer until they become conditioned reflexes. Many singers abandon conscious controls before their reflexes are fully conditioned which ultimately leads to chronic vocal problems. [ 6 ]
The Buteyko method is a form of complementary or alternative physical therapy that proposes the use of breathing exercises primarily as a treatment for asthma and other respiratory conditions. [ 7 ] It focuses on nasal breathing, relaxation and reduced breathing. These techniques provide the lungs with more NO and thus dilate the airways and should prevent the excessive exhalation of CO 2 and thus improve oxygen metabolism. Advocates of the Buteyko method say that it can alleviate symptoms and reliance on medication for patients with asthma, chronic obstructive pulmonary disease (COPD), and chronic hyperventilation. The medical community questions these claims, given limited and inadequate evidence supporting the theory and efficacy of the method. [ 7 ] [ 8 ]
In psychology, "Integrative Breathing" combines specific benefits of various schools of conscious breathing according to the needs of clients. [ 9 ] [ 10 ] Research considers drug abuse disorders, [ 11 ] post traumatic stress disorder , [ 12 ] alcoholism and smoking . [ 13 ]
Coherent breathing is a method that involves breathing at the rate of five breaths per minute with equal periods of inhalation and exhalation and conscious relaxation of anatomical zones. [ 14 ] [ 15 ]
Several forms of breathwork developed in the late 1960s and early 1970s are considered New Age practices. Holotropic Breathwork was developed by psychiatrist Stanislav Grof in the 1960s. It uses deepened breathing to allow access to non-ordinary states of consciousness. [ 16 ] Rebirthing-breathwork was developed by Leonard Orr in the 1970s. It uses conscious breathing to purge repressed birth memories and traumatic childhood memories. [ 17 ]
Some cultures have used breathing techniques for years to increase brain function and calm emotions. [ 18 ] There is little to know about the connection between breathing and the effect it has on the parasympathetic nervous system, but some studies have contributed to some of that knowledge; one study done on mice from the Stanford School of Medicine included the removal of neurons from the medulla oblongata, which has a direct connection to the locus coeruleus and is responsible for breathing rhythms. The locus coeruleus has connections that influence arousal. Removing the neurons did not affect the breathing of the mice, but it did increase the calm state of the mice. This seemed to show a stronger correlation between breathing and emotion. [ 19 ] Other studies have tried to understand the science behind pranayama, a yoga technique that involves slow, controlled breathing. Such breathing has been shown to decrease the heart rate blood pressure and increase activity in the parasympathetic nervous system, which reverses arousal states and calms down the individual. Researchers theorize that slow, controlled breathing resets the autonomic nervous system. [ 20 ] Still, little is known about the connection between breathing and emotions; however, using proper breathing techniques could be helpful in countless stressful situations, such as taking tests for school. [ 21 ] During normal breathing, we breath with neck, chest, and shoulder. In this process, we use our spine and muscles to such oxygem into lungs. Our voluntary muscles helps them to relax in the morning to ease tight sleeping muscles. When tissues do more work than usual, carbon dioxide and other waste products are released which causes blood vessles to widen and encourage fresh blood to flow in. [ 22 ]
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A consecutive case series is a type of case series clinical study that includes all eligible patients identified by the researchers during the study registration period. The patients are treated in the order in which they are identified. This type of study usually does not have a control group .
For example, in Sugrue, et al. (2016), a consecutive case series design was used to determine trends in hand surgery research. [ 1 ]
This article incorporates public domain material from Dictionary of Cancer Terms . U.S. National Cancer Institute .
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A consensual response is any reflex observed on one side of the body when the other side has been stimulated.
For example, if an individual's right eye is shielded from light, while light shines into the left eye, constriction of the right pupil will still occur (the consensual response), along with the left (the direct response). This is because the afferent signal sent through one optic nerve connects to the Edinger-Westphal nucleus , whose axons run to both the right and the left oculomotor nerves.
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Conservation medicine is an emerging, interdisciplinary field that studies the relationship between human and non-human animal health and environmental conditions. Specifically, conservation medicine is the study of how the health of humans, animals, and the environment are interconnected and affected by conservation issues. [ 1 ] It is also known as planetary health , environmental medicine , medical geology , or ecological medicine. [ 1 ] [ 2 ]
The environmental causes of health problems are complex, global, and poorly understood. Conservation medicine practitioners form multidisciplinary teams to tackle these issues. Teams may involve physicians and veterinarians working alongside researchers and clinicians from diverse disciplines, including microbiologists , pathologists , landscape analysts, marine biologists , toxicologists , epidemiologists , climate biologists, anthropologists , economists , and political scientists . [ 2 ]
A physician in the 1800s, Rudolf Virchow , once said "between animal and human medicine, there is no dividing line- nor should there be". [ 3 ] The intersection of the health of animals, humans, and their environment has been an area of discussion since then. The term conservation medicine was first described in the 1990s with the recognition of the impact human population, environmental degradation , illegal hunting, and biodiversity loss contributed to the health of wildlife populations in Africa. [ 4 ] The increasing interest in conservation medicine since then represents a significant development in both medicine and environmentalism . [ 5 ]
While the initial discovery of conservation medicine focused on health of wildlife populations, it became apparent that human health is also impacted by animals and the environment as humans became more aware of zoonotic diseases. [ 3 ] Diseases that spread between animals and humans such as certain strains of the flu , salmonellosis , West Nile virus , the plague , coronaviruses ( severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) ), rabies , brucellosis , malaria , HIV , avian influenza , Lyme disease , Nipah virus , and other emerging infectious diseases are among the few human diseases known to be connected to the environment or animal health. [ 6 ] As of 2023, up to 70% of emerging infectious diseases (EID) originate from animals, [ 7 ] which has brought the concept of conservation medicine to the forefront of current ideas in healthcare.
While the hands-on process of conservation medicine in individual cases is complicated, the underlying concept is quite intuitive, namely, that human health, wildlife health, and ecosystem health are all related. [ 8 ] The threat of zoonotic diseases that travel to humans from animals is central. For example, burning huge areas of forest to make way for farmland may displace a wild animal species, which then infects a domesticated animal. The domesticated animal then enters the human food chain and infects people, and a new health threat emerges. Conventional approaches to the environment, animal and human health rarely examine these connections. In conservation medicine, such relationships are fundamental. Professionals from the many disciplines involved necessarily work closely together.
Since the emergence of the idea of conservation medicine, many human physicians and veterinarians have adopted the initiative titled One Health . [ 9 ] One Health evolved from the early idea of One Medicine, which was developed by veterinary communities as early as the 1900s. [ 9 ] Originally, One Health solely promoted the interconnectedness of animal health and human health, and failed to recognize the role of the ecosystem's health in the health and wellbeing of animals and humans. [ 9 ] However, One Health is now a recognized and valued approach to optimize the health of people, animals, and the environment, and has been adopted by a multitude of organizations and governing bodies to guide their work in protecting global health. [ 10 ] The United States Centers for Disease Control and Prevention (CDC) and the United States National Institutes of Health (NIH) utilize the One Health approach to better understand and mitigate threats to human health. [ 10 ] [ 11 ] The World Organisation for Animal Health (WOAH) utilizes the One Health approach to improve animal health across the globe through advocacy and the spread of veterinary information. [ 12 ] The United States Environmental Protection Agency (EPA) highlights their use of One Health to protect the environment stating "when we protect one, we protect all". [ 13 ]
The concept of conservation medicine utilizes a One Health approach, and specifically works to decrease disease and health risks humans and animals experience due to the degradation of the natural environment. [ 14 ]
Looking at the environment and health together, conservation medicine has the potential to effect rapid change in public opinion on complex societal issues, by making the distant and ill-defined, local and pressing. For instance, global warming may vaguely define long-term impacts, but an immediate effect may be a relatively slight rise in air temperature. This in turn raises the flight ceiling for temperature-sensitive mosquitoes , allowing them to feed on higher flying migratory birds than usual, which in turn may carry a disease from one country or continent to another.
Likewise, the broad topic of suburban sprawl is made more relevant when seen in terms of the immediate imbalance it brings to rural ecosystems, which increases population densities and forces humans into closer contact with animals (like rodents ), increasing the risk of new cross-species diseases. When tied to actual cases (such as SARS or HIV/AIDS), this holistic outlook resonates more powerfully with the public than more abstract explanations.
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Conservative Dentistry , also known as operative dentistry or crown and bridge dentistry , is the area of dentistry that focuses on dental crowns and bridges. [ 1 ] [ 2 ]
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Conservative treatment is a type of medical treatment defined by the avoidance of invasive measures such as surgery or other invasive procedures , [ 1 ] usually with the intent to preserve function or body parts. [ 2 ] For example, in appendicitis , conservative management may include watchful waiting and treatment with antibiotics, as opposed to surgical removal of the appendix . [ 3 ]
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Consilia (plural of consilium , 'advice') is a genre of book, originating in medieval era plagues, where practical advice is given on a medical or other philosophical subject.
The format was originated by the Florentine doctor of medicine Taddeo Alderotti , under the pressures for down-to-earth advice, based on experiential observations, in treating the Black Death that decimated Italy in 1348 and recurred at generational intervals for the following centuries. A consilium was a doctor's written text in response to a particular case, where the malady had been determined; in the consilium the medical doctor identified the disease and prescribed the appropriate treatment. [ 1 ] The accumulation of consilia circulated in manuscript began, for the first time in Europe, to lay down a corpus of medical practice, case-by-case.
Medieval medical writings had tended towards theory rather than praxis , which was denigrated as ars mechanica , mere technician's work unsuited to the higher intellect. Characteristically they took the form of glosses and commentaries on the received texts of Antiquity , of Galen and Dioscurides , with nods towards Aristotle and the shadow of Hippocrates . Medicine was more closely allied in these with philosophy rather than with therapy and prevention ; however with the onset of plague , practical experience moved to the forefront of concern. [ 2 ]
Alderotti, who practiced and taught in Tuscany and the north of Italy, and served as doctor to Pope Boniface VIII , was a formative figure in the development of the faculty of arts and medicine at the University of Bologna . His more than a hundred consilia based on his clinical observation of actual cases formed the prototypes of a new genre of literature. [ 3 ]
Consilia followed a conventional format. The first section recorded the examination of the patient, detailing the patient's age, sex, social station, occupation and place of residence. and a list of the patient's symptoms, which served to identify the malady. A second section prescribed a dietary regime that was to be followed. [ 4 ] A final section prescribed specific medications and dosage, with the other interventions available at the time: bleeding , bathing , cauterisation , fumigation . [ 5 ]
The Consilia of Gentile da Foligno (died 1348, most probably of the plague) were among the first medical texts to be printed, in the 1470s.
This history of medicine article is a stub . You can help Wikipedia by expanding it .
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https://en.wikipedia.org/wiki/Consilia
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Constantin von Monakow (4 November 1853 – 19 October 1930) was a Russian-Swiss neuropathologist who was a native of Bobretsovo in the Vologda Governorate .
He studied at the University of Zurich while working as an assistant at the Burghölzli Institute under the directorship of Eduard Hitzig (1839-1907). After graduation, he was an assistant at St. Pirminsberg, where he performed scientific investigations of cerebral anatomy . In 1885 he returned to Zurich , where he later became director of the brain anatomy institute. In 1917 he founded the journal Schweizer Archiv für Neurologie und Psychiatrie (Swiss Archives of Neurology and Psychiatry), and was its editor-in-chief until his death. He died in Zurich in 1930.
Monakow made numerous contributions in his analysis of the sensory and motor pathways of the brain. He was interested in the functional relationships amongst the different regions of the brain , and conceptualized that in faculties such as intellect , coordination was needed among its many diverse parts. [ 1 ] From his brain research, he introduced the terms "chronogenic localization" and " diaschisis ".
In 1910 Monakow coined the term "diaschisis" to describe how an injury to the brain can create behavioral deficiencies that may be followed by eventual recovery. The word is derived from Greek, meaning "shocked throughout". He believed the brain to exist as a delicate balance between its different components, and if a component became disturbed through injury it could affect other parts of the brain not seemingly associated with the site of injury. Therefore, if the damage wasn't too severe, functional behaviour would recover once the period of diaschisis wore off.
His name is lent to "Monakow's nucleus" ( lateral cuneate nucleus ) [ 2 ] and to the "bundle of Monakow" ( rubrospinal fasciculus ). In addition, "Monakow's syndrome" bears his name, defined as contralateral hemiplegia , hemi anaesthesia and homonomous hemianopsia due to occlusion of the anterior choroidal artery . [ 3 ]
He was responsible for identifying the arcuate fasciculus as the fibre tract that connected the Broca's and Wernicke's speech areas. This anatomical link (which is now questioned) [ 4 ] “soon became a dogma in neurology and still today provides the backbone of anatomical models of language.” [ 4 ]
He is mentioned in Anti Oedipus , the first volume of Deleuze and Guattari's Capitalism and Schizophrenia , because of his work with Mourgue which they claim posits 'the introduction of desire into neurology.' [ 5 ]
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https://en.wikipedia.org/wiki/Constantin_von_Monakow
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Constructional apraxia is a neurological disorder in which people are unable to perform tasks or movements even though they understand the task, are willing to complete it, and have the physical ability to perform the movements. [ 1 ] It is characterized by an inability or difficulty to build, assemble, or draw objects. [ 2 ] [ 3 ] Constructional apraxia may be caused by lesions in the parietal lobe following stroke or it may serve as an indicator for Alzheimer's disease .
A key deficit in constructional apraxia patients is the inability to correctly copy or draw an image. There are qualitative differences between patients with left hemisphere damage, right hemisphere damage, and Alzheimer's disease . [ 2 ] [ 4 ]
Patients with damage to their left hemisphere tend to preserve items, oversimplify drawing features [ 5 ] and omit details when drawing from memory. In addition, left hemisphere patients are less likely to systematically arrange the parts of their drawing. [ 6 ]
Patients with damage to their right hemisphere have trouble correctly replicating spatial relationships of complex figures. Drawing elements are often piecemeal, transposed to different positions or orientations, or shown diagonally on the page. [ 5 ] As a result, right hemisphere patients tend to produce asymmetric or distorted drawings [ 6 ] characterized by hemispatial neglect , the omission of elements from one side of the model. [ 7 ] It was once thought that right hemisphere patients were twice as likely to make mistakes in 3D construction tasks as left hemisphere patients but this inaccurate conclusion was attributable to participant selection bias in that researchers excluded from studies individuals with severe left hemisphere lesions due to the debilitating language impairments of those individuals. However, included in studies were individuals with severe right hemisphere lesions. [ 8 ] Subsequent research has substantiated the absence of a marked difference in performance between left and right hemisphere patients on 3D construction tasks. [ 9 ]
Alzheimer's disease patients with constructional apraxia have unique symptoms. Their drawings contain fewer angles, spatial alterations, a lack of perspective and simplifications, which are uncharacteristic of left hemisphere or right hemisphere patients. Constructional disabilities are present early on in the disease and get progressively worse over time; [ 4 ] however even patients with advanced Alzheimer's disease may be able to do some constructional tasks. [ 10 ] Spontaneous drawing is affected early and is heavily dependent upon semantic memory ; therefore simplifications in the drawing may be due to impaired access to semantic knowledge. As Alzheimer's disease progresses, the patient's ability to copy objects becomes increasingly impaired and they may lose the ability to draw correctly a simple figure due to a motor loss in routine memories. [ 4 ]
Constructional apraxia cannot be localized to a specific hemisphere or cerebral area because drawing and constructional tasks require both perceptual and motor functioning. [ 7 ] [ 9 ] It has been linked to parietal lesions in the left and right hemisphere, stroke and Alzheimer's disease.
Initially, researchers tried to isolate the cause to left hemisphere lesions in the parietal lobe because of its similarities to Gerstmann syndrome ; however, lesions in the dorsal stream also result in visual agnosia and a piecemeal drawing. [ 2 ] Although constructional apraxia can result from lesions in any part of the brain, it is most commonly associated with lesions in the parietal-occipital lobes. Constructional apraxia is common after right parietal stroke and it continues after visuospatial symptoms have subsided. [ 5 ] Patients with posterior and parietal lobe lesions tend to have the most severe symptoms. [ 9 ]
In Alzheimer's disease research, the AT8 antibody has proven to be an early indicator of tau protein pathology. Constructional apraxia patients with the most AT8 pathology were least able to copy an image, while those best able to had the least neuritic pathology . Therefore, figure copying ability is highly correlated with Alzheimer's disease pathology. [ 10 ]
As the study of constructional apraxia impairments narrows, research is concentrating on analyzing drawing abilities. Drawing abilities may be decomposed into three steps: visual perception, visual imagery, and graphic production.
According to the two-streams hypothesis , as information exits the occipital lobe it follows two pathways. The dorsal stream ("where pathway") ends in the parietal lobe while the ventral stream ("what pathway") terminates in the temporal lobe. [ 7 ] [ 11 ] Damage to the parietal lobe is highly correlated with constructional apraxia since it is involved in drawing and copying. The parietal lobe is also critical for remapping spatial position across saccades . [ 5 ] There is an attentional subsystem responsible for moving the eyes, head, and body to focus on different images. Damage at various levels of this system could lead to trouble localizing a stimulus or hemispatial neglect which manifests as perseverative errors on the drawing. [ 12 ] There are a couple theories used to describe the neurological mechanisms behind drawing.
Kosslyn proposes that there is an early split of information in the dorsal stream. The first pathway captures coordinate relations by defining distances between points in space. These points become a continuum which can transform into other points through intermediate points. This coding of points would allow space to be perceived qualitatively, which would also help with movement. [ 7 ]
The other pathway encodes "categorical" information, which synthesizes information about the shape and spatial arrangement of an objects parts. It decomposes objects into their most basic form, by looking for boundaries, lines, or patches. These categorical relations in turn lead to abstract spatial relations that allow one to perceive objects as being "on top," "inside," "between," "beside," etc. [ 7 ]
The Van Sommers model describes two hierarchical systems for drawing: one for visual perception, another for graphic production. The visual perception model utilizes David Marr 's three stage system to describe visual perception in copying. In the first stage, an image us represented in 2D based on changes in intensity. Foreground and background are not distinguished. In the second stage, a 2.5D representation is formed which encodes the object in a viewer-centered coordinate system. Finally a 3D object-centered representation is established making it possible to appreciate volume. Visual representations of familiar drawings are stored in memory. This representation sends feedback to the other areas of the brain which encoded the spatial and physical properties of the object. Feedback from these areas allows the drawer to successfully encode the coordinate and categorical relations. [ 2 ] [ 13 ]
In the graphic production model, the viewer begins by making a series of depiction decisions about the dimensions, amount of detail to include, etc. Depiction decisions are not used when copying a drawing because they're dictated by the situation. Next, the production strategy is formed. If the drawing is unfamiliar, then the drawer will divide and rank the different portions of the drawings. If the drawing is familiar (e.g. a sun), then the drawer will reproduce the item line by lie regardless of the pictures organization due to automatic execution. The third component, contingent planning, reflects the importance of planning in drawing. Contingent planning is a result of production strategy. If the drawing is unfamiliar and requires a segmented approach, then the most appropriate sequence is determined before the drawing. At this point, the drawing task becomes a problem solving task. The fourth and final component of the model refers to the articulatory and economic constraints placed on the drawer by using a pencil. Certain directions are favored due to the orientation of the hand and fingers, etc. However, some feel the Van Sommers model does not adequately account for all aspects of drawing. [ 2 ] [ 13 ]
Drawing from memory in response to a verbal order requires the image to be recalled from associative memory and brought into the visual buffer. Once there, it can be successfully drawn and copied from memory. Familiar images (like the sun) may not require visual imagery to draw, as the production schemes and action programming stored in the associative memory and procedural memory may be sufficient to reproduce the drawing.
Construction problems are usually caused by visual perception deficits. They require normal vision and the ability to execute a series of motor activities. When looking at performance, it is important to consider perceptual and executive functioning . A patient with trouble visually recognizing patterns or spatial relations may have difficulty correctly building a model. In addition, problems planning, organizing, or carrying out action may impede the ability to solve a construction problem. [ 9 ]
Modern attempts to understand constructional apraxia have moved away from anatomical functions towards a cognitive neuropsychological approach. Both adults and children alike experience difficulty reproducing oblique lines. Some feel that these deficiencies may be attributed to planning since it is easier to plan horizontal and vertical lines than oblique lines. Research indicates that both adults and children are more able to draw squares than diamonds, although as children grow into adults they are more accurately able to depict diamonds. [ 6 ]
One study showed that constructional apraxia patients were significantly less accurate than the control patients in producing angles with vertical and horizontal orientations. In this study, constructional apraxia patients drew patterns usually found in children 8 and younger. Gregory argues that ontogenetically and phylogenetically earlier behavioral traits are present in the brain, but inhibited. When these inhibitory mechanisms become compromised, then the childlike behavior patterns re-emerge. Therefore, according to this theory, the inhibitory mechanisms in patients with constructional apraxia have failed, causing them to draw like young children who have difficulty drawing oblique lines. [ 6 ]
Constructional disabilities are often tested by asking the patient to draw a 2D model or assemble an object. Some researchers feel that neuronal mechanisms involved in drawing and copying differ, thus they should be tested individually. Free drawing is a commonly used test in which the patient is asked to draw a named object. It can be an effective tool in measuring the patient's ability to maintain spatial relations, organize the drawing, and draw complete shapes. The complexity of the task should be noted as such tasks often require lexical -semantic abilities as well as imagery abilities. [ 4 ]
Motor imagery has been explored as a potential therapy for constructional apraxia patients. Motor imagery is a process by which a specific action is mimicked in the working memory without a corresponding motor output. Since constructional apraxia is a visuospatial problem not a motor problem, rehabilitation-treatment based on motor imagery has not proven to be an effective in patients with right hemisphere stroke or hemispatial neglect. [ 14 ]
In 1934, Karl Kleist characterized constructional apraxia as a disturbance "in formative activities such as assembling, building and drawing, in which the spatial form of the product proves to be unsuccessful, without there being an apraxia for single movements." [ 15 ] [ 16 ] In the years following, the definition of constructional apraxia
diverged. There were those who felt it was an executive processing order and those who felt it was a visuospatial disorder. Due to discrepancies in definitions, constructional apraxia became a blanket term to describe any kind of constructional impairment. Modern researchers question whether the term "apraxia" is appropriate to describe this condition. [ 4 ]
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Consuelo Clark-Stewart (July 22, 1860 [ 1 ] – April 17, 1910) was an American physician and the first African American woman to practice medicine in Ohio . [ 2 ]
For twenty years, Clark-Stewart ran a thriving medical practice in Youngstown , Ohio, where she treated both black and white patients. [ 3 ] She was the daughter of Peter H. Clark , who is considered the first Black socialist , and the wife of William R. Stewart , one of the first Black attorneys and elected representatives in Ohio.
Clark was born in Ohio in 1861, one of three children of abolitionist Peter H. Clark and Frances Ann Williams Clark. [ 4 ] She graduated from Gaines High School in Cincinnati in 1879. [ 5 ]
After graduating from high school, Clark studied medicine privately with Dr. Elmira Y. Howard , [ 1 ] the first woman physician in Cincinnati. She then obtained a place at Boston University School of Medicine , [ 6 ] graduating in 1884 after earning the highest honors on her final exams. [ 7 ] She returned to Ohio and worked at the Ohio Hospital for Women and Children .
In 1890, Clark married attorney William R. Stewart . [ 4 ] Thereafter, she referred to herself as Dr. Consuelo Clark-Stewart. She moved with her husband to Youngstown, Ohio, where set up a private practice in medicine and treated both black and white patients.
In Youngstown, Clark-Stewart was active in the YWCA and in setting up free kindergartens . [ 6 ]
Clark-Stewart died of Pernicious anemia on April 17, 1910, at the Massillon State Hospital. [ 4 ] According to press reports, Clark was also mentally ill and had been judged insane. [ 3 ]
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https://en.wikipedia.org/wiki/Consuelo_Clark-Stewart
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Contact normalization is a process by which intercellular junctions mediate signals that allow normal cells to inhibit the transformed growth of neighboring tumor cells. Intimate junctional contact between tumor cells and normal cells is needed for this form of growth control. Contact normalization describes the ability of nontransformed cells to normalize the growth of neighboring cancer cells. This is a very widespread and powerful phenomenon. Tumor cells need to overcome this form of growth inhibition before they can become malignant or metastatic . Induction of a select set of genes has been associated with the ability of cancer cells to escape contact normalization. These include podoplanin ( PDPN ), vascular endothelial growth factor receptor 2/ kinase insert domain receptor ( VEGFR2 /KDR), and transmembrane protein 163 (TMEM163) receptors.
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https://en.wikipedia.org/wiki/Contact_normalization
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The Continental Association of African Neurosurgical Societies ( CAANS ) is the continental, non-governmental , learned society representing the neurosurgeons of African region. [ 1 ] [ 2 ] It is one of the 5 Continental Associations ( AANS , AASNS , CAANS, EANS and FLANC ) of the World Federation of Neurosurgical Societies (WFNS) . [ 3 ]
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https://en.wikipedia.org/wiki/Continental_Association_of_African_Neurosurgical_Societies
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Contingent contagionism was a concept in 19th-century medical writing and epidemiology before the germ theory , used as a qualified way of rejecting the application of the term " contagious disease " for a particular infection. For example, it could be stated that cholera , or typhus , was not contagious in a "healthy atmosphere", but might be contagious in an "impure atmosphere". [ 1 ] Contingent contagionism covered a wide range of views between "contagionist", and "anti-contagionist" such as held by supporters of the miasma theory . [ 2 ]
A form of contingent contagionism was standard in medieval European medicine. Contagion was not conceptualised as restricted to physical contact. A corruption of air could be transmitted from person to person, at short range. [ 3 ]
By the 1840s public health policy , at least in the United Kingdom , had become a battleground between contagionist and anti-contagionist parties. The former, in particular, supported quarantine measures against epidemics (such as the cholera pandemic ). The latter opposed quarantines. Anticontagionists, for example, argued that infection could be at a distance, from a cause that could be sporadic and possible diffused through the air, and taking advantage of "predisposed" individuals. [ 4 ] Public health measures quite typically combined contagionist and anti-contagionist aspects. [ 5 ] Anti-contagionists, such as Florence Nightingale who was a convinced miasmatist, could collaborate with contingent contagionists on sanitary measures. [ 6 ]
Decomposing organic waste, as " filth ", was considered implicated in many diseases, because of the gases it generated. The application of contingent contagionism could be that there was a contagious agent that was spread by filthy conditions. Sanitation as cleaning was therefore directly associated with public health . [ 7 ] It has been commented that those involved in public health at this time, successful in bringing down death rates, "often attributed disease causation to levels farther up the causal chain than direct biological mechanisms". [ 8 ]
The Medico-chirurgical Review in 1824 wrote that it had "always advocated" the doctrine of contingent contagion in the case of yellow fever "and indeed in most fevers". Having mentioned William Pym (contagionist) and Edward Nathaniel Bancroft (anti-contagionist) as extremists, it went on to say (italics in the original)
That the yellow fever of the West Indies [...] is rarely contagious, under common circumstances of cleanliness and ventilation , is as well ascertained as any fact in medicine. [ 9 ]
Which it qualified in terms of overcrowding, and an outbreak in 1823 on the sloop HMS Bann .
The influence of atmosphere on contagion was subject to a distinction: a "pure" atmosphere might effectively block airborne contagion, while an "impure" atmosphere was ineffective for that; or on the other hand "impure" atmosphere, as well as crowding and filth, might mean a disease could "acquire" the property of contagion. [ 10 ] A "malignant microenvironment" could be to blame, a hypothesis that had a consensus behind it in the aetiology of the middle of the 19th century. Inadequate ventilation was one factor to which the consensus pointed. [ 11 ]
Zymotic theory was an explanation of disease developed by Justus von Liebig and William Farr in the 1840s. A form of contingent contagionism, it began with a hypothesis on decomposition of large complex molecules, depending on collision with other such molecules. It relied on fermentation as an underlying analogy for disease. [ 12 ]
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Continuing medical education ( CME ) is continuing education (CE) that helps those in the medical field maintain competence and learn about new and developing areas of their field. These activities may take place as live events, written publications, online programs, audio, video, or other electronic media. Content for these programs is developed, reviewed, and delivered by faculty who are experts in their individual areas. Similar to the process used in academic journals , any potentially conflicting financial relationships for faculty members must be both disclosed and resolved in a meaningful way. [ 1 ] However, critics complain that drug and device manufacturers often use their financial sponsorship to bias CME activities toward marketing their own products.
Continuing medical education is not a new concept. From essentially the beginning of institutionalized medical instruction (medical instruction affiliated with medical colleges and teaching hospitals), health practitioners continued their learning by meeting with their peers. [ 2 ] Grand rounds, case discussions, and meetings to discuss published medical papers constituted the continuing learning experience. CME credit was first established for physicians in the United States in 1958 by the American Academy of Family Physicians . In the 1950s through to the 1980s, CME was increasingly funded by the pharmaceutical industry. Concerns regarding informational bias (both intentional and unintentional) led to increasing scrutiny of the CME funding sources. The Accreditation Council for Continuing Medical Education (ACCME) developed standards to keep what they define as ineligible companies from being able to influence the content of CME activities. [ 3 ] Most recently updated in 2022, the ACCME’s Standards for Integrity and Independence in Continuing Education have been adopted by the accrediting bodies of multiple health professions within the United States. [ 4 ] The pharmaceutical industry has also developed guidelines regarding drug detailing and industry sponsorship of CME, such as the Pharmaceutical Advertising Advisory Board (PAAB) and Canada's Research-Based Pharmaceutical Companies (Rx&D).
In the United States, many state licensing boards and specialty certification boards require CME for medical professionals to maintain their licenses/certifications. [ 5 ] Within the United States, requirements for CME activities for physicians are regulated by the American Academy of Family Physicians (AAFP) and the American Medical Association (AMA) in conjunction with the Accreditation Council for Continuing Medical Education (ACCME) and the American Osteopathic Association (AOA) for the respective credit systems. Entities such as state legislatures and specialty certification boards regulate what/how much CME must be obtained by physicians. [ 6 ]
In Canada, certification is provided by the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada (CFPC). The RCPSC is responsible for the development and implementation of all certifying examinations in each specialty other than family medicine. Specialist physicians who join the Royal College as fellows maintain their knowledge, skills, competence and performance through participating in the maintenance of certification program. For each five-year cycle, fellows of the college are required to document 400 credits, with a minimum of 40 credits obtained in each year of the cycle. Credits are earned at one to two credits per hour, based on the type of learning activity. The CFPC requires 250 credit-hours over a five-year cycle. Fifty credits must be obtained for each year of the cycle. To earn and maintain fellowship within the college, an additional 24 credit-hours of higher level learning are also required over each learning cycle. Similarly, each province and territory requires documentation of ongoing CME for licensure. [ 7 ]
In the United States there are three major physician credit systems:
There are other physician credit systems in other countries.
Formal : includes CME activities that have been formally certified by the credit system/accrediting body or the accredited CME provider. All systems have harmonized requirements including principles of educational design, evidence-based content, and the ACCME Standards for Integrity and Independence in Accredited Continuing Education. Examples include AAFP Prescribed and Elective, AMA PRA Category 1 Credit ™, and AOA Categories 1A and 2A.
Informal : includes self-directed learning activities that are not certified for credit by a credit system/accrediting body or the accredited CME provider. The parameters are defined by the credit system and may not include activities produced by or with influence from ineligible companies. Examples include AAFP Prescribed and Elective, AMA PRA Category 2 Credit ™, and AOA 1B and 2B. Some entities that require physicians to get CME credit, such as a state licensing board, don’t accept these types of activities to meet their CME requirements.
Continuing medical education activities are developed and delivered by a variety of organizations, including but not limited to:
In 2008, professional certification for CME planners was established by the National Commission for Certification of CME Professionals which is earned by standardized exam, and confers the Certified CME Professional (CCMEP) certificate. NC-CME maintains a registry [ 11 ] of these certified professionals. As of June 2011, the Registry included 320 professionals.
The CCMEP has since transitioned to the Certified Healthcare CPD Professional (CHCP) certification and is owned by the Alliance for Continuing Education in the Health Professions. [ 12 ]
In the 2000s, critics, such as Morris and Taitsman, [ 13 ] advocated that the medical profession eliminate commercial support for CME.
The 2022 update to the ACCME’s standards continues to severely restrict potential influence by ineligible companies for all accredited CME activities, whether or not there is commercial support. [ 14 ] Despite past ACCME requirements that program content be free of the influence of commercial interests, " CME providers can easily pitch topics designed to attract commercial sponsorship," and sponsors can award grants to programs that support their marketing strategies. [ 13 ] In 2009 the Institute of Medicine said that CME has become too reliant on industry funding that "tends to promote a narrow focus on the products and to neglect provisions of a broader education on alternative strategies," such as communication and prevention. [ 15 ]
For example, gabapentin (Neurontin), was approved by the U.S. Food and Drug Administration for adjunctive therapy in epilepsy, but Warner-Lambert sponsored CME activities that encouraged its use for off-label indications. In 2004, the U.S. Department of Justice brought civil and criminal charges against Warner-Lambert, which Warner-Lambert settled for $430 million, alleging that Warner-Lambert paid kickbacks to doctors in the form of lavish trips to attend presentations about off-label uses . [ 16 ] In 2010, AstraZeneca PLC was fined $520 million in the United States for off-label promotion to doctors for their anti-psychotic drug, Seroquel .
Industry-sponsored CMEs can violate federal statutes, according to the U.S. Department of Health and Human Services . "When a pharmaceutical manufacturer rewards high-prescribing physicians by directing a CME provider to pay (or overpay) them as CME faculty, consultants, or members of a speaker's bureau," wrote Morris and Taitsman. [ 13 ]
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Contoura Vision is a topography guided laser technology used to correct refractive error and thereby decreasing or eliminating dependency on glasses or contact lenses . The technology reduces side effects linked with laser procedures like LASIK and SMILE. [ 1 ] It was FDA approved in the US in 2016. The method provides measurement of 22,000 points as compared to 200 points provided by wave front-guided LASIK method. The imperfections in the cornea are recorded and then corrected using a laser. [ 2 ] [ 3 ]
Contoura Vision has resulted in vision outcomes better than 6/6 (or 20/20, the standardized normal vision) in multiple patients who were a part of validation trials by the US FDA. Contoura Vision is the only technology where consistent success beyond 20/20 vision has been achieved in the majority of patients. More than 40% of the patients that were evaluated were able to read one line on the visual acuity chart more than a person with 20/20 vision, and 13.5% could read two additional lines. [ citation needed ]
Fewer visual disturbances such as glare, halos, ghost images, difficulty in night time driving and reading were also reported by many patients. Contoura vision exhibited superior quality of vision compared to LASIK and SMILE technology. [ 4 ]
Contoura Vision was compared against Small Incision Lenticule Extraction (SMILE) to check the effectiveness by Kanellopoulos AJ and the results were published in Journal of Refractive Surgery in 2017. At 3 months, 86.4% of the Contoura Vision group and 68.2% of the SMILE group had UDVA (uncorrected distance visual acuity) of 20/20 (P < .002) and 59.1% and 31.8%, respectively, had UDVA of 20/16 (P < .002). Spherical equivalent refraction (±0.50 D) was 95.5% for the Contoura Vision group and 77.3% for the SMILE group (P < .002). Residual refraction cylinder (≤ 0.25 D) was 81.8% for the Contoura Vision group and 50% for the SMILE group (P < .001). Contrast sensitivity (6 cycles/degree) was 7.2 ± 1.01 in the Contoura Vision group and 6.20 ± 1.52 in the SMILE group. Objective Scatter Index measurements at 3 months were 1.35 in the Contoura Vision group and 1.42 in the SMILE group. [ citation needed ]
The author concluded that Contoura Vision was found to be superior compared to SMILE for all the visual performance parameters that were studied, irrespective the parameters were subjective and objective. [ 5 ]
This surgery article is a stub . You can help Wikipedia by expanding it .
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A contraceptive implant is an implantable medical device used for the purpose of birth control . The implant may depend on the timed release of hormones to hinder ovulation or sperm development, the ability of copper to act as a natural spermicide within the uterus , or it may work using a non-hormonal, physical blocking mechanism. As with other contraceptives, a contraceptive implant is designed to prevent pregnancy , but it does not protect against sexually transmitted infections .
The contraceptive implant is hormone-based and highly effective, approved in more than 60 countries and used by millions of women around the world. The typical implant is a small flexible tube measuring about 40 mm (1.6 in) in length. It is most commonly inserted subdermally in the inner portion of the upper, non-dominant arm by a trained and certified health care provider. [ 3 ] After insertion, it prevents pregnancy by releasing progestin which inhibits ovulation. [ 3 ] [ 4 ] The two most common versions are the single-rod etonogestrel implant and the two-rod levonorgestrel implant . [ 5 ] Brands include: Norplant, Jadelle (Norplant II), Implanon, Nexplanon, Sino-implant (II), Zarin, Femplant and Trust.
Some brands of the contraceptive implant, including Nexplanon, are over 99% effective. [ 6 ] The benefits of the contraceptive implant are dependent on the active ingredients. Depending on the type of implant, benefits of the implant may include fewer, lighter periods, improved symptoms of premenstrual syndrome , long-lasting up to three to five years, and the convenience of not needing to remember to use it every day. The implant is also useful for women who cannot use contraception that contains oestrogen. The implant can also be removed at any time and natural fertility will return very quickly. [ 7 ]
When the implant is first inserted, it is common to have some bruising, tenderness or swelling around the implant. [ 7 ] In some cases, adverse effects do occur, the most common being irregular bleeding or amenorrhea . [ 3 ] Although irregularity in bleeding can be troublesome for some women, this also allows for use in treatment of dysmenorrhea , menorrhagia , and endometriosis . [ 3 ] Less common symptoms include change in appetite, depression , moodiness, hormonal imbalance, sore breasts, weight gain, dizziness, pregnancy symptoms, and lethargy . [ 8 ] [ 9 ] Although rare, there is also a risk of complications occurring during insertion or removal of the implant. [ 3 ] In rare cases, the area of skin where the implant has been inserted can become infected, which can require antibiotics. [ 7 ]
Most commonly reported from the levonorgestrel-releasing intrauterine system LNG-IUG contraceptive; breast tenderness, headaches, swelling, and skin irritation. [ 10 ] contraceptive also corresponds with earlier waking, frequent mood swings, impaired concentration, and strain. [ 10 ] Irregular vaginal uterus lining shedding is a common pattern with Norplant users; if this occurs it will be seen during the first 60 days of use but it can subside or disappear over time. [ 11 ] The Implanon also has these negative side effects causing a considerable amount of vaginal bleeding irregularities, and amenorrhea in about 30–40% of its users during the following 90 days of starting use. [ 11 ]
With regard to helping women space their pregnancies appropriately, there is some debate about the most effective time to insert contraceptive implants after pregnancy. It is likely that implant insertion immediately following childbirth increases the number of postpartum implant users compared to when insertion occurs four to six weeks after childbirth (because some patients do not return for their six-week checkup). [ 12 ] However, there may be little or no difference between immediate and delayed insertion in terms of continued use of implants at six months or in terms of women's satisfaction, [ 12 ] even though some studies found higher continuation rates at six months if the implant was inserted immediately after childbirth. [ 13 ] Progestin containing implants (specifically etonogestrel) are safe for immediate insertion in both postpartum individuals and those post-abortion. [ 3 ]
An intrauterine device (IUD) is a small contraceptive device, often T-shaped, which is implanted into the uterus. They can be hormonal or non-hormonal, and are long-acting, reversible , and the most effective types of reversible birth control. [ 14 ] As of 2011, IUDs are the most widely used form of reversible contraception worldwide. [ 15 ] Among types of birth control they, along with birth control implants, result in the greatest satisfaction among users. [ 16 ] IUDs also tend to be one of the most cost-effective methods of contraception for women. [ 17 ] Cons of intrauterine devices, similarly to implants, is the need for a trained healthcare professional for both insertion and removal.
Brands include: Paragard, Kyleena, Liletta, Mirena, and Skyla. [ 18 ]
Hormonal IUDs contain the hormone levonorgestrel which is a progestin. Most commonly, products are inserted for 5 years, allowing them to release a low dose of hormones over that time frame. [ 3 ] The mechanism of action of both hormonal and non-hormonal IUDs is similar, plus the additional benefit of progestin causing a thickening of the cervical mucus. [ 19 ]
The levonorgestrel IUD is highly efficacious and has a failure rate of only 0.2% in the first year of use. [ 20 ] An additional benefit of hormonal IUDs is decreased blood loss, which 20-30% of patients will experience amenorrhea . [ 3 ] Within 1–3 months of removing the intrauterine device, however, patients should experience a return to their normal menstrual cycle. [ 3 ] The most common side effect of levonorgestrel containing IUDs is spotting during the first 3 months. [ 3 ]
Use in patients immediately postpartum can be discussed but the greater potential for expulsion and perforation must be carefully considered. [ 3 ]
Non-hormonal IUDs, also known as copper IUDs , are a hormone-free option of contraception available and work by two main mechanisms of action. They are thought to slow the rate at which sperm reaches the fallopian tubes or decreases fertilization of the egg. [ 19 ] An increase of copper ions, along with other cells and enzymes, is what affects functioning of the sperm and the prevention of pregnancy. [ 19 ]
Although they do have a higher risk of pregnancy compared to hormonal IUDs, failure rates with the copper IUD are still only approximately 0.8%. [ 20 ] They also provide protection from anywhere between 2.5 and 10 years depending on the brand and manufacturer. [ 19 ] Potential adverse effects of copper IUDs include heavier menses and increased menstrual cramping . [ 19 ]
Copper IUDs have the ability to be inserted anywhere from 10 minutes to 48 hours postpartum. [ 21 ] The disadvantage of this immediate insertion is the associated higher risk of expulsion or uterine perforation , however, the benefits greatly outweigh any potential risk. [ 21 ] They also are safe to use in lactation . [ 21 ]
An additional benefit of copper IUDs is their use in emergency contraception . Not only are they able to be used as a form of emergency contraception but a Cochrane review noted that they are the most effective method of emergency contraception as well. [ 19 ] When inserted within 7 days of unprotected intercourse, they are able to reduce the risk of pregnancy by 99% and provide the added benefit of ongoing contraception in the patient too. [ 19 ]
Several barriers exist to expanding research into implantable and other contraceptive methods for men, including vague regulatory guidelines, long device development timelines, men's attitudes towards convenience, and a significant lack of funding. [ 22 ] [ 23 ] [ 24 ] Several implantable devices have been attempted, both hormonal and non-hormonal.
In 2001, Dutch pharmaceutical company Organon announced clinical trials of its implantable etonogestrel -based male contraceptive would begin in Europe and the U.S., anticipating a marketable product as early as 2005. [ 25 ] [ 26 ] Despite promising results, research development stopped, with outside speculation that lack of marketability was a factor. Organon representative Monique Mols stated in 2007 that "[d]espite 20 years of research, the development of a [hormonal] method acceptable to a wide population of men is unlikely". [ 27 ] Schering / Bayer had been working on a similar annual implant with quarterly injections but cancelled the research in 2006/2007, [ 27 ] declaring that men would most likely view it as "not as convenient as a woman taking a pill once a day." [ 24 ]
In 2005, a collaboratory project led by the Population Council , the University of California, Los Angeles , and the Medical Research Council began researching a matchstick-sized implant that contains MENT (7α-methyl-19-nortestosterone or trestolone ), a "synthetic steroid that resembles testosterone." [ 28 ] Clinical trials were set to begin in 2011 or 2012, [ 22 ] and the project was ongoing as of 2016, with hopes of gaining approval as the first reversible male contraceptive. [ 28 ]
In 2006, Shepherd Medical Company received FDA approval for a clinical trial of its non-hormonal implant called an intra vas device (IVD), which consists of two plugs that block sperm flow in the vas deferens. Working on the success of its pilot study and solid results from its clinical trials, the company announced it would expand its trials to three U.S. cities later that year. Questions remained about how reversible the procedure would be in the long-term; however, it was expected to be more reversible than a vasectomy. In 2008, the company disbanded due to the economic crisis but has stated it would restart its research with proper funding. [ 29 ] [ 30 ] [ 31 ]
In January 2016, news broke of a non-hormonal, implantable valve—the Bimek SLV. It included a switch that attaches to the vas deferens , allowing the owner to stop and resume the flow of sperm on demand. A clinical trial of 25 participants was announced to further test the efficacy of the device. [ 32 ] [ 33 ]
Implantable contraception is also an option for animals, particularly for animal managers at zoos and other captive animal facilities who require reversible contraception methods for managing population growth in limited captive habitat. [ 34 ] The Association of Zoos and Aquariums ' (AZA) Reproductive Management Center (formerly known as the AZA Wildlife Contraception Center) at the Saint Louis Zoo in St. Louis , Missouri, has played a major role in researching and disseminating contraception information, via its Contraception Database. It houses over 30,000 records for hundreds of species. [ 34 ] [ 35 ] One of the most popular contraceptive methods used by zoos (as well as in domestic animals) is the melengestrol acetate (MGA) implant, a progestin -based hormonal contraceptive developed in the mid-1970s. Other progestin-based implants that have been placed in animals include Norplant , Jadelle , and Implanon . Androgen -based implants that use agonist (stimulating) gonadotropin-releasing hormone (GnRH) and, to a lesser degree, IUDs have also seen use in several domestic and exotic species. Whatever the implant, some care must be taken to minimize the risk of implant migration or loss. [ 34 ] [ 36 ] [ 37 ]
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In medicine , a contraindication is a condition (a situation or factor) that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. [ 1 ] [ 2 ] Contraindication is the opposite of indication , which is a reason to use a certain treatment.
Absolute contraindications are contraindications for which there are no reasonable circumstances for undertaking a course of action (that is, overriding the prohibition). For example:
Relative contraindications are contraindications for circumstances in which the patient is at higher risk of complications from treatment, but these risks may be outweighed by other considerations or mitigated by other measures. For example, pregnant individuals should normally avoid getting X-rays , but the risk from radiography may be outweighed by the benefit of diagnosing (and then treating) a serious condition such as tuberculosis .
Another principal pair of terms for relative contraindications versus absolute contraindications is cautions versus contraindications , or (similarly) precautions versus contraindications : these pairs of terms are respectively synonymous. Which pair is used depends on nomenclature enforced by each organization's style . For example, the British National Formulary uses the cautions versus contraindications pair, and various U.S. CDC webpages use precautions versus contraindications . The logic of the latter two styles is the idea that readers must never be confused: the word contraindication in that usage always is meant in its absolute sense , providing unmistakable word-sense disambiguation .
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Convalescence is the gradual recovery of health and strength after illness or injury .
It refers to the later stage of an infectious disease or illness when the patient recovers and returns to previous health, but may continue to be a source of infection to others even if feeling better. [ 1 ] In this sense, " recovery " can be considered a synonymous term. This also sometimes includes patient care after a major surgery , [ 2 ] [ 3 ] under which they are required to visit the doctor for regular check-ups . [ 4 ] [ 5 ]
Convalescent care facilities are sometimes recognized by the acronym TCF (Transitional Convalescent Facilities). [ 6 ]
Traditionally, time has been allowed for convalescence to happen. Nowadays, in some instances, where there is a shortage of hospital beds or of trained staff, medical settings can feel rushed and may have drifted away from a focus on convalescence. [ 7 ]
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A convulsion is a medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking. [ 1 ] Because epileptic seizures typically include convulsions, the term convulsion is often used as a synonym for seizure . [ 1 ] However, not all epileptic seizures result in convulsions, and not all convulsions are caused by epileptic seizures. [ 1 ] [ 2 ] Non-epileptic convulsions have no relation with epilepsy, and are caused by non-epileptic seizures . [ 1 ]
Convulsions can be caused by epilepsy , infections (including a severe form of listeriosis which is caused by eating food contaminated by Listeria monocytogenes), brain trauma, or other medical conditions. [ 2 ] They can also occur from an electric shock or improperly enriched air for scuba diving. [ 1 ] [ failed verification ]
The word fit is sometimes used to mean a convulsion or epileptic seizure. [ 3 ]
A person having a convulsion may experience several different symptoms, [ 1 ] such as a brief blackout, confusion, drooling, loss of bowel or bladder control, sudden shaking of the entire body, uncontrollable muscle spasms , or temporary cessation of breathing. [ 1 ] Symptoms usually last from a few seconds to several minutes, although they can last longer. [ 4 ]
Convulsions in children are not necessarily benign, and may lead to brain damage if prolonged. [ 5 ] In these patients, the frequency of occurrence should not downplay their significance, as a worsening seizure state may reflect the damage caused by successive attacks. [ 5 ] Symptoms may include: [ verification needed ]
Most convulsions are the result of abnormal electrical activity in the brain . [ 2 ] [ note 1 ] Often, a specific cause is not clear. Numerous conditions can cause a convulsion. [ 6 ]
Convulsions can be caused by specific chemicals in the blood, as well as infections like meningitis or encephalitis . Other possibilities include celiac disease , [ 7 ] head trauma , stroke , or lack of oxygen to the brain. Sometimes the convulsion can be caused by genetic defects or brain tumors . [ 1 ] Convulsions can also occur when the blood sugar is too low or there is a deficiency of vitamin B6 (pyridoxine). The pathophysiology of convulsion remains ambiguous. [ 5 ]
Convulsions are often caused by epileptic seizures, febrile seizures, non-epileptic seizures, or paroxysmal kinesigenic dyskinesia. [ 2 ] In rare cases, it may be triggered by reactions to certain medications, such as antidepressants, stimulants, and antihistamines. [ 2 ]
Epilepsy is a neuronal disorder with multifactorial manifestations. [ 8 ] It is a noncontagious illness and is usually associated with sudden attacks [ 9 ] of seizures, which are an immediate and initial anomaly in the electrical activity of the brain that disrupts part or all of the body. [ 8 ] Various areas of the brain can be disturbed by epileptic events. [ 10 ] Epileptic seizures can have contrary clinical features. [ further explanation needed ] [ 8 ] Epileptic seizures can have long-lasting effects on cerebral blood flow . [ 11 ]
Various kinds of epileptic seizures affect 60 million people worldwide. [ 9 ]
The most common type of seizure is called a generalized seizure, also known as a generalized convulsion. This is characterized by a loss of consciousness which may lead to the person collapsing. The body stiffens for about a minute and then jerks uncontrollably for the next minute. During this, the patient may fall and injure themselves or bite their tongue, may lose control of their bladder, and their eyes may roll back. A familial history of seizures puts a person at a greater risk of developing them. [ 12 ] [ 13 ] Generalized seizures have been broadly classified into two categories: motor and non-motor. [ 8 ]
A generalized tonic-clonic seizure (GTCS), also known as a grand mal seizure, is a whole-body seizure that has a tonic phase followed by clonic muscle retrenchments. [ 14 ] [ 15 ] GTCSs can happen in people of all ages. [ 15 ] GTCSs are very hazardous, and they increase the risk of injuries and sudden unexpected death in epilepsy (SUDEP). [ 16 ] SUDEP is a sudden, unexpected, nontraumatic death in patients with epilepsy. [ 16 ] Strong convulsions that are related to GTCSs can also cause falls and severe injuries. [ 16 ]
Not all generalized seizures produce convulsions. For example, in an absence seizure , also known as a petit mal seizure, the brain experiences electrical disturbances but the body remains motionless and unresponsive. [ 2 ]
A common cause of convulsions in children is febrile seizures, a type of seizure associated with a high body temperature. This high temperature is a usual immune response to infection, and in febrile convulsions, the reason for the fever is extra-cranial (such as a body-wide viral infection). [ 17 ] In Nigeria, malaria —which can cause sudden, high fevers—is a significant cause of convulsions among children under 5 years of age. [ 18 ]
Febrile seizures fall into two categories: simple and complex. [ 19 ] A simple febrile seizure is generalized, occurs singularly, and lasts less than 15 minutes. [ 19 ] A complex febrile seizure can be focused in an area of the body, occur more than once, and lasts for more than 15 minutes. [ 19 ] Febrile seizures affect 2–4% of children in the United States and Western Europe. It is the most common childhood seizure. [ 19 ] The exact reason for febrile convulsion is unidentified, though it might be the outcome of the interchange between environmental and genetic factors. [ 17 ]
Psychogenic non-epileptic seizures (PNES) are described as neurobehavioral conditions [ 20 ] or "psychogenic illnesses" which occur not due to the electrical disturbances in a person's brain but due to mental and emotional stress. [ 2 ] PNES are an important differential diagnosis and a common occurrence in epilepsy centers. [ 21 ] According to the 5th Edison of Diagnostic and Statistical Manual of Mental Disorders (DSM 5), PNES is classified as a "conversion disorder" or Functional Neurologic Symptom Disorder characterized by alterations in behavior, motor activity, consciousness, and sensation. [ 22 ] A few neuroimaging (functional and structural) studies suggest that PNES may replicate sensorimotor alterations, emotional regulation, cognitive control, and integration of neural circuits. [ 23 ]
There is a linkage between infantile convulsion and paroxysmal dyskinesia. [ 24 ] Paroxysmal kinesigenic dyskinesia (PKD) is characterized by sudden involuntary movement caused by sudden stress or excitement. [ 25 ] The relationship between convulsion and PKD is mainly due to the common mechanism of pathophysiology. [ 24 ]
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The Convulsionnaires (or Convulsionaries ) of Saint-Médard was a group of 18th-century French religious pilgrims who exhibited convulsions and later constituted a religious sect and a political movement . This practice originated at the tomb of François de Pâris , an ascetic Jansenist deacon who was buried at the cemetery of the parish of Saint-Médard in Paris . The convulsionnaires were associated with the Jansenist movement, which became more politically active after the papal bull Unigenitus officially banned the sect.
The connection between the larger French Jansenist movement and the smaller, more radical convulsionnaire phenomenon is difficult to state with precision. As historian Brian E. Strayer has noted, almost all of the convulsionnaires were Jansenists, but very few Jansenists embraced the convulsionnaire phenomenon. [ 1 ]
Jansenism was a religious movement and theology which arose simultaneously in northern France and Flanders in the mid-17th century. It was named for the Dutch theologian Cornelius Jansen , the Bishop of Ypres from 1635 to 1638. Jansen and his friend, l'abbe de Saint-Cyran , are generally considered the fathers of the movement. After Jansen died in 1638, his book Augustinus was published in 1640–41. As the title indicates, Jansen intended for his theology to closely follow that of St. Augustine . In the 1640s, Antoine Arnauld , a disciple of Saint-Cyran, became one of the leading French defenders of Jansenist theology against the attacks of other theologians, including Jesuit theologians who endorsed Molinism . [ 2 ] Pope Innocent X condemned Jansenism as a heresy in 1653, and Arnauld was expelled from the Sorbonne in 1655. [ 3 ] Nonetheless, the movement continued to exist through the 18th century. Socially, Jansenism was largely an urban phenomenon. [ 4 ]
In keeping with St. Augustine's influence, Jansenist theology presented a strong contrast between the original perfection of the Creation and the tragic, sinful state of humanity which followed the Original Sin . It emphasized fallen humanity's alienation from God, and asserted the necessity of God's "efficient grace" in order to avoid damnation. In painting such a stark contrast, Jansenist theology offered a kind of predestination and appeared to its critics as a denial of human free will . Jansenist writers, including Blaise Pascal , frequently criticized the Molinist position which placed more emphasis on free will. The early well-spring of Jansenist theology in Paris came undoubtedly from the convents and schools at Port-Royal des Champs near Paris, which was ultimately razed in 1708 because of its association with the Jansenist heresy. [ 5 ]
Despite some theological similarities to Calvinism , Jansenism maintained several other orthodox Catholic positions. Historian Dale Van Kley has written that for Jansenists, "no sin would be more heinous in their eyes than that of schism." [ 6 ] Jansenist authors frequently criticized Calvinist theology in order to maintain their own Catholic orthodoxy. Also, unlike Calvinists, Jansenists accepted - even relished - the existence of relics and miracles . The miracle, they believed, was a powerful historical event. God's grace, normally hidden from our sinful world, could be revealed in human history through a miracle. [ 7 ]
Unigenitus was a Papal bull which was promulgated by Clement XI in 1713 at the request of the French King Louis XIV . The King had solicited the bull in the hope that it would provide a final solution to the continuing Jansenist problem in France. In particular, the bull was provoked by the Jansenist theologian Pasquier Quesnel and his book Réflexions morales sur le Nouveau Testament . Unigenitus condemned many of Quesnel's propositions as heretical. It called attention to similarities between Jansenist theology and Calvinism. It also criticized the Jansenists for subverting the Church hierarchy by exalting the religious role of the laity and the lower clergy. [ 8 ]
A large controversy ensued. At least 200 books and pamphlets were published in 1714 alone, either in support of or against the bull. By 1730, there had been over 1000 publications on the subject. [ 9 ] In March 1717, four Jansenist bishops formally appealed Unigenitus at the Sorbonne. By March 1719, these appelants had the support of the theological faculties at the Universities of Paris, Rheims and Nantes, as well as many other prominent clergy, most notably Louis Antoine de Noailles , the Archbishop of Paris . All told, 10% of France's clergy supported the appeal, including 75% of Paris's parish priests. [ 10 ] This included 30 French bishops and roughly 3000 priests. [ 11 ]
Many of the clergy did not simply oppose Unigenitus out of sympathy for Jansenism. There was also a concern that the bull would increase Papal and Monarchical influence over the French Church , which operated with a good deal of autonomy in this period. [ 12 ]
By 1730, the controversy had reached a boiling point. Cardinal André-Hercule de Fleury and the new Archbishop of Paris, Charles-Gaspard-Guillaume de Vintimille du Luc had closed one seminary (Saint Magloire) that was strongly Jansenist, and had begun to summarily replace Jansenist principals and regents at other colleges. They exiled some of Paris' Jansenist priests, and exiled others. [ 13 ] The Jansenists, for their part, had begun to publish a journal, called Nouvelles Ecclesiastiques , in 1727. The journal frequently indicted 'despotism' in both Church and State. They made an explicit appeal to the "public," writing that such an appeal to public opinion was the only road left to them. [ 14 ]
François de Pâris (1690–1727) was a Parisian Jansenist and a popular religious ascetic whose tomb in the parish cemetery at Saint-Médard gave rise to the convulsionnaire phenomenon.
Pâris was born into a wealthy Parisian family. According to biographies published after his death, he was tutored as a young boy by Augustinians at Nanterre . Originally destined for a career in law, he went against his father's wishes and chose a career in the Church instead. After his face was horribly scarred by smallpox at age 22, he transferred to the seminary at Saint-Magloire, which was nearly dominated by Jansenists. In 1713, he gave up his annual family pension to the poor. After his parents died in 1723, he sold his family's property, gave the money to the poor, and went to live as a hermit in the poor neighbourhood of Saint-Marceau [ fr ] . He modeled himself after St. Francis and was apparently considered a local Saint by many. [ 15 ]
An active appelant , Pâris protested Unigenitus in 1720, calling it "the work of the Devil."
During the final years of his life, Pâris became increasingly reclusive, and his ascetic lifestyle became increasingly severe, and he practised self-flagellation :
His bare feet became cut and bruised from walking on the paving stones ... He slept on an old armoire, covered himself with a sheet bristling with iron wires that tore his flesh ... He wore a hair shirt, a spiked metal belt, and a chain around his right arm. He beat himself with an iron-tipped lash until the blood ran down his back. He lit no fire for warmth even during the coldest winter days. [ 16 ]
Only 36 years old, Pâris died on 1 May 1727. Large numbers of people from across the social spectrum, including the Cardinal Archbishop Noailles , came to attend his funeral in the small chapel at Saint-Médard. During the funeral and after, people began to collect snippets of hair and fingernails, splinters of wood from his casket or furniture, soil from his gravesite, and other souvenirs which might serve as holy relics. Shortly after the funeral, his tomb became the site of religious pilgrimages. His admirers composed hymns and self-styled hagiographies praising the late deacon as a saint. Many of the city's prominent Jansenists wanted Pâris to be made into a saint, and Cardinal Noailles even began the process of beatification . [ 17 ]
Pilgrimages to the tomb of Pâris continued over the years 1727–1730. During this period, roughly a dozen pilgrims declared that they had been miraculously cured at the tomb. This number of miracle cures exploded in 1731. Over 70 cures were announced that year, from a variety of ailments which included paralysis , cancer , and blindness , among others. Not surprisingly, the number of pilgrims also grew rapidly during the summer of 1731. Miracles were not necessarily unusual in this period, but the connection with Jansenism was considered a cause for suspicion. [ 18 ]
While the first recorded case of convulsions at the tomb of Pâris occurred in July 1731, one of the best recorded early cases is that of l'abbé de Bescherand, who made two daily pilgrimages to the cemetery:
During these visits, Strayer writes, "his body was wracked by convulsions that lifted him into the air, his face was contorted by grimaces, and foaming at the mouth, he yelled and screamed for hours on end." A number of other pilgrims began to exhibit similar convulsions, and the convulsion phenomenon began to rival and eclipse the miracle phenomenon. The cemetery's atmosphere became busy and noisy as people variously prayed, sang and convulsed. [ 19 ] Rumours spread through Paris that people were speaking in tongues, stomping on Bibles, barking like dogs, swallowing glass or hot coals, or dancing until they collapsed. [ 20 ]
After the closure of the cemetery in early 1732, the convulsionnaires continued to gather outside the gates. They were driven further underground in 1733, and began to assemble in private homes in Paris and in other French cities such as Nantes and Troyes. As a possible parallel to the contemporary Parisian salon , women often hosted the meetings while men preached. Social class was largely ignored, and nobility and clergy were sometimes present. [ 21 ] Many of the convulsionnaires began to live an austere and ascetic lifestyle in cooperatives , referring to each other as 'brother' or 'sister' and taking new names, usually from the Bible . [ 22 ]
Just like their saintly Pâris, the convulsionnaires appear to have regarded the body with increasing contempt as the movement evolved through the 1730s. They began the practice of secours (release), which involved the violent beating of the individual who was experiencing the convulsions. The secours was intended to release the individual from the painful experience of the convulsions, while simultaneously symbolizing the pain of persecution. [ 23 ] They viewed the body with disgust as the site of disease, sinfulness and corruption. [ 24 ] Eighty convulsionnaires were arrested in 1736 for beating and cutting each other. They also began to practice regular crucifixions—with nails—to further connect their suffering to that of Jesus Christ and the early Christian martyrs . [ 25 ] Brian E. Strayer argues that movement descended further into sadomasochism from 1740 onward. The torture became increasingly brutal while the spiritual content decreased. [ 26 ]
Gender analysis has revealed a predominance of unmarried women and girls experiencing convulsions. Catherine Maire has demonstrated that of 116 people who claimed miraculous healing at Pâris's tomb, 70% were women, and the majority of these were celibate or widowed. [ 27 ] Of an estimated 270 people experiencing or observing convulsions in 1732, 211 were women and only 59 were men. [ 28 ] Women made up 90% of the convulsionnaires arrested between 1732 and 1774, [ 29 ] and a smaller majority (55%) of the convulsionnaires imprisoned at the Bastille in particular between 1715 and 1774 were women. This 55% female majority, however, is in sharp contrast the strong male majority (82%) of Jansenists imprisoned at the Bastille during the same period. [ 30 ]
Other sources reinforces this view. In 1732, a visitor from another parish was quick to note that the convulsions were predominant among women. [ 31 ] The robe de convulsionnaire was invented to facilitate the convulsions for women. The reports of police spies referred to the female convulsionaries as prostitutes who allowed others to beat and torture their half-naked writhing bodies. [ 32 ] Philippe Hecquet , a Jansenist physician who sought to distance the Jansenist movement from the convulsionnaires phenomenon, claimed that female biology and moral inferiority were the causes of the convulsions. [ 33 ] By contrast, defenders of the convulsionnaires tended to minimize the role of women and emphasize the social diversity of the movement. [ 34 ]
Countesses, duchesses, and members of the Parlement of Paris , including the President Charles-Robert Boutin, came to observe the miracles at Saint-Médard in 1731. [ 35 ] Certain members of the nobility did continue to attend private convulsionnaire meetings through the 1730s, including the brother of Voltaire . [ 36 ] By and large, however, the dominant element among the convulsionnaire movement appears to have been lower-class women who were "assisted" by the lower male clergy. Daniel Vidal's study of convulsionnaires found the majority (60%) to be women, of which the largest portion (43%) came from the lower classes. By contrast, men comprised 78% of those who assisted the convulsionnaires, and nearly half of those were members of the clergy. [ 37 ] Catherine Maire's study also made note of this predominance of male clergy. [ 38 ]
As the historian B. Robert Kreiser has noted, the themes of persecution, martyrdom, apocalypticism and millenarianism , pervaded the "mental universe" of the convulsionnaire movement. Prophetic dreams and visions were common among its adherents, along with appeals to God's divine judgment and wrath. [ 39 ]
Broader Jansenist theology encouraged a certain degree of individual conscience among the laity. It allowed for the possibility that a bishop could be wrong about a matter of religious truth, while a lowly priest could be right. Therefore, it allowed for the possibility of resistance to the higher clergy. [ 40 ] The convulsionnaires took this belief even further. They identified themselves as God's persecuted faithful and compared themselves to the early Christians persecuted by the Roman Empire . Prophetic and apocalyptic speeches, often preached by illiterate artisans or women, railed against the apostasy of the Church hierarchy and prophesied the destruction of Babylon . [ 41 ]
The convulsionnaires left behind thousands of written works, including prayers, visions, parables , dialogues , letters, songs and poems. Strayer identifies three common themes in their writing: eschatology (their theology of the end-times), word games, and their relationship to the French Monarchy. Their eschatology was particularly concerned with the conversion of the Jews to Christianity, which they believed to be imminent. [ 42 ] The abbé Vaillant, a convulsionnaire leader who called himself 'Elijah' after the prophet who would accompany the Messiah , was deeply concerned with converting the Jews to Christianity and predicted that the end of the world would come in 1733. He was arrested in 1734 and imprisoned until his death in 1761. [ 43 ]
Their perception to the Monarchy appears to have been variable, but generally unfavourable. On the one hand, a number of them called Louis XV a "criminal" who would suffer God's wrath. They compared him to the Egyptian Pharaoh or even to the Antichrist . On the other hand, some convulsionnaire women dedicated their personal suffering and torture to the King after the attempted assassination of 1757 by Damiens . [ 44 ]
Altogether, the convulsionnaire phenomenon sparked a great deal of public interest. By mid-century, there had been 1600 publications on the subject. [ 45 ] The early convulsions which occurred in 1731 at the cemetery at Saint-Médard attracted large crowds of observers. It is likely that many of these went purely for amusement. Onlookers were even able to rent chairs for 6 sous so that they could sit and watch the strange business that was taking place. [ 46 ] The many rumours attracted many curious spectators, some of whom were actually converted to the convulsionnaire movement when they observed the convulsions or even experienced them for themselves. [ 47 ]
The cemetery's closure in January 1732 led popular opinion to sympathize with the convulsionnaires and Jansenists. This produced, in turn, a backlash against the Monarchy's religious prerogative. "All powerful though he was," one writer said, "the king had no right to suppress the news of the marvels of God." One protester posted a sign on the cemetery, which read: "By order of the King, it is forbidden to the Divinity to perform any more miracles in this vicinity." [ 48 ]
Public opinion, however, would turn against the convulsionnaire movement by the mid-1730s as more scandalous stories of torture and violence came to light. "In the popular mind," Strayer writes, "their tortures had crossed the line between the self-denial of spiritual mystics and sexual brutality. Increasingly, people viewed this strange blend of millenarianism, eroticism, torture, and hysteria as a medical problem rather than a religious phenomenon." [ 49 ] In 1735, a group of 30 Paris physicians proposed that "overheated imaginations" were the cause for the convulsions. [ 50 ]
Cardinal Noailles, the aged Archbishop of Paris, had declared in 1728 that he believed the miracles to be genuine. [ 51 ] However, Noailles died in 1729, and his successor, Archbishop Vintimille, was handpicked by Cardinal Fleury, who also served as Chief Minister of France under the young King Louis XV. As noted above, Fleury and Vintimille began a campaign to purge the Parisian clergy of Jansenists. This campaign extended to the convulsionnaires as well. Vintimille halted the process to beatify François de Pâris. Unlike his predecessor, he condemned the miracles as fraudulent in 1731, claiming that they were the result of "Satanic healing" produced by rebellious heretics. [ 52 ] Cardinal Fleury compared the convulsionnaires to previous heretical sects, notably the Camisards . [ 53 ] When permanent police surveillance failed to dissuade pilgrims from coming to the cemetery, the authorities decided to close it to the public. Hundreds of soldiers came to wall up the entrance on 29 January 1732. [ 54 ]
In 1735, Vintimille directed his Inspector General, Nigon de Berty, to conduct an inquiry into the phenomenon. In his report, de Berty established a set of well-defined criteria for miraculous healing. The cure had to exceed the laws of nature. It had to be immediate and perfect. It had to come as a direct result of a religious act, and more than one credible witness was necessary. [ 55 ]
The Parlement of Paris contained a small but eloquent Jansenist minority. One of the Parlement Jansenists, Louis-Adrien Le Paige, vigorously defended various aspects of convulsionnaire practice in Parlement as late as 1737. [ 56 ] Nonetheless, it appears that the Parlement was generally hostile to the convulsionnaires, launching an inquest against them in 1735. [ 57 ] This hostility may have been shared by some of the Jansenists in Parlement who were embarrassed by the convulsions and repudiated any connection to them (see below).
The authorities also sought to involve medical professionals in their bid to discredit the movement. In 1732, René Hérault , the Lieutenant General of Police in Paris, summoned 24 doctors and surgeons to examine seven convulsionnaire prisoners at the Bastille. The doctors determined that the convulsions were voluntary and not divinely inspired. Their conclusions and methodology were widely criticized. [ 58 ]
As mentioned above, the miracle for Jansenists represented God's grace manifested in human history, however briefly. Jansenist theologians and writers were also deeply interested in the power of lay witness and lay faithfulness to true religion. The initiative to create the Jansenist periodical Nouvelles Ecclésiastiques in 1727 owed largely to this interest in inviting ordinary Christians to witness religious truth for themselves. [ 59 ] As a result, the movement was thoroughly pleased by the miracles which occurred at Saint-Médard between 1727 and 1731. They separated the 'pure of heart' from the hard-hearted Church hierarchy. For the Paris Jansenists, the miracles served as proof that God was on their side and opposed Unigenitus . [ 60 ]
The Nouvelles Ecclésiastiques , working to generate publicity, eagerly proclaimed the miracles to the public and devoted two whole pages to them in 1728. Jansenist churchwardens exercised their influence over their parishes and vigorously encouraged the cult of François de Pâris. Many of the appelant clergy supported the early cult; some even began to preach and perform masses there. [ 61 ]
The spread of the convulsion phenomenon, however, divided the Jansenist camp. The Nouvelles Ecclésiastiques continued more or less to defend the convulsions through the 1730s. [ 62 ] But the split became evident. Jansenists published as many as 100 different tracts during the years 1732-34 as a heated debate emerged within the movement. Jacques-Joseph Duguet, one of the editors of the Nouvelles Ecclésiastiques fell out of favour with his colleagues when he condemned the convulsions. [ 63 ] This debate did not escape the attention of the Cardinal Fleury, who exploited this division by encouraging, even subsidizing the publications of those Jansenists who attacked the convulsionnaire phenomenon. [ 64 ] By 1742, popular opinion had turned so far against the convulsions that even the Nouvelles Ecclésiastiques began to revise their stance and withdraw their support. [ 65 ]
While the anti-hierarchical spirit of the convulsionnaire movement may have appealed to some of the philosophes, they generally looked down upon the phenomenon as a whole as emblematic of religious fanaticism . Historian Lindsay Wilson has suggested that the convulsionnaires challenged the philosophes' ideal of an enlightened public. [ 66 ]
For Voltaire , the convulsionnaire phenomenon epitomized irrational superstition and fraudulent religion. He attacked them repeatedly in his writings, and he never wrote about his brother who participated in the movement. Diderot saw the convulsionnaire phenomenon as not only a "sect of fools," but as the link between female nervous disorders and religious fanaticism. Some philosophes , including d'Alembert and La Condamine , attended secret convulsionnaire meetings as observers. D'Alembert, who observed a particularly bloody secours , argued that the convulsions would lose their appeal if only they were made public. He suggested putting them into the fair, perhaps as a kind of side-show, and charging spectators to watch. He predicted that the exposure and ridicule of the convulsionnaires would discredit the entire Jansenist movement, leaving it to fall into obscurity. [ 67 ] La Mettrie frequented the assemblies and even assisted at one. Strayer speculates that La Mettrie's experience may have influenced some of his physiological theories. [ 68 ]
David Hume , the father of empiricism, wrote, "There surely never was a greater number of miracles ascribed to one person, than those, which were lately said to have been wrought in France upon the tomb of Abbé Paris, the famous Jansenist, with whose sanctity the people were so long deluded. ... many of the miracles were immediately proved upon the spot, before judges of unquestioned integrity, attested by witnesses of credit and distinction, in a learned age, and on the most eminent theatre that is now in the world." [ 69 ]
E. Robert Kreiser (1975) describes the convulsionnaire movement using the language of identity formation. He suggests that the "spiritual energy" and religious solidarity achieved within the movement helped the individual members to foster individual identities for themselves within a cohesive group. [ 70 ]
Catherine Maire (1985 and 1998) stresses the political significance of the convulsionnaire movement, and its centrality to the Jansenist cause.
David Garrioch (2002) argues that the common Parisian kneeling before the tomb of François de Pâris was seeking an expression of faith "that offered the poor full membership of the spiritual community." [ 71 ]
Echoing Dale Van Kley's (1996) thoughts on the broader Jansenist controversy, [ 72 ] Brian E. Strayer (2008) suggests that
... the cemetery and parish of St-Médard [were transformed] into a stage - and an urban battleground - where the quarrel between orthodoxy and heresy could be fought to its bloody finale. In a very real sense, the convulsionnaire phenomenon constituted the last great European affair to combine both politics and religion into a mass movement involving both the common people and the elite. Its denouement would mark the end of a world in which religion dominated politics. [ 73 ]
A number of historians have pointed to the movement as politically subversive and threatening to the absolutism in 18th-century France.
Kreiser (1975) suggests that the movement's fundamental beliefs were simply incompatible with the established regime. They challenged the status quo by subverting the religious hierarchy, and were perhaps even more subversive than they realized. [ 74 ]
Catherine Maire (1985) argues that the convulsionnaire movement helped establish public opinion in France. [ 75 ]
Lindsay Wilson 1993 among others, points to the subversive power of the role of women within the movement. Not only did the female convulsionnaires challenge traditional models of Christian female religious behaviour, they were also sometimes 'priestesses' - invested with a ceremonial religious role usually reserved exclusively for men. The prospect of women claiming to serve as intermediaries between God and the people, Wilson writes, was perhaps the most unsettling aspect of the movement for some conservatives. [ 76 ]
Monique Cottret (1998) describes the predominance of working class individuals and women in the convulsionnaire movement as the " proletarisation " of Jansenism. She refers to writers in the Nouvelles Ecclésiastiques who promoted the movement's low-class origins as a sign of its greatness. [ 77 ]
Strayer 2008 echoing Kreiser and Van Kley 1996 argues that the convulsionnaires' "democratic, congregational polity constituted a serious indictment of the established, hierarchical order in both Church and state. By asserting that the convulsions were divinely inspired, the convulsionnaires threw down the gauntlet at the feet of the Bourbon Monarchy and its dependent episcopacy, challenging both the King's exclusive power to heal ('the King's touch') and the Church's right to control religious activity." This in turn, sparked a "vigorous political discourse" to respond the challenge to religious hierarchy. [ 78 ]
Wilson, in her book Women and Medicine in the French Enlightenment (1993), places the convulsionnaire phenomenon within the debate over so-called maladies des femmes (women's illnesses) in 18th-century France. She argues that women figured prominently in the struggle between the emerging professional medical community and other practitioners of medicine which might be called charlatans . She points to physicians (Philippe Hecquet) and theologians (Nigon de Berty) alike who attributed the convulsions to female hysteria , sexual frustration and menstrual irregularities, as well as woman's inherent moral inferiority. [ 79 ]
Jan E. Goldstein (1998) has also commented on Hecquet's 1733 treatise on convulsions, which directly links a woman's "imagination" to her uterus and also to the convulsions. "Imagination," Goldstein argues, was the "smear word" of choice among 18th century French writers who considered it antithetical to "enlightened" rationality. [ 80 ]
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Cooper-Saeed waves refer to donor heart conducted P waves on the 12-lead ECG tracing of heart transplant recipients, also demonstrating non-conducted P waves of the recipient heart . [ 1 ]
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Cooperative synapse formation describes the mutual amplification of synapses . It is needed to explain the distribution of the number of synapses between neurons for example in a rat cortex . [ 1 ] Spike-Timing dependence of structural plasticity is capable of explaining the emergence of cooperative synapse formation. [ 2 ]
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Wellness Recovery Action Plan ( WRAP ) is a recovery model developed by a group of people in northern Vermont in 1997 in a workshop on mental health recovery led by Mary Ellen Copeland. It has been extensively studied and reviewed, [ 1 ] and is now an evidence-based practice , listed in the SAMSHA National Registry of Evidence-Based Programs and Practices (NREPP) . [ 2 ] [ independent source needed ]
WRAP focuses on a person's strengths , rather than perceived deficits. WRAP is voluntary and trauma informed. People develop their own WRAP. [ 3 ]
Copeland's work is based on the study of the coping and wellness strategies of people who have experienced mental health challenges. She created a survey and administered it to 125 volunteers to find out what treatments worked for them. [ 4 ]
In 2005, Copeland's work led to the creation of the non-profit, the Copeland Center for Wellness and Recovery which continues her work through trainings around the world.
The Copeland Center for Wellness and Recovery is a non-profit mental health organization that created and pioneered the use of the WRAP and other works developed by Copeland. [ 5 ] The Center was established in 2005, and focuses their trainings and programs on persons seeking to take personal responsibility to improve their wellness. They also work with health service providers, businesses and community groups. [ 6 ]
The Copeland Center provides training on WRAP, peer support, trauma informed care, on working with youth, and creating organizational change agents.
They have introduced their practices through the training of WRAP Facilitators all over the U.S. [ 7 ] There are WRAP Facilitators in the United States, Canada, Japan, New Zealand, United Kingdom, the Netherlands, China, and Ireland trained by the Copeland Center or Advanced Level WRAP Facilitators trained by the Copeland Center. [ citation needed ]
Copeland helps train facilitators through the Center. [ 8 ]
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F. Copeland Shelden (1907 – December 19, 1977) was an American orthodontist who was a graduate of the Angle School of Orthodontia . He played in important part in forming the Charles H. Tweed Foundation for research. [ 1 ] [ 2 ]
He was born in Kansas City, Missouri . His father was Frank Shelden , who was also an orthodontist and a graduate of the Angle School of Orthodontia. He attended Wentworth Military Academy and College followed by education at the University of Missouri–Kansas City School of Dentistry . He obtained his dental degree in 1931. He attended the Angle School of Orthodontia in Pasadena, California , before attending dental school.
He was a previous president of the Midwestern component of the Edward H. Angle Society and Charles H. Tweed Foundation. He was also a diplomate of the American Board of Orthodontics. During his life he served on the faculty of dental school departments at the Tufts University School of Dental Medicine , Washington University School of Dental Medicine , and University of Detroit Mercy School of Dentistry . He also served on the board of directors of the Western Golf Association and played an important role in founding the Evans Scholars Foundation Chapter at the University of Missouri in 1967 and the University of Kansas in 1975.
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A copolyester is a copolymer synthesized by modification of polyesters , which are combinations of diacids and diols . For example, by introducing other diacids, such as isophthalic acid (IPA), or other diols, such as cyclohexane dimethanol (CHDM) to the polyester polyethylene terephthalate (PET), the material becomes a copolyester due to its comonomer content. [ 1 ]
Copolyesters retain their strength, clarity, and other mechanical properties even when exposed to a variety of chemicals that typically affect other materials, such as polycarbonates . This, plus their versatility and flexibility, allows manufacturers to use them effectively in the design of both high-volume, low-cost parts as well as critical, more expensive component parts.
Copolyesters offer versatility to meet a wide variety of applications. [ 1 ] Copolyester resins have proved to be effective in packaging applications, due to their toughness, versatility and chemical resistance. They are also frequently used in the manufacture and packaging of consumer goods and materials. Markets that rely on copolyesters include medical packaging, home appliances , consumer goods (pens, toys, sporting goods, etc.), and cosmetics , among others. [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ]
Table of Common Copolyester and Components
The main global manufacturers and suppliers of Copolyester resins are as follows (The brand names are in parentheses):
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Cor triatriatum (or triatrial heart ) [ 1 ] is a congenital heart defect where the left atrium (cor triatriatum sinistrum) or right atrium (cor triatriatum dextrum) is subdivided by a thin membrane , resulting in three atrial chambers (hence the name).
Cor triatriatum represents 0.1% of all congenital cardiac malformations and may be associated with other cardiac defects in as many as 50% of cases. The membrane may be complete or may contain one or more fenestrations of varying size.
Cor triatriatum sinistrum is more common. [ 2 ] In this defect, there is typically a proximal chamber that receives the pulmonic veins and a distal (true) chamber located more anteriorly where it empties into the mitral valve . The membrane that separates the atrium into two parts varies significantly in size and shape. It may appear similar to a diaphragm or be funnel-shaped, band-like, entirely intact (imperforate) or contain one or more openings (fenestrations) ranging from small, restrictive-type to large and widely open.
In the pediatric population, this anomaly may be associated with major congenital cardiac lesions such as tetralogy of Fallot , double outlet right ventricle , coarctation of the aorta , partial anomalous pulmonary venous connection , persistent left superior vena cava with unroofed coronary sinus , ventricular septal defect , atrioventricular septal (endocardial cushion) defect , and common atrioventricular canal . Rarely, asplenia or polysplenia has been reported in these patients. In the adult, cor triatriatum is frequently an isolated finding.
Cor triatriatum dextrum is extremely rare and results from the complete persistence of the right sinus valve of the embryonic heart . The membrane divides the right atrium into a proximal (upper) and a distal (lower) chamber. The upper chamber receives the venous blood from both vena cavae and the lower chamber is in contact with the tricuspid valve and the right atrial appendage .
The natural history of this defect depends on the size of the communicating orifice between the upper and lower atrial chambers. If the communicating orifice is small, the patient is critically ill and may succumb at a young age (usually during infancy) to congestive heart failure and pulmonary edema . [ 3 ] If the connection is larger, patients may present in childhood or young adulthood with a clinical picture similar to that of mitral stenosis . As the malformed membrane calcifies with age, thus further narrowing such opening, decreased cardiac output produces features of pulmonary venous hypertension and right heart failure—including symptoms of dyspnea and orthopnea , easy fatigability , palpitations and shortness of breath , among others. [ 3 ] Cor triatriatum may also be an incidental finding when it is nonobstructive.
Primarily diagnosed with imaging, such as echocardiogram (ultrasound of the heart), CT , and/or MRI . [ 3 ]
Treatment of Cor triatriatum varies among cases and is dependent upon presentation of symptoms—incidental finding of the condition in asymptomatic patients does not typically require immediate medical management, but for those exhibiting dyspnea and pulmonary congestion , surgical intervention is required. The disorder can be treated surgically by removing the membrane dividing the atrium. The surgery , which usually occurs by first excising the diaphragm and then closing the atrial septum , has a reported survival of 90% at five years, with almost all patients becoming asymptomatic post-surgery.
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Cord factor , or trehalose dimycolate (TDM), is a glycolipid molecule found in the cell wall of Mycobacterium tuberculosis and similar species. It is the primary lipid found on the exterior of M. tuberculosis cells. [ 1 ] Cord factor influences the arrangement of M. tuberculosis cells into long and slender formations, giving its name. [ 2 ] Cord factor is virulent towards mammalian cells and critical for survival of M. tuberculosis in hosts, but not outside of hosts. [ 3 ] [ 4 ] Cord factor has been observed to influence immune responses , induce the formation of granulomas , and inhibit tumor growth. [ 5 ] The antimycobacterial drug SQ109 is thought to inhibit TDM production levels and in this way disrupts its cell wall assembly. [ 6 ]
A cord factor molecule is composed of a sugar molecule, trehalose (a disaccharide ), composed of two glucose molecules linked together. Trehalose is esterified to two mycolic acid residues. [ 7 ] [ 8 ] One of the two mycolic acid residues is attached to the sixth carbon of one glucose, while the other mycolic acid residue is attached to the sixth carbon of the other glucose. [ 7 ] Therefore, cord factor is also named trehalose-6,6'-dimycolate. [ 7 ] The carbon chain of the mycolic acid residues vary in length depending on the species of bacteria it is found in, but the general range is 20 to 80 carbon atoms. [ 3 ] Cord factor's amphiphilic nature leads to varying structures when many cord factor molecules are in close proximity. [ 3 ] On a hydrophobic surface, they spontaneously form a crystalline monolayer. [ 9 ] This crystalline monolayer is extremely durable and firm; it is stronger than any other amphiphile found in biology. [ 10 ] This monolayer also forms in oil-water, plastic-water, and air-water surfaces. [ 1 ] In an aqueous environment free of hydrophobic surfaces, cord factor forms a micelle . [ 11 ] Furthermore, cord factor interlocks with lipoarabinomannan (LAM), which is found on the surface of M. tuberculosis cells as well, to form an asymmetrical bilayer. [ 1 ] [ 12 ] These properties cause bacteria that produce cord factor to grow into long, intertwining filaments, giving them a rope- or cord-like appearance when stained and viewed through a microscope (hence the name). [ 13 ]
A large quantity of cord factor is found in virulent M. tuberculosis , but not in avirulent M. tuberculosis . [ 1 ] Furthermore, M. tuberculosis loses its virulence if its ability to produce cord factor molecules is compromised. [ 1 ] Consequently, when all lipids are removed from the exterior of M. tuberculosis cells, the survival of the bacteria is reduced within a host. [ 14 ] When cord factor is added back to those cells, M. tuberculosis survives at a rate similar to that of its original state. [ 14 ] Cord factor increases the virulence of tuberculosis in mice, but it has minimal effect on other infections. [ 1 ]
The function of cord factor is highly dependent on what environment it is located, and therefore its conformation. [ 15 ] This is evident as cord factor is harmful when injected with an oil solution, but not when it is with a saline solution, even in very large amounts. [ 15 ] Cord factor protects M. tuberculosis from the defenses of the host. [ 1 ] Specifically, cord factor on the surface of M. tuberculosis cells prevents fusion between phagosomal vesicles containing the M. tuberculosis cells and the lysosomes that would destroy them. [ 5 ] [ 16 ] The individual components of cord factor, the trehalose sugars and mycolic acid residues, are not able to demonstrate this activity; the cord factor molecules must be fully intact. [ 5 ] Esterase activity that targets cord factor results in the lysis of M. tuberculosis cells. [ 17 ] However, the M. tuberculosis cells must still be alive to prevent this fusion; heat-killed cells with cord factor are unable to prevent being digested. [ 16 ] This suggests an additional molecule from M. tuberculosis is required. [ 16 ] Regardless, cord factor's ability to prevent fusion is related to an increased hydration force or through steric hindrance. [ 5 ] Cord factor remains on the surface of M. tuberculosis cells until it associates with a lipid droplet , where it forms a monolayer. [ 15 ] Then, as cord factor is in a monolayer configuration, it has a different function; it becomes fatal or harmful to the host organism. [ 18 ] Macrophages can die when in contact with monolayers of cord factor, but not when cord factor is in other configurations. [ 1 ] As the monolayer surface area of cord factor increases, so does its toxicity. [ 19 ] The length of the carbon chain on cord factor has also shown to affect toxicity; a longer chain shows higher toxicity. [ 20 ] Furthermore, fibrinogen has shown to adsorb to monolayers of cord factor and act as a cofactor for its biological effects. [ 21 ]
Cord factor isolated from species of Nocardia has been shown to cause cachexia in mice. Severe muscle wasting occurred within 48 hours of the toxin being administered. [ 22 ]
Numerous responses that vary in effect result from cord factor's presence in host cells. After exposure to cord factor for 2 hours, 125 genes in the mouse genome are upregulated. [ 23 ] After 24 hours, 503 genes are upregulated, and 162 genes are downregulated. [ 23 ] The exact chemical mechanisms by which cord factor acts is not completely known. However, it is likely that the mycolic acids of cord factor must undergo a cyclopropyl modification to lead to a response from the host's immune system for initial infection. [ 24 ] Furthermore, the ester linkages in cord factor are important for its toxic effects. [ 25 ] There is evidence that cord factor is recognized by the Mincle receptor , which is found on macrophages. [ 26 ] [ 27 ] An activated Mincle receptor leads to a pathway that ultimately results in the production of several cytokines . [ 28 ] [ 29 ] These cytokines can lead to further cytokine production that promote inflammatory responses. [ 30 ] Cord factor, through the Mincle receptor, also causes the recruitment of neutrophils, which lead to pro-inflammatory cytokines as well. [ 31 ] However, there is also evidence that toll-like receptor 2 (TLR2) in conjunction with the protein MyD-88 is responsible for cytokine production rather than the Mincle receptor. [ 23 ]
Cord factor presence increases the production of the cytokines interleukin-12 (IL-12), interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor (TNFα), and macrophage inflammatory protein-2 (MIP-2), which are all pro-inflammatory cytokines important for granuloma formation. [ 16 ] [ 28 ] [ 32 ] IL-12 is particularly important in the defense against M. tuberculosis ; without it, M. tuberculosis spreads unhampered. [ 33 ] [ 34 ] IL-12 triggers production of more cytokines through T cells and natural killer (NK) cells, while also leading to mature Th1 cells, and thus leading to immunity. [ 35 ] Then, with IL-12 available, Th1 cells and NK cells produce interferon gamma (IFN-γ) molecules and subsequently release them. [ 36 ] The IFN-γ molecules in turn activate macrophages. [ 37 ]
When macrophages are activated by cord factor, they can arrange into granulomas around M. tuberculosis cells. [ 15 ] [ 38 ] Activated macrophages and neutrophils also cause an increase in vascular endothelial growth factor (VEGF), which is important for angiogenesis, a step in granuloma formation. [ 39 ] The granulomas can be formed either with or without T-cells, indicating that they can be foreign-body-type or hypersensitivity-type. [ 37 ] This means cord factor can stimulate a response by acting as a foreign molecule or by causing harmful reactions from the immune system if the host is already immunized. [ 37 ] Thus, cord factor can act as a nonspecific irritant or a T-cell dependent antigen. [ 37 ] Granulomas enclose M. tuberculosis cells to halt the bacteria from spreading, but they also allow the bacteria to remain in the host. [ 16 ] From there, the tissue can become damaged and the disease can transmit further with cord factor. [ 40 ] Alternatively, the activated macrophages can kill the M. tuberculosis cells through reactive nitrogen intermediates to remove the infection. [ 41 ]
Besides inducing granuloma formation, activated macrophages that result from IL-12 and IFN-γ are able to limit tumor growth. [ 42 ] Furthermore, cord factor's stimulation of TNF-α production, also known as cachectin, is also able to induce cachexia , or loss of weight, within hosts. [ 43 ] [ 44 ] Cord factor also increases NADase activity in the host, and thus it lowers NAD; enzymes that require NAD decrease in activity accordingly. [ 3 ] Cord factor is thus able to obstruct oxidative phosphorylation and the electron transport chain in mitochondrial membranes. [ 3 ] In mice, cord factor has shown to cause atrophy in the thymus through apoptosis; similarly in rabbits, atrophy of the thymus and spleen occurred. [ 45 ] [ 46 ] This atrophy occurs in conjunction with granuloma formation, and if granuloma formation is disturbed, so is the progression of atrophy. [ 46 ]
Infection by M. tuberculosis remains a serious problem in the world and knowledge of cord factor can be useful in controlling this disease. [ 24 ] For example, the glycoprotein known as lactoferrin is able to mitigate cytokine production and granuloma formation brought on by cord factor. [ 47 ] However, cord factor can serve as a useful model for all pathogenic glycolipids and therefore it can provide insight for more than just itself as a virulence factor. [ 11 ] [ 48 ] Hydrophobic beads covered with cord factor are an effective tool for such research; they are able to reproduce an organism's response to cord factor from M. tuberculosis cells. [ 11 ] [ 48 ] Cord factor beads are easily created and applied to organisms for study, and then easily recovered. [ 48 ]
It is possible to form cord factor liposomes through water emulsion; these liposomes are nontoxic and can be used to maintain a steady supply of activated macrophages. [ 49 ] Cord factor under proper control can potentially be useful in fighting cancer because IL-12 and IFN-γ are able to limit the growth of tumors. [ 50 ]
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Corindus, Inc. was founded in Israel in 2002 by Rafael Beyar , an interventional cardiologist , and his student at the Technion, Tal Wenderow. The company's original goal was to use remote control and robotics to move coronary guidewires and balloon/stent catheters. [ 1 ] [ 2 ]
Corindus Vascular Robotics, Inc. (NYSE: CVRS) was later moved to the United States to be headquartered in Waltham, Massachusetts . The company's FDA-cleared CorPath® System became the first medical device that allows interventionalists to manipulate guidewires and balloon/stents from an interventional cockpit. [ 3 ]
The company went public in August 2014 and traded on the New York Stock Exchange under the ticker symbol CVRS .
Under the leadership of CEO Mark Toland and CFO David Long, the company continued to grow and received additional clearances from the FDA. Investments in the development of next generation products and expanded regulatory clearances lead to the negotiation of a potential strategic transaction. In August 2019, Siemens Healthineers publicly announced its intention to acquire Corindus for $1.1 billion. The final transaction closed in October 2019, representing one of the largest MedTech deals in 2019. [ 4 ]
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The Cormack–Lehane classification system is a method used in anesthesiology to categorize the view obtained during direct laryngoscopy, primarily assessing the visibility of the glottis and surrounding laryngeal structures. Introduced in 1984 by British anesthetists R.S. Cormack and J. Lehane, this system aids in predicting the difficulty of tracheal intubation. [ 1 ] In 1998, a modified version subdivided Grade 2 to enhance its predictive accuracy. [ 2 ]
The original system, described in 1984, comprised four grades: [ 2 ]
To enhance the system's predictive value, Yentis and Lee proposed a modification in 1998, [ 3 ] subdividing Grade II into:
Grade IIa: Partial view of the glottis.
Grade IIb: Only the posterior extremity of the glottis or only the arytenoid cartilages are visible.
This modification provides a more nuanced assessment of intubation difficulty and the classification correlates with the likelihood of difficult intubation. [ 3 ] [ 4 ]
Despite its widespread use, studies have shown variability in anesthesiologists' familiarity with the Cormack–Lehane classification and its inter- and intra-observer reliability. A study revealed that while 89% of participants claimed to know a classification system for laryngeal view, only 25% could accurately define all four grades of the Cormack–Lehane system. [ 5 ] Additionally, inter-observer reliability was fair (κ coefficient of 0.35), and intra-observer reliability was poor (κ of 0.15).
Other systems, such as the Mallampati score , are used alongside the Cormack–Lehane classification to predict difficult intubation. However, no single bedside test has proven entirely accurate in predicting Cormack–Lehane grades. [ 5 ]
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The corner stitch is a common suture technique. [ 1 ] It used to close wounds that are angled or Y-shaped without appreciably compromising blood supply to the wound tip. [ 2 ] [ 3 ]
The corner stitch is a variation of the horizontal mattress stitch , and is sometimes called the "half-buried horizontal mattress stitch". [ 4 ] The needle enters the skin on one side of the obtuse angle of the wound, passes through the deep dermis of the corner flap, and is re-inserted through the dermis of the other side of the obtuse wound angle. It finally re-emerges through the epidermis on the side of the obtuse angle, adjacent to the initial entry point. [ citation needed ]
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A coronary CT calcium scan is a computed tomography (CT) scan of the heart for the assessment of severity of coronary artery disease . Specifically, it looks for calcium deposits in atherosclerotic plaques in the coronary arteries that can narrow arteries and increase the risk of heart attack. [ 1 ] These plaques are the cause of most heart attacks, and become calcified as they develop.
These calcifications can be detected by CT imaging because of their opacity to x-rays. This severity can be presented as an Agatston score or coronary artery calcium (CAC) score. The CAC score is an independent marker of risk for cardiac events, cardiac mortality, and all-cause mortality. [ 2 ] In addition, it provides additional prognostic information to other cardiovascular risk markers. [ 2 ]
Obstructions may be present even with an Agatston score of zero, especially in younger patients. [ 3 ] A typical coronary CT calcium scan is done without the use of radiocontrast agent but it can also be performed using contrast-enhanced images as well, such as in coronary CT angiography . [ 4 ] The exam is best performed with cardiac gating to eliminate motion but can also be estimated in the presence of motion.
The well-established indications for the use of the CAC score include stratification of global cardiovascular risk for asymptomatic patients: intermediate risk based on the Framingham risk score (class I); low risk based on a family history of early coronary artery disease (CAD) (class IIa); and low-risk patients with diabetes (class IIa). [ 2 ]
In symptomatic patients, the pre-test probability should always be given weight in the interpretation of the CAC score as a filter or tool to indicate the best method to facilitate the diagnosis. Therefore, the use of the CAC score alone is limited in symptomatic patients. [ 2 ]
In patients with diabetes, the CAC score helps identify the individuals most at risk, who could benefit from screening for silent ischemia and from more aggressive clinical treatment. [ 2 ]
However, coronary CT angiography (CTA) is superior to coronary CT calcium scanning in determining the risk of Major Adverse Cardiac Events (MACE). [ 5 ]
There is potential to measure CAC on chest radiographs taken for other indications, possibly allowing some primary screening for coronary artery disease without adding to radiation exposure and with minimal marginal cost. [ 6 ]
The Agatston score , named after its developer Arthur Agatston , is a measure of calcium on a coronary CT calcium scan. [ 7 ] The original work, published in 1990, [ 8 ] was based on electron beam computed tomography (also known as ultrafast CT or EBCT). The score is calculated using a weighted value assigned to the highest density of calcification in a given coronary artery.
The density is measured in Hounsfield units , and score of 1 for 130–199 HU, 2 for 200–299 HU, 3 for 300–399 HU, and 4 for 400 HU and greater. This weighted score is then multiplied by the area (in square millimeters) of the coronary calcification. For example, a "speck" of coronary calcification in the left anterior descending artery measures 4 square millimeters and has a peak density of 270 HU. The score is therefore 8 (4 square millimeters × weighted score of 2).
The tomographic slices of the heart are 3 millimeters thick and average about 50–60 slices from the coronary artery ostia to the inferior wall of the heart. The calcium score of every calcification in each coronary artery for all of the tomographic slices is then summed up to give the total coronary artery calcium score (CAC score). [ 9 ]
The Agatston score is frequently used today because of its long history of clinical validation. Several variations of the Agatston score have been described, including mass-based calcium scoring, volume-based calcium scoring, or lesion-specific calcium-scoring have been developed. [ 10 ]
A lesion-specific calcium score has been developed. [ 11 ] Each individual calcified lesion is characterized and measured using parameters including the width, length, density, and distance from the entrance of the major coronary arteries. [ 12 ] Research has shown that the lesion-specific calcium scoring method is superior to the traditional Agatston score for the prediction of significant blockages in the heart. [ 10 ]
On average, a single scan will expose a patient to about 2.3 millisieverts of radiation, equivalent to 23 chest x-rays (front and side views). [ 13 ] [ 14 ] That average covers a wide range of doses depending on equipment type and scanning protocol. Using modern equipment and protocols, a 1 millisievert exposure is possible. [ 15 ] Because the exact radiation exposure for a specific patient depends on the equipment type in use, the patients build and a variety of scanning options (such as retrospective vs prospective gating) it is difficult for a patient to know what their radiation exposure will be.
A 2009 study indicated that for every 100,000 people screened with CAC testing every 5 years between ages 45 to 75 years (men) or 55 to 75 years (women), there would be 42 (men) or 62 (women) additional radiation induced cancer cases. [ 13 ]
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Coronary artery aneurysm is an abnormal dilatation of part of the coronary artery . This rare disorder occurs in about 0.3–4.9% of patients who undergo coronary angiography . [ 2 ]
The majority of individuals suffering from coronary artery aneurysms do not exhibit any symptoms; the development of complications or concurrent atherosclerotic coronary artery disease is what causes clinical manifestations to occur. The most common complications include coronary spasm , distal embolization , aneurysm rupture, local thrombosis , and compression of surrounding structures due to massive enlargement of coronary artery aneurysm. [ 3 ]
Acquired causes include atherosclerosis in adults, [ 4 ] Kawasaki disease in children [ 5 ] and coronary catheterization . With the invention of drug eluting stents, there has been more cases implying stents lead to coronary aneurysms. The pathophysiology, although not completely understood, might be comparable to that of aneurysms of larger vessels. This includes disruption of the arterial media, weakening of the arterial wall , increased wall strain and slow dilatation of the coronary artery portion. [ 2 ]
It can also be congenital. [ 6 ] [ 7 ] The following risk factors are thought to be associated with coronary artery aneurysms:
It is often found coincidentally on coronary angiography . [ 3 ] Other modalities that can be used to diagnose a coronary artery aneurysm include echocardiography , magnetic resonance imaging and computerized tomography . Although coronary angiography remains to be the gold standard, the invasive procedure comes with its associated risks, is more expensive than other modalities and the size of the aneurysm might be miscalculated if there is a thrombus in place. [ 2 ]
Treatment for coronary artery aneurysm include medical management, surgery and percutaneous intervention. Underlying coronary artery risk factors should be addressed in patients with atherosclerosis and proper guideline-mediated medications should be started. In those with risk for embolism or thrombosis , anti-platelet or anticoagulation therapy should be contemplated. [ 2 ]
In patients with Kawasaki disease prompt administration of intravenous immunoglobulin (IVIG) therapy should be given to prevent complication of coronary artery aneurysm. [ 9 ]
Generally, it has a good prognosis. [ 3 ] The prognosis of coronary artery aneurysm is dependent on its diameter. The smaller the aneurysm the better the prognosis. There is less risk for ischemic myocardial damage and mortality with smaller aneurysms. Aneurysms with an internal diameter > 8 mm have poorer outcomes, since these aneurysms can be occluded and be associated with complications such as arrhythmias , myocardial infarction , or sudden death. [ 2 ]
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https://en.wikipedia.org/wiki/Coronary_artery_aneurysm
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Coronary artery anomalies are variations of the coronary circulation , affecting <1% of the general population. Symptoms include chest pain, shortness of breath and syncope , although cardiac arrest may be the first clinical presentation. Several varieties are identified, with a different potential to cause sudden cardiac death .
Coronary arteries are vessels supplying blood and nutrients to the heart muscle ( myocardium ). [ 1 ]
Coronary arteries arise from ostia, openings of the aorta (the largest artery in the human body) at the upper third or middle third of the sinuses of Valsalva (the first part of the big pipe coming off the main pumping chamber). The walls of coronary arteries consist of three layers: the tunica intima or inner layer (possible site of lipid deposits and fibrosis, during life), the tunica media (a smooth muscle layer whose tone is modulated by the nervous system, influencing vessel diameter and resistance) and adventitia (where nervous endings are located). Normally, the initial portion of coronary arteries lies onto the external surface of the heart (epicardium) where fat deposits tend to form during life. [ citation needed ]
In normal anatomy, three essential coronary arteries are identified: right coronary artery (RCA), left anterior descending artery (LAD) and left circumflex artery (LCx). LAD and LCx usually originate from the bifurcation of a common vessel known as left main trunk or left coronary artery (LM or LCA). [ 2 ]
Coronary arteries are identified according to the myocardial territory they feed: [ 2 ]
1) the LAD supplies the anterior interventricular septum and anterior left ventricular free wall;
2) the LCx supplies the posterolateral left ventricular free wall;
3) the RCA supplies the right ventricular free wall;
In fact, despite a certain degree of variability in coronary artery anatomy among individuals, there is greater consistency in the regions of the heart that are supplied by the different coronary arteries. [ citation needed ]
The posterior descending artery , providing blood flow to the infero-posterior wall of the heart, originates from the RCA in 70-90% of individuals (“right coronary dominance”), whereas in 10-15% cases it originates from the LCx (“left coronary dominance”). [ citation needed ]
Coronary vessels diameter progressively decreases proceeding from their origin to the periphery. Besides the LM, LAD, LCx and RCA, arterial vessels that are large enough to be identified by clinical angiography are called “branches”, while capillaries represent the smallest peripheral vessels of the coronary tree that lack muscular tissue (and capacity to cause spasm ) and are responsible for oxygen and nutrients exchange within the myocardium. [ citation needed ]
Regarding coronary artery anatomy, a distinction must be provided when assessing abnormalities: [ citation needed ]
- normal : any morphological feature observed in >1% of an unselected population
- normal variant : an alternative, unusual but benign morphological feature identified in >1% of the same population (e.g. left main is absent in 1-2% of the general population with LAD and LCx originating from separate ostia - “absent left trunk” variant)
- coronary artery anomaly (CAA) : a morphological feature seen in <1% of that population, capable of causing dysfunction
The prevalence of coronary artery anomalies is inconsistent across the scientific literature, but they are considered to affect <1% of the general population. Specifically, recent data came from MRI screening of a large population (more than 5000 young children) and provided a precise estimate, suggesting that coronary artery anomalies are present in 0.45% of the US population (approximately 1.300.000 people). [ 3 ]
Anomalous origin of a coronary artery from the opposite sinus are relevant on a clinical level due to a significant association with sudden cardiac death, if they are accompanied by intramural course. Indeed, the main feature responsible for adverse outcomes is the “intramural” course (sometimes improperly referred to as inter-arterial) characterized by an acute ostial angulation (tangential course), “slit-like” ostium (compressed inside the aortic wall), and a proximal or initial section penetrating into the aortic tunica media (coronary arteries normally take off at a 90 degree angle) with subsequent course reaching the “correct” side of the heart. As a consequence, lateral compression of the coronary artery leads to coronary luminal (inside opening) narrowing, with reduced supply of blood and oxygen to the depending myocardial tissue, that is phasic (worse in systole , the phase of cardiac contraction, and tachycardia). Furthermore, the intramural segment of the ectopic artery, located inside the aorta, is typically but variably “ hypoplastic ”, smaller in circumference than the distal, extramural segments (it is unable to grow properly either before or after birth). [ citation needed ]
Autonomic and/or endothelial dysfunction may occur and induce spasm and/or thrombosis at anomalous sites (and critical ischemia ), although intracoronary clotting has been rarely observed. Therefore, stenosis of an intramural proximal segment, lateral compression and spastic hyperreactivity are the mechanisms that have been linked to clinical manifestation. Coronary narrowing is most likely the main process implied in ACAOS, and it may result in symptoms such as chest pain (“ angina pectoris ”), dyspnea (shortness of breath), palpitations, cardiac arrhythmias (heart rhythm disorders), syncope (fainting). In most cases, however, coronary artery anomalies are silent for many years and the first clinical manifestation of these pathological entities is sudden cardiac death (e.g. due to malignant arrhythmias such as ventricular fibrillation ) typically after strenuous physical exertion (when arterial compression is more severe, and cardiac work is maximal) such as in young athletes or military recruits. Of note, 19-33% (in different studies) of sudden deaths in young athletes are due to coronary artery anomalies. Clinical manifestations can be found in non-athletic, older individuals and are commonly associated with hypertension and aortic dilatation with worsening degree of compression.
L-ACAOS-IM (intramural) is seen in 0.1% of young children and, among coronary anomalies, it has the highest probability of clinical repercussions, being consistently associated with sudden cardiac death following physical exercise.
Several more varieties of L-ACAOS are described:
- prepulmonic (L-ACAOS-PP): origin of the LCA (or only the LAD) from the right sinus of Valsalva (RSV) with an epicardial course (on the surface of the heart) anterior to the pulmonary outflow tract - this does not usually cause stenosis nor requires intervention (benign anomaly, unless spasm occurs);
- subpulmonary, infundibular or intraseptal ( L-ACAOS-SP): the LCA (or only the LAD) originates from the RSV, initially runs inter-arterially (outside the aortic wall) then intramyocardially inside in the ventricular septum and finally epicardially in the anterior interventricular groove - this anomaly is considered benign since it is not associated with significant fixed degree of stenosis (but it could cause spasm);
- retroaortic (L-ACAOS-RA): origin of the LCA or the only LCx from the RSV or from the RCA, running behind the aortic root and at the central fibrous mitro-aortic septum – this is considered as a benign anomaly (but it could cause spasm);
- retrocardiac (L-ACAOS-RC) – LCA originates from the RCA at the atrioventricular groove - or wrap-around the apex (L-ACAOS-WA) – generally benign, unless spasm occurs.
R-ACAOS-IM [ 4 ] is observed in a higher percentage of cases (0.35% of adolescents) than L-ACAOS-IM [ 5 ] but is less likely to be associated with sudden cardiac death in athletes. Varieties of R-ACAOS such as prepulmonic, retroaortic and intraseptal can occur and are considered generally benign.
The most frequent symptomatic coronary anomaly in infants and young children is anomalous origin of the left coronary artery from the pulmonary artery , which may cause acute myocardial infarction at neonatal age and requires emergent surgery at the time of diagnosis. [ 6 ]
Anomalies at the mid segments include myocardial bridges , affecting >1% of the clinical population, and characterized by an intramyocardial course of coronary arteries within the muscle fibers. This may lead to systolic compression which is usually mild (coronary blood flow is mostly diastolic ). Significant ischemia is rare in isolated myocardial bridges, and if present this is generally due to localized endothelial dysfunction with a tendency to spasm. Most myocardial bridges are benign and do not require any intervention.
Coronary artery aneurysms are defined as a > 50% increase of the vessel diameter. Some cases are congenital/idiopathic, but most are secondary to atherosclerosis or Kawasaki disease (an immuno-inflammatory disease especially targeting coronary vessels wall). Potential complications include localized thrombosis, distal embolization, rupture, or late lipid deposits.
Coronary arteriovenous fistulas are anomalies at the termination consisting of an anomalous connection of coronary arteries to coronary veins, veins of the pulmonary or systemic circulations, or to any cardiac cavity. Smaller fistulas are usually benign, and only severe cases can be complicated by aneurysmatic dilatation with potential thrombosis and distal embolization, volume overload or “blood steal” from arterial circulation and subsequent ischemia. Treatment is generally not required.
There is an open debate about the cost/efficiency of generalized diagnostic screening in large populations. Carriers of coronary artery anomalies may receive positive results following stress/imaging tests. However, only in a minority of cases ischemia in the context of coronary artery anomalies is reproducible by stress or imaging testing and is mainly associated with particular conditions such as intense (maximal) exercise, which may lead to confusing results and misdiagnosis by techniques such as treadmill test or nuclear testing.
Nonetheless, routine screening of high-risk populations (e.g. individuals participating in competitive sports) should be generally encouraged in clinical practice of sports cardiologists.
Various imaging tests have a potential to identify coronary artery anomalies. Echocardiography (ultrasound scanning of the heart) is simple, non-invasive and economical. Its use for CAAs screening is limited because its diagnostic sensitivity is highly dependent on the operator's skills and is significantly lower in larger individuals (>40 kg). The diagnostic power of echocardiography is generally poor in most cases after infancy. Especially if clinical suspicion for CAAs is high (e.g. syncope following exertion and/or history of aborted sudden cardiac death). Cardiac magnetic resonance (CMR) is an excellent tool to identify coronary artery anomalies with a significantly higher diagnostic accuracy than standard echocardiography. Compared to CMR, coronary computed tomographic angiography (CCTA) provides more precise assessment of coronary anatomy, course and degree of stenosis , but its clinical use for screening is strongly limited by its cost, the need for ionizing radiation, intravenous contrast and, in many cases, drugs administration. Assessment of severity of stenosis is best achieved by intravascular ultrasound (IVUS) imaging and it should be considered in known carriers of ACAOS-IM or that have symptoms or positive stress test results or are involved in competitive exercises. IVUS consists of cross-sectional imaging of coronary arteries in a catheterization laboratory by advancing a thin probe inside the vascular lumen, obtaining precise in-vivo information about degree of area stenosis in different arterial segments, providing a solid basis for treatment strategies.
CAAs include a wide spectrum of entities with different severity. We can schematically distinguish anomalies at the ostium, such as congenital ostial atresia or stenosis or anomalous origin of a coronary artery from the opposite sinus [ACAOS] (examples: right coronary artery anomalous origin from the opposite sinus [R-ACAOS] and left coronary artery origin from the opposite sinus [L-ACAOS]); anomalies at the mid segments (such as myocardial bridge [MB]); anomalies at the termination (such as coronary arteriovenous fistulas). [ citation needed ]
Criteria for intervention in ACAOS-IM are:
- symptoms of effort-related chest pain, shortness of breath, syncope or aborted sudden cardiac death (Class I, Level of Evidence A/B) and/or high-risk professional lifestyle.
- positive treadmill stress test, ideally by nuclear technology, in the correct dependent myocardial territory, in the presence of intramural course (Class I, Level of Evidence B)
For special populations, e.g. athletes, treatment may be indicated with specific advice of medical experts, in the absence of the previously mentioned criteria. Cut-off for stenosis severity requiring intervention is not clear, although narrowing >50% in comparison to the distal normal segment is generally accepted as a marker of severity in L-ACAOS-IM. Decisions on treatment should be guided by the patient's individual characteristics such as age, symptoms, profession and level of engagement in physical activity. Pharmacological treatment and observation may be appropriate in selected, low-risk patients. Importantly, untreated carriers of significant ACAOS should not generally engage in competitive sports or strenuous activities.
Treatment options for ACAOS-IM include both catheter-based procedures ( percutaneous coronary intervention [PCI]) and surgical interventions. PCI consists of stent angioplasty of the proximal, intramural segment by placing a thin metal tube (a stent) in order to keep open the narrowed artery. PCI of R-ACAOS-IM is feasible and quite successful, but further experience is needed in L-ACAOS-IM since few cases have been treated percutaneously, while surgery is the recommended treatment in this subpopulation, at this time. Surgery consists of “unroofing” or denudation of the intramural coronary segment from the aortic wall: this approach is currently the gold standard. Coronary artery bypass grafting (CABG) and reimplantation of the ectopic artery are obsolete and not indicated, because of competitive flow in mild resting narrowings. [ 7 ]
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https://en.wikipedia.org/wiki/Coronary_artery_anomaly
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Coronary artery disease ( CAD ), also called coronary heart disease ( CHD ), or ischemic heart disease ( IHD ), [ 13 ] is a type of heart disease involving the reduction of blood flow to the cardiac muscle due to a build-up of atheromatous plaque in the arteries of the heart . [ 5 ] [ 6 ] [ 14 ] It is the most common of the cardiovascular diseases . [ 15 ] CAD can cause stable angina , unstable angina , myocardial ischemia, [ 16 ] and myocardial infarction . [ 17 ]
A common symptom is angina, which is chest pain or discomfort that may travel into the shoulder, arm, back, neck, or jaw. [ 4 ] Occasionally it may feel like heartburn . In stable angina , symptoms occur with exercise or emotional stress , last less than a few minutes, and improve with rest. [ 4 ] Shortness of breath may also occur and sometimes no symptoms are present. [ 4 ] In many cases, the first sign is a heart attack . [ 5 ] Other complications include heart failure or an abnormal heartbeat . [ 5 ]
Risk factors include high blood pressure , smoking , diabetes mellitus , lack of exercise, obesity , high blood cholesterol , poor diet, depression , and excessive alcohol consumption. [ 6 ] [ 7 ] [ 18 ] A number of tests may help with diagnosis including electrocardiogram , cardiac stress testing , coronary computed tomographic angiography , biomarkers ( high-sensitivity cardiac troponins ) and coronary angiogram , among others. [ 8 ] [ 19 ] Ways to reduce CAD risk include eating a healthy diet , regularly exercising , maintaining a healthy weight, and not smoking. [ 20 ] [ 9 ] Medications for diabetes, high cholesterol, or high blood pressure are sometimes used. [ 9 ] There is limited evidence for screening people who are at low risk and do not have symptoms. [ 21 ] Treatment involves the same measures as prevention. [ 10 ] [ 22 ] Additional medications such as antiplatelets (including aspirin ), beta blockers , or nitroglycerin may be recommended. [ 10 ] Procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) may be used in severe disease. [ 10 ] [ 23 ] In those with stable CAD it is unclear if PCI or CABG in addition to the other treatments improves life expectancy or decreases heart attack risk. [ 24 ]
In 2015, CAD affected 110 million people and resulted in 8.9 million deaths. [ 11 ] [ 12 ] It makes up 15.6% of all deaths, making it the most common cause of death globally. [ 12 ] The risk of death from CAD for a given age decreased between 1980 and 2010, especially in developed countries . [ 25 ] The number of cases of CAD for a given age also decreased between 1990 and 2010. [ 26 ] In the United States in 2010, about 20% of those over 65 had CAD, while it was present in 7% of those 45 to 64, and 1.3% of those 18 to 45; [ 27 ] rates were higher among males than females of a given age. [ 27 ]
The most common symptom is chest pain or discomfort that occurs regularly with activity, after eating, or at other predictable times; this phenomenon is termed stable angina and is associated with narrowing of the arteries of the heart . Angina also includes chest tightness, heaviness, pressure, numbness, fullness, or squeezing. [ 28 ] Angina that changes in intensity, character, or frequency is termed unstable. Unstable angina may precede myocardial infarction . In adults who go to the emergency department with an unclear cause of pain, about 30% have pain due to coronary artery disease. [ 29 ] Angina, shortness of breath, sweating, nausea or vomiting, and lightheadedness are signs of a heart attack or myocardial infarction, and immediate emergency medical services are crucial. [ 28 ]
With advanced disease, the narrowing of coronary arteries reduces the supply of oxygen-rich blood flowing to the heart, which becomes more pronounced during strenuous activities, during which the heart beats faster and has an increased oxygen demand. [ 30 ] For some, this causes severe symptoms, while others experience no symptoms at all. [ 4 ]
Symptoms in females can differ from those in males, and the most common symptom reported by females of all races is shortness of breath. [ 31 ] Other symptoms more commonly reported by females than males are extreme fatigue, sleep disturbances, indigestion, and anxiety. [ 32 ] However, some females experience irregular heartbeat, dizziness, sweating, and nausea. [ 28 ] Burning, pain, or pressure in the chest or upper abdomen that can travel to the arm or jaw can also be experienced in females, but females less commonly report it than males. [ 32 ] Generally, females experience symptoms 10 years later than males. [ 33 ] Females are less likely to recognize symptoms and seek treatment. [ 28 ]
Coronary artery disease is characterized by heart problems that result from atherosclerosis. [ 34 ] Atherosclerosis is a type of arteriosclerosis which is the "chronic inflammation of the arteries which causes them to harden and accumulate cholesterol plaques (atheromatous plaques) on the artery walls". [ 35 ] CAD has several well-determined risk factors contributing to atherosclerosis. These risk factors for CAD include "smoking, diabetes, high blood pressure (hypertension), abnormal (high) amounts of cholesterol and other fat in the blood (dyslipidemia), type 2 diabetes and being overweight or obese (having excess body fat)" due to lack of exercise and a poor diet. [ 36 ] Some other risk factors include high blood pressure , smoking , diabetes , lack of exercise, obesity , high blood cholesterol , poor diet, depression , family history , psychological stress and excessive alcohol . [ 6 ] [ 7 ] [ 18 ] About half of cases are linked to genetics. [ 37 ] Apart from these classical risk factors, several unconventional risk factors have also been studied including high serum fibrinogen, high c-reactive protein (CRP), chronic inflammatory conditions, hypovitaminosis D, high lipoprotein A levels, serum homocysteine etc. [ 38 ] [ 39 ] Smoking and obesity are associated with about 36% and 20% of cases, respectively. [ 40 ] Smoking just one cigarette per day about doubles the risk of CAD. [ 41 ] Lack of exercise has been linked to 7–12% of cases. [ 40 ] [ 42 ] Exposure to the herbicide Agent Orange may increase risk. [ 43 ] Rheumatologic diseases such as rheumatoid arthritis , systemic lupus erythematosus , psoriasis , and psoriatic arthritis are independent risk factors as well. [ 44 ] [ 45 ] [ 46 ] [ 47 ] [ excessive citations ]
Job stress appears to play a minor role, accounting for about 3% of cases. [ 40 ] In one study, females who were free of stress from work life saw an increase in the diameter of their blood vessels, leading to decreased progression of atherosclerosis. [ 48 ] In contrast, females who had high levels of work-related stress experienced a decrease in the diameter of their blood vessels and significantly increased disease progression. [ 48 ]
Air pollution , both indoor and outdoor, is responsible for roughly 28% of deaths from CAD. This varies by region: In highly developed areas, this is approximately 10%, whereas in Southern, East and West Africa, and South Asia , approximately 40% of deaths from CAD can be attributed to unhealthy air. [ 49 ] In particular, fine particle pollution (PM 2.5 ), which comes mostly from the burning of fossil fuels , is a key risk factor for CAD. [ 50 ]
The consumption of different types of fats including trans fat (trans unsaturated), and saturated fat , in a diet "influences the level of cholesterol that is present in the bloodstream". [ 51 ] Unsaturated fats originate from plant sources (such as oils). There are two types of unsaturated fats, cis and trans isomers. Cis unsaturated fats are bent in molecular structure and trans are linear. Saturated fats originate from animal sources (such as animal fats) and are also molecularly linear in structure. [ 52 ] The linear configurations of unsaturated trans and saturated fats allow them to easily accumulate and stack at the arterial walls when consumed in high amounts (and other positive measures towards physical health are not met).
High levels of cholesterol in the bloodstream lead to atherosclerosis. With increased levels of LDL in the bloodstream, "LDL particles will form deposits and accumulate within the arterial walls, which will lead to the development of plaques, restricting blood flow". [ 51 ] The resultant reduction in the heart's blood supply due to atherosclerosis in coronary arteries "causes shortness of breath, angina pectoris (chest pains that are usually relieved by rest), and potentially fatal heart attacks (myocardial infarctions)". [ 36 ]
The heritability of coronary artery disease has been estimated between 40% and 60%. [ 53 ] Genome-wide association studies have identified over 160 genetic susceptibility loci for coronary artery disease. [ 54 ]
Several RNA Transcripts associated with CAD - FoxP1 , ICOSLG , IKZF4/Eos , SMYD3 , TRIM28 , and TCF3/E2A are likely markers of regulatory T cells (Tregs), consistent with known reductions in Tregs in CAD. [ 55 ]
The RNA changes are mostly related to ciliary and endocytic transcripts, which in the circulating immune system would be related to the immune synapse . [ 56 ] One of the most differentially expressed genes, fibromodulin (FMOD), which is increased 2.8-fold in CAD, is found mainly in connective tissue [ 57 ] and is a modulator of the TGF-beta signaling pathway. However, not all RNA changes may be related to the immune synapse. For example, Nebulette , the most down-regulated transcript (2.4-fold), is found in cardiac muscle; it is a 'cytolinker' that connects actin and desmin to facilitate cytoskeletal function and vesicular movement. The endocytic pathway is further modulated by changes in tubulin , a key microtubule protein, and fidgetin , a tubulin-severing enzyme that is a marker for cardiovascular risk identified by genome-wide association study . Protein recycling would be modulated by changes in the proteasomal regulator SIAH3 and the ubiquitin ligase MARCHF10 . On the ciliary aspect of the immune synapse, several of the modulated transcripts are related to ciliary length and function. Stereocilin is a partner to mesothelin , a related super-helical protein, whose transcript is also modulated in CAD. DCDC2 , a double-cortin protein, modulates ciliary length. In the signaling pathways of the immune synapse, numerous transcripts are directly related to T-cell function and the control of differentiation. Butyrophilin is a co-regulator for T cell activation. Fibromodulin modulates the TGF-beta signaling pathway, a primary determinant of Tre differentiation. Further impact on the TGF-beta pathway is reflected in concurrent changes in the BMP receptor 1B RNA (BMPR1B), because the bone morphogenic proteins are members of the TGF-beta superfamily, and likewise impact Treg differentiation. Several of the transcripts ( TMEM98 , NRCAM , SFRP5 , SHISA2 ) are elements of the Wnt signaling pathway, which is a major determinant of Treg differentiation.
Limitation of blood flow to the heart causes ischemia (cell starvation secondary to a lack of oxygen) of the heart's muscle cells . The heart's muscle cells may die from lack of oxygen and this is called a myocardial infarction (commonly referred to as a heart attack). It leads to damage, death, and eventual scarring of the heart muscle without regrowth of heart muscle cells. Chronic high-grade narrowing of the coronary arteries can induce transient ischemia , which leads to the induction of a ventricular arrhythmia , which may terminate in a dangerous heart rhythm known as ventricular fibrillation , which often leads to death. [ 66 ]
Typically, coronary artery disease occurs when part of the smooth, elastic lining inside a coronary artery (the arteries that supply blood to the heart muscle) develops atherosclerosis . With atherosclerosis, the artery's lining becomes hardened, stiffened, and accumulates deposits of calcium, fatty lipids, and abnormal inflammatory cells – to form a plaque . Calcium phosphate (hydroxyapatite) deposits in the muscular layer of the blood vessels appear to play a significant role in stiffening the arteries and inducing the early phase of coronary arteriosclerosis . This can be seen in a so-called metastatic mechanism of calciphylaxis as it occurs in chronic kidney disease and hemodialysis . [ citation needed ] Although these people have kidney dysfunction, almost fifty percent of them die due to coronary artery disease. Plaques can be thought of as large "pimples" that protrude into the channel of an artery, causing partial obstruction to blood flow. People with coronary artery disease might have just one or two plaques or might have dozens distributed throughout their coronary arteries . A more severe form is chronic total occlusion (CTO) when a coronary artery is completely obstructed for more than 3 months. [ 67 ]
Microvascular angina is a type of angina pectoris in which chest pain and chest discomfort occur without signs of blockages in the larger coronary arteries of their hearts when an angiogram (coronary angiogram) is being performed. [ 68 ] [ 69 ] The exact cause of microvascular angina is unknown. Explanations include microvascular dysfunction or epicardial atherosclerosis. [ 70 ] [ 71 ] For reasons that are not well understood, females are more likely than males to have it; however, hormones and other risk factors unique to females may play a role. [ 72 ]
The diagnosis of CAD depends largely on the nature of the symptoms and imaging. The first investigation when CAD is suspected is an electrocardiogram (ECG/EKG), both for stable angina and acute coronary syndrome. An X-ray of the chest , blood tests , and resting echocardiography may be performed. [ 73 ] [ 74 ]
For stable symptomatic patients, several non-invasive tests can diagnose CAD depending on pre-assessment of the risk profile. Noninvasive imaging options include; Computed tomography angiography (CTA) (anatomical imaging, best test in patients with low-risk profile to "rule out" the disease), positron emission tomography (PET), single-photon emission computed tomography (SPECT)/nuclear stress test/myocardial scintigraphy and stress echocardiography (the three latter can be summarized as functional noninvasive methods and are typically better to "rule in"). Exercise ECG or stress test is inferior to non-invasive imaging methods due to the risk of false-negative and false-positive test results. The use of non-invasive imaging is not recommended on individuals who are exhibiting no symptoms and are otherwise at low risk for developing coronary disease. [ 75 ] [ 76 ] Invasive testing with coronary angiography (ICA) can be used when non-invasive testing is inconclusive or show a high event risk. [ 74 ]
The diagnosis of microvascular angina (previously known as cardiac syndrome X – the rare coronary artery disease that is more common in females, as mentioned, is a diagnosis of exclusion. Therefore, usually, the same tests are used as in any person suspected of having coronary artery disease: [ 77 ]
Stable angina is the most common manifestation of ischemic heart disease, and is associated with reduced quality of life and increased mortality. It is caused by epicardial coronary stenosis, which results in reduced blood flow and oxygen supply to the myocardium. [ 78 ] Stable angina is short-term chest pain during physical exertion caused by an imbalance between myocardial oxygen supply and metabolic oxygen demand. Various forms of cardiac stress tests may be used to induce both symptoms and detect changes by way of electrocardiography (using an ECG), echocardiography (using ultrasound of the heart) or scintigraphy (using uptake of radionuclide by the heart muscle). If part of the heart seems to receive an insufficient blood supply, coronary angiography may be used to identify stenosis of the coronary arteries and suitability for angioplasty or bypass surgery . [ 79 ]
In minor to moderate cases, nitroglycerine may be used to alleviate acute symptoms of stable angina or may be used immediately before exertion to prevent the onset of angina. Sublingual nitroglycerine is most commonly used to provide rapid relief for acute angina attacks and as a complement to anti-anginal treatments in patients with refractory and recurrent angina. [ 80 ] When nitroglycerine enters the bloodstream, it forms free radical nitric oxide, or NO, which activates guanylate cyclase and in turn stimulates the release of cyclic GMP. This molecular signaling stimulates smooth muscle relaxation, resulting in vasodilation and consequently improved blood flow to heart regions affected by atherosclerotic plaque. [ 81 ]
Stable coronary artery disease (SCAD) is also often called stable ischemic heart disease (SIHD). [ 82 ] A 2015 monograph explains that "Regardless of the nomenclature, stable angina is the chief manifestation of SIHD or SCAD." [ 82 ] There are U.S. and European clinical practice guidelines for SIHD/SCAD. [ 83 ] [ 84 ] [ 74 ] In patients with non-severe asymptomatic aortic valve stenosis and no overt coronary artery disease, the increased troponin T (above 14 pg/mL) was found associated with an increased 5-year event rate of ischemic cardiac events ( myocardial infarction , percutaneous coronary intervention , or coronary artery bypass surgery ). [ 85 ]
Diagnosis of acute coronary syndrome generally takes place in the emergency department , where ECGs may be performed sequentially to identify "evolving changes" (indicating ongoing damage to the heart muscle). Diagnosis is clear-cut if ECGs show elevation of the " ST segment ", which in the context of severe typical chest pain is strongly indicative of an acute myocardial infarction (MI); this is termed a STEMI (ST-elevation MI) and is treated as an emergency with either urgent coronary angiography and percutaneous coronary intervention (angioplasty with or without stent insertion) or with thrombolysis ("clot buster" medication), whichever is available. In the absence of ST-segment elevation, heart damage is detected by cardiac markers (blood tests that identify heart muscle damage). If there is evidence of damage ( infarction ), the chest pain is attributed to a "non-ST elevation MI" (NSTEMI). If there is no evidence of damage, the term "unstable angina" is used. This process usually necessitates hospital admission and close observation on a coronary care unit for possible complications (such as cardiac arrhythmias – irregularities in the heart rate). Depending on the risk assessment, stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina. [ citation needed ]
There are various risk assessment systems for determining the risk of coronary artery disease, with various emphases on the different variables above. A notable example is Framingham Score , used in the Framingham Heart Study . It is mainly based on age, gender, diabetes, total cholesterol, HDL cholesterol, tobacco smoking, and systolic blood pressure. When predicting risk in younger adults (18–39 years old), the Framingham Risk Score remains below 10–12% for all deciles of baseline-predicted risk. [ 86 ]
Polygenic score is another way of risk assessment. In one study, the relative risk of incident coronary events was 91% higher among participants at high genetic risk than among those at low genetic risk. [ 87 ]
Up to 90% of cardiovascular disease may be preventable if established risk factors are avoided. [ 88 ] [ 89 ] Prevention involves adequate physical exercise , decreasing obesity , treating high blood pressure , eating a healthy diet , decreasing cholesterol levels, and stopping smoking . Medications and exercise are roughly equally effective. [ 90 ] High levels of physical activity reduce the risk of coronary artery disease by about 25%. [ 91 ] Life's Essential 8 are the key measures for improving and maintaining cardiovascular health, as defined by the American Heart Association. AHA added sleep as a factor influencing heart health in 2022. [ 92 ]
Most guidelines recommend combining these preventive strategies. A 2015 Cochrane Review found some evidence that counseling and education to bring about behavioral change might help in high-risk groups. However, there was insufficient evidence to show an effect on mortality or actual cardiovascular events. [ 93 ]
In diabetes mellitus , there is little evidence that very tight blood sugar control improves cardiac risk, although improved sugar control appears to decrease other problems such as kidney failure and blindness . [ 94 ]
A 2024 study published in The Lancet Diabetes & Endocrinology found that the oral glucose tolerance test (OGTT) is more effective than hemoglobin A1c (HbA1c) for detecting dysglycemia in patients with coronary artery disease. [ 95 ] The study highlighted that 2-hour post-load glucose levels of at least 9 mmol/L were strong predictors of cardiovascular outcomes, while HbA1c levels of at least 5.9% were also significant but not independently associated when combined with OGTT results. [ 96 ]
A diet high in fruits and vegetables decreases the risk of cardiovascular disease and death. [ 97 ] Vegetarians have a lower risk of heart disease, [ 98 ] [ 99 ] possibly due to their greater consumption of fruits and vegetables. [ 100 ] Evidence also suggests that the Mediterranean diet [ 101 ] and a high fiber diet lower the risk. [ 102 ] [ 103 ]
The consumption of trans fat (commonly found in hydrogenated products such as margarine ) has been shown to cause a precursor to atherosclerosis [ 104 ] and increase the risk of coronary artery disease. [ 105 ]
Evidence does not support a beneficial role for omega-3 fatty acid supplementation in preventing cardiovascular disease (including myocardial infarction and sudden cardiac death ). [ 106 ] [ 107 ]
Secondary prevention is preventing further sequelae of already established disease. Effective lifestyle changes include:
Aerobic exercise , like walking, jogging, or swimming, can reduce the risk of mortality from coronary artery disease. [ 110 ] Aerobic exercise can help decrease blood pressure and the amount of blood cholesterol (LDL) over time. It also increases HDL cholesterol. [ 111 ]
Although exercise is beneficial, it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force found "insufficient evidence" to recommend that doctors counsel patients on exercise, but "it did not review the evidence for the effectiveness of physical activity to reduce chronic disease, morbidity, and mortality", only the effectiveness of counseling itself. [ 112 ] The American Heart Association , based on a non-systematic review, recommends that doctors counsel patients on exercise. [ 113 ]
Psychological symptoms are common in people with CHD. Many psychological treatments may be offered following cardiac events. There is no evidence that they change mortality, the risk of revascularization procedures, or the rate of non-fatal myocardial infarction. [ 109 ]
Antibiotics for secondary prevention of coronary heart disease
Early studies suggested that antibiotics might help patients with coronary disease reduce the risk of heart attacks and strokes. [ 114 ] However, a 2021 Cochrane meta-analysis found that antibiotics given for secondary prevention of coronary heart disease are harmful to people with increased mortality and occurrence of stroke. [ 114 ] So, antibiotic use is not currently supported for preventing secondary coronary heart disease.
A thorough systematic review found that indeed there is a link between a CHD condition and brain dysfunction in females. [ 115 ] Consequently, since research is showing that cardiovascular diseases, like CHD, can play a role as a precursor for dementia, like Alzheimer's disease, individuals with CHD should have a neuropsychological assessment. [ 116 ]
There are a number of treatment options for coronary artery disease: [ 117 ]
It is recommended that blood pressure typically be reduced to less than 140/90 mmHg. [ 122 ] The diastolic blood pressure should not be below 60 mmHg. Beta-blockers are recommended first line for this use. [ 122 ]
In those with no previous history of heart disease, aspirin decreases the risk of a myocardial infarction but does not change the overall risk of death. [ 123 ] Aspirin therapy to prevent heart disease is thus recommended only in adults who are at increased risk for cardiovascular events, which may include postmenopausal females, males above 40, and younger people with risk factors for coronary heart disease, including high blood pressure , a family history of heart disease, or diabetes . The benefits outweigh the harms most favorably in people at high risk for a cardiovascular event, where high risk is defined as at least a 3% chance over five years, but others with lower risk may still find the potential benefits worth the associated risks. [ 124 ]
Clopidogrel plus aspirin (dual anti-platelet therapy) reduces cardiovascular events more than aspirin alone in those with a STEMI . In others at high risk but not having an acute event, the evidence is weak. [ 125 ] Specifically, its use does not change the risk of death in this group. [ 126 ] In those who have had a stent, more than 12 months of clopidogrel plus aspirin does not affect the risk of death. [ 127 ]
Revascularization for acute coronary syndrome has a mortality benefit. [ 128 ] Percutaneous revascularization for stable ischaemic heart disease does not appear to have benefits over medical therapy alone. [ 129 ] In those with disease in more than one artery, coronary artery bypass grafts appear better than percutaneous coronary interventions . [ 130 ] Newer "anaortic" or no-touch off-pump coronary artery revascularization techniques have shown reduced postoperative stroke rates comparable to percutaneous coronary intervention. [ 131 ] Hybrid coronary revascularization has also been shown to be a safe and feasible procedure that may offer some advantages over conventional CABG though it is more expensive. [ 132 ]
As of 2010, CAD was the leading cause of death globally resulting in over 7 million deaths. [ 134 ] This increased from 5.2 million deaths from CAD worldwide in 1990. [ 134 ] It may affect individuals at any age but becomes dramatically more common at progressively older ages, with approximately a tripling with each decade of life. [ 135 ] Males are affected more often than females. [ 135 ]
The World Health Organization reported that: "The world's biggest killer is ischemic heart disease, responsible for 13% of the world's total deaths. Since 2000, the largest increase in deaths has been for this disease, rising by 2.7 million to 9.1 million deaths in 2021." [ 136 ]
It is estimated that 60% of the world's cardiovascular disease burden will occur in the South Asian subcontinent despite only accounting for 20% of the world's population. This may be secondary to a combination of genetic predisposition and environmental factors. Organizations such as the Indian Heart Association are working with the World Heart Federation to raise awareness about this issue. [ 137 ]
Coronary artery disease is the leading cause of death for both males and females and accounts for approximately 600,000 deaths in the United States every year. [ 138 ] According to present trends in the United States, half of healthy 40-year-old males will develop CAD in the future, and one in three healthy 40-year-old females. [ 139 ] It is the most common reason for death of males and females over 20 years of age in the United States. [ 140 ]
After analysing data from 2 111 882 patients, the recent meta-analysis revealed that the incidence of coronary artery diseases in breast cancer survivors was 4.29 (95% CI 3.09–5.94) per 1000 person-years. [ 141 ]
Other terms sometimes used for this condition are "hardening of the arteries" and "narrowing of the arteries". [ 142 ] In Latin it is known as morbus ischaemicus cordis ( MIC ).
The Infarct Combat Project (ICP) is an international nonprofit organization founded in 1998 which tries to decrease ischemic heart diseases through education and research. [ 143 ]
In 2016 research into the internal documents of the Sugar Research Foundation, the trade association for the sugar industry in the US, had sponsored an influential literature review published in 1965 in the New England Journal of Medicine that downplayed early findings about the role of a diet heavy in sugar in the development of CAD and emphasized the role of fat; that review influenced decades of research funding and guidance on healthy eating . [ 144 ] [ 145 ] [ 146 ] [ 147 ]
Research efforts are focused on new angiogenic treatment modalities and various (adult) stem-cell therapies . A region on chromosome 17 was confined to families with multiple cases of myocardial infarction. [ 148 ] Other genome-wide studies have identified a firm risk variant on chromosome 9 (9p21.3). [ 149 ] However, these and other loci are found in intergenic segments and need further research in understanding how the phenotype is affected. [ 150 ]
A more controversial link is that between Chlamydophila pneumoniae infection and atherosclerosis. [ 151 ] While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive regarding whether it can be considered a causative factor. [ 152 ] Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases. [ 153 ]
Myeloperoxidase has been proposed as a biomarker . [ 154 ]
Plant-based nutrition has been suggested as a way to reverse coronary artery disease, [ 155 ] but strong evidence is still lacking for claims of potential benefits. [ 156 ]
Several immunosuppressive drugs targeting the chronic inflammation in coronary artery disease have been tested. [ 157 ]
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Coronary artery ectasia is a rare disease that occurs in only 0.3-4.9% of people in North America. Coronary artery ectasia is characterized by the enlargement of a coronary artery to 1.5 times or more than its normal diameter. [ 1 ] The disease is commonly asymptomatic and is normally discovered when performing tests for other conditions such as coronary artery disease , stable angina and other acute coronary syndromes. [ 2 ] [ 3 ] Coronary artery ectasia occurs 4 times more frequently in males than in females and in people who have risk factors for heart disease such as smokers. [ 1 ] [ 4 ] [ 5 ] While the disease is commonly found in patients with atherosclerosis and coronary artery disease, it can occur by itself and in both cases, it can cause health problems. The disease can cause the heart tissue to be deprived of blood and die due to decreased blood flow, and blockages due to blood clots or spasms of the blood vessel. [ 2 ] This blood flow disruption can cause permanent damage to the muscle if the deprivation is prolonged. Coronary artery ectasia also increases the chance of developing large weak spots in the affected coronary arteries, or aneurysms that can rupture and result in death. [ 1 ] The damage can result in angina which is pain in the chest and is a common complaint in these patients.
Coronary artery ectasia is commonly found in patients with diseases of the connective tissue and an increased inflammatory response such as Marfan syndrome and Kawasaki Disease . [ 6 ] It can also be found transiently in patients that have undergone stent placement resulting in the stretching of the vessels 1. Coronary artery ectasia is characterized by an increased wall stress of the vessel, thinning of the arterial wall which causes progressive dilation and remodelling of the vessel. [ 2 ] The permanent dilation of the artery is thought to be mainly caused by inflammation, triggered by disease, chemicals, or physical stress of the vessel. [ 3 ] A meta-analysis study has shown that The pooled unadjusted OR of CAE in subjects with HTN in comparison by subjects without HTN was estimated 1.44 (95 % CI, 1.24 to 1.68) Bahremand, M., Zereshki, E., Matin, B.K. et al. Hypertension and coronary artery ectasia: a systematic review and meta-analysis study. Clin Hypertens 27, 14 (2021). https://doi.org/10.1186/s40885-021-00170-6 .The inflammatory response results in an over expression of matrix metalloproteinases , cysteine proteinases, and serine proteinases that causes the partial breakdown of the vessel and weakens it. [ 3 ] [ 7 ] The inflammation response will also trigger platelet activation which increases the risk of blood clots. The risk of blood clots will increase due to the turbulent blood flow of the enlarged vessel which can activate platelets and form clots. [ 8 ] Inflammation elevated oxidative stress is increased, and antioxidant activity is depressed in coronary artery ectasia. This imbalance can cause damage to the cells and cause them to die, weakening the vessels further. [ 9 ] The activation of the inflammatory response causes a detectable increase in C reactive protein , interleukin-6 , tumor necrosis factor alpha and cell adhesion molecules , which can be used as a diagnostic marker,. [ 5 ] [ 10 ]
To discover the extent and severity of coronary artery ectasia there are a variety of diagnostic tools used. The most common method for discovering the disease is through angiography . Angiography is the procedure where a contrast dye is entered into the vessels and an x-ray is taken, which will allow the vessels to be seen on the x-ray. [ 10 ] Using angiography clinicians are able to display the size, location and number of vessels affected by the disease. [ 10 ] Is can also be analyzed through other methods such as intravascular ultrasound , and magnetic resonance imaging . [ 10 ] Using these diagnostic methods, it has been discovered that the disease normally occurs most often in the right coronary artery , followed by the left anterior descending artery , and finally the left anterior circumflex artery . [ 11 ] Using these methods Coronary artery ectasia can be divided into four different types: Type 1¬→diffuse ectasia in 2-3 different vessels, Type 2¬→ diffuse disease in 1 vessel and local disease in another, Type 3¬→ diffuse disease in one vessel and Type 4¬→ localized or segmental ectasia. [ 11 ]
There are currently no cardiovascular society guidelines or recommendations for the treatment of coronary artery ectasia. Experts in the field urge clinicians to consider anti-platelet therapy, such as Aspirin, to reduce thrombus formation in pocket vortices associated with turbulent blood flow. Dual anti-platelet therapy and full anticoagulation are currently under investigation. The primary etiology of coronary ectasia in adults is atherosclerosis, thus treatment with statin therapy should be considered. Statin therapy may also reduce inflammation and matrix metalloproteinase activation which may reduce the progression of vessel ectasia. Some studies have also suggested the use of angiotensin converting enzyme inhibitors , as ACE gene polymorphisms have been implicated in disease progression. Risk factor modification is recommended; including tobacco cessation, blood pressure control and avoidance of illicit substance use, specifically cocaine. [ citation needed ]
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A coronary care unit ( CCU ) or cardiac intensive care unit ( CICU ) is a hospital ward specialized in the care of patients with heart attacks , unstable angina , cardiac dysrhythmia and (in practice) various other cardiac conditions that require continuous monitoring and treatment.
The main feature of coronary care is the availability of telemetry or the continuous monitoring of the cardiac rhythm by electrocardiography . This allows early intervention with medication , cardioversion or defibrillation , improving the prognosis. As arrhythmias are relatively common in this group, patients with myocardial infarction or unstable angina are routinely admitted to the coronary care unit. For other indications, such as atrial fibrillation , a specific indication is generally necessary, while for others, such as heart block , coronary care unit admission is standard. [ citation needed ]
In the United States, cardiac conditions accounted for eight of the eighteen conditions and procedures with high ICU utilization (ICU utilization in more than 40% of stays) in 2011. [ 1 ]
In the United States, coronary care units are usually subsets of intensive care units (ICU) dedicated to the care of critically ill cardiac patients. These units are usually present in hospitals that routinely engage in cardiothoracic surgery. Invasive monitoring such as with pulmonary artery catheters is common, as are supportive modalities such as mechanical ventilation and intra-aortic balloon pumps (IABP).
Certain hospitals, such as Johns Hopkins [1] , maintain mixed units consisting of both acute care units for the critically ill, and intermediate care units for patients who are not critical.
Acute coronary care units (ACCUs), also called "critical coronary care units" (CCCUs), are equivalent to intensive care in the level of service provided. Patients with acute myocardial infarction, cardiogenic shock , or post-operative "open-heart" patients commonly abide here.
Subacute coronary care units (SCCUs), also called progressive care units (PCUs), intermediate coronary care units (ICCUs), or stepdown units, provide a level of care intermediate to that of the intensive care unit and that of the general medical floor. These units typically serve patients who require cardiac telemetry, such as those with unstable angina .
Coronary care units developed in the 1960s when it became clear that close monitoring by specially trained staff, cardiopulmonary resuscitation and medical measures could reduce the mortality from complications of cardiovascular disease. The first description of a CCU was given in 1961 to the British Thoracic Society by Desmond Julian , who founded the first CCU at the Royal Infirmary of Edinburgh in 1964. [ 2 ] Early CCUs were also located in Sydney , Kansas City , Toronto and Philadelphia . The first coronary care unit in the US was opened at Bethany Medical Center in Kansas City, Kansas by Hughes Day, and he coined the term. [ 3 ] [ 4 ] Bethany Medical Center is also where the first "crash carts" were developed. [ 5 ] Studies published in 1967 revealed that those observed in a coronary care setting had consistently better outcomes. [ 6 ]
DF Beck performed the first successful resuscitation of a physician with myocardial infarction in 1953, and pioneered the use of open-chest defibrillation. Zoll introduced external defibrillation in Boston in 1956, and Kouwenhoven and colleagues at Johns Hopkins highlighted the effectiveness of a combo of mouth-to-mouth, sternal compression, and closed chest defibrillation in restoring cardiac function in ventricular fibrillation patients. The first diagnostic angiogram was discovered by Mason Sones in 1958, due to an accidental injection of dye directly into the coronary artery rather than into the entire circulation - something that was previously believed to be fatal. [ citation needed ]
These developments led to an interest in intensive care for myocardial infarction. In 1967, Thomas Killip and John Kimball published a report of 250 patients with acute MI's, who had experienced significantly better survival rates in CCUs compared to other institutions. This, along with other reports, led to an increase in coronary care units. Now catheterization units are commonplace in large cities. [ citation needed ]
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A coronary catheterization is a minimally invasive procedure to access the coronary circulation and blood filled chambers of the heart using a catheter . It is performed for both diagnostic and interventional (treatment) purposes.
Coronary catheterization is one of the several cardiology diagnostic tests and procedures . Specifically, through the injection of a liquid radiocontrast agent and illumination with X-rays , [ 1 ] angiocardiography allows the recognition of occlusion , stenosis , restenosis , thrombosis or aneurysmal enlargement of the coronary artery lumens ; heart chamber size; heart muscle contraction performance; and some aspects of heart valve function. Important internal heart and lung blood pressures , not measurable from outside the body, can be accurately measured during the test. The relevant problems that the test deals with most commonly occur as a result of advanced atherosclerosis – atheroma activity within the wall of the coronary arteries . Less frequently, valvular , heart muscle , or arrhythmia issues are the primary focus of the test.
Coronary artery luminal narrowing reduces the flow reserve for oxygenated blood to the heart, typically producing intermittent angina . Very advanced luminal occlusion usually produces a heart attack . However, it has been increasingly recognized, since the late 1980s, that coronary catheterization does not allow the recognition of the presence or absence of coronary atherosclerosis itself, only significant luminal changes which have occurred as a result of end stage complications of the atherosclerotic process. See IVUS and atheroma for a better understanding of this issue.
The technique of angiography itself was first developed in 1927 by the Portuguese physician Egas Moniz at the University of Lisbon for cerebral angiography , the viewing of brain vasculature by X-ray radiation with the aid of a contrast medium introduced by catheter. [ citation needed ]
Heart catheterization was first performed in 1929 when the German physician Werner Forssmann inserted a plastic tube in his cubital vein and guided it to the right chamber of the heart. He took an x-ray to prove his success and published it on November 5, 1929, with the title "Über die Sondierung des rechten Herzens" (About probing of the right heart). [ citation needed ]
In the early 1940s, André Cournand , in collaboration with Dickinson Richards , performed more systematic measurements of the hemodynamics of the heart. For their work in the discovery of cardiac catheterization and hemodynamic measurements, Cournand, Forssmann, and Richards shared the Nobel Prize in Physiology or Medicine in 1956. The first radial access for angiography can be traced back to 1953, where Eduardo Pereira [ clarification needed ] , in Lisbon, Portugal, first cannulated the radial artery to perform a coronary angiogram.
In 1960 F. Mason Sones , a pediatric cardiologist at the Cleveland Clinic , accidentally injected radiocontrast in a coronary artery instead of the left ventricle. Although the patient had a reversible cardiac arrest, Sones and Shirey developed the procedure further, and are credited with the discovery (Connolly 2002); they published a series of 1,000 patents in 1966 (Proudfit et al. ).
Since the late 1970s, building on the pioneering work of Charles Dotter in 1964 and especially Andreas Gruentzig starting in 1977, coronary catheterization has been extended to therapeutic uses: (a) the performance of less invasive physical treatment for angina and some of the complications of severe atherosclerosis , (b) treating heart attacks before complete damage has occurred and (c) research for better understanding of the pathology of coronary artery disease and atherosclerosis . [ citation needed ]
In the early 1960s, cardiac catheterization frequently took several hours and involved significant complications for as many as 2–3% of patients. With multiple incremental improvements over time, simple coronary catheterization examinations are now commonly done more rapidly and with significantly improved outcomes. [ citation needed ]
Indications for cardiac catheterization include the following:
The patient being examined or treated is usually awake during catheterization, ideally with only local anaesthesia such as lidocaine and minimal general sedation , throughout the procedure . Performing the procedure with the patient awake is safer as the patient can immediately report any discomfort or problems and thereby facilitate rapid correction of any undesirable events. Medical monitors fail to give a comprehensive view of the patient's immediate well-being; how the patient feels is often a most reliable indicator of procedural safety. [ citation needed ]
Death, myocardial infarction , stroke , serious ventricular arrhythmia , and major vascular complications each occur in less than 1% of patients undergoing catheterization. [ 4 ] However, though the imaging portion of the examination is often brief, because of setup and safety issues, the patient is often in the lab for 20–45 minutes. Any of multiple technical difficulties, while not endangering the patient (indeed added to protect the patient's interests), can significantly increase the examination time. [ citation needed ]
Coronary catheterization is performed in a catheterization lab, usually located within a hospital. With current designs, the patient must lie relatively flat on a narrow, minimally padded, radiolucent (transparent to X-ray ) table. The X-ray source and imaging camera equipment are on opposite sides of the patient's chest and freely move, under motorized control, around the patient's chest so images can be taken quickly from multiple angles. More advanced equipment, termed a bi-plane cath lab, uses two sets of X-ray source and imaging cameras, each free to move independently, which allows two sets of images to be taken with each injection of radio contrast agent . The equipment and installation setup to perform such testing typically represents a capital expenditure of US$2–5 million (2004), sometimes more, partially repeated every few years. [ citation needed ]
During coronary catheterization (often referred to as a "cath" or "cardiac cath" by physicians), blood pressures are recorded and fluoroscopy ( X-ray motion picture ) shadow-grams of the blood inside the coronary arteries are recorded. In order to create the X-ray pictures, a physician guides a small tube-like device called a catheter, typically ~2.0 mm (6-French) in diameter, through the large arteries of the body until the tip is just within the opening of one of the coronary arteries . By design, the catheter is smaller than the lumen of the artery it is placed in; internal (intra-arterial) blood pressures are monitored through the catheter to verify that the catheter does not block blood flow (as indicated by "dampening" of the blood pressure). [ citation needed ]
The catheter is itself designed to be radiodense for visibility and it allows a clear, watery, blood compatible radiocontrast agent, commonly called an X-ray dye, to be selectively injected and mixed with the blood flowing within the artery. Typically 3–8 cc of the radiocontrast agent is injected for each image to make the blood flow visible for about 3–5 seconds as the radiocontrast agent is rapidly washed away into the coronary capillaries and then coronary veins . Without the X-ray dye injection, the blood and surrounding heart tissues appear, on X-ray, as only a mildly-shape-changing, otherwise uniform water density mass; no details of the blood and internal organ structure are discernible. The radiocontrast within the blood allows visualization of the blood flow within the arteries or heart chambers, depending on where it is injected. [ citation needed ]
If atheroma , or clots , are protruding into the lumen, producing narrowing , the narrowing may be seen instead as increased haziness within the X-ray shadow images of the blood/dye column within that portion of the artery; this is as compared to adjacent, presumed healthier, less stenotic areas.
For guidance regarding catheter positions during the examination, the physician mostly relies on detailed knowledge of internal anatomy, guide wire and catheter behavior and intermittently, briefly uses fluoroscopy and a low X-ray dose to visualize when needed. This is done without saving recordings of these brief looks. When the physician is ready to record diagnostic views, which are saved and can be more carefully scrutinized later, he activates the equipment to apply a significantly higher X-ray dose, termed cine , in order to create better quality motion picture images, having sharper radiodensity contrast, typically at 30 frames per second. The physician controls both the contrast injection, fluoroscopy and cine application timing so as to minimize the total amount of radiocontrast injected and times the X-ray to the injection so as to minimize the total amount of X-ray used. Doses of radiocontrast agents and X-ray exposure times are routinely recorded in an effort to maximize safety.
Though not the focus of the test, calcification within the artery walls, located in the outer edges of atheroma within the artery walls, is sometimes recognizable on fluoroscopy (without contrast injection) as radiodense halo rings partially encircling, and separated from the blood filled lumen by the interceding radiolucent atheroma tissue and endothelial lining. Calcification, even though usually present, is usually only visible when quite advanced and calcified sections of the artery wall happen to be viewed on end tangentially through multiple rings of calcification, so as to create enough radiodensity to be visible on fluoroscopy.
Angiocardiography can be used to detect and diagnose congenital defects in the heart and adjacent vessels. [ 5 ] In this context, the use of angiocardiography has declined with the introduction of echocardiography . However, angiocardiography is still in use for selected cases as it provides a higher level of anatomical detail than echocardiography. [ 6 ] [ 7 ]
By changing the diagnostic catheter to a guiding catheter, physicians can also pass a variety of instruments through the catheter and into the artery to a lesion site. The most commonly used are 0.014-inch-diameter (0.36 mm) guide wires and the balloon dilation catheters. [ citation needed ]
By injecting radiocontrast agent through a tiny passage extending down the balloon catheter and into the balloon, the balloon is progressively expanded. The hydraulic pressures are chosen and applied by the physician, according to how the balloon within the stenosis (abnormal narrowing in a blood vessel) responds. The radiocontrast filled balloon is watched under fluoroscopy (it typically assumes a "dog bone" shape imposed on the outside of the balloon by the stenosis as the balloon is expanded), as it opens. As much hydraulic brute force is applied as judged needed and visualized to be effective to make the stenosis of the artery lumen visibly enlarge. [ citation needed ]
Typical normal coronary artery pressures are in the <200 mmHg range (27 kPa). The hydraulic pressures applied within the balloon may extend to as high as 19000 mmHg (2,500 kPa). Prevention of over-enlargement is achieved by choosing balloons manufactured out of high tensile strength clear plastic membranes. The balloon is initially folded around the catheter, near the tip, to create a small cross-sectional profile to facilitate passage through luminal stenotic areas, and is designed to inflate to a specific pre-designed diameter. If over-inflated, the balloon material simply tears and allows the inflating radiocontrast agent to simply escape into the blood. [ citation needed ]
Additionally, several other devices can be advanced into the artery via a guiding catheter. These include laser catheters, stent catheters, IVUS catheters, Doppler catheter, pressure or temperature measurement catheter and various clot and grinding or removal devices. Most of these devices have turned out to be niche devices, only useful in a small percentage of situations or for research.
Stents, which are specially manufactured expandable stainless steel mesh tubes, mounted on a balloon catheter, are the most commonly used device beyond the balloon catheter. When the stent/balloon device is positioned within the stenosis, the balloon is inflated which, in turn, expands the stent and the artery. The balloon is removed and the stent remains in place, supporting the inner artery walls in the more open, dilated position. Current stents generally cost around $1,000 to 3,000 each (US 2004 dollars), the drug-coated ones being the more expensive.
Interventional procedures have been plagued by restenosis due to the formation of endothelial tissue overgrowth at the lesion site. Restenosis is the body's response to the injury of the vessel wall from angioplasty and to the stent as a foreign body . As assessed in clinical trials during the late 1980 and 1990s, using only balloon angioplasty (POBA, plain old balloon angioplasty), up to 50% of patients developed significant restenosis; but that percentage has dropped to the single to lower two-digit range with the introduction of drug-eluting stents . Sirolimus , paclitaxel , and everolimus are the three drugs used in coatings which are currently FDA approved in the United States. [ citation needed ] As opposed to bare metal, drug-eluting stents are covered with a medicine that is slowly dispersed with the goal of suppressing the restenosis reaction. The key to the success of drug coating has been (a) choosing effective agents, (b) developing ways of adequately binding the drugs to the stainless surface of the stent struts (the coating must stay bound despite marked handling and stent deformation stresses), and (c) developing coating controlled release mechanisms that release the drug slowly over about 30 days. One of the newest innovations in coronary stents is the development of a dissolving stent. Abbott Laboratories has used a dissolvable material, polylactic acid , that will completely absorb within 2 years of being implanted. [ citation needed ]
CT angiography can act as a less invasive alternative to Catheter angiography. Instead of a catheter being inserted into a vein or artery, CT angiography involves only the injection of a CT-visible dye into the arm or hand via an IV line. CT angiography lowers the risk of arterial perforation and catheter site infection. It provides 3D images that can be studied on computer, and also allows measurement of heart ventricle size. Infarct area and arterial calcium can also be observed (however those require a somewhat higher radiation exposure). That said, one advantage retained by Catheter angiography is the ability of the physician to perform procedure such as balloon angioplasty or insertion of a stent to improve blood flow to the artery. [ 8 ]
Imaging in coronary angiograms is performed via fluoroscopy using X-rays, which pose a potential for increasing the patient's risk of radiation-induced cancer . The risk increases with the exposure time, consisting of 1) time guiding the probe into and out of the heart and 2) time illuminating the contrast agent to perform the angiogram. Absorbed radiation is also a function of body mass index , with obese patients having twice the dose of normal-weight patients; exposure to the operator was also doubled. [ 9 ] Coronary angiograms can be done either transradial (through the wrist) or transfemoral (through the groin). [ 10 ] The transradial route results in somewhat greater patient and operator exposure. Overall, patient exposure can range from 2 millisieverts (equivalent of about 20 chest x-ray plates) to 20 millisieverts. [ 11 ] For a given patient, exposure can vary within an institution and between institutions by up to 121%. [ 12 ]
Radiation exposure to the operator can be reduced by the use of protective equipment. Exposure to the patient can be reduced by minimizing fluoroscopy time.
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Coronary circulation is the circulation of blood in the arteries and veins that supply the heart muscle (myocardium). Coronary arteries supply oxygenated blood to the heart muscle. Cardiac veins then drain away the blood after it has been deoxygenated.
Because the rest of the body, and most especially the brain , needs a steady supply of oxygenated blood that is free of all but the slightest interruptions, the heart is required to function continuously. Therefore its circulation is of major importance not only to its own tissues but to the entire body and even the level of consciousness of the brain from moment to moment.
Interruptions of coronary circulation quickly cause heart attacks ( myocardial infarctions ), in which the heart muscle is damaged by oxygen starvation . Such interruptions are usually caused by coronary ischemia linked to coronary artery disease , and sometimes to embolism from other causes like obstruction in blood flow through vessels.
Coronary arteries supply blood to the myocardium and other components of the heart. Two coronary arteries originate from the left side of the heart at the beginning (root) left ventricle . There are three aortic sinuses (dilations) in the wall of the aorta just superior to the aortic semilunar valve. Two of these, the left posterior aortic sinus and anterior aortic sinus , give rise to the left and right coronary arteries , respectively. The third sinus, the right posterior aortic sinus , typically does not give rise to a vessel. Coronary vessel branches that remain on the surface of the heart and follow the sulci of the heart are called epicardial coronary arteries. [ 1 ]
The left coronary artery distributes blood to the left side of the heart, the left atrium and ventricle, and the interventricular septum. The circumflex artery arises from the left coronary artery and follows the coronary sulcus to the left. Eventually, it will fuse with the small branches of the right coronary artery. The larger left anterior descending artery (LAD), is the second major branch arising from the left coronary artery. It follows the anterior interventricular sulcus around the pulmonary trunk. Along the way it gives rise to numerous smaller branches that interconnect with the branches of the posterior interventricular artery , forming anastomoses . An anastomosis is an area where vessels unite to form interconnections that normally allow blood to circulate to a region even if there may be partial blockage in another branch. The anastomoses in the heart are very small. Therefore, this ability is somewhat restricted in the heart so a coronary artery blockage often results in myocardial infarction causing death of the cells supplied by the particular vessel. [ 1 ]
The right coronary artery proceeds along the coronary sulcus and distributes blood to the right atrium, portions of both ventricles, and the heart conduction system . Normally, one or more marginal arteries arise from the right coronary artery inferior to the right atrium. The marginal arteries supply blood to the superficial portions of the right ventricle. On the posterior surface of the heart, the right coronary artery gives rise to the posterior interventricular artery, also known as the posterior descending artery. It runs along the posterior portion of the interventricular sulcus toward the apex of the heart, giving rise to branches that supply the interventricular septum and portions of both ventricles. [ 1 ]
The vessels that remove the deoxygenated blood from the heart muscle are the cardiac veins . These include the great cardiac vein , the middle cardiac vein , the small cardiac vein , the smallest cardiac veins , and the anterior cardiac veins . Cardiac veins carry blood with a poor level of oxygen , from the myocardium to the right atrium . Most of the blood of the coronary veins returns through the coronary sinus . The anatomy of the veins of the heart is very variable, but generally it is formed by the following veins: heart veins that go into the coronary sinus: the great cardiac vein , the middle cardiac vein , the small cardiac vein , the posterior vein of the left ventricle , and the oblique vein of Marshall . Heart veins that go directly to the right atrium: the anterior cardiac veins, the smallest cardiac veins (Thebesian veins). [ 2 ]
There are some anastomoses between branches of the two coronary arteries. However the coronary arteries are functionally end arteries and so these meetings are referred to as potential anastomoses , which lack function, as opposed to true anastomoses like that in the palm of the hand. This is because blockage of one coronary artery generally results in death of the heart tissue due to lack of sufficient blood supply from the other branch. When two arteries or their branches join, the area of the myocardium receives dual blood supply. These junctions are called anastomoses. If one coronary artery is obstructed by an atheroma , the second artery is still able to supply oxygenated blood to the myocardium. However, this can only occur if the atheroma progresses slowly, giving the anastomoses a chance to proliferate. [ citation needed ]
Under the most common configuration of coronary arteries, there are three areas of anastomoses. Small branches of the LAD (left anterior descending/anterior interventricular) branch of the left coronary join with branches of the posterior interventricular branch of the right coronary in the interventricular sulcus (groove). More superiorly, there is an anastomosis between the circumflex artery (a branch of the left coronary artery) and the right coronary artery in the atrioventricular groove. There is also an anastomosis between the septal branches of the two coronary arteries in the interventricular septum. The photograph shows area of heart supplied by the right and the left coronary arteries. [ citation needed ]
The left and right coronary arteries occasionally arise by a common trunk, or their number may be increased to three; the additional branch being the posterior coronary artery (which is smaller in size). In rare cases, a person will have the third coronary artery run around the root of the aorta. [ citation needed ]
Occasionally, a coronary artery will exist as a double structure (i.e. there are two arteries, parallel to each other, where ordinarily there would be one). [ citation needed ]
The artery that supplies the posterior third of the interventricular septum – the posterior descending artery (PDA) [ 3 ] determines the coronary dominance. [ 4 ]
Approximately 70% of the general population are right-dominant, 20% are co-dominant, and 10% are left-dominant. [ 4 ] A precise anatomic definition of dominance would be the artery which gives off supply to the AV node i.e. the AV nodal artery. Most of the time this is the right coronary artery. [ citation needed ]
The papillary muscles attach the mitral valve (the valve between the left atrium and the left ventricle ) and the tricuspid valve (the valve between the right atrium and the right ventricle ) to the wall of the heart. If the papillary muscles are not functioning properly, the mitral valve may leak during contraction of the left ventricle. This causes some of the blood to travel "in reverse", from the left ventricle to the left atrium, instead of forward to the aorta and the rest of the body. This leaking of blood to the left atrium is known as mitral regurgitation . Similarly, the leaking of blood from the right ventricle through the tricuspid valve and into the right atrium can also occur, and this is described as tricuspid insufficiency or tricuspid regurgitation. [ citation needed ]
The anterolateral papillary muscle more frequently receives two blood supplies: left anterior descending (LAD) artery and the left circumflex artery (LCX). [ 5 ] It is therefore more frequently resistant to coronary ischemia (insufficiency of oxygen-rich blood). On the other hand, the posteromedial papillary muscle is usually supplied only by the PDA. [ 5 ] This makes the posteromedial papillary muscle significantly more susceptible to ischemia . The clinical significance of this is that a myocardial infarction involving the PDA is more likely to cause mitral regurgitation. [ citation needed ]
During contraction of the ventricular myocardium ( systole ), the subendocardial coronary vessels (the vessels that enter the myocardium) are compressed due to the high ventricular pressures.
This compression results in momentary retrograde blood flow (i.e., blood flows backward toward the aorta) which further inhibits perfusion of myocardium during systole.
However, the epicardial coronary vessels (the vessels that run along the outer surface of the heart) remain open.
Because of this, blood flow in the subendocardium stops during ventricular contraction.
As a result, most myocardial perfusion occurs during heart relaxation ( diastole ) when the subendocardial coronary vessels are open and under lower pressure.
Flow never comes to zero in the right coronary artery, since the right ventricular pressure is less than the diastolic blood pressure. [ 6 ]
The heart regulates the amount of vasodilation or vasoconstriction of the coronary arteries based upon the oxygen requirements of the heart. This contributes to the filling difficulties of the coronary arteries.
Compression remains the same. Failure of oxygen delivery caused by a decrease in blood flow in front of increased oxygen demand of the heart results in tissue ischemia , a condition of oxygen deficiency. Brief ischemia is associated with intense chest pain, known as angina . Severe ischemia can cause the heart muscle to die from hypoxia, such as during a myocardial infarction . Chronic moderate ischemia causes contraction of the heart to weaken, known as myocardial hibernation. [ citation needed ]
In addition to metabolism, the coronary circulation possesses unique pharmacologic characteristics. Prominent among these is its reactivity to adrenergic stimulation. [ citation needed ]
The following are the named branches of the coronary circulation in a right-dominant heart: [ citation needed ]
The vessels that deliver oxygen -rich blood to the myocardium are the coronary arteries . When the arteries are healthy, they are capable of autoregulating themselves to maintain the coronary blood flow at levels appropriate to the needs of the heart muscle .
The relatively narrow coronary arteries are commonly affected by atherosclerosis and can become blocked, causing angina or a heart attack . The coronary arteries are classified as "terminal circulation", since they represent the only source of blood supply to the myocardium; there is very little redundant blood supply, that is why blockage of these vessels can be so critical. [ citation needed ]
This article incorporates text from the CC BY book: OpenStax College, Anatomy & Physiology. OpenStax CNX. 30 July 2014.
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Coronary flow reserve ( CFR ) is the maximum increase in blood flow through the coronary arteries above the normal resting volume. [ 1 ] Its measurement is often used in medicine to assist in the treatment of conditions affecting the coronary arteries and to determine the efficacy of treatments used.
When demand for oxygen in the myocardium is increased, the vascular resistance of the coronary arteries has the ability to reduce, and this can increase the volume of blood passing through the blood vessels. This reduction occurs because the arteries dilate , which causes an increase in the diameter of the lumen . [ 2 ] [ 3 ] The greatest potential for this change is normally in the branches ( arterioles ) of the coronary artery that penetrate the myocardium, rather than those on the surface of the heart. [ 1 ]
Coronary flow reserve can be measured through a variety of methods, including digital subtraction cineangiography with coronary catheterization , [ 4 ] doppler echocardiography , [ 5 ] and positron emission tomography (PET). [ 6 ]
Coronary flow reserve is used in diagnostics and treatment of patients with conditions such as coronary artery disease and syndrome X . [ 7 ] In the treatment of these conditions, vasodilators are used to allow sufficient blood to flow past a stenosis , for example, and the measurement of CFR enables the efficacy of such interventions to be measured. [ 3 ] In patients with Anderson-Fabry disease , there is evidence to suggest that CFR can be reduced. [ 5 ] When coronary flow reserve is used in medicine, it is often expressed with a numerical value, which is formed by dividing the maximal coronary blood flow by resting blood flow. This allows for an objective view, which can aid diagnosis and treatment. [ 8 ]
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A coronary occlusion , or coronary artery disease , is the partial or complete obstruction of blood flow in a coronary artery . This condition was first discussed in 1910 by Sir William Osler . [ 1 ] This condition slows or blocks the supply of oxygen-rich blood to the heart . [ 2 ] This condition can lead to myocardial ischemia [ 2 ] and if untreated, may cause a heart attack and heart failure. [ 3 ] It is the most common form of cardiovascular disease , and is the leading cause of death in the United States, affecting 18 million adults. [ 4 ]
A coronary occlusion can be caused by smoking, having other heart or blood conditions, or being physically inactive. It is also hereditary . [ 4 ] Symptoms include chest pain, shortness of breath, pain in upper body, fatigue, nausea, an irregular heartbeat, and drowsiness. [ 5 ]
To diagnose a coronary occlusion, a doctor may view a patient's medical history, or perform a coronary angiography; a doctor will stick a catheter into the wrist or groin, lead it to the heart, and inject a liquid for X-ray imaging. [ 4 ]
To treat a coronary occlusion, medication may be used to relieve symptoms. Percutaneous coronary intervention or coronary artery bypass surgery may also be used. [ 4 ]
Symptoms include chest pain or angina , shortness of breath , and fatigue . [ 6 ]
A completely blocked coronary artery will cause a heart attack. [ 6 ] Common heart attack symptoms include chest pain or angina , pain or discomfort that spreads to the shoulder, arm, back, neck jaw, teeth or the upper belly, cold sweats, fatigue, heartburn , nausea , shortness of breath , or lightheadedness . [ 6 ]
Coronary occlusion is caused by the buildup of fats , cholesterol and other substances in and on the walls of the hearts arteries . [ 6 ] As plaque builds up, the arteries narrow. [ 7 ] Plaque often starts building up during childhood and is heavily influenced by genetics, but also lifestyle and high blood cholesterol. [ 7 ] This condition is referred to as atherosclerosis . [ 6 ] The buildup on the walls of the hearts arteries is referred to as plaque. Plaque causes arteries to narrow and block blood flow. [ 6 ]
Conditions that aid in the development of coronary artery disease are diabetes or insulin resistance , high blood pressure , sedentary lifestyle , and smoking or tobacco use. [ 6 ]
Risk Factors that are not controllable are age, birth sex , and family history . [ 6 ] Getting older increases the risk of damaged and narrowed arteries. [ 6 ] Men are at a greater risk of coronary artery disease, with women's risk increasing after menopause. [ 6 ]
Coronary occlusion is caused by plaque inside of the blood vessels that direct oxygen rich blood to the heart. [ 8 ] Plaque is caused by fatty deposits and scar tissue that cling to the walls of coronary arteries. [ 9 ] The development of plaque takes years and leads to stenosis of the coronary arteries and progressively reduces blood flow. [ 8 ] Due to the slower development of this condition, the body will adapt and create small blood vessels that circumvent the blockage. [ 8 ] The small blood vessels form a natural bypass of the blockage, but often do not supply enough blood to meet an increased demand when stressors are applied like exercise . [ 8 ]
When a plaque has a greater than 50% diameter stenosis, the reduced blood flow through the coronary artery during exertion may lead to angina . [ 10 ] Acute coronary events occur when a thrombus forms due to disruption of a plaque. [ 10 ] In acute heart attack, occlusion is greater than in unstable angina , where arterial occlusion is not full blockage. Downstream embolism of thrombus may also produce microinfarcts . [ 10 ]
Heart disease is often undiagnosed until a serious problem occurs, such as heart attack or cardiac arrest . [ 11 ] Regular checkups can lead to an early diagnosis and preventative treatment . [ 11 ] Screening tests and risk assessments should begin around age 20 if one does not have any risk factors. [ 11 ] Screenings should begin in childhood if one has risk factors such as obesity , sedentary lifestyle, or a family history of heart conditions . [ 11 ]
Healthcare providers will run blood tests to check for cholesterol , triglycerides , lipoproteins , sugar , or proteins that are a sign of inflammation . [ 11 ]
To assist in a diagnosis, healthcare providers may also order a electrocardiogram (ECG or EKG), coronary calcium scan , stress test , cardiac magnetic resonance imaging (MRI), cardiac positron emission tomography (PET), invasive coronary angiography , and/or coronary CT angiography . [ 11 ]
Healthcare providers may recommend lifelong heart-healthy lifestyle choices. [ 12 ] These choices included a heart-healthy eating plan , physical activity, quitting smoking, improved sleep hygiene , weight loss , blood pressure control , cholesterol control, blood pressure control, and stress management . [ 12 ]
Some medications may be prescribed to allow the blood vessels to widen and help the heart pump include ACE inhibitors , beta blockers , calcium channel blockers , nitrates , and Ranolazine . [ 12 ]
Some medications may be prescribed to manage cholesterol include statins , nonstatins, and fribrates . [ 12 ]
Some medications may be prescribed for other risk factors for heart disease like blood sugar and obesity such as empagliflozin , canagliflozin , metformin , liraglutide , orlistat , and semaglutide . [ 12 ]
Heart surgery may be needed to treat this condition. Some procedures include percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and transmyocardial laser revascularization ( coronary endarterectomy ). [ 12 ]
Preventative procedures like bariatric surgery can help lower coronary heart disease risk. [ 12 ]
Coronary artery disease cannot be reversed. [ 3 ] To reduce future problems, a patient may be referred to get exercise-based cardiac rehabilitation . [ 13 ]
Patients with coronary artery disease over 15-year period based on expectations in a 1-year follow up saw a mortality rate of those in the highest quartiles of expectations are 28-30 deaths per 100 patients. [ 14 ] The lowest quartile of expectations are 50-57 deaths per 100 patients. [ 14 ]
Prognosis for heart attacks when people reach emergency care promptly improve dramatically, though many people still die before reaching the hospital. [ 15 ] One out of every 10 patients who have a heart attack die within the first three to four months. [ 9 ]
Coronary artery disease is the leading cause of death in men and women. [ 16 ] This condition is the cause of one third of all deaths, which is especially worse in areas with lower socioeconomic status. [ 16 ] Mortality is nearly five times higher in men than women, but mortality difference narrows with age. [ 16 ]
Black women are more likely than white women to have a heart attack. Black adults have a higher mortality rate than white adults from heart attack. [ 17 ]
Asian adults have the least incidence of coronary artery disease . Asian Indian men, Filipino men and Filipino women have a higher risk than white people. [ 17 ]
Young Hispanic women who have a heart attack have a higher mortality rate than young Hispanic men. They have a higher mortality rate than young Black adults and young white adults. [ 17 ]
Further research directions in preventing and treating coronary artery disease include: [ 18 ]
Coronary occlusion was first discussed in 1910 by Sir William Osler who discussed coronary occlusion during the Lumleian Lectures . [ 1 ]
In 1912, James Herrick published an article in JAMA documenting his findings on coronary occlusion in animals. [ 19 ]
According to Robert K. Massie 's Nicholas and Alexandra: The Fall of the Romanov Dynasty , Tsar Nicholas II may have suffered a coronary occlusion right before he was toppled from his throne during the Russian Revolution in 1917. [ 20 ]
Coroners cited a coronary occlusion as the cause of death for Mongomery Clift .
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Coronary reflex is the change of coronary diameter in response to chemical, neurological or mechanical stimulation of the coronary arteries .
The coronary reflexes are stimulated differently from the rest of the vascular system . [ citation needed ]
Cocaine abuse frequently can cause a coronary spasm, resulting in a spontaneous myocardial infarction . [ citation needed ]
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Coronary steal (with its symptoms termed coronary steal syndrome or cardiac steal syndrome ) is a phenomenon where an alteration of circulation patterns leads to a reduction in the blood flow directed to the coronary circulation . [ 1 ] It is caused when there is narrowing of the coronary arteries and a coronary vasodilator [ 2 ] is used – "stealing" blood away from those parts of the heart.
This happens as a result of the narrowed coronary arteries being always maximally dilated to compensate for the decreased upstream blood supply. Thus, dilating the resistance vessels in the coronary circulation causes blood to be shunted away from the coronary vessels supplying the ischemic zones , creating more ischemia .
Mild coronary steal may occur without any symptoms, but as the syndrome progresses, chest pain is usually the first obvious symptom. In worse cases, symptoms can include dizziness, flushing, headaches, nausea, and shortness of breath. [ 3 ]
It is associated with dipyridamole . Dipyridamole is thus a pharmacological success diagnostically, but a therapeutic failure because of the coronary steal phenomenon. [ 4 ]
Coronary steal is also the mechanism in most drug-based cardiac stress tests ; When a patient is incapable of doing physical activity they are given a vasodilator that produces a "cardiac steal syndrome" as a diagnostic procedure. The test result is positive if the patient's symptoms reappear or if ECG alterations are seen. [ citation needed ]
Hydralazine can potentially cause this condition as well, as it is a direct arteriolar vasodilator. [ citation needed ]
It has been associated with nitroprusside . [ 5 ]
Coronary arteriovenous fistula between coronary artery and another cardiac chamber, like, the coronary sinus, right atrium, or right ventricle may cause steal syndrome under conditions like myocardial infarction and possible angina or ventricular arrhythmias, if the shunt is large in magnitude. [ 6 ]
It can also be associated with new patterns of blood vessel growth. [ 7 ]
Coronary steal syndrome can be diagnosed by:
Coronary steal is sometimes treated by surgery. [ 8 ]
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Coronary thrombosis is defined as the formation of a blood clot inside a blood vessel of the heart . This blood clot may then restrict blood flow within the heart , leading to heart tissue damage, or a myocardial infarction , also known as a heart attack. [ 1 ]
Coronary thrombosis is most commonly caused as a downstream effect of atherosclerosis , a buildup of cholesterol and fats in the artery walls. The smaller vessel diameter allows less blood to flow and facilitates progression to a myocardial infarction . Leading risk factors for coronary thrombosis are high low-density lipoprotein cholesterol , smoking, sedentary lifestyle , and hypertension . [ 2 ]
Symptoms of coronary thrombosis are not always evident at the start. Symptoms include chest pain, shortness of breath, and discomfort in the upper body.
A coronary thrombosis is a medical emergency (life threatening) and requires emergency care at a hospital.
A coronary thrombus is asymptomatic until it causes significant obstruction, leading to various forms of angina or eventually a myocardial infarction . Common warning symptoms are crushing chest pain, shortness of breath, and upper body discomfort. [ 2 ]
Coronary thrombosis and myocardial infarction are sometimes used as synonyms, although this is technically inaccurate as the thrombosis refers to the blocking of blood vessels with a thrombus, while myocardial infarction refers to heart tissue death due to the consequent loss of blood flow to the heart. Due to extensive collateral circulation , a coronary thrombus does not necessarily cause tissue death and may be asymptomatic. [ citation needed ]
The formation of coronary thrombosis generally follows the same mechanism as other blood clots in the body, the coagulation cascade . Also applicable is the Virchow's triad of blood stasis, endothelial injury, and hypercoagulable state . Atherosclerosis contributes to coronary thrombosis formation by facilitating blood stasis as well as causing local endothelial injury. [ citation needed ]
Due to the large number of cases of myocardial infarction leading to death and disease in the world, there has been extensive study towards the generation of clots specifically in the coronary arteries . [ citation needed ] Some areas of focus:
Clinical signs of myocardial infarction (heart attack) or angina if coronary thrombus is symptomatic:
Imaging modalities used to evaluate the presence of coronary thrombi: [ 9 ]
Postmortem examiners may look for Lines of Zahn , to determine whether blood clotted in the heart vessels before or after death. [ 11 ]
Management of symptomatic coronary thrombosis follows established treatment algorithms for myocardial infarction. Treatment options include: [ 12 ]
To address the possibility of identifying and treating asymptomatic coronary artery disease to prevent development of coronary thrombosis, a study published 2018 determined that preemptive treatment with percutaneous coronary intervention did not lead to a difference in death or myocardial infarction over a 15-year period. [ 13 ]
There are numerous treatments currently being studied for management and prevention of coronary thrombosis. Statin drugs, in addition to their primary cholesterol -lowering mechanisms of action, have been studied to target a number of pathways that may decrease coronary inflammation and subsequent thrombosis. [ 14 ]
Another realm of potential treatments in early stages of adoption is in therapeutic use of contrast ultrasound on thrombus dissolution. [ 15 ]
Thrombosis is defined as the formation of a thrombus (blood clot) inside a blood vessel , leading to obstruction of blood flow within the circulatory system . Coronary thrombosis refers to the formation and presence of thrombi in the coronary arteries of the heart. The heart does not contain veins, but rather coronary sinuses that serve the purpose of returning de-oxygenated blood from the heart muscle. [ citation needed ]
A thrombus is a type of embolism , a more general term for any material that partially or fully blocks a blood vessel. An atheroembolism , or cholesterol embolism, is when an atherosclerotic plaque ruptures and becomes an embolism. Atherosclerosis is the progressive thickening of blood vessels and plaque formation that eventually can lead to coronary artery disease . [ citation needed ]
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Coronary vasospasm refers to when a coronary artery suddenly undergoes either complete or sub-total temporary occlusion. [ 1 ]
In 1959, Prinzmetal et al. described a type of chest pain resulting from coronary vasospasm, referring to it as a variant form of classical angina pectoris . [ 2 ] Consequently, this angina has come to be reported and referred to in the literature as Prinzmetal angina . [ 3 ] A subsequent study distinguished this type of angina from classical angina pectoris further by showing normal coronary arteries on cardiac catheterization . This finding is unlike the typical findings in classical angina pectoris, which usually shows atherosclerotic plaques on cardiac catheterization. [ 3 ]
When coronary vasospasm occurs, the occlusion temporarily produces ischemia . A wide array of symptoms or presentations can follow: ranging from asymptomatic myocardial ischemia, sometimes referred to as silent ischemia, to myocardial infarction and even sudden cardiac death . [ 4 ] [ 1 ]
Coronary vasospasm classically produces chest pain at rest, also known as variant angina (vasospastic angina or Prinzmetal's angina). [ 5 ] Chest pain is more common at certain times of the day, usually from late night to early morning. [ 6 ] These episodes can be accompanied by nausea, vomiting, cold sweating, and even syncope. [ 7 ] [ 8 ] Coronary vasospasm is also associated with symptoms of fatigue and tiredness, dyspnea, and palpitations. [ 5 ] These can sometimes be the primary presenting symptoms, but they can also occur in conjunction with chest pain. [ 5 ]
There are cases of coronary vasospasm that occur without any symptoms at all, leading to episodes of silent or asymptomatic myocardial ischemia. [ 7 ] [ 8 ]
Depending on how long the occlusion lasts, a spectrum of different myocardial ischemic syndromes can occur. Shorter episodes of occlusion can lead to what is referred to as silent myocardial ischemia due to its asymptomatic nature. [ 1 ] These episodes can also be accompanied by arrhythmias. [ 1 ] Longer episodes of occlusion can lead to stable or unstable angina, myocardial infarction, and sudden cardiac death. [ 1 ]
Unlike classical angina pectoris , traditional cardiovascular risk factors are not thought to be significantly associated with coronary vasospasm. [ 9 ] The exception to this is with smoking, which is known to be a modifiable risk factor for vasospastic angina. [ 9 ] [ 10 ]
There are several risk factors that are thought to precipitate, or trigger, episodes of coronary vasospasm. Many of these factors work by exerting effects on the autonomic nervous system. One of the mechanisms through which this occurs is via increasing sympathetic nervous system activity. The resulting increased sympathetic outflow leads to vasoconstrictive effects on blood vessels. [ 9 ] For example, cocaine use can trigger vasospasm in coronary arteries through its actions on adrenergic receptors causing vasoconstriction. [ 11 ] Exercise, cold weather, physical activity or exertion, mental stress, hyperventilation are additional precipitating factors. [ 9 ] [ 7 ]
The exact pathophysiology behind coronary vasospasm has not been elucidated. Instead, a combination of different factors has been proposed to contribute to coronary vasospasm. [ 12 ] In general, it is thought that an abnormality within a coronary artery causes it to become hyperreactive to vasoconstrictor stimuli. This abnormality can be located in one segment of the coronary artery, or it may be diffuse and present throughout the entire artery. If and when vasoconstrictor stimuli act upon the hyperreactive segment of the artery, then vasospasm can result. [ 9 ] Ultimately, when large coronary arteries undergo vasospasm, this can lead to either complete or transient occlusion of blood flow within the artery. As a result, ischemia to the tissues served by the artery can occur. Symptoms due to ischemia can follow. [ 13 ]
Some of the factors that have been proposed to contribute to coronary vasospasm include the following: [ 1 ] [ 12 ]
There are no set criteria to diagnose coronary vasospasm. Thorough history taking by a clinician can assist in the diagnosis of coronary vasospasm. In cases where symptoms of chest pain are present, identifying features that distinguish episodes of vasospastic angina from traditional angina can aid in the diagnosis. [ 6 ] Features such as chest pain at rest, a diurnal variation in tolerance for exercise with a reduction in tolerance for exercise in the morning, and responsiveness of chest pain to calcium channel blockers as opposed to beta blockers can be important clues. [ 6 ]
EKG can occasionally be used to diagnose episodes of coronary vasospasm. However, relying on EKG is not always possible due to the transient nature of coronary vasospasm episodes. [ 6 ] [ 19 ] Due to the challenge of capturing episodes of coronary vasospasm spontaneously, provocative testing to induce coronary vasospasm during coronary catheterization can be used to make the diagnosis. [ 19 ] Provocative testing relies upon the use of pharmacological agents that promote or trigger episodes of vasospasm. Agents commonly administered include ergonovine and acetylcholine . Both pharmacological agents have vasoconstrictive effects on coronary arteries. [ 19 ] However, in the clinical setting, provocative testing is not routinely performed. [ 20 ] The reason for this is due to the adverse effects of these pharmacological agents. [ 20 ]
When coronary vasospasm causes an artery to undergo complete occlusion, an EKG might show evidence of ST-segment elevation in the leads indicative of that artery's territory. Transient ST-segment depression can also occur, usually in the setting of sub-total occlusion of an artery. [ 7 ]
Additional EKG findings in coronary vasospasm include evidence of arrhythmias that might be induced by ischemia: ventricular premature contractions, ventricular tachycardia, ventricular fibrillation, and more. [ 7 ]
Chest pain due to coronary vasospasm was described in the medical literature by Prinzmetal et al. in 1959. [ 2 ] This discovery led to this type of angina being referred to in the literature as Prinzmetal angina. [ 3 ] [ 20 ] A following study further distinguished this angina from classical angina pectoris due to the fact that the results showed that the patients with chest pain due to coronary vasospasm lacked evidence of atherosclerosis on cardiac catheterization. [ 3 ] [ 20 ] Angina due to coronary vasospasm is also known as variant angina. [ 20 ]
During the 70’s and 80’s, intense research [ 21 ] headed by Dr. Robert A. Chahine resulted in the delineation of Spasm's role in Prinzmetal's angina, allowing for easy identification and effective treatment. [ 22 ]
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When extracting lower wisdom teeth , coronectomy is a treatment option involving removing the crown of the lower wisdom tooth, whilst keeping the roots in place in healthy patients. This option is given to patients as an alternative to extraction when the wisdom teeth are in close association with the inferior alveolar nerve , and so used to prevent damage to the nerve which may occur during extraction. [ 1 ]
Reduces risk of neuropathy [ 2 ] compared with full extraction.
The risk of altered sensation is significantly lower than convention surgical removal of mandibular third molars . Approximately 0.65% of individuals encounter postoperative deficits in the Inferior alveolar nerve (IAN) following coronectomy, a significantly lower occurrence compared to the 5.10% observed after conventional extraction procedures. Patients undergoing coronectomy are anticipated to experience easier recovery from IAN deficits compared to those undergoing extractions. Limited studies indicate a 100% recovery rate in coronectomy patients, whereas only 66% of patients undergoing extraction recover within one month. 62.2% of the roots will migrate post-coronectomy, erupting away from the inferior alveolar canal. This makes extraction of the remaining roots safer. [ 3 ]
There is a 5% chance of failure of coronectomy, the root will become mobilized during transection. [ 4 ] In 5% of the cases, follicle remnants will form deep periodontal pockets which will lead to infection. [ 5 ]
Coronectomy should be considered if there are signs that the patient is at a high risk of nerve damage during extraction:
The patient should be aware of the potential risks of the procedure such as:
A plain film radiograph allows the proximity of the tooth to the inferior alveolar canal to be assessed. The plain film can be assessed to identify the tooth as high risk If there is; loss of the lamina dura, darkening of the canal and grooving of the root. If the mandibular third molar is deemed to be high risk, a cone beam CT ( CBCT ) is taken in addition to the plain film. The justification of additional radiography can be justified by the surgeon as it allows them to gain further information regarding the tooth roots and the inferior alveolar canal should the roots be mobilised when transecting.
Verbal consent must be attained by the surgeon prior to the procedure of a coronectomy. Additionally consent must be gained if removal of the roots is required due to mobilisation. The patient should be informed of early and late infection meaning the roots may need removing.
If the patient presents with dry socket, irrigate with chlorohexidine mouthwash and place resorbable dressing such as Alvogyl. If the patient has recurrent infection, consideration to remove the roots should be noted. [ citation needed ]
In a few cases the remaining roots may erupt which can minimise the morbidity of the inferior alveolar nerve, however the roots may be in close contact to the inferior alveolar nerve requiring surgical separation. [ 1 ]
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A corpectomy or vertebrectomy is a surgical procedure that involves removing all or part of the vertebral body ( Latin : corpus vertebrae , hence the name corpectomy), usually as a way to decompress the spinal cord and nerves. Corpectomy is often performed in association with some form of discectomy . [ 1 ]
When the vertebral body has been removed, the surgeon performs a vertebral fusion . Because a space in the column remains from the surgery, it must be filled using a block of bone taken from the pelvis or one of the leg bones or with a manufactured component such as a cage. This bone graft holds the remaining vertebrae apart. As it heals, the vertebrae grow together and fuse . [ 1 ]
This surgery article is a stub . You can help Wikipedia by expanding it .
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Decomposition is the process in which the organs and complex molecules of animal and human bodies break down into simple organic matter over time. In vertebrates , five stages of decomposition are typically recognized: fresh, bloat, active decay, advanced decay, and dry/skeletonized. [ 1 ] Knowing the different stages of decomposition can help investigators in determining the post-mortem interval (PMI). [ 2 ] The rate of decomposition of human remains can vary due to environmental factors and other factors. [ 3 ] Environmental factors include temperature , burning, humidity , and the availability of oxygen. [ 3 ] Other factors include body size, clothing, and the cause of death . [ 3 ]
The five stages of decomposition—fresh (autolysis), bloat, active decay, advanced decay, and dry/skeletonized—have specific characteristics that are used to identify which stage the remains are in. [ 4 ] These stages are illustrated by reference to an experimental study of the decay of a pig corpse. [ 1 ]
At this stage the remains are usually intact and free of insects. The corpse progresses through algor mortis (a reduction in body temperature until ambient temperature is reached), rigor mortis (the temporary stiffening of the limbs due to chemical changes in the muscles), and livor mortis (pooling of the blood on the side of the body that is closest to the ground). [ 5 ]
At this stage, the microorganisms residing in the digestive system begin to digest the tissues of the body, excreting gases that cause the torso and limbs to bloat, and producing foul-smelling chemicals including putrescine and cadaverine . [ 6 ] Cells in tissues break down and release hydrolytic enzymes , and the top layer of skin may become loosened, leading to skin slippage. [ 7 ] : 153–162 Decomposition of the gastrointestinal tract results in a dark, foul-smelling liquid called "purge fluid" that is forced out of the nose and mouth due to gas pressure in the intestine. [ 7 ] : 155 The bloat stage is characterized by a shift in the bacterial population from aerobic to anaerobic bacterial species. [ 8 ]
At this stage, the tissues begin to liquify and the skin will start to blacken. Blowflies target decomposing corpses early on, using specialized smell receptors, and lay their eggs in orifices and open wounds. [ 8 ] The size and development stage of maggots can be used to give a measure of the minimum time since death. [ 9 ] : 251–252 Insect activity occurs in a series of waves, and identifying the insects present can give additional information on the postmortem interval . [ 10 ] Adipocere , or corpse wax, may be formed, inhibiting further decomposition. [ 9 ] : 16–18
During advanced decay, most of the remains have discolored and often blackened. Putrefaction , in which tissues and cells break down and liquidize as the body decays, will be almost complete. [ 1 ] A decomposing human body in the earth will eventually release approximately 32 g (1.1 oz) of nitrogen, 10 g (0.35 oz) of phosphorus, 4 g (0.14 oz) of potassium, and 1 g (0.035 oz) of magnesium for every kilogram of dry body mass, making changes in the chemistry of the soil around it that may persist for years. [ 8 ]
Once bloating has ceased, the soft tissue of remains typically collapses in on itself. At the end of active decay, the remains are often dried out and begin to skeletonize . [ 1 ]
The climate and temperature in which a corpse decomposes can have great effect on the rate of decomposition; [ 11 ] higher temperatures accelerate the physiological reactions in the body after death and speed up the rate of decomposition, and cooler temperatures may slow the rate of decomposition. [ 11 ]
In summer conditions, the human body can skeletonize in nine days. [ 12 ] Warm climates can mean that finger prints cannot be obtained after four days, [ 13 ] and in colder climates or seasons they may remain for up to fifty days after death. [ 13 ] [ 14 ]
The amount of moisture in the environment in which a corpse decomposes also has an effect on the rate of decomposition. [ 11 ] Humid environments will speed up the rate of decomposition and will influence adipocere formation. [ 11 ] In contrast, more arid environments will see corpses dry up faster and decompose more slowly. [ 11 ]
Whether the corpse is in a more anaerobic or aerobic environment will also influence the rate of decomposition. [ 2 ] The more oxygen there is available the more rapid decomposition will take place. [ 15 ] This is because the microorganisms required for decomposition require oxygen to live and thus facilitate decomposition. [ 15 ] Lower oxygen levels will have the opposite effect. [ 15 ]
Burial postpones the rate of decomposition, in part because even a few inches of soil covering the corpse will prevent blowflies from laying their eggs on the corpse. The depth of burial will influence the rate of decomposition as it will deter decomposers such as scavengers and insects. [ 2 ] This will also lower the available oxygen and impede decomposition as it will limit the function of microorganisms. [ 15 ] The pH of the soil will also be a factor when it comes the rate of decomposition, as it influences the types of decomposers. [ 16 ] Moisture in soil will also slow down decomposition as it facilitates anaerobic metabolism. [ 11 ]
Submersion in water typically slows decomposition. The rate of loss of heat is higher in water and the progression through algor mortis is therefore faster. Cool temperatures slow bacterial growth. Once bloat begins, the body will typically float to the surface and become exposed to flies. Scavengers in the water, which vary with the location, also contribute to decay. [ 17 ] Factors affecting decomposition include water depth, temperature, tides, currents, seasons, dissolved oxygen, geology, acidity, salinity, sedimentation, and insect and scavenging activity. [ 18 ] Human remains found in aquatic surroundings are often incomplete and poorly preserved, making investigating the circumstances of death much more difficult. [ 19 ] If a person has drowned, the body will likely initially submerge and go into a position that has been named "the drowning position." This position is when the front of the body is face down in the water, with their extremities reaching down towards the bottom of the body of water. Their back is typically slightly arched down and inwards. This position is important to note as when this occurs in shallow water their extremities may drag across the bottom of the body of the water, leaving injuries. [ 20 ] After death, when a body is submerged in water a process called Saponification occurs. This is the process in which adipocere is formed. Adipocere is a wax-like substance that covers bodies created by the hydrolysis of triglycerides in adipose tissue. This occurs mainly in submersion, burial environments or areas with lots of carbon but has been noted in marine environments. [ 21 ]
Body size is an important factor that will also influence the rate of decomposition. [ 22 ] A larger body mass and more fat will decompose more rapidly. [ 22 ] This is because after death, fats will liquify, accounting for a large portion of decomposition. [ 22 ] People with a lower fat percentage will decompose more slowly. [ 22 ] This includes smaller adults and especially children. [ 22 ]
Clothing and other types of coverings affect the rate of decomposition because it limits the body's exposure to external factors such as weathering and soil. [ 2 ] It slows decomposition by delaying scavenging by animals. [ 2 ] However, insect activity would increase since the wrapping will harbor more heat and protection from the sun, providing an ideal environment for maggot growth which facilitates organic decay. [ 2 ]
The cause of death can also influence the rate of decomposition, mainly by speeding it up. [ 23 ] Fatal wounds like stab wounds or other lacerations on the body attract insects as it provides a good spot to oviposit and, as a result, could increase the rate of decomposition. [ 23 ]
Corpse farms are used to study the decay of the human body and to gain insight into how environmental and endogenous factors affect progression through the stages of decomposition. [ 8 ] In summer, high temperatures can accelerate the stages of decomposition: heat encourages the breakdown of organic material, and bacteria also grow faster in a warm environment, accelerating bacterial digestion of tissue. However, natural mummification , normally thought of as a consequence of arid conditions, can occur if the remains are exposed to intense sunlight. [ 24 ] In winter, not all bodies go through the bloat stage. Bacterial growth is much reduced at temperatures below 4 °C. [ 25 ] Corpse farms are also used to study the interactions of insects with decaying bodies. [ 8 ]
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https://en.wikipedia.org/wiki/Corpse_decomposition
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The Corpulence Index ( CI ) (also Ponderal Index ( PI ) or Rohrer's Index ) is a measure of corpulence , or of leanness in other variants, of a person [ 1 ] calculated as a relationship between mass and height. [ 2 ] It was first proposed in 1921 as the "Corpulence measure" by Swiss physician Fritz Rohrer [ 3 ] [ 4 ] and hence is also known as Rohrer's Index. [ 5 ] It is similar to the body mass index , but the mass is normalized with the third power of body height rather than the second power. [ 6 ] In 2015, Sultan Babar showed that CI does not need to be adjusted for height after adolescence. [ 4 ] [ 6 ] Babar also tested the corpulence index against the BMI as a method of predicting body fat content in the NHANES III study, which calculated body fat percentage based on bioelectrical impedance analysis . The corpulence index performed somewhat better than the BMI in terms of sensitivity, specificity, and predictive value. It also out-performed the Lorentz index and Broca's estimate of ideal body mass . [ 6 ] [ 7 ]
with m a s s {\displaystyle \mathrm {mass} } in kilograms and h e i g h t {\displaystyle \mathrm {height} } in metres, giving a measure with the same dimensions as density . The corpulence index yields valid results even for very short and very tall persons, [ 8 ] which is a problem with BMI — for example, an ideal body weight for a person 152.4 cm tall (48 kg) will render BMI of 20.7 and CI of 13.6, while for a person 200 cm tall (99 kg), the BMI will be 24.8, very close to the "overweight" threshold of 25, while CI will be 12.4. [ 9 ]
Because of this property, it is most commonly used in pediatrics . [ 10 ] [ 11 ] (For a baby, one can take crown-heel length for the height. [ 12 ] ) The normal values for infants are about twice as high as for adults, which is the result of their relatively short legs. [ citation needed ] It does not need to be adjusted for age after adolescence. [ 6 ] It has also been shown to have a lower false positive rate in athletes. [ 13 ]
The corpulence index is variously defined (the first definition should be preferred due to the use of SI-units kg and m) as follows:
For infants, units of grams and centimeters are used instead, then the value is multiplied by 100. [ 18 ]
PI child = 0.1 × PI adult = 100 × mass g height cm 3 {\displaystyle {\text{PI}}_{\text{child}}=0.1\times {\text{PI}}_{\text{adult}}=100\times {\dfrac {{\text{mass}}_{\text{g}}}{{\text{height}}_{\text{cm}}^{3}}}}
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https://en.wikipedia.org/wiki/Corpulence_index
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Cortical blindness is the total or partial loss of vision in a normal-appearing eye caused by damage to the brain 's occipital cortex . [ 1 ] Cortical blindness can be acquired or congenital, and may also be transient in certain instances. [ 2 ] Acquired cortical blindness is most often caused by loss of blood flow to the occipital cortex from either unilateral or bilateral posterior cerebral artery blockage ( ischemic stroke ) and by cardiac surgery. [ 2 ] In most cases, the complete loss of vision is not permanent and the patient may recover some of their vision ( cortical visual impairment ). [ 2 ] Congenital cortical blindness is most often caused by perinatal ischemic stroke, encephalitis , and meningitis . [ 3 ] Rarely, a patient with acquired cortical blindness may have little or no insight that they have lost vision, a phenomenon known as Anton–Babinski syndrome .
Cortical blindness and cortical visual impairment (CVI), which refers to the partial loss of vision caused by cortical damage, are both classified as subsets of neurological visual impairment (NVI). NVI and its three subtypes—cortical blindness, cortical visual impairment, and delayed visual maturation —must be distinguished from ocular visual impairment in terms of their different causes and structural foci, the brain and the eye respectively. One diagnostic marker of this distinction is that the pupils of individuals with cortical blindness will respond to light whereas those of individuals with ocular visual impairment will not. [ citation needed ]
The most common symptoms of acquired and transient cortical blindness include:
The most common cause of cortical blindness is ischemia ( oxygen deprivation ) to the occipital lobes caused by blockage to one or both of the posterior cerebral arteries. [ 2 ] However, other conditions have also been known to cause acquired and transient cortical blindness, including:
The most common causes of congenital cortical blindness are:
A patient with cortical blindness has no vision but the response of his/her pupil to light is intact (as the reflex does not involve the cortex). Therefore, one diagnostic test for cortical blindness is to first objectively verify the optic nerves and the non-cortical functions of the eyes are functioning normally. This involves confirming that patient can distinguish light/dark, and that his/her pupils dilate and contract with light exposure. Then, the patient is asked to describe something he/she would be able to recognize with normal vision. For example, the patient would be asked the following: [ citation needed ]
Patients with cortical blindness will not be able to identify the item being questioned about at all or will not be able to provide any details other than color or perhaps general shape. This indicates that the lack of vision is neurological rather than ocular. It specifically indicates that the occipital cortex is unable to correctly process and interpret the intact input coming from the retinas.
Fundoscopy should be normal in cases of cortical blindness. Cortical blindness can be associated with visual hallucinations , denial of visual loss ( Anton–Babinski syndrome ), and the ability to perceive moving but not static objects ( Riddoch syndrome ). [ citation needed ]
The prognosis of a patient with acquired cortical blindness depends largely on the original cause of the blindness. For instance, patients with bilateral occipital lesions have a much lower chance of recovering vision than patients who suffered a transient ischemic attack or women who experienced complications associated with eclampsia . [ 2 ] [ 3 ] In patients with acquired cortical blindness, a permanent complete loss of vision is rare. [ 2 ] The development of cortical blindness into the milder cortical visual impairment is a more likely outcome. [ 2 ] Furthermore, some patients regain vision completely, as is the case with transient cortical blindness associated with eclampsia and the side effects of certain anti-epilepsy drugs.
Recent research by Krystel R. Huxlin and others on the relearning of complex visual motion following V1 damage has offered potentially promising treatments for individuals with acquired cortical blindness. [ 11 ] These treatments focus on retraining and retuning certain intact pathways of the visual cortex which are more or less preserved in individuals who sustained damage to V1. [ 11 ] Huxlin and others found that specific training focused on utilizing the "blind field" of individuals who had sustained V1 damage improved the patients' ability to perceive simple and complex visual motion. [ 11 ] This sort of 'relearning' therapy may provide a good workaround for patients with acquired cortical blindness in order to better make sense of the visual environment.
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https://en.wikipedia.org/wiki/Cortical_blindness
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Cortical deafness is a rare form of sensorineural hearing loss caused by damage to the primary auditory cortex . Cortical deafness is an auditory disorder where the patient is unable to hear sounds but has no apparent damage to the structures of the ear (see auditory system ). It has been argued to be as the combination of auditory verbal agnosia and auditory agnosia . Patients with cortical deafness cannot hear any sounds, that is, they are not aware of sounds including non-speech, voices, and speech sounds. [ 1 ] Although patients appear and feel completely deaf, they can still exhibit some reflex responses such as turning their head towards a loud sound. [ 2 ]
Cortical deafness is caused by bilateral cortical lesions in the primary auditory cortex located in the temporal lobes of the brain. [ 3 ] The ascending auditory pathways are damaged, causing a loss of perception of sound. Inner ear functions, however, remains intact. Cortical deafness is most often caused by stroke , but can also result from brain injury or birth defects. [ 4 ] [ 5 ] More specifically, a common cause is bilateral embolic stroke to the area of Heschl's gyri. [ 6 ]
It is thought that cortical deafness could be a part of a spectrum of an overall cortical hearing disorder. [ 3 ] In some cases, patients with cortical deafness have had recovery of some hearing function, resulting in partial auditory deficits such as auditory verbal agnosia. [ 3 ] [ 7 ] This syndrome might be difficult to distinguish from a bilateral temporal lesion such as described above.
Since cortical deafness and auditory agnosia have many similarities, diagnosing the disorder proves to be difficult. Bilateral lesions near the primary auditory cortex in the temporal lobe are important criteria. Cortical deafness requires demonstration that brainstem auditory responses are normal, but cortical evoked potentials are impaired. Brainstem auditory evoked potentials , also called brainstem auditory evoked responses, show the neuronal activity in the auditory nerve, cochlear nucleus, superior olive, and inferior colliculus of the brainstem. They typically have a response latency of no more than six milliseconds with an amplitude of approximately one microvolt. The latency of the responses gives critical information: if cortical deafness is applicable, long latency responses are completely abolished and middle latency responses are either abolished or significantly impaired. [ 2 ] In auditory agnosia, long and middle latency responses are preserved.
Another important aspect of cortical deafness that is often overlooked is that patients feel deaf. They are aware of their inability to hear environmental sounds, non-speech and speech sounds. Patients with auditory agnosia can be unaware of their deficit, and insist that they are not deaf. [ 8 ] Verbal deafness and auditory agnosia are disorders of a selective, perceptive and associative nature whereas cortical deafness relies on the anatomic and functional disconnection of the auditory cortex from acoustic impulses.
Although cortical deafness has very specific parameters of diagnosis, its causes can vary tremendously. The following are three case studies with different reasons for cortical deafness.
Auditory perception can improve with time. There seems to be a level of neuroplasticity that allows patients to recover the ability to perceive environmental and certain musical sounds. [ 10 ] Patients presenting with cortical hearing loss and no other associated symptoms recover to a variable degree, depending on the size and type of the cerebral lesion. Patients whose symptoms include both motor deficits and aphasias often have larger lesions with an associated poorer prognosis in regard to functional status and recovery. [ 10 ]
Cochlear or auditory brainstem implantation could also be treatment options. Electrical stimulation of the peripheral auditory system may result in improved sound perception or cortical remapping in patients with cortical deafness. [ 3 ] However, hearing aids are an inappropriate answer for cases like these. Any auditory signal, regardless if has been amplified to normal or high intensities, is useless to a system unable to complete its processing. [ 4 ] Ideally, patients should be directed toward resources to aid them in lip-reading, learning American Sign Language, as well as speech and occupational therapy. Patients should follow-up regularly to evaluate for any long-term recovery. [ 10 ]
Early reports, published in the late 19th century, describe patients with acute onset of deafness after experiencing symptoms described as apoplexy . The only means of definitive diagnosis in these reports were postmortem dissections. [ 10 ] Subsequent cases throughout the 20th century reflect advancements in diagnoses of both hearing loss and stroke. With the advent of audiometric and electrophysiologic studies, investigators could diagnose cortical deafness with increasing precision. Advances in imaging techniques, such as MRI , greatly improved the diagnosis and localization of cerebral infarcts that coincide with primary or secondary auditory centers. [ 10 ] Neurological and cognitive testing help to distinguish between total cortical deafness and auditory agnosia , resulting in the inability to perceive words, music, or specific environmental sounds.
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https://en.wikipedia.org/wiki/Cortical_deafness
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A cortical implant is a subset of neuroprosthetics that is in direct connection with the cerebral cortex of the brain . By directly interfacing with different regions of the cortex, the cortical implant can provide stimulation to an immediate area and provide different benefits, depending on its design and placement. A typical cortical implant is an implantable microelectrode array , which is a small device through which a neural signal can be received or transmitted.
The goal of a cortical implant and neuroprosthetic in general is "to replace neural circuitry in the brain that no longer functions appropriately." [ 1 ]
Cortical implants have a wide variety of potential uses, ranging from restoring vision to blind patients or helping patients with dementia . With the complexity of the brain, the possibilities for these brain implants to expand their usefulness are nearly endless. Some early work in cortical implants involved stimulation of the visual cortex, using implants made from silicone rubber. [ 2 ] Since then, implants have developed into more complex devices using new polymers, such as polyimide . There are two ways that cortical implants can interface with the brain, either intracortically (direct) or epicortically (indirect). [ 3 ] Intracortical implants have electrodes that penetrate into the brain, while epicortical implants have electrodes that stimulate along the surface. Epicortical implants mainly record field potentials around them and are generally more flexible compared to their intracortical counterparts. Since the intracortical implants go deeper into the brain, they require a stiffer electrode. [ 2 ] However, due to micromotion in the brain, some flexibility is necessary in order to prevent injury to the brain tissue.
Certain types of cortical implants can partially restore vision by directly stimulating the visual cortex . [ 4 ] Early work to restore vision through cortical stimulation began in 1970 with the work of Brindley and Dobelle. With their initial experimentation, some patients were able to recognize small images at fairly close distances. Their initial implant was based on the surface of the visual cortex and it did not provide as clear of images that it could, with an added downside of damage to surrounding tissues. More recent models, such as the "Utah" Electrode Array use deeper cortical stimulation that would hypothetically provide higher resolution images with less power needed, thus causing less damage. One of the major benefits to this method of artificial vision over any other visual prosthetic is that it bypasses many neurons of the visual pathway that could be damaged, potentially restoring vision to a greater number of blind patients. [ 4 ]
However, there are some issues that come with direct stimulation of the visual cortex. As with all implants, the impact of their presence over extended periods of time must be monitored. If an implant needs to be removed or re-positioned after a few years, complications can occur. The visual cortex is much more complex and difficult to deal with than the other areas where artificial vision are possible, such as the retina or optic nerve . The visual field is much easier to process in different locations other than the visual cortex. In addition, each areas of the cortex is specialized to deal with different aspects of vision, so simple direct stimulation will not provide complete images to patients. Lastly, surgical operations dealing with brain implants are extremely high-risk for patients, so the research needs to be further improved. However, cortical visual prostheses are important to people who have a completely damaged retina, optic nerve or lateral geniculate body, as they are one of the only ways they would be able to have their vision restored, so further developments will need to be sought out. [ 4 ]
Advancements in visual implants focus on stimulating specific areas of the visual cortex . The middle temporal (MT) region, crucial for perceiving motion, is a key target for electrical stimulation to create smooth motion artificially. Precise electrode implantation in MT poses a challenge due to its location, which is surrounded by sulci. Ongoing research explores multi-area stimulation between MT and primary visual cortex (V1), aiming to understand its impact on generating phosphenes (visual illusion) and motion perception. This multi-area approach, targeting different regions in the visual system, holds promise for improving the clarity and performance of visual implants, offering a potential avenue for more effective vision restoration. [ 5 ]
While there has been little development in developing an effective auditory prosthesis that directly interfaces with the auditory cortex , there are some devices, such as a cochlear implant , and an auditory brainstem implant , introduced by Dr. William House and his team, that have been successful in restoring hearing to deaf patients. [ 6 ] The cochlear implant targets the cochlear or auditory nerve, and individuals who have issues with this nerve can never benefit from it. As an alternative, the auditory brainstem prosthesis can be used. [ 7 ]
There have also been some studies that have used microelectrode arrays to take readings from the auditory cortex of animals. One study has been performed on rats to develop an implant that enabled simultaneous readings from both the auditory cortex and the thalamus . The readings from this new microelectrode array were similar in clarity to other readily available devices that did not provide the same simultaneous readings. [ 8 ] With studies like this, advancements can be made that could lead to new auditory prostheses.
To address the challenges faced by conventional auditory prostheses, many unconventional auditory prostheses, such as bone conduction implants and middle ear implants are still under ongoing research. The bone conduction prosthesis stimulates the cochlea by triggering skull vibrations. The middle ear prosthesis, either partially or completely implanted, triggers direct vibration of the ossicular chain (ossicles or ear bones). Despite the complications these prostheses may cause, their purpose is to enhance the transmission of sound vibrations into the inner ear and, consequently, improve hearing abilities. [ 9 ]
Some cortical implants have been designed to improve cognitive function. These implants are placed in the prefrontal cortex or the hippocampus . Implants in the prefrontal cortex help restore attention, decision-making and movement selection by duplicating the minicolumnar organization of neural firings. [ 10 ] A hippocampal prosthetic aims to help with restoration of a patient's full long-term memory capabilities. Researchers are trying to determine the neural basis for memory by finding out how the brain encodes different memories in the hippocampus.
By mimicking the natural coding of the brain with electrical stimulation, researchers look to replace compromised hippocampal regions and restore function. [ 11 ] Treatment for several conditions that impact cognition such as stroke , Alzheimer's disease and head trauma can benefit from the development of a hippocampal prosthetic. Epilepsy has also been linked to dysfunction in the CA3 region of the hippocampus. [ 12 ]
A Brain-computer interface (BCI) is a type of implant that allows for a direct connection between a patient's brain and some form of external hardware. Since the mid-1990s, the amount of research done on BCI's in both animal and human models has grown exponentially. Most brain-computer interfaces are used for some form of neural signal extraction, while some attempt to return sensation through an implanted signal. [ 3 ] As an example of signal extraction, a BCI may take a signal from a paraplegic patient's brain and use it to move a robotic prosthetic . Paralyzed patients get a great amount of utility from these devices because they allow for a return of control to the patient. Current research for brain-computer interfaces is focused on determining which regions of the brain can be manipulated by an individual. A majority of research focuses on the sensorimotor region of the brain, using imagined motor actions to drive the devices, while some studies have sought to determine if the cognitive control network would be a suitable location for implantations. This region is a "neuronal network that coordinates mental processes in the service of explicit intentions or tasks," driving the device by intent, rather than imagined motion [ 13 ] An example of returning sensation through an implanted signal would be developing a tactile response for a prosthetic limb. Amputees have no touch response in artificial limbs, but through an implant in their somatosensory cortex could potentially give them an artificial sense of touch.
A current example of a brain-computer interface would be the BrainGate , a device developed by Cyberkinetics . This BCI is currently undergoing a second round of clinical trials as of May 2009. An earlier trial featured a patient with a severe spinal cord injury , with no control over any of his limbs. He succeeded in operating a computer mouse with only thoughts. Further developments have been made that allow for more complex interfacing, such as controlling a robotic arm.
The applications of BCIs have been emerging over the years, particularly in addressing the challenges posed by neurodegenerative diseases such as amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD), Alzheimer's disease (AD), and spinal muscular atrophy (SMA). [ 14 ]
In AD, a progressive fatal neurodegenerative disorder, BCIs face challenges due to cognitive decline. Some innovative studies used a technique called "classical conditioning with functional magnetic resonance imaging (fMRI) and BCIs.". The main idea was to form a connection between certain intentional mental activities or thoughts and emotional responses or stimuli. Despite limitations, this novel approach seems to hold potential for the neurorehabilitation of AD. [ 14 ]
BCIs also play a role in enhancing motor function by translating neuronal firing into motor commands in PD, which is characterized by motor impairments. Research using local field potentials from deep brain stimulation (DBS) electrodes has shown improvements in motor functions. Neurofeedback through BCIs, based on electroencephalography (EEG) or fMRI, has been explored to regulate brain activity. BCIs with EEG feedback primarily aim to specifically detect intentional movements, with the goal of reducing neurological tremors when combined with technologies like functional electrical stimulation (FES). [ 14 ]
Moreover, BCIs offer potential improvements in muscle control in SMA patients, those who suffer from neurodegeneration in the anterior horn of the spinal cord, resulting in progressive muscle weakness. Some studies with SMA patients have explored integrating BCIs into control systems to enable remote devices such as TVs and telephones. Other studies have focused on enabling SMA individuals to manipulate a robotic arm using surface electromyography (sEMG). [ 14 ]
Perhaps one of the biggest advantages that cortical implants have over other neuroprostheses is being directly interfaced with the cortex. Bypassing damaged tissues in the visual pathway allows for a wider range of treatable patients. These implants can also act as a replacement for damage tissues in the cortex. The idea of biomimicry allows for the implant to act as an alternate pathway for signals.
Having any sort of implant that is directly connected to the cortex presents some issues. A major issue with cortical implants is biocompatibility , or how the body will respond to a foreign object. If the body rejects the implant, then the implant will be more of a detriment to the patient instead of a benefit. In addition to biocompatibility, once the implant is in place, the body may have an adverse reaction to it over an extended period of time, rendering the implant useless. [ 15 ] Implanting a microelectrode array can cause damage to the surrounding tissue. Development of scar tissue around the electrodes can prevent some signals from reaching the neurons the implant is meant to. Most microelectrode arrays require neuronal cell bodies to be within 50 μm of the electrodes to provide the best function, and studies have shown that chronically implanted animals have significantly reduced cell density within this range. [ 15 ] Implants have been shown to cause neurodegeneration at the site of implantation as well.
Neural coding represents a difficulty faced by cortical implants, and in particular, implants dealing with cognition. Researchers have found difficulty in determining how the brain codes distinct memories. For example, the way the brain codes the memory of a chair is vastly different from the way it codes for a lamp. With a full understanding of the neural code , more progress can be made in developing a hippocampal prosthetic that can more effectively enhance memory.
Due to the uniqueness of every patient's cortex, it is difficult to standardize procedures involving direct implantation. [ 4 ] There are many common physical features between brains, but an individual gyrus or sulcus (neuroanatomy) can be different when compared. This leads to difficulties because it causes each procedure to be unique, thus taking longer to perform. In addition, the nature of a microelectrode array intended effect is limited due to the stated variance's presented in association with individual cortex uniqueness i.e. differences. Present day microelectrode arrays are also constrained due their physical size, and achievable data processing/capability rates; which continue to be governed in relation to the characteristics dictated in accordance with Moore's Law .
As more research is performed on, further developments will be made that will increase the viability and usability of cortical implants. Decreasing the size of the implants would help with keeping procedures less complicated and reducing the bulk. The longevity of these devices is also being considered as developments are made. The goal with the development of new implants is "to avoid the hydrolytic, oxidative and enzymatic degradation due to the harsh environment of the human body or at least to slow it down to a minimum which enables the interface to work over a long time period, before it finally has to be exchanged." [ 2 ] With extended operational lifetimes, fewer operations would need to be performed for maintenance, allowing for The amount of polymers that are now able to be used for neural implants has increased, allowing for a greater diversity of devices. As technology improves, researchers are able to more densely place electrodes into arrays, permitting high selectivity. [ 2 ] Other areas of investigation are the battery packs that power these devices. Effort has been made to try and reduce the overall size and bulkiness of these packs to make them less obtrusive for the patient. Reducing the amount of power each implant requires is also of interest, as this will reduce the amount of heat the implant makes, therefore reducing the risk of damage to the surrounding tissues.
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https://en.wikipedia.org/wiki/Cortical_implant
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